HomeMy WebLinkAbout0006DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
1 -1 -6
BOX 1
1111•
�
41'
g.6'
'
Iti
41m. ;
'r ,�
,
L ,T•
'�
r
16
or
:Z'
1111•
AIN
186 PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Mast Provide Z Z 88
P.C.H.D. -Perm it #- - -: - - - --
OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Located at MP�IoR i�C�"o
Owner /applicant Name HOM6S:'tE ,Iasa°c . Formerly
Mailing Address P.D. Box 18S Zip ioS14
Ti.:ioRil�a/COD . 1�Jctn/ ~('OItIC
'F r.TTEiLSo wJ
Town or VWage
Tai Map Block l Lot 19
Subdivision Name M IMUJ Subdv. Lot b 8
Date Permit Issued g as
'Separate Sewerage System built by Address
Consisting of 12-SO Gallon Septic Tank and '10c L.F. _.6tmqwr1rlol.) Tkrawci -A
Water Supply: Public Supply From Address
or: Private Supply Drilled by Town SH !✓ So:IS Address 13ox 21 1 A- a"WoyK 0 rti
Building Tape gmooelwca Has Erosion Control Been Completed ? — Y,�
Number of Bedrooms Q Has Garbage Grinder Been Installed? iV 0
Other Requirements D i-.-M jklT In wJ go),.
I certify that_the system(s) as listed,serving the above premises were constructed essentially as shown the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulations, in acco dance wi a filed plan, and the permit issued by the
Putnam County Department Of Health.
Certified by P.E.X R.A.
Date /
Address ( S 'klr.J ASSOG.o'T�S RT.:5Z C — Ift"MM". t-►`T' License No, 1-4008
Any person occupying premises served by the above systems) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting 'frorn such usage. Approval of the separate sewerage system shall become null and void as soon as a publ': unitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes avallable. Such approvals are
subject to modificat n or change when, in the judgment of the CCoommis�sion? -of Hsa!V4 such revocation, modification or change Is necesssaarmy.,,„
Data Title
I..
IV_ H
a
b
FAT, SITE LNIS I — PICL'\1 g
Ltite
it U,
Tr
CR SUEDI1TISIC'1 LCT
"/� '� ,� � ,�kL /Ins~ _tom �bn_v
CWTIER �tLO1%1k.0./iLQ. ��� . `'� LG�- l,lQ.t..T'L
/ - / "
ccm2m rc
a. SUS area la=- -tee as per a=rcve✓1 plans
b. Fill sc-c-t i cn - Date of plac -anent TT
2:1 barrio- LC^ ? WIMH AVG.DPTfi
I
c_ Natural soil nct s -inred I
d_ Stcr_e, bra::, et—c—, QrG-1 e_r t-l�n 13' frCiil SDS arm I I
I
e_ 100 f t_ frCC.^. TNGL =r course /:tielrrl ands _ i
I
SL y-t C DISPOSAL S ST-Em
a. Sentic tank size - 1,000 1,230
b_ Sentic tart i ^st=i 1 level
c . 10' Mini-mum Z= G 1 i CLyT ^� �? OIi I ✓ �I�
d. YXD 900 henE_S , c1 °.e ^_cut wi t�rl i n 10 f--. of 45' tand
e_ MST_R B- PUTICN ECK
1. A11 cut °__- G:. sa- a eleva ? cn - watarr tes ze,3
2. Prote =ec-: 'CIF-1 CW 1 = GSA
3. M?nL -,LL :l 2 =- cr. icrinal scil hetre!an bc.x and ranc_?es
E. JUNCIIC'N E' set-
1. L= r,c', L �rncth iris tall.;
L_ Distance LC wa Ls- II °. S'1" fL. I L✓r
3. Installed- acccrd -_c toys i an
d Dis anca c_:Lar to ca_nt=_
5. S_cce oz t_- e_rcn ac^ =n'table 1/16 - 1 /32 Vfcc - I
6. 10 f �t fr=, crc- :-_- 77 line - 20 r=e= - fGLLT'(� -iCilc I
7. DentL-: c' i= =' =': < 30 L^"C.es fi-r-M S'__acR
8. Rc= a 1 i s eE C?
°. Size e= c =v 3/4 - 1 diet
10. Denth c_ C `ce_� in t_`nc-! 12" in .-iLm- un
prao OR DC EE S YST S
1. Size of L:_<< C'.`T� ^ter
2. G- eT ic- �rLK I I
3. Ala_ , Visual /audic ( I I
4 Pum-c eas__•a acces-sible ma -r_ole to trace I I I
5.-First h�={ Ca =lee I I I
6. Cycle wi .==_ DV Esmil t1 Dranar ma ^_` ( I
esti mat =lcN ce cycle
Ecuse lc=_=_,�z rar acn'rcvei plans.
- =
. N'Li;r-r of hey ^=z I i
V. Wes' i .
a. We 1 as Le_'" acorcved Plans
b. Di_Starce fry, SLS ae=, measurer ft.
C. C_sina 18" Lmv-e trace.
d_ S.2-=Face dra_race arcurd well acce.CL.c ie
vi. GU�-Z? T'! i WQRK.i C
a- F_-xes prow r l v crcut
b_ Al pines —�; �1v bat i 11ec
c_ A13. pi ces flush with inside or bc�
d_ Eac'�ill cent ainE stones < L" in di aIrr`t`
'r'tc1n Qrv1� insta i It_" acccrdinC to plan
e_ C
f_ Q. tain drai^ cut= 1l protect & c_r.to Evi =t.w�_�rccur
Q. FCOtina Oral: c C_SC_^.arce away f =c n S�5 area
i_ 1- _osicn ccn=cl CrcVlcec cn s1Gces czeatar t.i.P_ 1j3_
R
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
INSPECTION
NAME Orig. Routine
-¢ Orig. Complain
ADDRESS d- Orig. Request
No. Street Town TM No. Compliance
Complaint Camp
MAILING ADDRESS Final
P.O. Box Post Office Zip Code Group Illness
Construction
TELEPHONE
Reinspection
PERSON IN CHARGE ,� Field, Sampling Only
OR INTERVIEWED oun Field Conference
Name and Title Cv1rr,
DATE TYPE FACILITY
TIME ARRIVED
A�
TIME LEFT"
Other
Explain
FINDINGS: I . . A 11 A I i i
INSPECTOR:
PERSON IN CHARGE OR
tle `S�- 6�' �Y
vity Report. SIGNATURE:
TITLE:
TELEPHONE:
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.to a -RY
,rx ,yam, -0- I - /.-/ 1,
John M. Simmons, M.D.
Deputy O mnissioner of Health - FIELD ACTIVITY REPORT - Sheet of
INSPECTION
NAME �C �l ,U -(9�_� Orig . Routine
• - Ori Ccm lain
Town
TM No.
MAILING ADDRESS
P.O. Box Post Office Zip Code
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED UU'
r�-,� �,�Yvu,�,�,ti�� -mac. '(�A.0 L ,�. C J
Name &0 Title
DATE % TYPE FACILITY
TIME ARRIVED fJ a r" TIME LEFT 0-41YL
FINDINGS:
,j . P
Orig. Request
Ccmpl iance
Complaint Comp
Final
Group Illness.
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
INSPECIOR:Y li%/t / /'�i�C 7.:'/�l �I ���� (� I ! TELEPHONE:
Signature and Title
1
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
P' FEN-L SITE LISrE'CTICN Late S
Imo_
r7-
V.
VI
tCN q
�4 IL OR SD-EDrTT'SICN LCT / - L / /
fF y kin c Fv rr,
s •ir_G =. DIS:rCS�r, PQF=_
I
a_ r arE= lc=--=- as F?r aT_mrovEd plans
b_ F_ll Sec-Licr. - Date oz plat= ra-rZt.
I
2:1, barrio_- . LCUE W_L, J `r A�iG _ DFT?i
es i _TPc t == --ow car ry C e
c. rTz_jz = soil rct s -iLCea
, cr- -Ier an 13' f--cm SDS z— I
d_ c_ e, bra* e --- t�n
vl
( _I
e- 100 f t _ f;u. Nit= ccur =e /'.Ye t_f ar+� i
�a- GYP ICG _ _ as =,E-r a-ccro v ed p l am_n c
I
SL't r^ DISPCSA SYS=
(�(
b_
a. 5c -mac tank __-_ - 1,000
!`_ 1_ -- - -GI
C_
u_
C_
e_
L_
c_
1 '
_ LiCi:
L 10 f cf Cc� er
L^ L ti I -
I I I tip
T`� TT1
L-�__ 'L'_____ +X
1 J 1 1 CL T' c_ c c. _' i e °[TcL_c.T?
ea
tip' n "iL i 2 C` r= - i cCl i 'Lc - CC:i arld -
�._.[.Tf[T!".�'i ^C =� I I
L . � =_ � ^_cam LC• we �� �..Lr �s rr.�.= =_..�Y � _ �. I Z--I�
C= `
� .
_can I ,`.� _-Cr Erg = nc_ci_ r 517 I I
I . -_
lv. reoLn C f. C
1 p; =c-
c^ crc�c I
ar
2. Over- -L c-
n,r, onr. i sr - ^�cc; =�1 o rr��O1c `i0 CicCe I_
cn s_cces CrEatar ttan 15-5-
Al i9 �-// , n/I /I i9 �/
6. o icle wi -,_-m_=__= i by
es i _TPc t == --ow car ry C e
HCDISE
a. Ec,.:ce Da-- a=cved pla:_s
of
I
�a- GYP ICG _ _ as =,E-r a-ccro v ed p l am_n c
b_
D_ ta, Lca f :r= Si.S ar==. J: == _dam' f `_
C_
C`- n 1 11 awe Crac e-
wall, accEctat`
ic.0 T�
GL���_ fiLRf�•,
b.-
eis rte-- -__-,- caG: =illy,
I
I
c_
All f-usft w_ t= inside cf bct
I
C_
_ i 1 1 Iil -t_ -�' ccnt ins stones < c " in d2.amet=r (
_yam1
�I
e_
_[ r 1', 7 ^.C-- 1 I cam[ y
C:_-- = n c_�_ -- � -__ --- acccr�i_ ^.c �o c i .r_
f-
C•= :_.._n dr= _ & c_r . to `m-st _ ;rata__ ccL: r s
cLvaV f=r l SDS -rc=
cn s_cces CrEatar ttan 15-5-
Al i9 �-// , n/I /I i9 �/
• •l A�OI %. /T I�L.fTT TTT/1T.T TTT/1TT
►�
W O
WL'LL %�WLCJLEL1VP, 1AL;ILVA1
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION;ev
STREET ADDRESS: vtl III W GRID NUMBER:
Re s
WELL OWNER
N ME: # ADDRESS:
/Ca C - / l/P
❑ PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
`6. RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS- O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
"H NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL 5 ?,� ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH 3If fit
MATERIALS: '%&STEEL ❑ PLASTIC O OTHER
LENGTH.BELOW GRADE ft.
JOINTS: O WELDED THREADED O OTHER
DETAILS
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE 19,OTHER
WEIGHT PER FOOT - Ib. /ft.
DRIVE SHOE: ❑ YES 'Q NO
I LINER: O YES ONO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (f t)
DEVELOPED?
FIRST
❑ YES ❑ NO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST ; It detailed pumping
METHOD: O PUMPED t tests were done is in-
t
❑ COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER ' ❑ YES ❑ NO
VELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
i�9
well
Dia-
ne1er
FORMATION DESCRIPTION
CODE
ft.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It,
YIELD
gpm.
Land
14
14 ft.rAA9nK.1
a ry r te
.�
WATER - 9.CLEAR TEMP.
QUALITY .O CLOUDY HARDNESS
O COLORED ANALYZED? 'YES ❑ NO
ANALYSIS ATTACHED ?VJES 0 N
STORAGE TANK: TYPELveLU: -"{fibL
CAPACITY kpjf U.->t PA Z:�b GAL.
PUMP INFO MATIUN j
TYPE � r ✓ CAPACITY
MAKER MD r r 1% DEPTH �
MODEL 1-5 5 VOLTAG�� HP �
WELL DRI ERN E A E
ADOR � 1 S � 3- SG w S sl rkTURE
' 7 Q /� mnwl� 1✓� -C�c�,. -e, /1'2j
F- 1c�r- tESrr� ,�s��ct.a-�s
Owner or Purchaser of Building
Building Cons,tructed by
Location - Street
�iD�NGE ,
-Buffing ...Type
Municipality
Section
Bloc
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-
vices 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 s s e `
Dated this =!"cl day of Se�Ieye� 19ga Signatur
Title _
f 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
cashin associates, p.c.
design professionals
route 52
carmel, new york 10512
(914) 225 -8088
TO
Ito fzow-m to s
NL"' Ioslz
LETTER OF TRANSMITTAL
DATE 9. 20. 88
JOB. NO.
ATTENTION
RE:
p. H1nI �O�Z
01.
t2T TL OF C�v6T�fJCT /oi✓ - OI-(Pl t
'
WE ARE SENDING YOU Attached ❑ Under separate cover via
• Shop drawings Prints
• Copy of letter ❑ Change order
Plans
0
❑ Samples
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
01.
t2T TL OF C�v6T�fJCT /oi✓ - OI-(Pl t
'
7 • ZS • ga
�1�.. �...vMPLET O �i
2
� • 18.88
-� � � +s
Au
1, -t-
I
•S
C o X25
THESE ARE TRANSMITTED as checked below:
XFor approval ❑ Approved as submitted ❑ Resubmit
• For your use ❑ Approved as noted ❑ Submit_
❑ As requested ❑ Returned for corrections ❑ Return
• For review and comment ❑
❑ FOR BIDS DUE
_ copies for approval
copies for distribution
corrected prints
19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS (fnyw.'Mp A1.T m= Eon 8m 'Sal'iT ugt> �
S In <::�>Vmr-
COPY TO:
�ue✓rs�
SIGNED: C��...�
If enclosures are not as noted, kindly notify us at once.
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245.3203
Director: Albert H. Padovani M. T. (ASCP)
r
TORLISH WELL DRILLING
PO Box 271
Armonk, NY
10504
L J
LABORATORY REPORT ON THE QUALITY OF WATER
LAB N
Date Taken: 17 ��-"`l Time: 2
Date Rc'd: �;.f 4- 4-, Time: 1
Date Reported: JUL. 2 U 1988
Collected By: Duane Torlish
Referred By:
Sample Location: ,,,
Phone N 273 -3448
Phone N I Sample Type:
Repeat Test? _ (check one)
INORGANIC NON-METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
Acidity
Alkalinity
_ Chloride
_ Detergents, MBAS
_ Hardness, Total
Nitrogen, Ammonia
Nitrogen, Nitrate
Phosphate, Total
_ Sulfate
_ Sulfide
Sulfite
METALS (mg /L)
Copper
_ Iron
_ Lead
_ Manganese
Mercury
_ Sodium
Zinc
MISCELLANEOUS
pH (units)
_ Color (units)
_ Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA
40C
4 °C
V/Standard Plate .Count 2-5
(CFU /1.OmL)
pH
MEMBRANE FILTRATION
TECHNIQUE
Total Coliform
_ Other:
Fecal Coliform
Fecal Streptococcus
MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A = Not Applicable
LT = Less Than ( <)
GT = Greater Than (>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
REMARKS /COMMENTS (For Lab Use)
L''Potable
Non- ootable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
_ HNO3
HC1
H2SO4
_ NaOH
ZnOAc
Na2S203
Other:
Incoming
}'E
t/GT
40C
4 °C
pH
LE 2
pH
GE 9
= pH
GE 12
_ Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE WA ) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH N YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTI
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT DR KING WATER
CODES, FOR HE�P.A�AMETERS TESTED., AT THE TIME OF COLLECTION.
/Y / ( V 0 11 \'� 2/86 (Rvsd7 /87 )RWE
Owner /Applicant Mime Flo S ►T .a+ssoc.• Renewal_ O ltevbilon
Date of Previous .Approval '
MaWng Address F'.O_ dux 18 6 Town�i (oPi l Via. , : IY 24 : 1 o Sft 4
Building Type; �dal��l�►CR� Lot Area LIZ /s.C.B� FlllSectlon.Only Depth :Volume
Number of Bedrooms- Design Flow G P D t3?so o PCHD Notification is Required When Fill Is completed
Separate Sewerage System to consist of 1 2.80 Gallon Septic Tank and 7D 0 4.-F .4�.B�a le P.TiO+✓:. / I�G' /3/�C H
To be constructed by . F3 t< L--!,eTEXM I,.te'C Address
Water. Supply: Public Supply From Address
or: Private Supply Drilled by-7-- .8 ' -> �Addeess
•l
'Other Requirement, ,s'F+et��i-rto�t Sox 1 R.O_I3 F'et,� 212 CV `fDS.)
i represent that I ami wholly end completely: responsible for .the design and location, of the proposed system(s); 1), that the separate sewage disposal system
i above, described Will be eonstructed,as shown on the'approved amendment there to and in accordance with the standards, rules an regulations o e Putnam
County, ,00 , rtment of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Heelthwill
ii be submitted. to 'the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the,builder..that said builder will
place in good ,'operating conditioo-` any part of said sawage,disppsal system during the period. of.two.(2) years lmmed lately ' following thedats of.the Issu-
ance of the approval -.of the Csrtificate of Construction Compliance of the original system or any repairs t ereto. 2).that the drilled well described above
will be located as -shown on the approved plan and that said well will be Installed in ccordance a the sts rds, rules and regu ions of ahe Putnam
County .Department of .Health.
Date' Signed P.E. I R.A. -
AddreuSi-it1.�' /��gDC. g L License No ZOO®
APP,ROVEO,F,OR - CONSTRUCTION: This approval expires two years from the da a issued unless construction of the building has been undertaken and is
revocable for .cause or may be amended or modified when consi red ne , the Commis 'on of ealth. Any change or alteration of construction
requires a n perms ed 'for disposal of domestic a sewage, o pr t a r ply ly.
/87 Date `__ =- By Title��
1
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #�!l
WELL LOCATION
Street Address
OR �O 'D MDb
Town/Village/City / Tax
LL �D. AT ?L'��SO�I
Grid Number
I 9
WELL OWNER
Name Mailing Address
o 'SI TV- Assoc . P. 0. ka S Ttib W.,4VVoo-c Nay
.%Private
0 Public
USE OF WELL
1 - primary
2- secondary
13,RESIDENTIAL ❑PUBLIC SUPPLY DAIR /COND /HEAT PUMP
O BUSINESS O FARM 0 TEST /OBSERVATION
0 INDUSTRIAL 0 INSTITUTIONAL 0 STAND -BY
0ABANDONED
0 OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT yAjfj S gpm /#
PEOPLE SERVED__ /EST. OF DAILY USAGE ge,e, gal
REASON FOR
DRILLING
NEW SUPPLY
OREPLACE EXISTING SUPPLY
OPROVIDE ADDITIONAL SUPPLY
❑DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
.REASON FOR
DRILLING
�Ie:vJ �cs:�y i i,a
Sv (-
WELL TYPE
DRILLED
DRIVEN
E]DUG
GRAVEL
El OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. 8
WATER WELL CONTRACTOR: Name !� 8T►2M� �1�'L� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __X_NO
NAME OF PUBLIC WATER SUPPLY: N A TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OIjREAR OF THIS APPLICATION ON
(date)
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 Pfie Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on a..form provi b t n o t
Health Depar mer
Date of Issue: L- �" 19
Date of Expiration: 19 rmit Issuing f clal
White copy: H. D. File
Permit is Non - Transferrable
Yellow copy: Building Inspector
Pink Copy: Amer
2 87 OrancrP mnvs WPl 1 Dri 11 Pr
APPENDIX B
PUTNAM aXJNI'Y DEP.AMEM OF HEALTH - DIVISION OF ENVIROR�ffMAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
AL.
(:flame of Owner)
REVIEW SHEET - CONSTRUCTION PERMIT
(Street Location)
DATE RE VI : V3,1
B
y
DCCUMT-NI'S
Per;nit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc
(3) Fill. -----
ca.---
House Plans - Two sets
Well / permit; PFKS letter
Variance Request
�AL
Legal' Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checker
Wetland ( Town /DEC Permit R & D)
Data On DDS Plans & Permit Sarre
REQUIRED DETAILS ON PLANS
Se=wage System Plan - (north arrow)
Serge System Hydraulic Profile - Gravity Flcw
Fill Profile & Dimensions - Vole
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder rate)
Design Data: Perc and deep results
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flea,suff. size
If Pturped Pit & D Box Shown & Detailed
House - No, of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systens
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 '0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PL!N
Fields
10' to P.L., Driveway, Large Tre-s,Top of fil
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. ex`an
15' to Drains - Curtain,, Leader, Footing
35'to catch basin, stormdrain,piped watercours
10' to Water Line (pits -201)
50' intermittent drainage course
Seotic Tanks
10' fron Foundation; 50' to well
15' Well to PL 9
EWA�
a
x :F
a i,, P
a_
imm
1273
_
100 vr. aood elev.
00 ft. reservo
DATE RE VI : V3,1
B
y
DCCUMT-NI'S
Per;nit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc
(3) Fill. -----
ca.---
House Plans - Two sets
Well / permit; PFKS letter
Variance Request
�AL
Legal' Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checker
Wetland ( Town /DEC Permit R & D)
Data On DDS Plans & Permit Sarre
REQUIRED DETAILS ON PLANS
Se=wage System Plan - (north arrow)
Serge System Hydraulic Profile - Gravity Flcw
Fill Profile & Dimensions - Vole
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder rate)
Design Data: Perc and deep results
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flea,suff. size
If Pturped Pit & D Box Shown & Detailed
House - No, of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systens
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 '0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PL!N
Fields
10' to P.L., Driveway, Large Tre-s,Top of fil
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. ex`an
15' to Drains - Curtain,, Leader, Footing
35'to catch basin, stormdrain,piped watercours
10' to Water Line (pits -201)
50' intermittent drainage course
Seotic Tanks
10' fron Foundation; 50' to well
15' Well to PL 9
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date N( �N �o. �qee
Re: Property of 4mg e 5/7-P A 50ciW re,5, 1 t'ut .
Located at moo.Je-r
(T) �'.o,izsc�;.l Section 1 Block 1 Lot �q
Subdivision ofd,��,/
Subdv. Lot # 8 Filed Map # Date
Gentlemen:
This letter is to authorize
a duly, licensed professional engineer or registered architect
(Indioate ,
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
connection with this matter and to supervise the•construction•of said..
system or systems in conformity with the provisions of Article 14$ or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned
P.E. , R:A., ,#
CASH � ►-—,� ,� -SSC, Ci�-rE5 . �'• C .
Address
^OL17� SZ C.raRr•1El_ fJY
Telephone
Very truly..yours,
Signed
� ..
Owner of Property.
%30 X
Address
J Li D/�icrcuoo o� , dt�- i/ 105 9 i/
Town
Q 79 -6 30 6
.Telephone
DIVISION OF ENVIRCRIENML
HEADS SERVICES
DESIGN DATA SHEET`- SUBSUFACE SEWAGE'DISPOSAL SYSTEM' FILE NO.
Owner, :�rort Sr,�� ,ctssoc,�.�s
Address P o. 6Aox ' les 771,;,7gtt,;�,, Ljy
Located at (Street)_",,6,,0p_ 6 t�400wJe-f *4,�.L Q -. Sec: '1 Block 1 Lot 1
. 9
(indicate nearest
_
cross street) ' DoT ;`is g, •.
Municipality
Watershed.
80IL PtRCD=CN TEST DATA ,RDQUIRED
TO BE SLMKrTEED WITH APPLICATIONS
Date of Pre - Soaking z S4 Be
Date of Pervnlation Test 2• zs B�
HOLE
NU- ER C1= TIME'
PEROQLATIM PEF MInION • .
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 •
3 2: S t- q: i l• 5a 2c>
2.3 3 3 0
4 4; 21 5 i 151 20
Z3 3 30
5
Zt 24 3 28
3 90
29 3 30
5
2
3
4
5
NOTES: ' 1.' Tests to be repeated' at same depth unt�U apprmimtely equal soil rates
are • obta.ined .at each percolation test hole. All data to' be • suhmitted
for review.
9 rent -h m--asuremp-nts to be made from too of hole.
i
DEPTH. HOLE -NO. HOLE NO.- 2- HOLE ND.
F •
G. L. IT 1
j. ToP5oiC ol�'Sp'�`-
lo
3'
4'
5'
•e
9' .
10'
13'
14'
INDICATE LEVEL AT. WHICH CROUNMATER IS ENCOUNTERED
INDICATE rmm TO WHICH WATER LEVEL RISES AETFR BmG ENcommim. Ce'
DEEP"HOLE OBSERVATIONS, MADE BY: ,t M� p�rz r cm i-a,�� t-j4 1.1-51. DM: —
DESIGN '
Soil Rate Used y -30 Min/1" Drop; . • S.D.. Usable Area "Provided moo ch.
No. of Bedrooms q Septic Tank Capacity i2 o gals:' Type MATSoaRy
Absorption Area Prove ded By �, e,-j L.F. x 24" width trench
Other B ox 1 Q o B . . F�
Name (re.s+Ul -! fissmc,,6 -r-+�s . P. c . Signature
Address Rom -ra~ sz SFAL `
OF
Cr- Q►-�e� 1JY osl2 rOt..srri .
THIS SPACE FOR USE BY" HEALTH DEFAKU�FINT ONLY:
0
Putnam County Department of-Ilealth
Division of Environmental Sanitation
AFFIDAVIT CORPOMNTE WNER, APPLICATION
FOR PERMIT APPLICATION -SUBMITTED TO
PUTNAM COUNTY HDILTH DEPARTMtNT
TO:.Commissioner of flealth In the matter of application for
- - - - - - - - - - - - - - - - - --- - - - - - - - - - - - --- - - - -
&L e- e-(
— — — — — — — — — — — - - - - -- — - --- -- - represent'
that I am an officer or employee of the,corporation and am authorized
to act for e4q es.,7-e rPe5
(name of corporation)
having offices at. TA Q-A�.A LW
Yhps e officers
are ----------•—/-----------------
President
/V/ t C 4 C4 J 10
(Name
-9n-ff Nd-dr—ess-)—
-7-KeP,5,
eel. i/" e,4^t leye 6x� c�e Al;
V4a*=*@i@WWen t O/U
—Y
71MUd — — — — — — — ---- — — — —
(Namt: and A ress)
Secretary
__ —_— — — --- — — — --- — — — — — ----- — — — --- — — — —
(Name and Address)
Treasurer
- - — — — — — — — — — — — —
(Name and Tdjres8) —
and that I;.am and will be individually responsible for any or.all acts
of 'the corporation with r ' espect to the approval requested and all silb.-
.sequent.acts relating thereto.
S%vorn to e this day Signed
ae f o r re r, m
of, 19 vr Title
KELLY H. WILSON
NOTARY' PUBLIC, NEW YORK STATE
No. 4862945
QUALIFIED IN 0,10ESS COUNTY
COMMISS ION.EXPIRES 7 21JU
7 �•> R:F� i �i° t, t. k.`s. -'+'E '�• c �'` rr -t a� f a a ) � H t
a
t
r , �, , t`.,c: ,.Na �, r. •. -% .f 9! t�j:� C. -�s '�• _ 1 u�. _ t � t f¢ ,
...,. .. :.,.•. ,;:._.., r:_...._.r. .::: ...- .- ..:._- ,+.,_. ,, -._.. -v .!,;.d a., a, �., Ana -a': t:i'. -
.. ... , • -�,. ... ..., t ?- '�' :.:.. , ....7. .; .. r: ... 4s.. {._ Via' d ....._ t . �" y' v 3.., i., F,' (. d _ . f -! t.., .. t. M1..
. .. ,... , - r.. tt�. r� y�. , :.•.7. s, , . .t •.... , .. .. , !r,. :,. .. _ y � T.�. :, t, { ;:M14r �' P- 1 A � < uatf' --'r .� Yc.4:' �,.
"�� ,.tz,; x ...a, -. ;... C 3:;.?t. '�+r wx. t :�", • ;.i !_ 's3 5 _ r y r � -:�9t ; t'., i<- � ,
. t .T s f"• .J` ' '•. x-:,Y' t'' - ,ir • -,r 3 z"3M ,RL ! } 1k r. ,!
.;�, t - r rf t `..h.. �o.. Tom.? ;•�.'. 'e.
s•P �;.:- g ,�, dr - e<n .c� .�,t''`F'x;' �=;.: � :i .r 5 ,r-•_ sy.: c, �. r 5�.�
� . ,.. , � .... ... .; ,+ S �.... _G ," ,,�°.a4 t� �...'�:.. a �
,a, ....,.e,.,r, ;,.,.,r. .. -.. .,a t3c'rt .,., t ,r;'F':r. P.:. 5 'rYr, R2, •w s� s. .L°v -�
�.. -. ir.... iti z „•. ate, �. -H� ,•,,y, t�,4. ±,+,�;..�
_.. -.. u ._x tt � :•�: 4,, i' „ bb t .•.,'i tF. ..�l N, :� !` +rrz �.
..F�Y
5 '�C ',F), S .�, t � - f.♦,
;�, � ,v t is i. g� L•d�+'
�, cd
R 3 w
• y � ' S "13 os-oro t;.. � . Z °� 4 $ �. 7 �.$ %' to '11� z "� ''
81 '1c0
10- 20, iv U �rNi NTH' w
MiN11r 14M
- � -•i�` .1 rtNe++ "-tea
NFA"A
YW
.
b•
IOT TVA .�wd.aaa' As4�uanlx�)