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HomeMy WebLinkAbout4762DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26 -1 -60 BOX 36 04762 W INTA .� 6, Fr ly. IN iS ''6 04762 b SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use On ,Repair Permit issued in last 5 years Repair within Boyd's Corners, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC - mapped wetland t& 1.14003i979� f' ' s rte. r _M REPAIR PERMIT # `� C ❑ of in Watershed Delegated ❑ Joint Review 19 TOWN VV + & r%G .y TM # 77, 16 ✓ "- FJ IfD 1M,1 b PHONE # 471y oZ6 Name & Relationship (i.e., owner, tenant, contranror)� DATE 'Z C1 FACILITY TYPE PCHD CO PLAINT # PROPOSED INSTALLER cri�i -a.c� f 2� PHONE #y ��'f ADDRESS `6 REGISTRATION /LICENSE # /0 KIP Proposal (include a separate sketch locating the Rouse, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and utent of the repair. 0-,F_,6 ,L ?)it' Iv ((Deb Cls c— P(f— I, as owner,agree to the conditions stat d this form C,12 SIGNATURE %t TITLE a.,VT-u,0vL DATE (owner) agree ' fir h ecemlir - :7;the sapti _insta ler, •to.cornply.withthe sp t ia , . SIGNATU vtr✓ ". TITLE CH7 DATE e g-< _ (installer) Proposal approved with the following conditio s: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Q� Proposal Denied ❑ O Inspector's Signature rf itle Da (e Expiration Date ,Repair proposal is in compliance with applicable codes Yes D No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 O MEMORY TRANSMISSION REPORT :TIME _:.. =:�. BEFc ^1� TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 048 DATE SEP -10 11:53AM TO 85262595 DOCUMENT PAGES 001 START TIME SEP -10 11:53AM END TIME SEP -10 11:55AM SENT PAGES 001 STATUS OK FILE NUMBER 048 * * SUCCESSFUL TX NOT ICE * ** PUTNAM COUNTY HEALTH DEPARTMENT MIVISION OF E=NVIFTO"MF=-NTAL HEALTH SERVICES ..�_ C3 SITE. LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT ,,Kapalr Pa It imsued In last S years Repair within 8oya's Comers. W. Bn3nch or Croton Falls Ras_ Repair within zoo ft. ar a watai.00ursa ar DEC- rnappod wetlan G TOWN C-�i/$Yp•�_ VA UT Delegated j O Joint Review ONE Iv �1 S'r _>4 Noma & Relationship (i.e.• ownor. tenant.mrr DATE �,�2 sr._ �G�> LiTY TYP'J.= F2, -Q-- .S PCHb COI�Py �T At P6"10�SED 1 et t s=R _ [u4� -d.� PHQNE #.77�� - .. _, . -, r _ '. :x:�• �]a^�e. A�L....r dew -:SF � .._ -. �„ _ir., . .,� _:_ t, l��?I F?SFr v_.F ; S._- - ✓yi =rn M,- 6"L Proposal property (inca¢atle a separate sice,tcl•t lotzating tl-t# ous:e, tines, all adjacent wetlsl watF•tin 2p0 ffee,t o4 repair arm ttae location of existing ancf proposed sysaertn) NOTE: The Dapartmant may require submittal of proposal from licensed professional depending on the nature and ant of the, repair. 1. as owner , agree /tto the conditions stat d this for SIGNATURE jt C ?�_..�c± Y_ <__ �,/ = e,_�iTLE �. r ✓o-*. ss�.dt_ GATE S" �^"'�p (owner) 1. the septic insta ler, agree to comply with the conditions of this permit for the septic system repair SI(3NATU TITLE �i DATE (anstaii�r) - � Pr000salaoorovad with the: following conQitio s_ Y. Procurement of any Town ParmiL if applicable_ 2 Sae a ms exacts r r sz ftac2ft Pay Ova - - Samoa— Faas*W.aac =2p a 30 days of tt a repair. in 4upak=1e, st —ri'm: a Owvne name, Site Street Nama, Town and Tax Map number b. Location of installed components tied to two fixed points c- System description (e_g., t 250 gal_ Concrete septic tank, e[c.) d. Installers' name and phone. number 3. System repair to be porformcd In accordance with the above proposal and conditions 4_ The proposed 6STS repair is considered a bast fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5_ No completed work Is to be ta0 ,knIlod until authorization to do so has bean obtained from the [::iapartntent / IM7- ERNtAL LjsE ONLY Proposal Approved__ Q Proposal Oenled 0 In peccor's Signature ltle Dam Expiration Date Repair proposal is in compliance with applicable codes Yes O No !j� COPIES: I PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 ij buicr -..- S- 9 336 1' moll ijL sp li FA ]77 FA ii irk viv by 6 li -3- 6 ch --po L4.1 i\� FQ T Py 0 u` 4. (0 .e3 86V,5-- 5---26 X jjv- - 1�i 102- 0Q 103. 9 cn ca tip r 93. CO 92.41 / 15 Cl P ti 6 ifs sE ' 0,0 s .58 28. AS J 1 J � d r Sc tidy eor i Z 8.7 T. Aq4 ggp- jT U�G% RD CRANBERW RD g f 0 P7 "RAMCRS jc: Cc PUTAIA;V, N., � 70,116-1 Otb 8FtEZ?, ST szo� "40 Fl 5� ,u 10537 on amt 1 /Z km -,- " ;L 11 '/ 1 zsV I . ... x- 7q R R Iq eA�� LA 131 T,y ltt/� i\-% j j SKY LA 1;. CCC, 10 SLEEPY BROOK LA/ , Ke I t14 . i I - 11 r4ol VA L L E Y L 41 - ,, z ,, h, KO ( , . I , '/ i HNSON CT f - ms EliO 0 sou z wild c 1� IVO zli c) J, f Cu 4�ci POE q, ou Flo ,Z7 Z, Al e x 19 0 Ai < uj C, > fKINGST�Q N RD X, 0 Ho, OW 0 Cem fAv � V6 ' E131 407 to e-z 6 Ap, W to Es3 6 ic s- U .2-) of � 1 w1300 '*0 f-0' LL DN5 'a PO Ml - + ©wE 4. e, LL ip't, Oq 130' rO 4L All '; I i 25 i i �I fa�•e5 \` �`, \ CRIPTION \ \ \ \ \ 0� ` J►^,J^+- \ 1 1 1 \ G� An \ 1 1 \ \ \ 1 1 1 1 \ 1 \ 1 \ 1 cg- Mad0N�w �y. >' o 0 o�• a 14 C S a k.1 4 ° 85 86 lev I r '. 160 \ 83 1 a2 �♦ 1036 151 1 81 1 , \ 1\ `\ 80 \ `\ 78 - 1 y 156 •SPECIAL DISTRICT'INFORMATION t3 ♦ 4 �`♦ `\ 152 154 � `♦ `. 155 ` STATE LINE COUNTY LINE ® ° TOWN LINE "— "- VILLAGE LINE — "- BLOCK LIMIT — -- ORIGINAL LOT LINE ------- PROPERTY LINE ;4 to 0 J �.2ti.f -I /JEJ J.i,'O�r,✓ H �2E0.(/ 9 /.[/G •,( J � �� . _ ! oPC4 - "/ U� t �' ! r �3• /; �_ i LGTJ zf 7, fa e49 -,(/ G(/ 1 Z m / l •,�o �+ _ �j 3 OCK J/ Ol/ / /AP r (/T /TL c O�' u I �`/ 'r.:l (� A 4 C 1 � �OY- �' r ^ V iJ rs'a - elrA14M GoU,vrY c_� �e t o�F /ce. optD sbti� . oae,irES7r' :72.8 S%y. °9v77-5EO To scu�irj� r /TG E �' . z ��'�- :.E..;.:/r}y cq.:.v - •lcco.eofJ,veE'sy /Jf/ -. . rO.G T /TL E _ . • _ - 1 /� . SV,� YEi'S of rf /_= .t/.c /r i0,e,4:' Jri7TE GA+VO i �II I T /TLr. - 9J;JOC 147710,(: - t .� � � ' :.;URVEYED A5 IN f'OS!�E "`- iS1�iN ': ,� -'�' � a� �� � '�� f•'� ' ✓/t,(� ✓.�J.:; /to, /.%%O .U. ^I✓. L'aYe,C� ENCR0ACHm Erg iS OELOW c;Jrnoe. IF n v.: . _ - SURVEY UJ- F,P,)f >�CRTY SURVEYED._ - - _ �? %ri -•C /' C.'^,` �. _ _._ _ ! NOT SHOWN HCRIZON. fU!•- Ii-J . 1i FOR -_ -- 5I" .rJ- CERT,r,:.D'70..5',CC✓ TfJ. , J J. MLBUR I'llis 1 CIVIL ENGINEER & SURVE•:OR /r r ✓/ .��•v ��7 - .� V.D. N.JNT2q SEA N•.`(. .Q °•aL - +'. _ _ _____ _a_.._. I �--•{. _ _. �..�- .. ..__ l _ �. `•' • - 111 \ \\ i t 46 V f d7-'d 8o /V ry PelzAl~ C0611-171y ol 770 JltcOelrjj "r0 .-1 77 771- 5 ss'ry'�' URVEYED A N SURVEYED. ENC140ACHM ENT'S n E LOW (;RAQE, IF At N'. SURVLY OF P!iol-l:s:;�TY NOT SHOWN HEREON, SITU Al 1: It-, CEi-,ZT;l";M TO-!4-,-7 --- ------ ---- 7L ------------------ ................. ........ ..... J. WILBUR IRISH CIVIL ENGINEER & SURVEYOR TZ 5C ',O� -------- --o:,T W.D. M�N C 7 (• :.o— 2o' I NORMAN ANDERSON INC 152 BARGER ST 1'LTTNP�VI VAL LEY; N '10579... . BILL TO DROGIN SUZAN 10 WINDY RIDGE COLD SPRINGS, N.Y. 10516 845- 265 -3425 FAX 265 -9133 Invoice DATE INVOICE #.. 2/12/2003 3400 -698- P.O. NO. TERMS PROJECT i QUANTITY DESCRIPTION RATE AMOUNT PUMP SERVICE 2/11/03 BROKEN WIRE 50.00 50.00 Tape, clamps, splice kits, etc. ;l,;' :. 30.00 30.00 1.5 LABOR (2 MEN) 100.00 150.00 subtotal 230.00 Total $230.00 9 �� a `' . .. � .. .. L -, -..... i \, �. �'� _,` ` i �` `� r � �, i �'�. a � \ �� -C�.�' r /"' ., r ',. 1 U�,� /I l pa VL\ (f, �e) O'A 0 NORMAN ANDERSON INC 152 EARGER ST PU`I'1>vTA��I �Jt�I;Li;`f; �1Y 1 °OS9 BILL TO DROGIN SUZAN 10 WINDY RIDGE COLD SPRINGS, N.Y. 10516 845- 265 -3425 FAX 265 -9133 ___..DATE INVOICE # 2/12/2003 3400-698- P.O. NO. TERMS PROJECT QUANTITY DESCRIPTION RATE AMOUNT PUMP SERVICE 2/11/03 BROKEN WIRE 50.00 50.00 Tape, clamps, splice kits, etc. 30.00 30.00 1.5 LABOR (2 MEN) 100.00 150.00 subtotal ,1 230.00 TOW $230.00 AM c� Sheet of PUTNAM COUNWDEPARTMENT -OF HEALTH . --,;' �3 .; . � ':::. ,b -« �'�T, :'.T.�1"r�'''�'� i��' �''r�r� t[l- �• � ► �.f. 4 �7j Y7 �t` [1 C1 t<.y ... _. •, . , _.,- .,. ._ �;�- . ,_�_ Y .�- ,._ t �,�, ��:.,,�"� "_�ii"�a'�'A.. H.P., :y.. ..=�,R� IC�.� - � • �W �0 FIELD ACTIVITY REPORT.' •r s - Kto P AT)TIRR.R C: Street Town, ..State ..Zip PERSON IN CHARGE QR TNTFRVT .WFT) -. T�atP Name and Title TYPE OF FACELITY FINDINGS 11,�, 4\ v- 14' Signature and Title I acknowledge r Jo this report: SIGNAT `SS' 02/96 Title; + R.a,� 1 LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH i Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Norman Anderson Inc. 152 Barger Street Putnam `Talley NY, 10579 November 25, 2003 Dear Mr. Anderson, ROBERT J. BONDI County Executive Re: Proposed Well: Lirtzman (T) Putnam Valley I have received a well permit application (WP -97), a well abandonment form (WA -97), and a certified check in the amount of $100.00 for the above referenced proposed well. Comments are offered as follows: 1. One of the two submitted site plans is attached, and must be amended to clearly show the locations of the existing well, proposed well, existing septic systeM.and house. The proposed well shall be dimensioned from two fixed points. If there are any questions please contact me at (845) 278 -6130 ext. 2235. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very,aruly yours, Brian R. Stevens Public Health Technician cc: RM, e is PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE_ S ::�t:>:��e.•••�a`v 1.- .r- l:�.Mao =�-. Q::: rr.: o-�e'.w -nw: .. .►MSt'�a..�..- :i.�..i�'is:, i... . _:�tr=-`o'.ri::�a... i.� i'ti.:a t•�.�• -:.'. r�'e'.n�. +..�:►KiaeR. vi.- z:.- ii- ;���• »Q S APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # Well Location: Street Address: T000wnNillage Tax Grid # �ap /Block l Lot(s) Well Owner: N me: Address: Well Type: Drilled Driven Dug Gravel . Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1. =: :primary Business Farm Test/Observation Other (specify) 2= secondary Industrial Institutional Standby , ell Name: Address: W ,Water . Contractor: Reason For Abandonment: Description of Work To Be Performed: )ate: Applicant Signature: /.J4- PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam j County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR '4a' d provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the. in tion delineated on the application for this permit has been completed. ;- L;04 k.Date tf Issue inl? Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 IFUTNAM COUNTY DEPARTMENT OF HEALTH DHVISION OF ENVIRONMENTAL RONME NTAL H EAL'l H S ER VffC ES APPLICATION TO CONSTRUCT A MAT]ER WELL please print or type Permit # Well➢ Location: Street ddre T illX.,�;47ap Grid # �'�, Block Lot(s) Weep Owner: 14arne, Address: Use of Wen: Residenti& Public Supply.. Air /Cond/Heat Pump Irrigation I- pnirimmai y Business Farm Test/Monitoring Other (specify) 2- secondla>ry Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served ---- Est. of Daily Usage �o a gal. Reason for Replace Existing Supply Test/Observation Additional Supply IlDirifling New Supply (new dwelling) Deepen Existing Well Detailed. Reason for IIDdHing Wepp Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No x fs well located in a realty subdivision? ................... ............................... ................... Yes No Name of subdivision Lot No. Water Well Contractor: Address: /'s'�G��,...e.,,,_ l/r•$�1 Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. /� y Date...1/ '1 0 ;: Applicw _i 414ttu°e: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall -take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water/ ell ller ce ified by Putnam County. r' Date of Issue c Permit Iss ' ffcial: Date of Expiratio Title: Permit is Non -T>ran f >r>r� "Ye White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 r_<71 .F PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ . R. WELL. COMP.LET�C;N::RPI[dx- .� Well Location Street Address: TownNillage: Tax Grid # (q j r'CO *0 GO AT) licep-oKSo U- Maptt J-4 Block ( Lot(s) GD Well Owner: Name: . Address: f L a2R . �,I A ,_ I ZP4A Use of Well: Residential Public Supply Air cond/heat pump Irrigation 1- primary Business Farm Test/monitoring Other(specify) 2- secondary Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Total length ft. Nfaterial .­ASteel _ Plastic Other Casing Details Length below grade ; Joints: -' Welded Threaded . Other Diameter P in. Seal: X Ce ent grout — Bentonite ' Other Weight per foot 'alb /ft. Drive shoe: Yes , No Liner _ ' Yes o Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? Scree etails First Yes No Second Hours ell Yield Test _ Bailed _ Pumped Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) During,yield test() Depth of completed well infeet Well Log Depth From Surface Water Well Formation If more detailed ft. ft. Bearing Diameter(in) Description information Land Surface descriptions or Lf j� �4 . sieve,ana$yses-- �=:._. are available, please attach. � n ZVI If yield was tested Feet Gallons Per Minute Pump /Storage Tank Inforffiation at different depths Pump Ty p acity during drilling, Depth G O Mo( list: Voltage y3 D IF Tank Type k/XZOVolume . 7 Date W II Co pleted Putnam County Certification No. Date of epoA W II Driller (signature) -3t NO 7& Exact location of well with distances to at least two permaneI landrfarks to be prov(ided on a separate sneevptan. id Well Drillees Name Address:�`'y Signature: Date: Jp 4 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 -3t NO 7& Exact location of well with distances to at least two permaneI landrfarks to be prov(ided on a separate sneevptan. id Well Drillees Name Address:�`'y Signature: Date: Jp 4 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97