HomeMy WebLinkAbout4554DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
85.05 -1 -41
BOX 34
04554
PIG
me
11M 8.
90
so
` �L,
2.
I le-z�l
MINES
log I
m
r
kP
04554
Y
3/86 .,
CERTIFICATE OF CONST]
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512 ]
Engineer Mast Provide.
P.C.H.D. Permit # Vq IUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM j l'�It:}N� 11r
�W�� rWIDT �• y . ..... 4=`. t
Ti e- '.TCIWnAM �i';IilY�e �••.. �— "•v -�-
Map - �Sslock— �Lot_y
tPpllcant Name — ;�� �' p� —^ Forme rly Sabdlvlsion Name Sabdv. Lot #
Address Z?t'�'o L�• . I--- ZIP
Separate Sewerage System built by � v, / 4 eU.
1. Consisting of � Gallon Septic Tank and
Date Permit Issued
rr.
Water Supply: Pabllc Supply From Address Q
or: PH to Supply Drilled by �f1.� Addrrees�s�+, bggg,,&,z � . a 1
Building Type Has Erosion Control Been Completed? r'jj^'
Number of Bedrooms Has Garbage Grinder Been Installed? ^d��
Other Requirements
I certify that the system(s) as listed serving the above premises were
of which are attached), and in accordance with the standards; rules and
Putnam County a rtme Of Health.
Date ' Certified by.
Address ������
sssenti ly a shown on the plans of the completed work ( copies
c or n ith a filed plan, and the permit pssued by the
P.E. A.
R.A.
License No.
Any person occupying premises served by the above system(s) shall p mptly take such action as may be necessary tesecure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate erage system shall be ate null and void as soon as a pubi(: sanitary sewer becomes
available and the approval of the private water supply shall becom 11 and old when blic water supply becoon avallabN. Such approvals are
subject to o ifiratio % hange when, in the judgment of mi nor of Ith, ch r ocation Ification or change Is necesur
�..�.
Date 8 Title � _
'.
IN% CO
11+,ee,15 2 1
WELL (;VMYLh'1:1Ur4 mxuAi
DEPARTMENT OF HEALTH
vJsjb f Of Eivironme 1eal Hiiallb -Sery
PUTNAM COUNTY DEPARTMENT OF HEALTH
Us
Of f ic Us Only
WELL LOCATION
STAEET AOURESS' 'JIMNIVILLAG111.11 T TAX GRID NUMBER:
JW!t _?7
,e fo�
WELL OWNER "
KME: AUUhtbyj
PRIVATE
0 PUBLIC
USE'OF WELL
1 - primary
2 - secondary
A RESIDENTIAL 0 PUBLIC SUPPLY ❑ AIR/CONO./HEAf PUMP ❑ ABANDONED
0 BUSINESS 0 FARM ❑ TEST/OBSERVATION 0 OTHER (specify)
0 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY 0
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE _%rOo gal.
REASON FOR
DRILLING
❑REPLACE EXISTING SUPPLY []TEST/OBSERVATION []ADDITIONAL SUPPLY
NEW SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH !�ro ft. I
STATIC WATER LEVEL T, Cf !TtDATE
MEASURED
DRILLING
EQUIPMENT
-ROTARY 0 COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH -2-f tL
MATERIALS: STEEL 0 PLASTIC I7 OTHER
LENGTH BELOW GRADE ft.
JOINTS: 0 WELDED' ZTHREADED 0 OTHER
DIAMETER
SEAL: XCEMEN-T GROUT OBENTONITE 0 OTHER
WEIGHT PER FOOT Ib.1ft.
, DRIVE SHOE.OES ❑ NO
1_1 ER: 0 YES WO
SC . BEEN
DETAILS
.7
DIAMETER (in)
'SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
0 YES ONO
HOURS
SECOND.:
GRAVEL PACK
1
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK In,
TOP
DEPTH
BOTTOM
OEM it
WELL YIE D TEST If detailed pumping
METHI 0: PUMPED i tests were done is in-
��,V'fr ' !ormation attached?
❑ COMP ESS
❑ BAILED '0 OTHER 0 YES 0 No
it more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
11PT1 FROM
SURFACE
Water
Bear-
Ing
Well
Dia-
mete
In
FORMATION DESCRIPTION
coal
ft.
ft
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land Surface
I I
'.23-
WATER CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
0 COLORED ANALYZED? 0 YES 0 No
ANALYSIS ATTACHED? C3 YES 0 NO
STORAGE TANK: TYPE
CAPACITY GAI�
I
PUMP INFORMATION
TYPO A24� CAPACITY
MAK DEPTH
vaLTAG
WELL DRILLER NAME ),44, OA /rte
ADORES SIGNATURE
7,
t _ri7dq I 4.��
YMi. ENVIR8NMENTA|- SERVICEF;
321 Kear Street
' Ynrktown Hei.Fihts, N.Y. 10598
(914) 245-2800
Alh j rt Ft. Pad �
v i, Di tor�
,�
LAB #: 32.413661 CLIENT 36 NoN STAT PROC PAGE
KUVACH, NICHO!'AS ' . DATE/TIME TAKEN: 04/12/96 16:00
PO BOX 741 DATUTIMER' 'D: 04/12/96 16:50
SHRUB OAK, NY 105880741 RFPORT DATE: 04/15�96
PHONE:. (914)_526-2499
SAMPLTNG STTE: 14 SPL7TROCK RD SAMPL-E TYPE.,: POTABLE
' : PVTNAM VAiLEY KITCHFN TAP _ PRESFRVAT7VES: NONE
COL 'U BY: NTCHOLAS KUVACH TEMPERATURE..: { 4C
CO IFORM METH: MF
DATE Fl,_'AG PROCFDURF RFSiU-T NORMAL — RANGF
`
04/12/96 MF T. COL TFORM ABSENT /100 ML ABSENT
COMMFNTS:
BACT THESF RFSU|'TG IND7CAT AS NOT) OF A -
SAT?SFACTORY SANTTARY QUALITY ACCORUIN[ L L) THE NEW YORK STATE
� AND EPA FEQERA| DRINKING WATER STANDARDS, FOR THF PARAMFTERS
- TESTED, AT THE TIME`OF COLLECTION.
SUBMJTTFD
� Albert « H. Padovani, M.T.(ASCP) '
Director `
PUTNAM COUN'T'Y DEPARTMENr OF HEALTH
DIVISION -.F , - " 1; � -: T,-r�A� L ERViGFS
Kp,tEN . _ �• �. �-... . :..�:�..«�.: -�< .�.: _ � -- _ �,-�.
.=
T. F,e ,5Eoe
Owner or Purchaser of Building
AllGhjpG4 S C ; ku l/ &/-/ .
Building Constructed by
Location - Street
NTN AM U Pr L- L F y
Municipality
sI N6rL ig-7 EA-M ! L Y R t h',,Ld
Building Type
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANME 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
"Cert i��xte> of;;Construc�tion. Compliance" for the sewage .:; spp!s41-- �systgW,.. car 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 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 z� day of P/i ,/L 19�
Signature �ZIZ/ li
Title
General Contractor (Owner) - Signature
Name
Address ,,aU7-11,4✓n V,41- Z- E y Al Y
rev. 9/85
mk
494/%rx!
Corporation Name (if Corp.)
C
Address
PUTNAM COUNTY DEPARTMENT OF HEALTH
4 Geneva Road, Brewster, N.Y. 10509
Date
TO:
FROM:
For your information
For signature. For your files_
Referred for handling _
� --(mac- p
l( Attached as requested _
Returned as requested �02 ' -r / 3
Please see me
Mead and return
COMMENTS:
11
-%4-
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmns, M.D.
Deputy Camnissioner of Health i
NAME
ADDRESS
No.
- FIELD, ACTIVITY REPORT - Sheet -/— of
wlzmkN
MAILING ADDRESS
P.O. Box Post Office Zip Code
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED _1\fi(-LDj6e
Narre and'Title
DATE TYPE FACILITY 9V
TIME ARRIVED TIME LEFT
FINDINGS:
4
Orig. Routine
Orig. Complain
Orig. Request
Compliance
Complaint Camp
Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
- - I
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report.
WIM
SIGNATURE. ����� C
TITLE:
leV .
LO/88
mh''00 tM buiWiiq has D en uo ien nd and is
ilik i'Any abanOa or altaratbn of- eoentruetbn
'only.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 - 6130.
`" 1�PPIiTCA`I'TON'''TO CONSTRUCT A `WATER"
PCHD PERMIT #���
WELL LOCATION
Street Address
0.
own Villa i ity
Tax Grid Number
.sus- -
WELL OWNER
ame
�cD 4e�-
Maili g
ss 6
Wirr ivate
lc D Public
USE OF WELL
1 - primary
2 - secondary
EHTSIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION 0 OTHER (specify,
b INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE Sal
0 REP CE EXISTING SUPPLY O TEST/ OBSERVATION Gl ADDITIONAL SUPPLY
CRCEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
9ArILLED
DRIVEN
®DUG
®GRAVEL. ®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: aaTCO
Lot No.
WATER WELL CONTRACTOR: Name
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES '_�NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
..; ' DIST9410E- TO PROPERTY. FROM-NEAREST WATER' 'MAIN;-
LOCATION SKETCH & URCES OF CONTAMINATION PROVIDED.
630SEPARATE SHEET
.5 O
dat ) (sig ature)
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- -Repo.rt - on- a form- provided - -by the Putnam - County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations'be contained on this
property and in such manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19_J
Date of Expiration 197- t Permit Issuin icVnk"copy:
Permit is Non - Transferrable White copy: HD File Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUTNAM COUNTY DEPARTMERr OF HEALTH
DIVISION OF ENVIRONMERML HEALTH SERVICES
Owner AddressiZ --.
Located at (Street) !!!;? Sec. �Block Lot
(Adidate nearest cross street)
Municipality lZeThA.vri J!41/e1.1 Watershed
Date of Pre- Soaking Z . /ii
Date of Percolation Test
HOLE
NUMBER C=
TIME
PERCOLATION
PERCOLATION
Run
Elapse Depth to Water From
Water Level
No.
Time Ground Surface
In Inches Soil Rate
Start -Stop
Min. Start
Stop
Drop In Min /In Drop
Inches
Inches
Inches
2
3
4
5
2
q
4
5
1
V,
3
4 =.. .
5
2
7
2W2
2
0
NOTES: 1. Tests 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 fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE .SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
rDEPTH• _ HOLE,TATO� �.. - HOLE. N0. H9LEa�NO
G.L.
1°
2'
3'
4' 1
5' Y-/
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDRATER IS ENCOUNTERED jt;�oa.t
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:��2sc.l DATE:
DESIGN
Soil Rate Used ijo - 0 Min /1" Drop: S.D. Usable Area Provided �
No. of Bedrooms Z3 Septic Tank Capacity /DO C7 gals. Type
Absorption Area Provided By 4,10 L.F. x 24" width trench
Other
F -v
Name L Signature - ---�-'
f1co IA-.
Address SEAL
�� •s,. �,
No. 50505
THIS SPACE FOR USE BY HEALTH DEPARZMENP ONLY: 90F. 014
Soil Rate Approved sq.ft /gal. Checked by Date
vc...:.35,
tMARVIN O'DELL K
Bldg. Inspector
JOHN MAHONEY TOWN' OF PUT.NAM VALLEY
Deputy Zoning Inspector
BUILDING, ZONING,: AND SANITARY -DEPARTMENT
March 4, 1994
Mr. Roy A. Fredricksen
P.O. Box 950
Mahopac, N.Y. 10541
Re: Property Status
Roberts Drive'
TM #85.5 -1 -41
Dear Mr. Fredricksen:
Pursuant to your request, please be advised
that the-property noted above and described
on your SSDS plan:(septic design) dated
February 2,1994, is a pre - existing parcel.
This .parcel is shown on a subdivision of
"Glenbrook" map'fi.led November 14, 1952.
QWI`+HALL _
PUTNAM VALLEY, N.Y.
(914) 526 2377
BETTE STOCKINGER
Bldg. Dept. Clerk
MO'D:es
Very truly yours,
e
MARVIN 0 LL
Building Zoning Inspector
PUTNAM COUNTY DEPARTMENT OF HEALTH
"DIV
Date 9� /L� /Sr��
Re: Property of
Located at P-cz FOA�
(T) Section VAJ 4L 50,S-- Block
-L—Lot 4
Subdivision of
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer �r 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
c -an o,::--supervise -th6 -cons,-uru�c -'6n
0
system or 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., #
--PO BOX ��0
Address
W) LJ
I U
?-c-q - o?3 -7 L
Telephone
Very truly yours,
Signed '4�9 - �77- , ""A,-
Owner of Property
Address
Town
Telephone
Roy Fredricksen
PO Box 950
Mahopac, NY 10541
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Dear Mr. Fredricksen:
y__II
ORL F -P, -.,__Ef?;,�EY. -;PLS —
Acting Public Health Director
August 4, 1995
Re: Frei de
Split Rock Road
(T) Putnam Valley
A final inspection was conducted by the writer on July 31, 1995. At the time of
inspection it was noted that a portion of the system was constructed in ledge
rock. Current codes require that five feet of separation distance is available
between the bottom of the trench and ledge rock.
Additional deep test holes are requested around the SSDS. Contact this office to
arrange a mutually suitable time for the deep hole witnessing.
Very truly yours,
Robert Morris, P. E.
Public Health Engineer
RM /Jp
PC -?
PUT NAM COUNTY DEPARTMENT, OF HEAL-7H
i PPCICATIdN 'FO ✓A`PPROVAL OF PLANS FOR A WASTEWATER DhSPOSAC SYSTEM
1. Name and Address of Applicant:���- -��- -�
2. Name of Project: �'g� c�] ,_ 3. Location T /V /C: 1 VI��,B
4. Project Engineer: rav 5. Address: ?Osc�"'e 57q-C-_-)
License Number: Phone: S°
6. Type of ,,Project:
Private /Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject to State Environmental Quality Review (SEAR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? .............
9. Has DEIS been completed and found acceptable by Lead Agency?
10. Name of Lead Agency
11 ".° Is, this- project. in an area -under-the contro).,of. local ..p.lanni n.g,. zonings
or 'other officials, ordinances? .......................................... °
12. If so, have plans been submitted to such authorities? 2�-
13. Has preliminary approval been granted by such authorities? •Date Granted:
14. Type of Sewage Disposal System Discharge...... Surface Water round 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? ..................
18. If yes, name of water supply
Distance to water supply " -
19. Is project site near a public sewage collection or disposal system ?..... _ z:� _
20. Name*of sewage system Distance to sewage system
21. Date test holes observed: 22. Name of Health Inspector:DC -�.� .
23. Project design flow (gallons per day) ....... ...............................
11/93
2.
24. Is.State Pollutant Discharge Elimination System (SPDES) Permit required ?..
_ e {. .T.- :��. ..... ..�:?i� >t$._ �a,.,.�j:'.. ..a-..a `- '�3 -..� '?p,'. ._ ...%dA.•'- " �..'r C 'r _^ „-- ..�::.y>".e ��`P It �'.'. .. r:�ii.�.'.;:av`O•w�� °i
25. Has SPDESpApplication been submitted to local DEC Office?
26. Is any portion of this project located within a designated Town or State
wetland? .................................. ............................... d
27. Wetland ID Number .......................................................
28. Is Wetland Permit required? ............. ...............................
Has application been made to Town or Local DEC Office? ..................
29. Does project require a DEC Stream Disturbance Permit? ................... -1z'
30. Is or was project site used for agricultural activity involving application
- of pesticides to orchards or other crops, solid or hazardous waste disposal, J
landfilling, sludge application or industrial activity? ........ YES or NO C�
31. Is project located within 1,000 feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? ..............YES or NO
DESCRIBE:
32. Is there a local master plan or file with the Town or Village? ...........
33. Are community water, sewer facilities planned to be developed within 15 years?
34. Are any sewage disposal areas in excess of 15% slope? ... ..... j
� .- :....� . -- •.- .. :. is .. . -. v' -. �.: :- G ... ti.. r_: �.�. .. • � L•- : . _ .. .__ _ . -. . -. - .. v..t.:. v .... t. .� c .: -. � .. . _^ C. :.a.. . _
35. Tax Map ID Number ........................... ..............................1
36. Approved Plans are to be returned to: ................ I Applicant SeEngineer
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 Clas A Alis enalQor pursuant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
MAILING ADDRESS: WWAOA ,, i41 Y / OT
1•
a.,
�+ P
4
r =;
s
tZ
4 6'
t {l:
k
��r
NI.
Roc-v-- E?o A y
otE .So-1�a 145.too