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HomeMy WebLinkAbout0055DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.15 -1 -7 BOX 1 00055 I'r I ; ,� L Lj , j `I 00055 YES PUTNAM COUNTY HEALTH DEPARTMENT p DIVISION OF ENVIRONMENTAL HEALTH SERVICES OPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR r �- °-0 Internal Use Oniv PERMIT # �Z 4_ -� ' ❑ epair Permit issued in last 5 years 11 Aot in Watershed ❑ Repair within Boyd's Comers, W. Branch of Croton Fails Res. � Delegat9d ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION TOWLL N TM # 5 OWNER'S NAME � � 6 At E S K O, /PHONE# MAILINGADDRESSK .5-2 ,l ,2i` ' -Yf ree:t ta Yf 67r,60 n IJ V APPLICANT. New & Relationship p.e., owner, tenarn, contractor) DATE I /'��:%+9iS� FACILITY TYPE ffOf PCHD COMPLAINT # PROPOSED INSTALLER T mac! Gl �i _ PHONE # t11%1-�'�"1 ADDRESS P C"^e- REGISTRATION /LICENSE # Proposal (include a separate sketch locating the house, 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 li ensed professional depending on the nature and extent of the repair. Sy:5 �e » © k.. eu cepf. r Pr sf roo, I, as owner,agree to the conditions stated on this form SIGNATURE TITLE W r) t° r- DATE (owner) I, the. septic installer, agree to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE HIV- DATE pnstaller) EM foll wi 1. F�rocure ent 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. b. No completed work is to be backfilled until authorization to do so has been obtained from the Department INTERNAL USE ONLY Proposal Approved is in COPIES: PCHD; Owner; Installer PC -RP 99ML Proposal Denied ❑ codes Da 0 S— Il No ❑ Rev. 2/07 } 5 iv � s``` tLs z. `.3 � � Y c- �' A � � s �' �^•rfi��: �' "�' -. s-� '� � s -7'� .� z '"r•`� r 7.'V�r XWgE,, 'cam' .. i� ?' L � .�• f .'.� � � a a 1 .may 5`�SC� ry 3^� � +'- ti. �. ,,� �`c NIV, u £ � � 3.. `� ,, rt � �'t r "€ x -ate" �.:. ,� -�:_ -• Z.: 1.1 WV �,10t NL IV314 401M3Nllf�idd3tl X14603 W .: . . . . . . . . ... PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner•a Address: Located at (street): T1VI' %S s % 7 Municipality: � -CiSc9i/1 Watershed: `� 14 l SOIL PERCOLATION TEST DATA _ Witnessed by: C r Date. of Pre - soaking: f O Date of Percolad6n Test: Hole No. Hole depth (Inches) Raw No. _ Time Start— Stop Elapse water from Water Percolatiou 2 .. Time ground level drop 3 3:0 q — 3.3 surface 4 . min/inch 5 1 Start - Stop 2. 3 4. 5.. 2 -3 4 1 2 3 4 5 Notes: 1. Tests to be repeated at same depth until. approximately equal percolation rates are obtained at each percolation test.hole. (i.e., <_ 1 min for 1-3,0 min/inch, < 2 min for 31 -60 min/inch). All data to be-submitted for review. 2. Depth measurements to be made from top of hole. Foam DD-97, pg 1 of 2 Depth to Elapse water from Water Percolatiou .. Time ground level drop Rate surface in inches, . min/inch (inches) Start - Stop Notes: 1. Tests to be repeated at same depth until. approximately equal percolation rates are obtained at each percolation test.hole. (i.e., <_ 1 min for 1-3,0 min/inch, < 2 min for 31 -60 min/inch). All data to be-submitted for review. 2. Depth measurements to be made from top of hole. Foam DD-97, pg 1 of 2 . Indicate level at which groundwater is encountered A/,,, A Indicate level at which mottling is observed Indicate level to which. water level rises after being encountered . Deep hole observations. made by: _ _ . Daze / z i Design Professional Name: Address: Signature: Design Professional's Seal Revised July 2013 4i. -A 45 A)lJe'( netv 1,64- IWO r-7- APPROVED /0� JUL 2 61973 J�e U IILALW PUPACoul T N 121 1 �il IVISIOIJ OF jFMVjRot4oWAt "IFAITR "IOVKF' WOM7 I 3,V -A 45 A)lJe'( netv 1,64- IWO r-7- APPROVED /0� JUL 2 61973 J�e U IILALW PUPACoul T N 121 1 �il IVISIOIJ OF jFMVjRot4oWAt "IFAITR "IOVKF' WOM7 I i \ ! aw Y *�. ', i �Y1rrG}. 3t 3rCI�F x�tsY33ii r;gr,- `1 , .i �Ay� � I N MU S- a 311 -rnun %OVAf Town 19 Pond $ k 4 + f 62 _ 4 B Camp y t n Pandy a o tembeck " rce a ;Corners V FO o p9 +an r1 iers Moporia BREWS R HS Y §,� f.. LL ®ES �O�ensu� �� ae Brewster ' € ai3 v� inn es Pond ern MS 1 < RD Ill l l � PUTNAM COUNTY ••DEtARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N. Y. 10512 CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM A Town or village Located at ®� © %/tj� i ection Block r Owner /%4QlPOL /i,S \Lot Job Separate Sewerage System built by`'��CJL90iJ� E Gf VA 71 -6 ' Address Consisting of / ,0C) Gal. Septic Tank ` a lineal Feet X width trench Other requirements Water Supply: Public Supply From Private Supply Drilled BY Address Building Type No. of Bedrooms �,3 Date Permit Issued — Has Erosion Control Been Completed? I certify that the system(s) as listed serving the above premises were constructed essentiall 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, he permit issued by the Putnam County Department of Health. I� 7 P.E. R.A. Date f Certified b Address ' `' `,s "� v License No.�� Any person occupying premises served by the ab4e systems) 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. Date .�.9' - / By i 2402 I YORKTOWN MEDICAL LABORATORY INC. Yorktown Heights, N.Y.10598 P.O. Box 99 321 Kear Street 245 -3203 RESULTS OF EXAMINATION OF WATER OWNER CITY, VILLAGE, TOWN & /OR NAME OF SUPPLY I DATE REPORTED 9 ROUTE FISHKILL, N.Y. m np ___ T.nm -1� OoLL BACTERIA'PER ML. (Agar plate count at 35'C). .29 COLIFORM.GROUP (Most probable No, /100m1.) LESS THAN 2.2 . HARDNESS*, TOTAL -ppm DETERGENTS - ppm NITRATES (as N) - ppm IRON, TOTAL - ppm FLOURIDE (F) - mg. /1. 'These results'indicate that the water was YES PER: LAKE CARTEL PHARM. of a: satisfactory sanitary quality when the 6Q was H. P.ADOVANI, M. iA -!/ M E R R 0 L I N D USTRIt WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF- HEALTH 3/71 Division of Environmental Health Services COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submitted to County Health Department together with laboratory report of 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 NAME MR L.JXMITTAMPTES ADDRESS ROUTE 90 FISHKILL, NEW YORK 12524 LOCATION OF WELL (No. 8 Street) (Town) (Lot Number) P 'roRK PROPOSED USE OF WELL BUSINESS FLI DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL 11 SUPP Y El INDUSTRIAL ❑ CONDITIONING (s(specify) DRILLING EQUIPMENT a COMPRESSED ❑ CABLE ❑ OTHER il ROTARY AIR PERCUSSION PERCUSSION (Specify) CASING DETAILS LENGTH (teat) 60 DIAMETER (inches) Si rWEIGHT PER FOOT � THREADED ❑ WELDED D I ES O YES ❑NO S CASING ES NO YIELD TEST �j HOURS G.P.M. ❑ BAILED ❑ PUMPED L 1$ COMPRESSED AIR YIELD (G.P.M.) 316 GPN WATER LEVEL MEASURE FROM LAND SURFACE— STATIC (Specify feet) DURING YIELD TEST [feet) Depth of Completed Well in feet below Land surface: 280 ft. _ SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well including I 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 0 Drilling 50 in overburden - it solid rook at 50 ft. 50 60 ri sng roe - setting using - grouted 60 280 rifling in rock - If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPLETED 6/16/73 DATE OF REPORT 6/27/73 WELL DRILLER (Signature) F. F. AL & 8011w CE_ �, >, Owner or Purchaser of building Building Constructed by AJO/IF Ty' .ST Location - Street Municipality , Section Block Building Type Lot / GUARANTY OF SEPARATE SF,WAGE 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 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 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 occupant of the building utilizing tha cv .qi-am The undersigned further agrees to accept as conclusive. the determination of the Director of the Division of Environmental 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 Y of da ✓u- � y 19-X3 Signature g Title P•PG S (if 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 ' PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL' HEALTH 'SERVICES -_.._. ...COUNTY OFFICE BUILDING, _CA N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. _.T 2- u. u L.' ,�. Owner �iQiQOz- /Np(/sTRi,ES Address Located at ( Street No�T /� sT Sec. Block' Lot' ;; r � indicate nearest cross street) - -- -- _ - -- Municipality Pi4T7-,---/-?S041 Watershed SOIL'PERCOLATION TEST DATA''REQUIRED TO'-BE SUBMITTED'WITH APPLICATIONS Hole Number - CLOCK TIME PERCOLATION -` PERCOLATION Run apse Depth to Water Water Level No: `: Time 'From' Ground Surface -'in -Iriches*­ - -- -Soil Rate Start -Stop Min. Start Stop . Drop in Min. /in drop' Iriches Inches _" Inches, ./o 2. /':`ss ... -off_. _.. 7 9 z .. 7 J... J 7 �_.... a .�-7. 7 :. 77, 7 2' 1 2 Notes: 1) Te'�ts to be repeated at same depth until approximatelyy equal soil rates are obtained at each percolation test hole. App data to be submitted for review. 2) Depth measurements to be made from top of hole. I �� 46ti� F �oo�od 1 L }1`"i i 1 � /J7'>En 7Jh i5 �yJ�'(�]".D",• -� �i —{Y � ' ?NNE + � I ' 9aci GnL wYc. >Anrr - `_. $ �� 1 � - mac, ,.•-�. S G