HomeMy WebLinkAbout4314DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
84. -1 -22
BOX 33
ir
��
1
Is
6.
1
r
ti�
04314
Ij
PU1I WV0UM:DErARTNMMT OF SM
MddM djj"�� Red& SMO�,cmaieL Pu. idsi? '
OF,
, .1111111illim
001 1tIICl101�1 FOR S RWAGN DWOSAL STUZM
Town or
Imooed at Valmie
2-2—
Renewal— 0—, Revissim ❑
N Alew n7 17
Doe of
NAbS Adhose
41— Town ZIP :Czd?
FI dr- W'71
BWIL�R& Two W Am FM Seedw 0* Dep& _VohWW
Nu . obee of 5 . edivoem- Dwilm Flow G P D O O PCHD Nodlindoss Is Reqobmd Wheat FM Is cowleted
Sepwaft . SWMMV S*M 14 eimm of VvL/Gwjn Sq* T.& -.d 3 V& e'n 641
To be, oembude.d by Addma
W"W Sql*3
PV*SW* Firos• —Addmn
jgA) A =5
on S"* �- 4_Aildn+a
Odur
i,;:p,- i,;m�li,�ll��in,�cbinvi�iolV.roiOonsiblefor�th�qatig�l,S!ldIOCation,bf,thS,PfOPOtO SYNtSM(S); 1) that the NP11111 0 2VdlWl
above It— M M
wiii.bee6nstiiiit"'&'Ssh"no�tiiiilp'proved,ah*endrnent'there to and in accordance with'the'.standards. rules 4M,Q.M3n IMM
County. Department of Heaft , Is, and that on completion thereof '& "Cartif icate 'of Construction Compliance" satisfactory to the Commissiongrof Multhwill
be submitted to the Depan- . a . M. and a written guarantee will, be furnished the'awnW. his su or assigns by the bulkier. that mid builder will
t
Mace in. good opera ing cmWition env,, part of said sewage disposal system during the par r Immediately following thedate of the issu.
omit of the approval of the' Certificate' of tonsiriscUon'Ce'rnpliance of the original cyst t 2) that the drilled well described above
will in located as ON36M on the approved plan and that mid well'Will be Installed. i ccordi lei and fequWMnS of the Putnam
county Departnisid "of Health.:
Date P.E. _!!�'RA.
L. Cdr
-7
Address- , —LicanSM
APPROVED FOR CONSTRUCTION: This a . Poroval expires two years from the -date issue gsti tl building Ms been undertaken and is
revocable for, ca' or modified when considered n Co ny change or alteration of condirucMn
use or may be amended
maulres new permit. Aiiiixoved.for 'disposal of domestic sanitary.. 0
MV.
10 Title
/88
PUTNAM COUNTY DEPARTMENT OF HEALTH
'R
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date If /i��✓
Re: Property of
Located a t 22
3
(T) j` v Section Z Block Z Lot �--
Subdivision of
Subdv. Lot # ,Filed Map # Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer or.registered architect
(Indicate ".
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 papers on my behalf in
connection with this matter and to supervise the construction of said
in cIonformi'ty wi. th:= the.,_provisians.,of_Arrt_icle 145 or ._
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:. -;-
Pao, R.A•,,#
'Telephone
Very, truly ,yours,
Owner of Property
-�- Address
_ � •.. o� � Jam''
Town
2
Telephone
IBM
• �- is w •iy' �• «�
DESIGN D= `SHEET- SUBS UFACE - SEWAGE DISPOSAL SYSTFbi.-
Owner AlelC Ma fl A Address
- FIGE ICU.
Located at (Street) �,� /i�� %bra/ Sec. �� Block
Lot
(indicate nearest cross street)
Municipality Watershed
SOIL, PmcOLA oN TEST DATA RDQUIl2F.D TO BE SUB arm WITH APPLICATIONS
Date of Pre- Soaking. ?�, Date of Percolation Test
HOLE
REBER CI= TIME PERCOLATION
PERCOLATION
Run Elapse Depth to Water Fran Water Level
No. Time Ground Surface In Inches
Soil Rate
Start -Stop Min. Start Stop Drop In
Min /In Drop
Inches Inches Inches
4
5
4
5
NOTES: 1. Tests to be repeated'
are obtained at each
for review.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. All data to-be subaittOd
be made from top of hole.
TEST PIT DATA REQUIRED TO-BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
INDICATE LEVEL TO WHICH HATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: �� �/ �% DATE:
- DESIGN i
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided
No. of Bedroams Septic Tank Capacity % eO4,1 gals. Type
Absorption Area Provided By L.F. x 24" width trench
.e M-
Nam � --/ /% Sgnat �P� of N6W�
Address �� �i�.�JL� %� �//; S
I.
THIS S15ACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
PC
PUTNAM COUNTY'DEPARTMENT OF HEALTH.
APQLICATION FOR APPROVAL'OF ,PLANS.FOR A WASTEWATER DISPOSAL SYSTEM
i " c "' F- .,•,^'- F r+1s 1�- ^..+ ... =.ti w Sv'Y r •H•. . j 3 r r+ -1-•.
ti v d
1'."I'' Name -and, Address of Appl i cant �'f C >•� �rs� ��^
Kw
t
v cc
_ 2 Name "of Project D-� w t 3 Location T /V /C
4. Project ,Engineer fj`"" ��,/%1 ✓ 5. Address Z�7Z �. -errs ,D�
,
!/ �r
License Number Phone
6�
- y T •
Pro ect.'
Private /Residential'` Food Service Commercial
':' Apartments Institutional Mobile. Home Park
`Off.ice Building Realty Subdivision :Other (specify)..
r •
J.: Is this project `subject: to State. Environmental' Quality Review•(,$EOR)? "
JygQ Status (Check One) Type I. Exempt '
Type I.
i� Unlisted,
8. Is a Draft Environmental Impact Statement '.(DEIS) required ?. ;..y
9. Has ,DEIS been completed and found acceptable by: Lead. .Agency? ..
10. Name. ,of . Lead Agency,!.
11. Is this project''inian .area under the control 'of ' local planning, zoning,
_ or other .off.icials;lydinances? _ . ..... .....: ... _11!,
12. If so, have plans been submitted to sucA authorities? .................... ..
13 Has preliminary approval been granted by-such authorities? d% Date Granted:
14., Type of Sewage Disposal System Discharge... ► Surface,Water k-' Ground Waters
15. If surface water discharge, what is the stream class designation ?:.......
16. Waters index number ( surface) .... .... ..... ..............:'......... +.... �'
17. Is project located near a public water supply system ?, .................. AO&
18. If.yes, name of.water supply Distance to water supply
19. Is project site near a public sewage collection or disposal system ?..... . �o
20.. Name of sewage system Distance to sewage system
21. Date test holes obt6rved: 22. Name of Health Inspector:
23. Project design flow (gallons per day) ............. 6 .......................
11/93
y n
Y .,2 0
l
.
4..,$s State .Pollutant Discharge Elimination'System (SPDES) Permit reguired?,r.
:HaF: DE4 pPaic�t M., 1] �b �tt�d: to local DEC Offices
_
26m Is'eny portion ,of this pro3ectlocated within .a designated Town or. State:
.
wei;land ?mma. mom
x
2 y Wetland
/. 0 .ID Number e m o 0 0 0. m o o '.o o a oo o e o m`m m m m o`o m m m o$ m m m oo'o 000 0 0 0 0 0 .
!�
v
sWetland P ®rmit re4ui�ed? om0000m,00mom. 0000a0000000a000000000000mo mo
.. .. .. -
... Has appli cat ion.. been . made to Town or; Loce.1 DECOffic ®? s >o me'mmmmm.mm m:
.�,
2Q.o Does, project reauire`a DEC Stream Disturbance Permits am
30.' Is-or was project site used fort- agricultural activity involving application
of pesticides .to `orchards``,or.lother `crops, solid or hazardous waste disposal,.
landf:illing, sludge:applicat.ion or „industrial:::actibity? '. e..'.'YES or. NO
31.'Is project located within 9.,000 1set of existence of abandoned landfill,
hazprdous waste site ,'.salt stockp,ile,- landfill, sludge disposal site or,
any other potential known source of.contamination? o.,`.. ,o.....YES or No
DESCRIBE:'
32. Is there a local master plan or file with the Town or Village? ......... ..m
33..Are community water,.sewer faciliti ®s planned to be developed.within 15 years?
34.. Are any sewage disposal areas in excess.of-15% slope? ...ema .............va .
m.
• - . .��!' •-Tax _KapLI D•. _Numbg a; . -m-o .as- o -a..a w.ma43.0 -A w a m 'a m .m ip..o m e 4:. 2 0 0 •bow m3� -E.de L.&. R. O_7 P. o. o, p_ s p ._.e, 4m-o _....
.
36. Approved Plans are to be returned to.:. :.o m .. .. Applicant
Engineer
If the application is. signed by a person other than the applicant shown in Item
1., the
application must be accompanied by a Letter of Authorization. Failure to comply
with this
provision may be grounds for the rejection of any submission.`,
I hereby affirm, under penalty of perjury, that information provided on this
form is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
MAILING ADDRESS:
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
u:r -. Mi <..... .. ;..-" REVI'1aWSH ET -FOR -,CQNST.RL►CT-ION ^PERMIT-.=
iG / !� ��.�'� � E'OF OWNER
STREET LOCATION / ✓!�
REVIEWED BY / v /�l � DATE.' �3 y TAX MAP # C/
Y DOCUMENTS J `/N
01 PERMIT APPLIC ON OSION CONTROL IOUSE,WELL; SSDS
.... _ ,
f PERC & DEEP HOLES LOCATED
WEL-L—PERMIT _�� t'SI'WS LETTER REPRESENTATIVE OF PRIMARY &EXPANSION
LETTER OF AUTHORIZATION LOCATION MAP
DESIGN DATA SHEET (DDS) 1 p-C EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE a
ORPORATE RESOLUTION /v /% F PUMPED, PIT & D BOX SHOWN & DETAILED
SHORT EAF W R USE - NO OF BEDROOMS ,p
PLANS - THREE SETS WELL& & SSDS'S W/IN 100' OFoPROPOSED S ��
HOUSE PLANS -.TWO SETS j k PROPERTY METES &BOUNDS `J
VARIANCE REQUEST HOUSE SETBACK NECESSARY (TIGHT LOT)
SUBDIVISION
SUBDIVISION
IISION APPROVAL CHECKED
REQUIRED DEPTH
LAIN DRAIN REQUIRED STANDPIPES
GENERAL
;D
OUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE
NO BENDS; MAX.BENDS 45° W /CLEANOUT
FILL SYSTEMS
ePTHRIZONTAL ;SLOPE 3:1 TO GRADE
CS FILL NOTES
TIFICATION NOTE
UAGES FILE & DIMENSIONS
VOLU ME
,o? JFILL IN EXPANSION AREA
TRENCH
• - - LF DRENCH PROV -IDED 60 Ff MAX•
ARALLEL TO CONTOURS
CS 0% EXPANSION PROVIDED
41T REQ'D. SEPARATION DISTANCES SPECIFIED
IIT S ,AME ON PLAN - FROM SSTS
ATIO jj� 0 P.L., DRIVEWAY, LARGE TREES, TOP OF FILL
J o fP 2 ' 0 FOUNDATION WALLS _I SWELL TO PL
7_7 // rT0 WELL, 200' IN DLOD, 150' PITS
STREAM WATERCOURSE LAKE (inc. expan)
REQUIRED DETAILS ON PLANS 50 T91 CATCH BASIN, 35' STORMDRAIN, PIPED WATER
SEWAGE SYSTEM PLAN - (NORTH ARROW)
SSDS HYDRAULIC PROFILE_ GRAVITY FLOW
CONSTRUCTION NOTES
ESIGN DATA: PERC & DEEP RESULTS
T CONTOURS EXISTING & PROPOSED
DRIVEWAY & SLOPES, CUT
OTING /GUTTER/CURTAIN DRAINS
COMMENTS:
0' TO WATER LINE (pits -20')
' INTERMITTENT DRAINAGE COURSE
b' /500' RESERVOIR, ETC. ,150' GALLEY SYSTEMS
15'min to CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 0/o,35' -1 %,100' - <1%
20'min to CD discharge /I00'with 182 cons day discharge
SEPTIC TANK
I0' FROM FOUNDATION; 50' TO WELL
FORM ST -2
-v
j tom,
ge
pv
^y,�r -,•� �e� yk,.�°t � l�S�a�,, � •j� Y §"'Sq. � �.F �y s' c : � � F �, 7 r ' x- ,¢�t'i ,
=y .3t -`.. !s����ja.'%iF�'.s�4 � 4 ,��� } ,.�,• t r� � �� tf s.t �f: �4r �+�i;
r
yT a
r
MEN
"IV_ I_SIO_N OF ENVIRONMENTAL HEALTH. SERVICES '
.. ,� n, - .• �. ..:- Si b'.a .,f. � -...: .cr.- �i�.�.. r ���... -=`N F < . -' t_ a. .� ��{'l..c.'� .. e. r:0.^: ..may �1��
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT #
Located at
Ae / oi' f
J I
Town or Village
Owner /Applicant Name
Tax Map 7 `V
Block /
Lot -
Formerly
Subdivision Name
Subd. Lot #
Mailing Address % �' ='� _ °, �'/ ✓'/ %'r...
Date Construction Permit Issued by PCHD'�
1 '%
• C
Zip`
Separate Sewerage System built by �.:. j f`d tr- ° ,, . >; :° Address tags 4�
�• f 9 / 4'
�• � � Yy;f do. ij
Consisting of Gallon Septic Tank and
Other Requirements: "-
Water Supply: Public Supply From.
or: `'� Private Supply Drilled by
Address
Address ✓ ..,�d k, ,.- .yv y'.
- Builc ing•Type.. _ � ' f. ` :Iias�erosion control.- beeacompleted?
Number of Bedrooms Has garbage grinder been installed ?`��''
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: ? I" 6J Certified by
Address
P.E. -I-" R.A.
License #
Any person''occupying premises served (s) shall promptly take such action as may be necessary
to secure the correction of any unsanitary' ting from such usage. Approval of the separate sewage
n��
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject to modification or change when, in the Judgment judgment of the Public Health Director, such
revocation, modification or ch is necessary.
By- Title: S Q Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Desi rofessional
Form CC -97
Moos Counntry Homes
PUTNAM COUNTY DEPARTMENT OF lH[EALT1[-1(
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location_-
_4
181 Peekskill. Hollow Road
PutnamValleX
Map CXy Block Lots) ;Z
Well Owner:
Name: Address:
Moos Country Homes, 4 Timber RidSe Court, Carmelo MY 10512
Use of Well:
1- primary
2- secondary
X Residential Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
X Rotary Cable percussion X Compressed air percussion Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock Other
Casing Details
Total length 50 ft.
Length below grade 49 ft.
Diameter 5 in.
Weight per foot 19 lb /ft.
Materials:. X Steel Plastic --- -Other
Joints: Welded X Threaded . Other
Seal: __X Cement grout J Bentonite Other
Drive shoe: X Yes No
Liner _ Yes X No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield. Test
_ Bailed X Pumped X Compressed Air
Hours 6
Yield b gpm
Depth Data
Measure from land surface- static (specify ft)
441
During yield test(ft)
70'
Depth of completed well in feet
110,
Well Log
If more detailed
information
descriptions or
sieve analyses
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation"
Description
ft.
ft.
Land Surface
35
Drillin
in o
den clay and boulders
35
Hit roil
at 35
35
`i0
Drilling.
in rc�c
, ,set casin,
Dk f 1 1 :
in iroc
iiit�w a
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type Sub Capacity 7jji;v+.
Depth 90° Model7GS05412
Voltage 230 HP
Tank Type EX250 Volume 44 yal
Date Well Completed
6/7/65
Putnam County Certification No.
002
Date of Report
3/9/2000
Well Dri}ler (Sjguture)
Christopl;isr '�eal
NOTE: Exact location of well with distances to at least two permanent lanamarxs to be provtaea on a separate sneevptan.
Well Driller's Name P. F- Beal & Sons, Inc.
Signature: /=
Christopher Beal
Address: 4 Pttxam Ave., 6r34;t;Mo NY 10509
Date: 3/9/2000
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
NE
- ►
NORTHEAST LABORATORY OF DANBURY
39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404
(243)7, 48:79.03-_-- FAX.(203);:74 ,0652 :,. NY Cert ..41471" _.
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
P.F. BEAL & SONS
4 PUTNAM AVENUE
BREWSTER, N.Y. 10509
SAMPLE SITE:
SAMPLING POINT:
SOURCE:
TREATMENT:
TEST PERFORMED
DATE SAMPLE COLLECTED: 3/10/2000
TIME COLLECTED: 10:00 A.M.
COLLECTED BY: C. BEAL
DATE RECEIVED @ LAB: 3/10/2000
TESTED BY: LAB #11471
REPORT DATE: 3/16/2000
MOOS COUNTRY HOMES, 181 PEEKSKILL HOLLOW RD., PUTNAM VALLEY, N.Y.
TANK HOSE BIB
WELL -NEW
NONE
BACTERIAL:
Total Coliform (Bacteria)
PHYSICALS:
Color
Odor
pH
Turbidity
CHEMISTRY:
Nitrite N
Nitrate N
Alkalinity
Iron'
Manganese
Sodium
Lead
RESULT: MAXI VIUM CONTAMINANT LEVEL
0 per 100 ml 0 per 100 ml
0
15 .. .
ND
3 Units
7.85
no designated limit
0.12
NTUs
5 NTUs
<0.005
mg/L as N
1 mg/L as N
4.70
mg/L as N
10 mg/L as N
185.0
mg/L
no designated limits
220.0
mg/L:
no designated- limits- <_�:• :...:.- . - -;. -• _. _ ..
: <0A3" __
m" v _ ..,�
-0:10
<0.01
mg/L
0.30 mg/L
[Note: Combined Limit for Iron plus
Manganese = 0.50 mg/L]
3.3
mg/L
20 mg/L **
0.002
mg/L
0.015***
ml = milliliter mg/L = milligrams per Liter ND = none detected NTU =Units
* *Notification Level ** *Action Level
RESULTS BASED ON SAMPLES SUBMITTED:3 /10/2000
SAMPLE, AS TESTED ABOVE: MOTABLE 47] NOT POTABLE
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
Laboratory Director
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
PUTNAM COUNTY DEPARTMENT OF HEALTH
DEW20N OF ENWRONM ENTAL HEALTH. S ERVI. ES....... .
GUARANTEE OF SUBSURFACE FACIE SE Y Y AG E TREATMENT SYSTEM
Owner or Purchaser of Building Tax Map Block Lot
Building Constructed by Town/Village
Location - Street Subdivision Name
Building Type
Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is 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 treatment system, or any repairs made by me to such system, except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
- system.
The undersigned further agrees to accept as conclusive the determination of the Public Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of'the building utilizing the
system.
Dated: Month.// x1 /Dav . Year
General Contractor (Owner) - Si
Corporation Name (if corporation)'
Address:
State �.? �� /� Zip
Signature: r�---
Title:
Corporation Name (if corporation)
Address:
State Zip
Form GS -97
Mr
qrQw
t.
. ....... ...
f7
Af
41
Rn
aN
tl
-7777�*.%.;.�,,,,:,.::,,�
_TZ
0
x x
t?'Al 40 1;
10