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HomeMy WebLinkAbout4439DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84.14 -1 -12 BOX 34 04439 5", PUINAM�CODNTY :D OFHEALTB V R 'T 1. Division 8i -P -,T.Irtww, C&FORGMAGE e- 7 lAmftd 5 t Fortherly. Swk MaWng NIROD e -Address 'm I Date Pinhh: :% Gaaistlns of. GaffonS eptic Tank and Wster Su"01 P6bfi.'S A Address on P Y: Supply 10 O000ic:::�, 'Su Jd _pO1j.DrWeJ 6y Address Balldln�'Type Has Erosion con-irw liken Completed? Number. or,'B,edrooms .�.,Ii".Garba'e .',Grlidei-BeeiiLmstaffed?— % q F I certify that ith­ Mjj'.�he .abov_e.:premises were constructed esse lane of ,the . work copies t of "Icft' errs , ac ch c the standards re one.. AM the:0iiiift'isgued by the County De : Putn* rtment,of He& 4�4- P.E: _ R.A. 7 w '06sn ho. Add . re , , _ _ .,"W� . as , 1A h Y'CLatmw 1v Any person oteupytnq pnmisas served [ty -the ove systems) shslt,'promptly take wcn action;,_ "ry`3WaeWs thorioriecklon of any unsanitary cond1to rs resulting Approval the a OCOM P s "Cvol - War beConse available and - I r an a-PU IV Mai a viliabe Sueh .:ijprovals an subject to modifwstion':Or change 'Wfie in ` n t •of fire ComrnIssi0 of m-- 1tb c revocation, modO lention"or cha , 'if no'cessary. F PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVI.RO:' MENTAL HEALTH SERVICES. T? r_ � . / <5e" � �;' )0 r" /IGi v- , '&r' /?--, Owner or Purchaser of Building L7 W"" ef'- Building Constructed by Location - St //r t Municipality /6 ;"; Building Type Ii ,52 144.1 / Section- Block Lot /' / c7 a 9 -'-;' U S vision�.Name Subdivision Lot # GUARAN= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, worlananship, 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 = : _:.' -`C -i. -i 3tP- �f'ConsTr.c`act or; Compliance' °: fgr.. die',. age °: S O I_syst 1 0 " y ^'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 Director of the Division of Environinental Health Services 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 this _ day of 19 `d General Contractor,( . a) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk A Signature �'.1(�J�'j•� t7����L ✓ y,�n� Title Corporation Name (if Corp.) Address WZ.UJLJ UVr1rjjziiV" Ax!ruai DEPARTMENT OF HEALTH 0 PUTNAM COUNTY DEPARTMENT OF HEALTH office Use Only WELL LOCATION STREET AOUR Ss. TAX GRID C I fti A WELL OWNER NAME: ADDRESS.: h Cf WBIVATE 0 PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL ❑ PUBLIC SUPPLY ff'AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM 0 TESTIOBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING DREPLACE EXISTING SUPPLY ❑TEST/OBSERVATION [:]ADDITION . AL SUPPLY M-NEW SUPPLY (NEW DWELLING) E]DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft.1 STATIC WATER LEVEL —9c> ft.1 DATE MEASURED DRILLING EQUIPMENT OYAOTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED OKPEN END CASING ❑ OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 136 ft. MATERIALS: CWEEL PLASTIC 0 OTHER LENGTH BELOW GRADE 1311 ft. JOINTS: ❑ WELDED HREADED ❑ OTHER DIAMETER in. SEAL: ❑ CEMENT GROLIT' .;.0 B'IENTON11t 1WHER WEIGHT PER FOOT Ib./ft. 1. DRIVE SHOE: ❑ YES Q.N,01' LINER: DYES OM SCREEN DETAILS_ DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED?, FIRST —0-YE5 ONO HOURS - SECn GRAVEL PACK 0 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK in. I TOP DEPTH _tL. BOTTOM DEPTH — It. WELL YIELD TEST If detailed pumping METHOD: 0 PUMPED t tests were done is it,- • COMPRESSED AIR formation attached? • BAILED 0 OTHER 0 YES 0 NO If more detailed formation descriptions or sieve analyses VELL LOG are available, please attach. DEPTH FROM . SURFACE water Bear- ing Well Dia- meter In FORMATION DESCRIPTION CDOE ft. I ft. WELL DEPTH it. DURATION hr. min. DRAWDOWN ft. YIELD 9prn. Land Surface c_ If, WATER 0 CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? 0 YES ONO ANALYSIS ATTACHED? 0 YES 0 NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE, CAPACITY MAKE H MODEL VOLTAGE ,1_0 HP -31* ri WELL DRILLER NAMEA/dw, ,ko #k tj4r S A AI)OFIESS.P.C) 0 101-4 14 A 1MU4(,4 a/ 0:1 LAB Yorktown Medical Laboratory Inc 321 Kear Street Date Taken: ' 6/25/'90 Time: 8 AM Yorktown HeiQh�� X,_I059g. ....Y- Date RC' d : �} Time: - : -. a*;' %.•s�Y. '�- ei.'ir ;r+• :T.4:..• ".'=i":.%..:Y -m=..Da6`.-" RF' i' �r�' i 'l.A' (914) 245 -2800 Collected By: VAN HOV E Director: Albert H. Padovani M. T. (ASCP) PO /Client # r -I Referred By: C70SSROADS PHARMACY Sampling Site: BASEMENT TAP: CROSSROADS PHARMACY CINDY LANE, PUTNAM VALLEY, NY POB 16.1 PUTNAM VALLEY, NY 10679 L .J REPORT ON THE QUALITY OF WATER Phone ( 914 ) 528 -0097 (VAN HOVE) INORGANICS (—mg /L) MICROBIOLOGICAL 100mL — Alkalinity Standard Plate Count — Chloride _ (CFU /1 mL) — Copper — Detergents, MBAS Membrane Filtration Method Hardness,,Calcium — _ Hardness, Total /Total-Coliform Iron — _ Lead — Fecal Coliform — Manganese Fecal —. Streptococcus — Mercury, — Nitrogen, Ammonia Most Probable Number Method Nitrogen, Nitrate. — — Nitrogen, Nitrite Total Coliform — Phosphate, Total Silver _ — Fecal Coliform Sodium Fecal Streptococcus . -.._. . . _ Sulfide Presence /AbsensesJ(PA)� Sulfite _ Zinc Total Coliform P A PHYSICAL MISCELLANEOUS KEY FOR TERMINOLOGY — PH (S.U.) CFU = — Color (Units) IT = Conductance (ohms /c) GT = Odor'(TON) NA = Turbidity (NTU) SA = — TNTC Colony Forming.Units < = Less Than = Greater Than Not Applicable See Attached Too Numerous To Count t fly : ; . - � 111NI�i►�I�F.3 • _ • � THESE RESULTS INDICATE THAT THE WATER SAMPLE Q -SATISFACTORY SANITARY QUALITY ACCORDING TO TH$ WATER CODES, FOR THE PARAMETERS TESTED, AT THE THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW ING WATER COPES, FOR '1,'F�E P4RIV TESTED, AT THE. (For Lab Use) SAMPLE TYPE: (Check.One) f,/ Potable _ Non- potable OUTGOING: (Check Each) HNO _- HC13 — H2SO4 _ NaOH _ ZnOAc — Na2S2O3 Other: .INCOMING: (Check Each) v;ILE �40C _ GT 4 /LE 200C GT 200C _pHLE2 — pH GE 12 _ Other: (WAS NOT) (NA) OF A YORK STATE PUBLIC DRINKING OF SAMPL2COIJECTION. TION. (DID NOT MEET THE YORK STAT DRINK - TIME OF S 7 /87(Rvsd1 /90)RWE L � N t CONSTRUCTION` rPERMIT'F Subdivision ts. f Owner /Address Building Type Number of Bedrooms _ Separate Sewerage'System `to con To be' constructed by Wate► Supply ` 'P.ub�lic 5 '` ,Private , _ ';Address /: Other Requirements , I representahat I sin wholly and cc above described will be constructed County Oepart`meni of Health -a be submitted to the Department; pWce in' good operating conditio arice of, the approval of the Cert will be located as shown pn the app County Departure t of Health Ad'c APPROVED FOR CONSTRUCT!, revocable.for cauge-"or may be,amei requires'a new perms Approves Date r- Rev 9r81 .�"ayf"���'"`°.. .•aw, 2FF°T';✓'�-- '^'"'Fyt y�4 lh� .�. pC,S PU ,NA'M COUNTY MEPARTMENT OF HEALTH ' 1 Drvis>on of Environmental Health Services Carmel N Y 10512 ,'SEWAGE'QISPOSAL SYSTEM ' �iA'7v Town i' Tax. Subd Lot R - / Renewal' Revision { ' . ' r Fill Section Only ❑ � �;A-� l� iqn Flow G/P /D � P C H� D Notl Yication _Re ired_ ,9u f § .// 3 17;_ 9rL..e[ Lot 5 3 of o 't✓ �+L� G Gel Septic Tarilc a antl � { ' 'Addiess . K Ny From h h ply toy be drilled by - -�` ' letelv`� resoonsitileaor the Ae`sian and location. oi - tlie-`er000'sed. systemtsl. rll that t the . 1�­ "' -.1, *�,� '� z ­. %_ " year fom the < d necessary t mta y, age a :. .. I* rules an �egu a ions o e _a u nam , Ito the Commissioner of Healthwlh' $ igss `s he builder that said builder wilt, t, following thedats of;the isw= of tli -sit .drilled well described above rul d r u a ons :of the L Putnam PE RA °t:1ie�Ejhse No .� �e °p}tik�fn9 has been `undertaken and is, ,l 9A'�ya?Ige atbn of construction= f iaau . _• Title �/ : y . ny �,— _.......,...,..«- P- v..........o.,•....«- ., -m.�n .-, Kma+.,* ar., r.-. a,,r:. »........- ,.,...n:c_- +n«^*-'": •,.w �caZ- :c- r:ti.�,.,- ;� --*'- x,.-- �;,,.;.�..:�,...,r / i I� PUTNAM COUNTY DEPARTMENT OF HEALTH Permit e ' Division of Environmental Health Services, Carmel, N. Y. 10512 CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM ( _ ow_n or age oc'tera 614- Tax Map ~Block Lot Subdivision _ 6 ����' C ✓� Subd. Lot P Q Renewal _[3 Revision _13 Owner/Address '�� S 1 4° rim � r cc Building Type Lot Area Number of Bedrooms _ Design Flow G/P /D O Separate Sewerage System to consist of 900 Gal. Septic Tank To be constructed by Water Supply: Public Supply From Private Supply to be drilled by Address _ Other Requirements 5 ) ( ss ' ya. r ko + ✓t Dur-a i Date Of Previous Approval Fill Section only ❑_ P.C. H. D. Notification Required and j� and 40C% �.- 2 Jt ,5 VV Y f' `Y-e'• ytC_ 1 %e,�S Address I represent that 1 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 and—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 asslgns=by "the builder, that said builder will place in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately. following thedats of the Issu- ance of the approval of the Certificate of. Construction Compliance of the original system or any repairs ttrereio; 2) that =the drilled well described above will be located as shown on the approved plan and that said well will be installed In accordance wit the standards„ rules ^.anC; regu,a ,ons. of the Putnam sa n County Department of H Ith. yy '/ ,!� Date Signed v I / ' d 0." .E R.A. �f q Z . l j a Address ? / l r o, , Lt Lic' ense ~No. APPROVED FOR CONSTRUCTION: This approval expires one year from the date Issued unless stru¢tion of the biAl iii has5bebn undertaken and is revocable for cause or may be amended or modified when considers ecessary by the Commis ' r of 1- 14lih., A6r, changcorialt�ratlon of construction requires a new permit. Approved for disposal of domestic ar age, and /o private er supplyTgn'1,� °'- ,.' =}b ^a5?a' Date / d By Rev. 9 -81 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION..OF ENVIRONMENTAL HEALTH SERVICES " OOUNTY -OFFICE BUILDING, CARI�IEL; DESIGN DATA SIFT- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. owner J ; : lam- :� ��,�! / Address Z -d -eAf,, Located at ( Street� Sec . /1 !� Block Lot / �'Tncucate/neprest cross street) Munici lit rs >Tl7tr���' Watershed ?�' Y SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS �� 33 33 If 4 5 1 2 .. 3 5 lotes:' - "1) t4 s to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2 ) Depth measurements to be made from top of hole. Hole' Number CLOCK TIME PERCOLATION PERCOLATION Elapse Depth to Water a �,er ve No. Time From Ground Surface iri Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches. Inches Z% / / 2- 2-3j2- 2, f 2- �% . / .. z- �� 33 33 If 4 5 1 2 .. 3 5 lotes:' - "1) t4 s to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2 ) Depth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES D_E_..F_ qA- OIE ` N0 < y. : • ;K.e HOLE `V0 HOLE* .;iN:. _. T G.L. _ ✓ S�' %' / .6�� 12" 18" 301 361 42" 48" 5411 60" 66" 7211 78" 84 ' INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED , INDICATE...101FL_: TO WHICH .WATER LEVEL- RISES AFTER •_ ..ENC�UI�ITFRED - -TESTS MADE• BY ..... - ;� 1 i �('r� =✓i Date , �� DESIGN, Soil Rate Used 1_5 Min/1 "Drop:. , S. D. Usable.. Area Provided !6—c-PG'G + No. of Bedrooms Septic Tank Capacity T0 Gals. Type K_a� V �, r Absorption Area Provided By c,o L.F.x24" width trenc . Other C. 'ID .S Name h Signature Address `2, 7 Z _n EAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by Date �., a.. d'..qt o_, a D'EC 15 1982 PUTNAM COUNTY KEPI Pty HEALTH JOSEPH F. SULLIVAN, P.E. YORKTOWN HEIGHTS, N. 10598 (914) 962-4248 RECHVER.) SEP 2 7 1990 PUTNAN11 COUNTY OEPT. OF !'%'EA!TFj - PUTNAM COUNTY HEALTH DEPARTMENT. ya q - 4 y'a ' .1h"i EMc ;DIVISION OF ENVIRONMENTAL HEALTH SERVICES >: John M.. Simmons,. - Depu y-, Commiss onerfof Health :" - FIELD ACTIVITY REPORT : Shee.t. of .. INSPECTION -NAME VA Af Navy nOrig. Routine ,Orig. Complain ADDRESS uNDY LAWS .. MWAM VAUZ -Y- Orig. Request .; No: Street Municgality'(T)(V)(C) Compliance R Compl aint Comp : MAILING ADDAES'S __ 'Final s P.O. Box` . 4 Posit_ Office. = :. Zip Code Group Iliness �KGonstruction TELEPHONE. Reinsp_ectioh- ,PER50N; IN CHARGE' -Field Sam T in :0, I P:. g' q : ,.. OR INTERVIEWED ,MR .4 V}tipf }dpy l Field Conference` - Name and Title. - Other DATE off° /$ - $lo TYPE FACIZITY `pro, TIME 'ARRIVED ° ' :., %Q '.TIME LEFT /� - Explain FINDINGS-: yA tdit `.M :- ur5' SVS "C!►9 ra/s- PAt,IED rr tie Pi APPjjO 6 tA-ST %FAGi.�9 �� ' ` [=coin �,•n ahr . 5,� . S :. �s _ �t�ms p_"_ ( O wi_o sot, iimv IL ijnU . � - z .x ",� .. • r :r "�S:r '. t .-a: .r •. "t' ..., :x ... � � .s.. r. ..... .ac,� -r t'^ > ..►c,n_ � -t�f - cr -•,� .... _ _.. % r 15' f L'I DEPT, OF 'HEALTH . szl %4r /l/,,�` nc S Se nioj e- 4Jf sCrj A7174'G+We i'C �i2nr'F :�ti4�..,�.%�.� d,� °�`n� rv��,•Y / //? +iii * /L° SSAE�ypNClS�gi �/ •• J�?G !I� .� /oG� � LO� Gay °cs s l3 el -4 "o Y,;,5