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HomeMy WebLinkAbout4621DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.09 -1 -8 BOX 35 I No oil 11 r 11 �, 1 1 rim ' , � ,i i .,� �. L , L, 1 16 16 � ml 04621 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N. Y. 10512 ,. a .JNSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM 7C ?WN Town or Village Located at -<;o%iy ep *Q Section Block Subdivision _ _ _ -- Lot - -: 'Job • Owner Address-... Building Type Lot Area `i_ %�GS' cJ,I�J, e/�L�d�C�ti°Q /�✓12 L.�S �y.}� Number of Bedrooms v Total Habitable Space / ?0 G i Square' Feet Separate Sewerage System to consist of Gal. Septic Tank �/ lineal feet X Width trench' To be constructed by Address Water Supply: Public Supply From —S� Private Supply to be drilled by Address Other Requirements ia�hti�" 1 represent that I am wholly and completely responsible for the design and location of the N'Ei above described will be constructed as shown on the a proposed system(s); 1) tha ��srpirate ��Wa a 'sposal system,: approved amendment there to and in accordance with the standar rt i� j '"� County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisf �'oe�'I° a u, nam be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or a i nsy�� Health,wili place in good operating condition any part of said sewage disposal system during the period of two 2 9 the r, h Bid. wilder, will ' ance of the a p ( )years �tliat,f e b the.•)ssu- pproval of the Certificate of Construction Compliance of the original system or any repairs they o tha will be located as shown on the approved plan and that said well will be installed in accordance with the standard rud s an 11 d ttr ePutnam County Department of Health. d o �' s Date Signed :. PpE' A Address ® e 1iA it APPROVED FOR CONSTRUCTION: This a it pal @ `•I pproval expires one year from the date issued unless construction of the b ndertaken and is tevocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change eration of construction., equires a ne, permit. 4---r02 pved for disposal of domestic sa ' y sewa e, rivate water supply only. By k /!7 Title / PUTNAM COUNTY DEPARTMENT OF HEALTH �r Division of Environmental , Health Services) Carmel,. N.-.Y., 10512. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM /yi✓ TN.4 M Town or Village /yi /✓/✓� g / Section Block Located at _ ) Owner /✓l) 0,4 Lot _i Job A4,9 . dJc�N Address 'loU —If Separate Sewerage System built by A--�� r < Consisting of i1 cQ Gal. Septic Tank lineal Feet X " width trench {i i Other requirements Water S Public Supply From Private Supply Drilled By ° �'�'1`74A/ AW10— 'v Address R�1 N C No. of Bedrooms Date Permit Issued�� Building Type / / e Has Erosion Control Been Completed? z'/ f ���U� I certify that the system(s). as listed serving the above premises were constructed essentially as shown on the plans of the completed work (copies of which', are ' attached), and in accordance with the standards, rules and regulations, plans filed, and the permit issued by the Putnam County Department of Health. ' Date if / z Certified by ' `r' P.E. Address License No. ' �Qi2' %C r'CQJ)V pf�',f Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary. conditions resulting from such usage. Approval of the separate sewerage 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 of the Commissioner of Health, such revocation, modification or change is necessary, B Title '(( Date —T� y V _ . � k , , �' 1 . .�. i � .. .. . .. > ? - •' .. - � -. _ .� E ...+F.r .,,�1 . •:L •i - 6R(� ro Ste.... r• V L r.t - .. T x, r t - #5003 YORKTOWN MEDICAL LABORATORY INC. H.O. Box 99 321 Kear Street Yorktown Heights,, N.Y. 10598 245-3203 DATE COLLECTED RESULTS OF EXAMINATION OF WATER 2- 12 -,72.. 3 NER DATE RECEIVED Norman,, Ronald 49 Ao Church St. Bedford Hi11 2 -12 -72 FY, VIL,LAGE,'TOWN & /OR NRM1; OF SUPPLY. DATE REPORTED Finnerty Rd. Putnam.Valley, New York )21.1 4-72 .MPLING POINT++�I ICTIrRIA PER ML. (Agar plate count at 350 C) .COLIFORM GROUP (Most probable No. 1100m1'.) HARDNESS, TOTAL ppm 3 Less :than 2e 2 ?TERGENTS - ppm NITRATES (as N) - Ppm IRON, 'TOTAL- ppm .. .OURIDE (F)`-mq. /l• zese'results•indicate that the water was Yes of a satisfactory sanitary.quhlity when the sample was. collected. -�• c - -� _q ,..., .._ _ I V. H. P OVANI; M T (AS ) 7 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME R 0 0 n L ✓a A-) n K x4 yl &/ PHONE 7,3 SITE LOCATION �(� F i 0U i(1 1z R T �4 ROAD TO g MAILING ADDRESS puT- A/ fW UP t, L r %r /05" -7 Of PERSON INTERVIEWED PCHD Canpl.aint # 6) t Name & Relationship (i.e, owner tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER W fi L T15 g LIM P -G o 6t 1 �(S f PHONE Z Pro (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal fran licensed professional engineer or registered architect. PAO 0/1) 1= QyV+L. (S is S-ba G=/9L fi it "I (� <�, J� C�- Z C7 Proposal approved _— Proposal Disapproved spector's Signature & Title Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. [, as saner, or repo a en of owner agree to the above conditions. iIGNATURE ,(, ' TITLE DATE ME: White MD); Yd lcw (fin ffi ); Pink (Applicant) ., Ilk 30 kC) ---7 1 1 NFU> p�v Posy � 7 PUTNAM COUNTY HEALTH DEPMnO�J DIVISIOWOF ENVIRONMENTAL HEALTH SERVICES PROPOSAI, FOR SEWAGE DISPOSAL SYSTEM REPAIR MM'S NAME PHCNE 9-' 6, q 7 3 SITE LOCATION F- TO MAILING ADDRESS /os -79 PERSON INTERVIEWED PCHDCatplaint # Iliq Name & Relationship (i.e, owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER (,(JPL-Fl n v J PHONE N -7 Pro (include sketch locating all 'adjacent wells)': NOTE: %Repair ,must be in same. lo6ation - and of 'same type as original 'sewage &6' system* posal Different location-may require submittal of proposal fran.,licen'sed professional engineer or .registered 'architect. - 0. - V G, L. X Proposal approved Proposal Disapproved s Siqnature & Title Z-� /Z Dafe roppsal approved with the following conditions: 1. Procurement'of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. OwnerIs name., b. Site Street Name Town and Tax Map number. c. Location of installed carponents tied to two fixed points (e.4.,hodse corners). .g' '6,gal. con deep d. System description (e .., 12.15 concrete septic tank, three precast 61 diam. x, 6 drywells Sur rounded by one t + gr ayel) e Installer Is. name and nunber. te - rpp�ir to be performed in accorda�ce` with the above proposal �.,'Sys Im and conditidiis.:- T-F as owner, or reported agent of/bwner agree to the above conditions. SIGNATURE TITLE FW: V&te (PCl`D); Yellcw (Tam Ell); Pink Qaila3nt) DATE Ii 0 I N .➢ P LY'�" .�. .. "..d:w.I '�4J • _..- . -,...ry s�..,� .: . ri._:w:`':.`,:1\.:. -r ._ ,. ,. , . ... ..:�..•... "..:.A: ,.... ..... ..i7: N' «n =i` fir. •..:. __�+. ... •.a .•�r:•R.. r... . .-:i- Owner or Purchaser of Building Municipality Building Constructed by Location - Street Building Type Section Block 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 Director of the Division of Environmental Health Ser- Vi.e,e.s - & -f•- --tare. pa;finam -Co. — ty:- :Dep�a-rtrreYrt .of= ��ealt i as to wYiether-or not ahe_ _....; Y ,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� Signatures -L' .��; Tom/ �L���% G 1/ /•��. If c rporation, give name 1 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 WELL COMPLETION REPORT 3/71 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK .This... epQ�;..�-. 0:: p � pJe c�d:key..weal,d,.- gr,rn&surb ;�nixYed3 .t �auratyc Health Dapartrrrerrt tcyether- vritii laboratory report of -4 analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NX-:4 ✓wr '�yt ter"° y"� ADDRESS �Jl Y r ILy �d LOCATION OF WELL (No. 6 Street) (Town) (Lot Number) PROPOSED . USE OF WELL ® DOMESTIC ❑ ESTABLISHMENT FARM ❑ TEST WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING OTHER DRILLING EQUIPMENT COMPRESSED if ) ❑ ROTARY AIR PERCUSSION 1-1 P PERCUSSION El (Specify) CASING DETAILS LENGTH (feet) () f DIAMETER(Inches) it IWEIGHT PER FOOT © THREADED ❑ WELDED DRIVE SHOE ❑ YES ❑ NO WA CASING GROUTED? YES ONO YIELD TEST El BAILED ❑PUMPED HOURS G.P.M. COMPRESSED AIR f— YIELD (G.P.M.) /6- � WAVER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specifyfeet) DURING YIELD TEST [feet) f Depth of Completed Well i in feet below Land surface: /70 SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (Inches) (F GRAVEL PACKED: Diameter of well including gravel pack (Inches): GRAVEL SIZE (Inches) FROM (feet) TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMP TED � DATE OF REPORT L ER (5' rfa'�ure7 JWELLDR,�L t (/ l PUTNAM COUNTY DEPARTMENT OF HEALTH .. ... � .. .e �r .: o ,:? ...: +v s - t• � - - � .... .. -.r ,.eo .. � � • .•t -r �.. v. . „ .... r. . �F::7... .' � o .. �';,.i„_•;C.?�"h'.l. 'fi.r , DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re.* Property of .'ov.9z.�la:N�� . Located at Tw.,':o;t? . Section Block Lot: Gentlemen.: This letter is to authorize;,E, a duly licensed professional engineer 4--or registered architect (Indicate) to apply for a Construction Permit fora separate sewerage system;. to serve the above noted property in accordance.with the standards, rules. or regulations as promulgated by the Cormr_issione.r of the. Putnam County Department of Health, and to sign all necessary papers on my behalf in _.. connection° w . -th, this- matter ;and to supervise. the construction •o_f•:.s.aid . .... ..... w,+.. .,v .. .r .,,.. .. .. s .... .. -. -. ... .. . — .. y.. .. ..,a 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: Very truly yours, Signed O'ner.,of Property / Z_/ ress rc, S2 Telephone .Address:. y�P`R ©'�a t Telephone. iv U/q; 2qEE��vrp t. ERG1M PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVISION OF ENVIRONMENTAL HEALTH,SERVICES 1 -DESIGN 'DATA SHEET - SEPARATE SEWAGE .DISPOSAL .SYSTEM FILE NO. Owner on/lv L10 1,1o.F'1xw1 Address -599,4 - Located at (Street)_; /Iy ^/E ,421� Sec.._. Block Lot'_ (Indicate nearest cross. street) Municipality �vrNl�M f.�,rr��,E' Watershed, SOIL PERCOLATION TEST DATA REOUIRED TO BE SUBMITTED WITH��APPLICATION. Hole Number CLOCK TIME PERCOLATION PERCOLATION Ruh .;. Elapse Depth to Water. � Water Level No: Time: From. Ground Surface 'in Inches Soil Rate Start Stop Min. Start Stop Drop in Min/in.drop Inches Inches Inches 2 1S- % /� ��i" /�- `� .�. /�IAI 4 lei ell 5 2 1 i 3 Notes 1) Tests to be repeated at same depth until approximately.equal soil rates are ob- tained at each percolation test hole. All data-to be submitted for review. I 2) Depth measurements to be made from top of hole. 48 " 5 Orr N. M, 661? 72i1 OED 781r U[ 8 41 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY �%. A/FiY�e i'' CAe,o IY 7', ,e <l Date /?�/J f 2 %, 122,1 Soil Rate Used DESiGN Min/1" Drop: S.D. Usable Area Provided No. Of Bedrooms Septic Tank Capacity DO Gals. Type C-a�✓C Absorption Area Provided By_/at5L.F.x24 ". 36" j,--,' width trench. Other i . Name Signature Address SEAL To1/V/V 147J; AX 4 1 UTNADI COUNTY DEPARTMENT OF HEALTH !,il Rate Approved Sq. Ft. /Gal. Checked by ��l ENGlVk PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL .ADDITION /. REPAIR FORM SECTION A. GENERAL INFORMATION Name of Project (V) 4 TM Year of Construction Size of Parcel l ' SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. Offilly ORolling X06; } Slope ®Gentle slope Flat 2. OEvidence of wetlands OLow areas subject to flooding OBodies of water Chrainage ditches DRock outcrops M 3. Property lines evident? 4: Water courses'exist on, or adjacent to parcel? ' NO S. Existing individual wells within 200ft of the existing SSTS? O SECTION C.. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS) 1. Physical character of existing SSTS area. w i A. Clevel Mentle slope B. OWell drained Modere Some' omewhat poorly drained in Steep slope drained Cloorly drained C. Area available for SSTS. (Primary. & Reserve) DExtremely limited 13Somewhat limited 41dequate l ft x ft Inspector D. INSPECTION Date MNo evidence of failure DEvidence of failure . DEvidencd. of seasonal failure (Indicate North) to HOUSE f---------------------------------------------------- d' t4) (1) Indicate location of SSTS 1-` A. Size and type of septic tank gallons Metal Concrete I]Plasti*c' B. Type of absorptio area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate-setbacks, front street,- backyard and s de yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. - EXISTING WATER SUPPLY 0 --d COMMENTS : DShared well Individual well Drilled MDug OCasing above ground OR FORMERLY DRING 4'' lji 99.84 a .. 2 WEI L l�RO FlL E j $JA'' ? . HORS / „ _ 4 , y VERTI _ NOTES 30 ° DEEP. peRGULAr/ONRESULTS- .I'DR0f 1N 5 1WIN : � _• I 5' DEEP Q�QU1Y0 _h9l�R,LEq¢'FRl1liX.4T�.' - O SYSTEM.i GONSISrOF125L.F. ABSORBrIONTRENCH, 36 "WIDE 24 ",DEEP, SPACED 9' O °O.C. . SEPr /.0 TA ;X.TO BE 900 GALS: CONCRETE. FIELDS T .BE 4 "'PERFORATED ORANGEBURG PIPE " OR EOUAL 4SOLID TANx r0 JUNGr /ON BOXES 9 t BETWEEN. �4 ° CAST IRON' P/PE,TO BE USEQ. %BETWEEN ; HOUSE 9' 76VK. . ALL CO1V'97RUCT10N TO BE.VONE. IN ACCORDANCE WITH STArF6 LOCAL HEALTH CODES rSEEWYS. pARI TU P, 6E /0l. r.,�aTE 4.._ /U . p •' a 300.GAL,7.SPI_R. BEDROOA! PLR. DAY USED. 300 GALS._ ? '' BEDROOMS : = 900 ': GdZ;S. O,. 900 64L4,'APPLIEDRATE24 . 375 S. .I m. 375 'S F,� .g EX. SITE PLAN,; F PROPERTY ®./ ly. A L NO /�l A u ,APPROVED OWN ®F PUTNA M VALE Y FEQ 171972 PUTf•�fj1 �jGL i L IN.OF HEALTH .PUT/ N �'7'!!// � C V NT Yi 7 y.r ,' � . IOFR£iiAA. DIVISION• OF • ENVIRO MENTAL HEALTH SERVICES N ' .. 5C 0/ , i . 30' B MAY ;'1;`i9,'7 4