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HomeMy WebLinkAbout0023DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 1 -1 -24 BOX 1 X4111I . ". :;; . Use. I IN t-6 1 is ,. J N , M . -k. ' ,,� Ir 11 ell' , i� i�� � - lvh 6. 00023 Lemma at_ Srt6id/w F 4 P> 101i SEWAGE Owtwr /Appliage PUMAM IDDUR1T DEPA11MMENT OF IM aTH Dlvlalw d Rawl HoWM 3•nloa. CmuwL N.T.141d12 Ertabnar to Pw d& Pw",# . CSSSII+ICA B O w T ... Pack I �d let / Ter: Map-1,12 -Ebek 0 Rone"FO ❑ Revlaha ❑ Date of Ptevlsae Approval t�tata� ®� ti•�di ` Stidbt� ljp• p� / L at A><aa F� SeetMa 0* 0 D.* Volaoe �" lYws�ar st BeieN ' ,y 1 Daip Flow G P D PCSD�Nyotleeadmi b Dequh" Wbm M 6 oarpWad S.priaw S..wap SYBMW t. aaarbt.c, G.9.. Septle Task mad_�l2/(0 ��_� Ak . ' \l tk To M: ommko led by Addrwe Wahr St*ptr. Pieta Sates FMaa Address see SI>pply Ddllod by ' ` Addren Odm Rabb 1 r•present1hat 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate fass di col stem above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ns o ha County Oep rtment of mmltl% and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Haalthwill be submitted to the Oepertment. and a written guarantee. will be furnished the owner. his sucasws, hairs or assigns by the builder. that aid builder will pNc• ki .good operating condition any part .of said cocoas• disposal system during the period of two (2) yews Immediately following tMdat• of the issu- awe of the approval of the Certificate of Construction Complionco-ot-the orighm system or any repairs thereto; 2) that the drilled wall d•saibed Afte wile a located as slmorrn on iM aopromhe plan and that Mid well coil In tall in ac anp with the ► Is and r M ns of the Putnam County D•portmant of Health. _ Date J© Sign KE PA. Add/ea t lens• No APPROVEO FOR CONSTRUCTION: This approval expires two years from the date issued unless constr ion of the building has been undertaken and is revocable for cause or may be amended or modified when considered n•eefWry by the Commissioner Of Health. Any change or alteration of construction "Qubb now W Approved for disposal of domestic Unitaryr ater supply only. 0/88 at. --r- -- p: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva.Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT WELL LOCATION Street Address o Village City Tax Grid Number %O �j - WELL OWNER Name I Mailing Addres OPrivate Public USE OF WELL a - primary 2- secondary 1% RESIDENTIAL O BUSINESS 0 INDUSTRIAL ❑ PU LIC SUPPLY O AIR /COND /H6 AT PUMP O FARM O TEST /OBSERVATION d INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT o� gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_ y�gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLING O TEST /OBSERVATION L1 ADDITIONAL SUPPLY 0 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING 4-t2 I r2eOLZZIA WELL TYPE DRILLED DRIVEN ODUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES I/ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES V NO NAM - OF PUBLIC WATER SUPPLY: F4 TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED WON SEPARATE SHEET >4�_� *1 10 _,.t"w (date) (si tc 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 Report 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 drill low we��t'pn a gntained on this property and in such a anner as not to degrade or otherwise co a�n{{i.n )` ��ilface or groundwater. Date of Issue• 19 Date of Expiration 19 C Permit I ((��1 frf �E Permit is Non - Transferrable White copy: HD rax4b 3 � j ink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller IIJ Fj CHALET #2 = 2BR., 1 3/4B.ATH 27 X 36 r . IIJ Fj CHALET #2 = 2BR., 1 3/4B.ATH 27 X 36 r PUTNAM COUNTY . DEPARIlMENr OF HEALTH _ DIVISION OF ENVIRONMENIAL HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner `��'� I - %� �/I �'� f�1�_� Address V. V. i� !I�� , 11.�G- D. a)( � 2 , 'A Located at (street) oo "d : l Q19 uJ Sec. Block Lot (indicaternearest cross street) Municipaiity/�T ��� Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITrM WITH APPLICATIONS Date of Pre- Soaking 20 Date of Percolation Test fa 2 0 1 f 2 3 4 5 SOMS i 'i' H * AN3 NUNS: 1. Tests to be repeated at, same depth uUND rely equal soil rates are obtained .at each percolation test 014* V3 data to' be submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 HOLE NLV BE9 CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. .Tiine Ground Surface r In Inches Soil Rate Start -Stop Min. Start Stop. Drop In Min /In Drop Inches Inches Inches �3 3 4 3 1a' 10- I.A:q ° -3 � �j (o /S � � I . i LA 5 1 -3s - a= s 3 11 „ !/ '� 2 o -a 35 3� a4`� as �ZIt 'iz" ;20.0. 3 =,�0-- 3.10 30 �3/2�4 3 /-� 10 "3'q0 �J��� � 4 30 ����5 o2S3/$ 1yn✓ 5 1 f 2 3 4 5 SOMS i 'i' H * AN3 NUNS: 1. Tests to be repeated at, same depth uUND rely equal soil rates are obtained .at each percolation test 014* V3 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 DEPTH HOLE NO. I G.L. 21 3' 4'. 51 61 81 91 10, HOLE NO. HOLE NO. 121., 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER.BEING ENCOUNTERED DEEP HOLE OBSERVATIONS; MADE BY DATE: DESIGN Soil Rate used min/l,, Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capality gals.. Type Absorption Area Provided By ��76,7 L.F. x 24" width trench Other Name Signatui Address SEAL THIS SPACE FOR USE BY HEALTH DEPARD1ENT ONLY: Soil Rate Apprcvyec sq.ft/gal. Checked by Date If, 0 IuK 04*2- HOLE NO. 121., 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER.BEING ENCOUNTERED DEEP HOLE OBSERVATIONS; MADE BY DATE: DESIGN Soil Rate used min/l,, Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capality gals.. Type Absorption Area Provided By ��76,7 L.F. x 24" width trench Other Name Signatui Address SEAL THIS SPACE FOR USE BY HEALTH DEPARD1ENT ONLY: Soil Rate Apprcvyec sq.ft/gal. Checked by Date If, IMI RANDOLPH W. LAURENT, P.E. HARRY W. NICHOLS JR., P.E. October 5, 1994 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)278 -6108 - (FA)Q 278 -2658 CONSULTING SITE ENGINEERS RE: Individual SSDS Partout International Corp. Subdivision Mooney hill Road Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -1 "Proposed SSDS ",.dated 10 -5 -94. 2. "Application For Approval Of Plans For A Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System, dated 10- 5 -94.' 4. "Application to Construct a Water Well ", dated 10 -5 -94. 5. "Design Data Sheet ". 6. "Letter.of Authorization ", dated 10 -5 -94. 7. Two (2) copies of Residence Floor_ Plan(s), for "Bedroom Count Only ". 8. Check in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely, LAURENT ENGINEERING ASSOCIATES, P.C. Randolph Laurent, P.E. RWL:bd 94052 encs. cc: Mrs. S. Tompkins w /enc. Obi t add 9— 130 h661 -80AC S H LIV H *Ai13, AINnoo ,miand Q 1. Name and Address of Applicant:D'P�IG � � %��� � I�G t?o, ��x• X22 ?2 2. Flame of Project: 4. Project Engineer: f���N ��• 1- i�Uf�'- I License Number: -751 Phone: 17,J V _ 6108 3.._, Location /V /C: �}cD 5. Address: N(r,"ODr-t-5 Di iG e5�W Fro 1�4 OIL-4-T-wo �oa� 6. Type of .Pro ect: ✓ 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)? 1Y2 Status (Check One) Type I.. Exempt L/ Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? tJU .,9. Has DEIS been completed and .found acceptable by Lead Agency? rJ /A 10. Name of Lead Agency ti. Is this .Project in an area under the control of-local planning, zoning, or other officials, ordinances? ........ ....... ........................ 0o 12- If so, have plans been;sub;mitted to such, authorA ties? .. .. . . . .............. • I S 1�3. Has preliminary approval•been granted by such authorities? Q A Date Granted: c4. Type of Sewage Disposal ,'System' Discharge ........ Surface Water v Ground Waters 5. If surface water discharge, what 'is the strewn class designation ?. �...... �l� 6. Waters index number (surface) .....�..... n1 7. Is project located near a public water supply system? iJ0 3. If yes, name of water supply QJA ' Distance td=water supply 3. Is project site near a public sewage collection or lisp a s r'..... IJo )- Narre of sewage system /fi Dist,;ojewage system Date observed: %r�, �� 23. Name of HeIitA10 s 0�AV30 .3 J Prc)Ject design flow (gallons per day) ..................... APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant:D'P�IG � � %��� � I�G t?o, ��x• X22 ?2 2. Flame of Project: 4. Project Engineer: f���N ��• 1- i�Uf�'- I License Number: -751 Phone: 17,J V _ 6108 3.._, Location /V /C: �}cD 5. Address: N(r,"ODr-t-5 Di iG e5�W Fro 1�4 OIL-4-T-wo �oa� 6. Type of .Pro ect: ✓ 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)? 1Y2 Status (Check One) Type I.. Exempt L/ Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? tJU .,9. Has DEIS been completed and .found acceptable by Lead Agency? rJ /A 10. Name of Lead Agency ti. Is this .Project in an area under the control of-local planning, zoning, or other officials, ordinances? ........ ....... ........................ 0o 12- If so, have plans been;sub;mitted to such, authorA ties? .. .. . . . .............. • I S 1�3. Has preliminary approval•been granted by such authorities? Q A Date Granted: c4. Type of Sewage Disposal ,'System' Discharge ........ Surface Water v Ground Waters 5. If surface water discharge, what 'is the strewn class designation ?. �...... �l� 6. Waters index number (surface) .....�..... n1 7. Is project located near a public water supply system? iJ0 3. If yes, name of water supply QJA ' Distance td=water supply 3. Is project site near a public sewage collection or lisp a s r'..... IJo )- Narre of sewage system /fi Dist,;ojewage system Date observed: %r�, �� 23. Name of HeIitA10 s 0�AV30 .3 J Prc)Ject design flow (gallons per day) ..................... 2. 25. Is State Pollutant Discharge Elimination System.(SPDES) Permit required ?.._ K) p 26. Has SPDES Application been submitted to local DEC Office? ............... _ )/A 27. Is any portion of this project located within a designated Town or State wetland ? .................... ............... .............. r.)�) 28. Wetland ID Number ......................... ............................... ►J /b 129. -Is Wetland Pe rmit, required? .............. ............................... R1n Has application been made to Town or Local DEC Office? 30. Does project require a DEC Stream Disturbance Permit? ..................... 31. Is or was project site used for agricultural activity ihvolvih g application of pesticides_ to orchards' or other crops, solid or hazardous waste disposal; landfilling, sludge application or industrial activity? YES or NO v 32. 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 k)il DESCRIBE: 33. Is there a local master plan or file: with the, Town or Village? 34. Are conmunity water, sewer facilities planned to be developed within 15 years? MlkfQ0W ) 35. Are any sewage disposal areas in excess of 15% slope? ., ...................... 100 35. Tax Hap ID Number ...... :.. .....= 37. Approved Plan's are' to'"be. returned to:: ................ . . App'1 icant Y/ Engineer If the application` is signed by a person ocher 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 pek4'ury,• that inform,at,ion provided on. this fon is true to the best of my know7edSe and be7i.ef. False statements made herein are punishable as a Class A Hisderreanor pursuant to Section 210.45 of the Penal La IT . 3IG,NATURES & OFFICIAL TITLES: JAILING ADDRESS: IJ � 1050�i �s. Y� BRUCE R. FOLEY Acting 'Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, . New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 May 19, 1997 Harry Nichols Laurent Engineering vtillbrook Office Center Route 22 & Milltown Road Brewster, NY10509 Re: Proposed Compliance Tompkins Mooney Hill Road (T) Patterson Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: There is no record of any as -built inspection being requested or completed by a representative of this Department. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Very truly yon, Robert Morris, P. E. Public Health Engineer RWjp LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)27 8-6108 - (FAX) 278-2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS May 1, 1997 Robert Morris, P.E. . Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS _Compliance Mooney Hill Road Patterson, N.Y. Dear Robert: Enclosed are the following: L. Four (4) prints of Drawing S -1 "As -Built Plan! %, dated 4- 30 -97. 2. "Certificate of Construction Compliance.for Sewage Disposal System ", dated 4- 30 -97. 3. "Guarantee of Subsurface Sewage Disposal System ", dated 4- 30 -97. . 4. Well Completion and Well Log Report, dated 5- 25 -95. 5. Water Analysis Report, dated 3- 21 =97. 6. Money order in the amount of $200.00 payable to Putnam County Health Department. If there are any questions concerning the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Ni ols, Jr., P.E. HWN:TR:bd 94052 cc: S. Tompkins w /enc. WrjLL l.VrlrLCr11VL4 1%ZrV1C1 DEPARTMENT OF HEALTH Division Of Environmental H iealtCi Seivices W 1 O PUTNAM COUNTY. DEPARTMENT 6P HEALTH •. Office Use Only _ 9 J. ` WELL LOCATION. STREET AouRESS: I r taz 01b NUMBEe�t ., uhe .l rso . WELL OWNER NAME:, ADDRESS: �h as // Q P8IVATE PUBLIC USE OF WELL 1= primary 2 - secondary 0 RESIDENTIAL b PUBLIC SUPPLY AIR /CONb. /HEAT PUMP ABANDONED 0 BUSINESS PARM b PEST /OBSERVATION 0 OTHER (Spdcifyl p INDUSTRIAL b (NSTITUTIOIVAL b STAND BY t7 MOUNT OE USE YIELD SOUGHT. gptn.mo.•PEOPLE Sb b /EST OF DAILY USAGE t U gal. REASON FOR DRILLING [REPLACE EXiSTI1JG SUPPLY tjTEST /OBSERVATION [1ADDITIONAI, SUPPLY EW SUPPLY .(NEW C]DEEPEN- .EXIST tik.VELL , . .,... UvEI, DEPTH ft: STATIC WATER,,LEV' ft BATE MEASURED DEPTH DATA DRILLING EQUIPMENT b ROTARY .. COMPRESSED AIR PERCUSSION 0 DUG. b WELL POINT O CABLE PERCUSSION O OTHER (specify); , WELL TYPE b SCREENED 0 OPEN END CASINGOPEI HOLE IN BE ROCK 0 OTHER _,. . CASING DETAILS TOTAL.LENdTH . , .,. l - fL . MATERIALS $TEFL ❑ PLASTIC D OTHER LENGTH BELOW .GRADE.•, :. _ ft.. JOINTS: CL WELDED THREADED . 0 OTHER i'c DIAMETER 7 in.. SEAL: CEMENT GROUT .,DBE ITONITE 00THp WEIGHT PER FOOT Z Z (b.lit.`. DRIVE SHOE ES ..p NO . LINER CI YES NO SCREEN DETAILS bIAMEtEA (in,) _ 'SLOt SI2t LI:N i, (tt) DEPTH t0 SCREEN th) OEvil-OIED? FIRST HOURS SECOND. GRAVEL PACK iJb GRAVEL . 512E. DIAMETER OF PACK TOp SOTT061 WELL YIELD TEST. r (I ttetait�d 'tirn In - � � � i ,. b P 9 M 00: O PUMPED r testa weed Bond Is iti- t �f GQMPRES$ED AIR (OrtildtioildttaCht:d BAILED d OTHER , E7 YES b NO LL .:LOG 11 TWA detailed 1600 tton descriptions de sieve analyses are i vatiabld. please attach H FRAM.. RFACE . Wo�it I"g will m 1ef In tpplAAltON OESCAIt+itOd 61,) ft WELL DEPTH It. DURATION hr, mtn. DRAWOOWN YIELD opm/ 19A, r J 4 WATER CLEAR tEMP, QUALITY O CLOl10Y HARONES5 O COLORED ANALYZED? : b YES ONO ANALYSISATTACNED? d YES ,.ONO„ ..,;. ;, :.. STORAGE TANK: .TYPE.. CAPA C I T.Y ;.GA>t. PUMP INFoHiHATiON TYPE MAKER MODEL CAPACITY " DEPTH VOLTAGE HP WELL DRILLER NAME DATE ALBERT M. , HYATT & SONS, INC; J XK AoORESStGFtTtTIJgE Well Drilling ' Rte. 311 R. R. 2. t36X 171A. PATTERSON. NEW YORK 12563 V/ V./ � NORTH AMERICAN � LABORATORIES, INC. CERTIFICATE OF LABORATORY ANALYSIS LAB ID NUMBER: 97 =1514 CLIENT: Hyatts Pump Service RR 2, Box 141C Holmes, NY 12531 SAMPLING LOCATION: S. Tompkins,Moony Hill Rd, Patterson, NY COLLECTED BY: C. Hyatt DATE COLLECTED: 03/21/97 DATE RECEIVED: 03/21/97 DATE OF REPORT: 03/21/97 TIME COLLECTED: 1:00 PM ANALYTE RESULT* UNITS MAX CNTMT LEVEL ** METHOD ANALYZED Total Coliform Absent E. Coli Absent Must be "Absent" SM18(9223) 03/21/97 Must be "Absent" SM18(9223) 1 03/21/97 This sample, as submitted to the laboratory, and as compared to the New York State limits for drinking, water quality for the tests performed, was: ✓ ACCEPTABLE. NOT ACCEPTABLE. NYS ELAP #11218 Maryann Fasano, Assistant Laboratory Director CT Lab Approval #PH -0171 * Underlined results are unacceptable according to health department and /or US EPA codes. ** Maximum Contaminant Level (maximum permissible concentration allowed by health department and /or US EPA codes). 618 Clock Tower Commons, Brewster, NY 10509 -9241 / 914 - 278 -7600 / Fax 914 - 278 -7754 / E -mail: NoAmLab ®aol.com PCII , f f Oa`JNI Y D�.T'P.R'IIrENT OF fiEP.L,'LH DIVISION .OF ENVIRD\,*.•Ez ..L f F_b_LTH SERVICES owner or. Purchaser of Building Section Block Lot Building Constructed. by %tion - Street Subdivision ' M nicip l.ity Subdivision Lot Building Type: S iCE DXS'Q�]L SXS r f CK)ARPN�E OF SDT_URFAC � I represent that i. aTil wholly and co.mpletely responsible for the lotion, woruienship, material, . construction and drainage of the sewage disposal systen serving t_he above described property, -and. that it has -been constructed as shown- on the approved plari or .approv.ed' a -mend yen thereto. and: in accordance with the, standards,. rules .and regulations of the :Putrain County Depas't<rent of Health, and hereby �rzntee to the a ner, his successors, heirs or assigns, to place in go&d operating condition any part of said system constructed. by me which fails to operate for a period of two years. #medi.ately. following the date of approval of the "Certificate of Construction Compliance" for the se-KGge disposal system, or any repai-rs Node by rvv to such systems; except where the failure to operate_ properly is caused by. Lhe willful or negligent act of the cccupant.of the .building utilizing the system..,. The undersigned further agrees to accept as conclusive the deteu ira.tion of the Director of the Division of L'nvironienta]_ Health Services of the Putia:a County De rte :ent o� Health as to �.hether or not. the failure of the system to operate eras caused by the willful or neelice-nt act ot= the occupant of the building utilizing the system. Dated this j/7,� day o r• 191?7 i Sic nature Title L v Genera Co. actor INC" F�kJs/><C �. o • �oX -522 SAM 5, es s l NT 1256 ;�) p- ddress rev_ 9/85 Mic y _S, WELL COMPLETION REPORT 3171 -t *J This report is. to be completed by well driller andzsubmitted tQ analysis of water sample indicating water is of satisfactory bacteri .PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL','NEW YORK County Health Department together with laboratory report of al quality before certificate of construction compliance is issued. [_ REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION I OWNER NAME ADDRESS LOCATION OF WELL (No. d Street) J own) (lot Number) A PROPOSED USE OF WELL BUSINESS DOMESTIC ESTABLISHMENT ❑ FARM ❑ TEST WELL i ❑ SUPPLY El INDUSTRIAL ❑ AIR OTHER CONDITIONING ❑ (Specify) DRILLING EQUIPMENT COMPRESSED CABLE El ROTARY Ipl A R PERCUSSION ❑ PERCUSSION ❑ O� E y) CASING DETAILS LENGTH (test) / DIAMETER( Inches) WEIGHT PER FOOT p�' L^J THREADED ❑WELDED O YES NO CASING nUTED? YES NO YIELD TEST HOURS G.P.M. ❑ BAILED ❑ PUMPED COMPRESSED AIR . YIELD (G.P.M.) t0 WATER LEVEL MEASURE FROM LAND SURFACE— STATIC(Specify feet) �( DURING YIELD TEST (feet) �O Depth of Completed Well in feet below land surface: 6CIO SCREEN MAKE LENGTH OPEN TO AQUIFER (loot)' DETAILS SLOT SIZE DIAMETER (Inches) IF 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 O V If yield was tested at difFerent depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED CIAT§ OF RIFPORT WELL DRILLER (Signature)t.�i''�l ti / � V +_. PUTNAM CDUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building l Building Constructed by �' / c10.0117 . Location - Str� Municipality /W Building Type Section Block Lot Subdivision Name Subdivision Lot # GUARANPI'EE 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 "Certificate of Construction Compliance" for 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 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 4 day of lV1 Signature ` rrriq,. ��✓ v Title General Contractor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 mk C� Corporation Name (if Corp.) Yorktown Medical Laboratory, Inc LAB Y,;.02s6 . ' '321 "Kcar Street ' Yorktown Heights. N.Y.10598 Collection - Station Used Carmel _ Peekskill _ (931x245.203. Mt.. Kisco Nev City _ Director: Albert N. Padotvni AL T. (ASQ) — Date Taken: Date Received: 7 AY Date Reported . : 'PDX A . Collected By: l�(p Referred By: PP 4,e 0_ N F J Sample Source fr-p L -7 LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA L /Standard Plate Count per 1.0 ml (Agar plate.@ 35. °C) NEMBR:ANE FILTRATLON TECHNIQUE (MFT) Total. Coliform per 100. m1 Fecal Coliform ner 100 ml Fecal Streptococcus per 100 ml Vr ^C: T) ID .BLE NUMBER TECHNIpUF, (MPN). Total Coliformn: MPN Index n.er 100 ml Fecal Coliform: M P N :Index. per. 100 ml OTHER ANALYSES THESE RESULTS. INDICATE THAT THE WATER SAMPLE. OF A SATISFACTORY. SANITARY QUALITY ACCORDING' WATER STANDARDS, FOR THE PARAMETERS TESTED, A Albert H. Padovani, M.T. ASCP), Director J iAS (WAS NOT) (NOT APPLICABLE) TH NEW YORK STATE DRINKING TIME OF COLLECTION. _ LEGEND RDS - Recommend Disinfect- ing Water Source < a less than TNTC a Too Numerous Too r....., grrWoe �m r -s. r '{� • y �'a.,h 'w' .n •rya e2-. 1. F. •s � r 1 PUT'NAM COUNTY DEPARTMENT OF HEALTH - _DIVISION OF ENVIRONMMAL.HEALTH SERVICES . tl�070 01-7 t° X � FIELD INSPECTION REPORT p'e (Nam�! of Owner) (Street Location) INITIAL SITE INSPECTION YES NO Wetlands on /or proximate to property......... .. Property lines or corners found ................... Can estimate house location ....................... Willdriveway.need cut ....... .................... Must trees be removed - note these................. Deep holes representative of entire SDS area...... Additional deep holes needed..... ............... Sufficient SDS area available considering driveway cut, house location, separation distances,ete... Adjacent wells /septics ....... .. .... Z) D. H. 1 Lot Depth to G. W. Depth to rock Soil Descri tion 0 ft. 3 ft. -6 ft. 9 ft. 12 ft. D. H. 2 Lot Depth to G. W. Depth to rock Soil Descrii 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. — DATE: _ FINAL SITE INSPECTION INSP.BY: House SSDS located per approved plan ........ .... Length of trench measured Width of trench average Slope of tile line and trench acceptable......... Rocco allowed for expansion trenches .............. Over 100 ft. fran watercourse .................... Natural soil not stripped or SDS •. unnecessarly graded...... . .. ff..... 10 ft. maintained fran property line and 20 ft. fran house.... .. .................Y...... Distance well to SSDS (ft.) ...................... Number of bedroans checks ........................ Stones, brush, stumps, rubble, etc., greater than 15 ft. fran nearest trench.. . 15 ft. of peripheral soil horizontally fran trench...... ....... ........................ Boxes properly set ............................... Could surface runoff from driveway, roads, ground surface, etc., channel near SDS area.... Does lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE .................. �c DATE: INSP. BY: CAS 6/ D. H. -Deep Hole G.W.- Groundwater D.H. 3 Lot Depth to G.W. Depth to rock Soil uescr 0 ft. 3 ft. 6 ft. / 9 ft. 12 ft. YES NO CAS ` •pG�i Sri / ohs �-- r^ ` ����� - 7� Cl� __ � �o,� ; � �� � ' � - _ �5 � ��' �� � � . \. � l /�f !/ (/ �� �`Vn/ "� i �� d �� � _ . - �� �: �_ � . �o // 0 0% c� .3 �� S fl.-r / �.5 ,. � �� � f `.r � s PUTNAM COUNTY DEPARTMENT OF HEALTH bivisi6g'OF ENVI-PONMENTA I L.-BEA . LTR. -SERVICES COUNTY.iOFFICE BUILDING, CARMEL., N.*'Y. 10512 DES.IGN'DATA BHEET= SEPARATE SEWAGE `DISPOSAL SYSTEM FIIE'NO.--- 169e, 2 a,-; .''Address.",- a _'15 e- A", W111:71 a '04 L66at6d--dt (Street (Indicate nearest cross streetT f Municipality Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE S'UBMITTED`WITH APPLICATIONS—..- ilK•i I ". wrVV - ­­ -- Ljl V No. Time From Ground Surface in Inches Soil Rate.:: Staj�t Stop.... in- - lUn. /in dro, Stb&t`:�$tbp Min. p Inches. Inches Inches 4 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 from top of hole. glo,3 ev C; 0 4, ........ ... 4 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 from top of hole. Soil Rate Used Min/1 "Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity Gals Type Absorption Area. .Prvide- _ByL.F..x2�+ "..: e r Wama 61Rnature � •• "•o �, Address THIS SPACE FOR USE BY HEALTH- EPARTMENT ONLY: ]ate Soil Rate Approved Sq. Ft /Gal. Checked b _ PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF HEALTH SERVICES FIELD INSPECTION REPORT DATE: C G / 'D -P17 %�G �yGi� �l INSP. BY: (Name of Owner) (S eet Location) INITIAL SITE INSPECTION YES NOI CCMENTS Wetlands on /or proximate to property .............. Property lines or corners found......... ........ Can estimate house location ....................... Willdriveway need cut .................. ........ Must trees be removed - note these....... ....... Deep holes representative of entire SDS ea...... Additional deep holes needed..... ••. ..... Sufficient SDS area available consideringiveway cut, house location, separation distanc ,etc... Adjacent wells /septics ............. ..... ...... D. H. 1 Lot Depth to G.W. Depth to rock Soil Descri 0 ft. 3 ft. 6 ft. 9 ft. 12 ft L] D. H. 2 JG.. Depth to Depth to Soiscriptioi 0 ft. 3 ft. 6 ft. 9 ft. 12 ft. D.H: - Deep Hole G.W.- Groundwater D.H. 3 Lot Depth to G. W. Depth to.rock. Soil Descri tion DATE: G 0 ft. FINAL SITE INSPECTION INSP.BY: YES 3 ft. House SSDS located per approved plan ............. Length of, trench measured % Width of,trench average Slope of tile line and trench acceptable......... a �( Z 9 ft. Over 100 ft. from watercourse .................... 12 ft. Soil Descri tion DATE: G - FINAL SITE INSPECTION INSP.BY: YES NO CHI'S House SSDS located per approved plan ............. Length of, trench measured % Width of,trench average Slope of tile line and trench acceptable......... a �( Z Roan allowed for expansion trenches .............. Over 100 ft. from watercourse .................... Natural soil not stripped or SDS area unnecessarly graded.......... . ..... .......... 10 ft. maintained fran property line and 20 ft. fran house... ........................ a --7 s Distance well to SSDS (ft.) ...................... Number of bedrooms checks ........................ Stones, brush, stumps; rubble, etc., greater than 15 ft. from nearest trench.. ............ 15 ft. of peripheral soil horizontally from trench ..... ............................... Boxes properly set.. . .......................... p y� 6. / Could surface runoff fran driveway, roads, ground surface, etc., chan nel near SDS area.... Does lot drainage appear OK in area of SDS....... FINAL GRADNG OF SITE ACCEPTABLE.. I DIMENSION CHART (in ft.) No. A 8 D- / 35.9, 59 2 B8.5 375 3 94.5 43.5 4 /00.5 4-95 5 /07 SG G N3 G /•5 7 /i9.5 68 8 /OB . 45.5 9 9G 78 /0 /03.5 BO 95 /Z /i9 96 /3 /16 95 V TN /S /5 ZO CEZr /FY . THAT THE SEWAGE .015POU4- SYSTEM W45 CON5rRUGTED AS /ND /GAPED ON rVS P[AA/ AND TNAr THE SYSTEM WA5 /NSPEGTED BY ME BErOCE /r wA5 GO vERED OVEe . THE SYSTEM WA5 CONSTRUCTED /N A000.2OAAlGE W/rfl A" STANDARD, RULES AND CEGUGAT /DNS 'OF THE PuTNAM WUArY 06GA- -,PA l&vr Of REAk, AND rNE NEW KO,ec SLATE DEPARTMENT Of 115.4 • A � exh 1 v�. 1 A. l II o � � DWI 0 F y