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HomeMy WebLinkAbout4539DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.05 -1 -19 BOX 34 Tw IN r� 04539 Qlf A :6. N� Is% r- ''� I . . ' r 04539 Ls WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK a•.jh)i��po.Ct�S tq? besom�leted by, Nell_ drille3;-a fd- suhr;�ltted..tr�'County�klealth Departme►�t'togeth'er vritFi•I "aEsona'fo�y repoat -of = ` ana(ysls of water sample indlcafing water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION . ii f OWNER NAME ADDRESS LOCATION OF WELL (No. � � (Town) (Lot Number) 1 j4v, PROPOSED USE OF WELL BUSINESS MESTIC [] ESTABLISHMENT FARM ❑ TEST WELL 11 SUPP Y El 11 ❑ CONDITIONING ❑ (specify) DRILLING EQUIPMENT [:1 ROTARY ROTARY COMPRESSED ❑ OTHER 12 AIR PERCUSSION ❑ y) CASING DETAILS LENGTH (feet) .23 l DIAMETER( Inches) ��� WEIGHT PER FOOT `� E4 THREADED ❑ WELDED DaLy, SHOE YES ❑ NO CASING N YES ? NO YIELD TEST HOURS G.P.IiA._ ❑ BAILED ❑ PUMPED COMPRESSED AIR YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify teet) DURING YIELD TEST fleet) JD.pth of Completed Well r l feet below Land surface: SCREEN DETAILS MAKE LENGTH OPEN TO AQUIFER (lest) SLOT SIZE DIAMETER (Inches) ' IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): . GRAVEL SIZE (inches) FROM (feet) TO (loot) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch eXaCt location of well with distances, to at least two permanent landmarks. FEET to FEET 131 If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL C MVL ED I DATE OF REPORT WELL D ER (Sign.}! 6) t, .., �x _ r` Owner or Purchaser of Building Municipality , Building Constructed by Section ` Location - Street Block Building Type Lot GUARANTY OF SEPARATE SEWAGE 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 guaranty to the owner, his succes- sors, 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 initial use of the sewage disposal 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-occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive. the de- termination of the Direct_or.of__the Division „of Environmental- _� vti -e-es •of - -the= gut -r iarir - County- DDepartment 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 v G/ 19 ?f-'Signature Title corporation, give name and address) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF. SYSTEM. Division of Environmental Health Services, Putnam County Department of Health PUTNAM COY .,� : _ ;� Diwson of :Environs �Q! aSTRUCTION _P_.ERMIT` ,F.QR SEINA - E� $POS N ,+- a.��"itirc' •a.;' I� :rte_- z- •L�,.��� �"�" � �'z.S°tr =wsY � � � Y .. Subdivisiofi,' �I . {' .�'� �'. _ .�•2 (nl_t? I A � � �: J 0. wner Jlrv,t,'I 3�L^ Buil- ding Type L N I—A!' LotEArea a Number of Bedrooms 5 4 r Separate„ Sewerage= System -to ,cotlsist .of - To be constructed by –.a Water Supply Public Supply From ; :Frnrate Supply to, be drd_led by ,Address Other Requirements -'- - I =represeht _that' -,am whoily.'ai d completely iesporis�ble for the above clekribid, wit be consteucted.a; shown on the approved a' w�.'COUnty "Deparfineiit ofr Health ,and that o`rf completion there be `submitted to 'tle Department, ,and a written guarantee w ,'lace in` good: dperating cbndition `!any part; of said;' sewage; ;ance of:the a roval-.6f he ,Cdr,t to of'Coristruction'Cor County Department of Health Date a � . /! � , Address {L .revocatile,fbr cause or may .6e amended or motl�fied requires a new permd Approved for disposal of Dat,., kTMENT OF HEALTH` Serwcec eermel; w Y 10512 r yil M -VALE ii- Section Iflock ` Lot': Job � Adtlress _ :- ,AA3(C.Id;�:, YIL TotalHabitatile Space- �9o`T Square Feet ' Tank 3 G - It feet .X width trench r: ,Address - -- �s m of the proposed 4ystem(s) 1) that ;the separate sewage tli`sposal, system 5 and` m accordance 'Of, the u :nam �f ConstrucLonComplance satisfactory to the''Gommissioner of''.Healthwill ie owner his successors, "h eirsYorassign5;by the - budder, that said budiier will; ur�ng the period of two'(2) years immediately foilowing;thedate.00 the issu 3 rigmal� system or any repairs thereto 2) "that the.:drJled ;well deGhbetl above n accorifancewdh "the standarCs rules; and regulations ` of tFie Putnam �� yy �- PE: RA late issued unless construction of the budding, has been undertaken and'N�s �y�itheCommiss�oner of.' Health:. Any,change?or alteration of=construct:ion, - nd /or prwate water supply only � � � �� `' TitIeCG1/it3G1 n r: r PUTNAM COUNTY DEPARTMEN T OF HEALTH Tai ] VV r 1>P � N I, !P.4Yc' ... ♦. �.a'.<'. t t� �..�]•! — C��h/S ... Gentlemen: Date_ a� /7 Re : Property of = i'T45M 139Z- -w -s Located Section Block Lot ASAP 1319 PJZiN(-y FAR"' This letter is to authorize jems Hk) Sui A -4,j S C) ^ a duly licensed professional engineer or registered architect (Indicate) to apply for a Construction Permit for a separate sewerage system; to serve the above noted property in accordance with the standards, rules or regulations as promulgated 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 system--nor- = ,systems in conform "ty `witfi`the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly urs, Signed Owner of Propert Countersigrie P.E. WA 0!5 (Seal} ` r. Address /eJ'4/ Telephone 1�34'J /V 0 iris -Address Telephone _. .... PU`.PNAM COUNTY DEPARTMENT OF. HEALTH DIVISION.OF ENVIRONMENTAL HQ1,TII SERVICES - .>. }^ '' .- -. .- -, v.� . ' ..'.t p._ r4:. r, ' �� :� ,•. ,:.. - ',?+- ��_-'; a -;:C, va -;r .0 -:'� °,n,: t •"'. ,° .. .+>". �:.: ` t "%35£...�r3..:' �, .�`_.. .. ...: .,:. - " COUNT`Y� OFFICE BUILDING, CARMI ?L,, N. Y. 10.512 DESIGN DATA SHEET- SSEPARAT/E SEWAGE DISPOSAL SYSTEM_ FILE NO.' Owner E,=rri3rqoez C�,<.� . Ca� % Address /3.,;?- 4 VjE 130L V4n:'J?J Located at (Street Sec. Block Lot ;26 �Indicate cross street i j.div. ,yr��. �.i p• ,er,,J.(> r-A4,44 Municipality %u r •v,�� (S� « ,L �� Watershed ' SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH'APPLICATIONS . 5 .• 4. 5 Notes: 1) Tests to be repeated at same depth "until aroximatelyy equal soil rates are obtained at each percolation test hole. All pp data to be submitted for .review. 2) Depth measurements to be made from top of hole. Hole Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse No. Time Start -Stop Min. Depth. . to 1%,a From Ground Start Inches ter Surface Stop Inchos Water ve in Inches Drop in Inches Soil Rate Min. /in drop 4 5 .• 4. 5 Notes: 1) Tests to be repeated at same depth "until aroximatelyy equal soil rates are obtained at each percolation test hole. All pp data to be submitted for .review. 2) Depth measurements to be made from top of hole. • Soil Rate Used 3:� l Min/1 "Drop: .UL;J1h1V S.D. Usable Area Provided _5 c'v0 ` No of Bedrooms - Septic Tank Capacity Pacity a,U TEST PIT DATA REQUIRED TO RE SUBP417970 WITH APPLICA`.PION Absorption Area Provided o d By go DESCRIPTTOH 01" SOIL' .F,'NCOUN'.LT,'R,R :IN ��'1',.>'I': 1IOl�S . DEPTH HOLE . NO. % HOLE NO. HOI;E .CVO. _Y Name 6.. i na ur, e Address 12FO 4 12" 3i G.�.Z�4yrL S(��v� y: ��i'i THIS SPACE FOR USE BY MUM DEPARTMENT ONLY: 48" . 72„ rr . 84" INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO VMCH WATER LEVEL RISES-AFTER BEING ENCOUNTERM TESTS. 14ADE BY afa�J ,�/1larUC %' �L� Date: Y _ • Soil Rate Used 3:� l Min/1 "Drop: .UL;J1h1V S.D. Usable Area Provided _5 c'v0 ` No of Bedrooms - Septic Tank Capacity Pacity a,U Gals . Type' ... w`c.; ... . Absorption Area Provided o d By go L.F.x24" ,� 336 width t,re.nc.hl,. '.. ,. Name i na ur, e Address 12FO 4 e n¢ S L THIS SPACE FOR USE BY MUM DEPARTMENT ONLY: Soil Rage Approved Sq. Ft /Cal. Checked by Date Rit"aim County Department of Health 777 PJ xvision of Environmental Sanitation AFFIDAVIT COREPRATE.,0W.NP APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health n the matte application for P'l9Y am that I Am 4P PffioPr Or employee e 0 f the Pqrpor t* p and a tQ act fair n. Te - 9T corpora ... On havin2 pffipp9 at 1,3 -2 Z, 3,1 4-JA) - - - - - - r" !rM rT! In- W- M.M. e," W" M. nr M" •" � -J.,4 AJ V,,j Vhose officprp are r" V4 7" Im M dW"Wd�,r- (94me An - eas secretary -Ve and TO Ware and aAddress] and that, I am and will be individually of the corporation with respect to the ae ept acts relating thereto. swpr.n to before me thaisday Z of —3.9 EDWARD H. DMER NOTARY PUBLIC STATE OF NEW YORK . ..;'Arlission expires Much 30, 1W responsible for Any pr all ac to approval requested RPO All 00— agned CO3VS;- . el porate FIELD CITECK L'L"S`r Date: _ -Ins. . b ','.:.,:.:;.... ° -°'v:o bi..,,1 ' -fi,.> . Y"`.;'X'..•4,= •; .8.,9,..::i .�,�i ^'�a+'�_. •.�-. �:i? v .ii °..- _ - :�o^.�,- .:,.:.'.".�..v„'�:. w i'- ti•:.''- i..''�°S_ . . . S;.w..' ..""s': I INITIAL SITE INSPECTION Yes. No Comments ,Property lines or corners found . . . . . . . . Can estimate Douse location . . Will driveway need cut . ✓ -- Must trees be removed -note these . .,. Is deep hole representative of entire SDS area Additional deep holes needed. . . . . ✓ Suff'icien't SDS area available considering driveway cut, house location, separation . distances, etc. DEEP HOLE DATA Dapth : G 7 4- r d Water elevation: o Rock elevation: Soils description: SAjy Lo #4 avltadr -e 'Date: FII \L . SITE ITNISPECTIOl Insp . by: House located where shown on approved plan SDS located where approved - len Lh of trench measured Width of trench average Slope of the line.and trench acceptable _ Room allowed for expansion trenches .y�e" .:.5Q -- f t -'r?om ,swamp,. ,Taterco *,aj,",se Natural soil not stripped or SDS area . to necessarily graded 10 Fb. maintained from prop.line and 20 ft. from house . . . . Separation of trench from house, well etc. follows plan . Number of bedrooms checks . . . . . . . . Stones, brush, stumps, rubble, etc-. greater than 15 ft. from nearest trench . . . . . - 15 Ft. of peripheral soil horizontally from trench ... ... Junction boxes properly set Could surface run off from driveway, roads., ground surface, etc. channel near SDS,.. , area. . . . . . . . . . . . . . . . . Does lot drainage an e-ar 0. K. in area of SDS FINAL GRADING OF SITE ACCEPTABIX REVIEW CIECK. SI MT IM(--ets Std.( Remarks' es No . House P lans 0. K. I c/ Design data sheet ti Peres presoaked? v ; Ian,. 30" pert test depth - Const. results for 3 runs. D. Hole log O.K. -Corporate Affidavit for cthe? than individual a/ i Authorization for engineer Letter from Mater Supply if applicable �✓ �q l If variance requested -such noted.on plans & apps. D ;TAILS if change is proposed,) Existing contours shown show new contours) Slopes for driveway cuts, etc. shown Water service line location v Footing drain, etc. location .i Top slope, bottom slope of fill k Percolation tests.and deep test pit location_ Septic tank size and conformance toL std. ✓ !' f 3 B.R. house minimum rouse setback shown q �I Distribution setback. shown below frost All water within 50 ft. of PL shown Plan and profile SW All other. wells a.nd..SDS..closer- 2001 shown = car reference made - _ _ ✓ .� _ i_ __ Property boundaries (metes and bounds- clearly shown.: SEPARATION DISTANCES SPECIFIED ON PLAN 1.0' to P. L. •� 20 " to Foundation walls , r00' to Nearest well 100' to stream, march, lake, etc. Incl.expansion ; 15' to Curtain drain 10' to water line (pits -20 15' to storm drain 10''to large trees 10' from foundation to septic tank 15' to pipe from leader drain &.footing i N `p�y"Pogtai.: S.`(sTirtJ\ 1hiSTt>\LAT�I�N.. _. E'�et�l TC� .-N.K...' gt?s.utiFlS.w'C�a�•1S r AR:ra_ G 0 (Q s r�. 0 .a 3 o� (J) 1 v� �O v N 99`D 3�`f0 /W 1if.4s' AX ;3 N Q 01 v� �O v N 99`D 3�`f0 /W 1if.4s' AX 01 „o�\ RD Al d C 4 'j 1 N h7 Ica un "� I a C\ �° s r7 Q f, �"o\Vi \ht.