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HomeMy WebLinkAbout4289DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.83 -1 -29 BOX 32 �r �., M66-6 1160 1 k04 �. IL �. �+. ., , PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. k 3186 Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit q �J 1 on CERTIFICATE OF COMPLIANCE CONSTRUCTION PERMIT FOR SEWA DISPOSAL SYSTEM Permit N 1 14Jt--, \)J Le Located at �'a� Town or Kulage, Subdivision Name - r Sabd. Lot IY 'T. Map �ti7 Block ..: Lot ��i �` Renewal_ ❑ Revision ❑ Owner /Applicant Name V_ `'r^ `s d�� 1 ' . �! Date of Previous Approval p Mailing Address v � ?►W" u Town tt%�sf/n P Zip u 0+S 6?_ Building Type mt, 4�,ek, Lot Area °� t � FN Section Only Depth Volume Number of Bedrooms Design Flow G /P /D 16 i0 PCHD Notification Is Required When Fill Is cot Separate Sewerage System to consist of and 11 SCt'Fo* ti C*Ti q 'u!G To be constructed by I�Ni ►r[ Tii -N -,�a Address Water Sapph: //Public Supply From or: Private S ply Drilled by Other Requirements Zjiw�rcl:zw. I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regulations o - o u nam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage disposal system mg th riod of two (2) years immediately following the date of the issu- ance of the approval of the Certificate of Construction Compliance of t originals em or any repairs thereto; 2) that the drilled well described above \ will be located as shown on the approved plan and that said well will be in st danje with t a ards, rules and regu a i-1�fioni of the Putnam � County Dep Plus ktof Health. �` Date 9 Sign d �a P.E. _y R.A. AU1 Address ? ' J„4� �� License No Y- WI \PPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless construction of the building has been undertaken and is voc ;ble for cause or may be amended or modified when con a necessary by the Commissioner of Health. Any change or alteration of construction " luires a new permit. Ap roved for disposal of donlesti -- it rysewage, and/ rive a water supply only, t By B%�v Title R V 3/ 86 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 ,l Engineer Most de (g '$ CER TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Ar fj, Located at Town Let Tax Map _Bleeor V e t_30_ n Owner /applicant Name 2° (ra'��ti� Formerly Subdivision Name r - Subdv. Lot # Mailing Address Z S Le t OWL —ZIP '0537 Date Permit Issued Separate Sewerage System built by , 0I %rP Address © - Consisting of 1,0013 Gallon Septic Tank and 151 / O -61 Water Supply: Public Supply From Address or: "/ Private Supply Drilled by Address Building Type (�P L. f..ut Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? PO Other Requirements I certify that the system(s) as listed serving the above premises were constrqAed essen'4aily as shown o e plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and reg tions, in ctance Ve iled plan, and the permit issued by the Putnam County D pa tment Of Health. Date 5 %� �; �g wCertified Dy A � / q P.E. i R.A. Address x'12 f " '— /� tl�sM�� ,Y, f0J�It7 License No. J Any person occupying premises served by the above system(s) shall promp, y take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewers system shall become II and void as soon as s pub.': unitary sewer becomes available and the approval of the private water supply shall become nu n void hen a u water supR�Y bocomas available. Such approvals are subject to modifi tion or ch a when, in the judgment of the Co i oner f Heal evocation, m Iflution or change is necessary. i�Y t 1 � PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �� - `o &rie�) �a 1 Owner or Purchaser of Building Building Constructed by c:>2T . /- ° Location - Street Municipality Buildin Section Block Lot Subdivision Name qj -s� Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location,.;., workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any _ ....�_ .repairs -ir+ i ta.s ^ vys arrtr_- �L ept. wfiere �th?e:'failura tcy_c�pei te. prcig ly - =%G_: caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusiv e the Director of the Division of Environinental Health Services Department of Health as to whether or not the failure of the caused by the willful or negligent act of the occupant of th e the system. Dated this 7 � � day of Ai4 V 19 General Contractor (Owner) - Signature Corporation Name (if Corp.) c;25 c;25 Address rev. 9/85 mk Signature Title the determination of of the Putnam County system to +rate was building utilizing Corporation Name (if Corp.) Address � O Z7 _l L111 ICWVO" �ei. rT�T T 11AL/fT)T TTTnLT nnnnnm �� -/�! WP�LL i�Vl•LL LLj11Vly LW1 Vitt DEPARTMENT OF HEALTH _ Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT 6F HEALTH Office Use Only WELL LOCATION STREET RESS TAX GRID NUMBER: WELL OWNE -R NAM ADDRESS: � 10-PUBLIC E USE OF WELL 1 -primary 2 : secondary RESIDENTIAL ❑ PUBLIC SUPPLY Q AIR /COND.IHEAT PUMP ❑ ABANDONED O' BUSINESS ❑ FARM O TEST/ OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -8Y ❑ MOUNT OF USE YIELD SOUGHT gpm. 1N0. PEOPLE SERVED �^ / EST. OF DAILY USAGE gal. REASON FOR DRILLING NEW SUPPLY ❑. PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL 7 U ft. DATE MEASURED y �� DRILLING EQUIPMENT 'K ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT O CABLE PERCUSSION 11 OTHER (specify): WELL TYPE ❑ SCREENED Q OPEN END CASING. 0 OPEN HOLE IN BEDROCK 0 OTHER TOTAL LENGTH ft. MATERIALS: gSTEEL ❑ PLASTIC O OTHER CASING DETAILS LENGTH .BELOW GRADE � ft. JOINTS: ❑ WELDED 0 THREADED ❑ OTHER DIAMETER `I in. SEAL: O CEMENT GROUT O BENTONITE &THER WEIGHT PER FOOT L5_ lb.'/ft. DRIVE SHOE) YES ❑ NO I LINER: O YES ONO SCREEN DETAILS ` ,. tj_ DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST ❑ YES ❑ NO HOURS - SECOND: _ _ GRAVEL PACK ❑ YES O NO GRAVEL . SIZE. DIAMETER OF PACK in. TOP DEPTH tL BOTTOM OEM It. WELL YIELD TEST It detailed pumping t METHOD: ❑ PUMPED ; tests were done is in- COMPRESSED AIR , formation attached? O BAILED O OTHER ; ❑YES ONO WELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ��9 Well Dia- In FORMATION DESCRIPTION voce ft. iL WELL DEPTH It. DURATION hr, min. DRAWOOWN ft. YIELD gpm. Lartace I r Ud �rr r l _ d —t WATER ❑ CLEAR TEMP. QUALITY O CLOUDY ARDNESS O COLORED fi -ED O YES ONO ANALYSIS ATTACHE ? O ES O NO STORAGE TANK: TYPE CAPACITY G L. PUMP INFORMATION TYPE MAKER MODEL Z CAPACITY DEPTH VOLT GE HP WELL DRI NAME / , y,� DATE Q ADORE jt /.i y uSIGMMPE / / �i Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 Director: Albert H. Pedoveni M. T. (ASCP) 1 L J LABORATORY REPORT ON THE QUALITY OF WATER INORGANIC NON- METALS (mg /L) _ Acidity Alkalinity Chloride Detergents, MBAS Hardness, Total Nitrogen, Ammonia ....Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite METALS (mg /L) ':2.014097 ; LAB N G Date Taken: S S '��� Time • %r Date Rc' d: Time: Date ° <:Rported - Collected By:'Y� SS/ Referred By: Sample Location: I7. ,'07,0 Phone N Phone # Sample Type: Repeat Test? _ (check one) MICROBIOLOGICAL (CFU /1'OOmL) GENERAL BACTERIA A,�'Stan.dard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE L.,-.'Total Coliform_ Fecal Coliform Fecal Streptococcus MOST PROBABLE NUMBER TECHNIQUE Copper _ Iron _ Total Coliform Index Lead ...... ,Mangy .. ,,... � �• X03. d - �-�•_ -- ..,.- anese P 1T yy .. r..r . - .. of � PP1• ....n.• .. � l,f -Q.L .. pn ...,� rim i6c'� _ Mercury Sodium KEY FOR TERMINOLOGY _ Zinc N/A = Not Applicable MISCELLANEOUS LT = Less. Than ( < ) GT = Greater Than (>) _jZPotable Non- potable STP INF _ STP EFF Other: Sample Status: (check each) Outgoing HNO3 HC1 H2SO4 NaOH ZnOAc Na2S203 Other: _ ✓LE 4 °C _ GT 4 °C _ pH LE 2 PH -GE 9 pH GE 12 PH (units) TNTC= Too Numerous To Count _ Other: Color (units) CON = Confluent ( =TNTC) Odor (TON) NR Non- reactive Turbidity (NTU) REMARKS /COMMENTS (For Lab Use) THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (NIA) OF A SATISFACTORY SANITARY, QUALITY ACCORDING TO THE NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID.) (DIDN'T) (N /A) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. 1x/ 4z 6d -1 �GLr' f / %,/� 2 /86(Rvsd7 /87)RWE Albert H. Padovani, A.T. ASCP),.Director. ` DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 7 TI PLI^A7r.:1., k TC� .�t�NSTRiI;C'1;,. _A WATER' WELL;-­; - - PCHD PERMIT # WELL LOCATION Street Address own Vill e City Tax Grid Number WELL OWNER Na Addres Y �'�� _ rivate ❑ Public USE OF WELL 1 - primary 2 - secondary 9-IfE'SIDENTIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ INDUSTRIAL U INSTITUTIONAL ❑ STAND -BY ❑ ABANDONED ❑ OTHER (specify ❑ AMOUNT OF USE YIELD SOUGHT ' ' gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE WO gal REASON FOR DRILLING EnEW SUPPLY ❑REPLACE EXISTING ❑ PROVIDE ADDITIONAL SUPPLY SUPPLY ®DEEPEN EXISTING WELL ❑ TEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE Lj5RILLED 13DRIVEN ®DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO.FLOODING? YES ---'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: U�Wf, ;KNtSk, Lot No. if" 41 41 -2- WATER WELL CONTRACTOR: Name - Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTARCE -70, PROPERTY. FR(P24 NEWS.T WATER-'MAIN,-.. , _ : : ; _ ' . b = . i LOCATION SKETCH &.SOURCES OF CONTAMINATION PROVIDED []ON REAR OF THIS APPLICATION B10 4EET (da e) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue:. 9 —d/ 19�� Date of Expiration: 198 q° Peirmit Issuing Official Permit is Non - Transferrable PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of 4- Located at (T) Q t,, Section 10� Block Lot Y Subdivision of Subdv. Lot Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professionalengi neer or regi.stered architect (Indicate 73— to apply for a Construction Permit for-a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary.papevs on my behalf in connection with this matter and to supervise -the construction of sa.,i!d systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned: P.E., R.A., # 277- 5k Address 40 Telephone Very truly yours, Signed_ Owner of Property Address W5 Town Telephone SOIL PERaX AZ'ION TEST _ DATA RDQUIRM TO BE SUB 41= WITH APPLlaaICNS Date of Pre- Soaking 3 3c �d 7 _ Date of Percolation Test HOLE IK BER CU)C K TIME PERCOLATION PEROOLATICN Run NO. Start -Stop Elapse Time _Min. Depth to Water From Ground Surface - Start Stop Inches inches Water Level- In Inches. Drop In Inches Soil Rate Min /In Drop l Rio :-Ly 21 ,., 2 _3 2 5 _ 31y Fo •� Z, 2 It 3 �,� 2 ? G r�y Ziy` t� r. 5. 2 R 3I ; i. ar..p 'e�'. � � f� 11w >(�. '.• .'.. .. .hilt 1�— A r • .z .. .1.. _1 .. to baf ted at 'same °' uota` tel soil rates �. xepea a�pacvaca1 are ` data. to' be . wAnittbd or-. 2o`� -i ith measure eats to 'be made from top of bole. rt WKO Ili -DEPW ` HCLF- -SNO:' _= - HOLR. N0. _ _ - _ROLES N0. Y G.L. 1' 2' 3' 4' 5' 6' 7' SA4A_ A 7 • Nam& c<�et �ti s -.�. :Signature - .''...... 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