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HomeMy WebLinkAbout0065DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.15 -1 -18 BOX 1 WIN rr 60 m Is I ly III ,. j 00065 r' PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY a r SITE LOCATION S _in YV. �TM# OWNER'S NAME Rill I q v p PHONE MAILING ADDRESS /O -Ac•o0 i0 r- 94 6, PERSON INTERVIEWED PCHD Complaint # ame Relationship i.e., owner, tenant, etc. �. DATE %�Gt S/ % , p $ TYPE FACILITY 1 A fLl wJi de PROPOSED INSTALLER F ADDRESS S'd�/tf� (,�/ 1 f1v 1iJ'. /V ��REGISTRATION# /SC/ Proposal (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 from licensed professional engineer or registered architect. 1 ogsWem yew Pia? �roN^ 7&-, n k T 4!w*l v /ski ' • 15w si , i* a � x 3a �I,�er� des ueI afe T u 1/ 64wV 16 kg o- 1'4 ,' ru ks, po &h ha ,4 4- fo &wA tla W bl oX (4 D/►le- 06V IW ✓c 4 -70 `1;K e L6- 0,0 10mg t I, as owner, or rgported ent o o er agree to the conditions stated on this fork SIGNATURE t'/ TITLE on 4n //` //1 AIT 30 1 %S ha /c 001141V 0A Ad - / A /.dl e) hu/'er/ ��� �✓!� f �WGL�, S��GQ Dr DATE !& �/ 0_5_ 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 components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 1. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved, Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE � POJ j" 00.0 8 ® well 1 dilo 1 - 30 I 4e�o, aW�j &i led�� . �o, INA -t O'L PC 60 k /4 - ® -wet 1 n Aell �wslsg /v if CO,ane or Purchaser of building . b � ti Building Constructed by Lod tion - treet Building .Type a Municipality Section . Block Lot GUARANTY OF SEPARATE SLIMIAGE 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 the St+cl-nm 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 day of ter_ 19 Signature Title (if corporation, g vex( name and & dr ss c---------------------------------------------------------- THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REOUIRED 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 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 NAM fL // "�` j ADDRES —.�� o T I LOCATION OF WELL o. 3 treat) T wn) (Lot Number PROPOSED USE OF WELL DOMESTIC ❑ ❑ SUPPLY ❑ BUSINESS ESTABLISHMENT INDUSTRIAL ❑ FARM TEST ELL ❑ CONDITIONING ❑ OTHER DRILLING EQUIPMENT ROTARY ❑ COMPRESSED AIR PERCUSSION CABLE OTHER ❑ PERCUSSION ❑ (Specify) CASING DETAILS LENGTH (lest) 3 DIAMETER (inches) rr WEIGHT PER FOOT A� THREADED ❑ WELDED SHOE ES ❑NO CA�fRG ? YES O YIELD TEST ❑ BAILED ❑ PUMPED COMPRESSED AIR HOURS . G.P.M. w YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE—STATIC (Specifyfeet) DURING YIELD TEST (feet) ( Depth of Cori feted Well in feet below, land surface: AID SCREEN DETAILS MAKE LENGTH • P F7f AQUIFER (feet) SLOT SIZE flrN DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): GRAVEL :MFROM (feet TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, )o at least two permanent landmarks. FEET to FEET ;s i b� If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE ILI 1A DATE WELL O LET DAT O X,�y WELL DRILLER (Signature) f vY7 a BREWSTER LABORATORIES Box 224 - BRMSTER, N. Y. WATER ANALYSIS REPORT r SAMPLE NO. 3128 SOURCE: 1?1cAZoon. - faucet - well supplry. Saplin Court Sec. 165 Patterson, 1'l. Y. Lot BI -13 COLLECTED: Feb. 5, 1-0,74 BY: l . `o o d BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method Feb. 9, 10 This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 0 Per 100 ml. itwtickwit P. E. Director B ........ /9/ n A To 21' 57' Iz 71 �71 Cc) Z'A R vvrz L L,, 0 .5Y rlc-- 1! 5- z z APPROVED FEB 131974 PUT cou Of EALTIH 8 te . , -- I . ..... I . ...... ... .Rrkro • __4gWRKe-", DIVISI Of f,*qIRONMENTAL 141AL H SERVICS? olc% s OF 0- Zo "I 71 A/ ..... ...... ............................. . . . . . . . . . . . . . . . . . . . I ............................ 715 WA 11 le 'Z APPROVED FEB 131974 PUT cou Of EALTIH 8 te . , -- I . ..... I . ...... ... .Rrkro • __4gWRKe-", DIVISI Of f,*qIRONMENTAL 141AL H SERVICS? olc% s OF 0- A/ J A0,4 15 APPROVED FEB 131974 PUT cou Of EALTIH 8 te . , -- I . ..... I . ...... ... .Rrkro • __4gWRKe-", DIVISI Of f,*qIRONMENTAL 141AL H SERVICS? olc% s OF 0- A/ J A0,4 PUTNAM COUNTY DEPARTMENT OF InUTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA - SHEET- SEPARATE SEWAGE DISPOSAL, SYSTEM FILE NO. Owner Address Located at (Street Sec. Block Lot cat eares cross s reet Municipality � Watershed SOIL PERCOLATIONT TEST DATA REQUIRED TO BE SZTBMI WIT APPLICATIONS 7 l3 " 5 d 1 3. tl- 5 1 _ 2 4 5 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. Hold Number CLOCK TITS PERCOLATION PERCOLATION apse 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 l �ff�D ° 2&7 '7 (p'� l �O � %C� , 7 2 7 l3 " 5 d 1 3. tl- 5 1 _ 2 4 5 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. PUTNAM COUNTY DEPARTMENT OF HEALTH s DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA.SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. ' Owner i, Address Located at (Street A See. Block Lot cate7heares t cross s ree Municipality Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMI WIT APPLICATIONS Hold Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse. Deptn 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 1 3 .4 5 2 3 ... 4 5 Notes: 1). Tests to be repeated at same depth until aroximatelyy equal soil rates are obtained at each percolation test hole. All pppp data to be submitted for review. 2) Depth measurements to be made from top of hole. s ! Date: Insp.by: INITIAL SITE 'INSPECTION Yes No Comments . Property lines or corners found _— - Can estimate house location Will driveway need cut . . . . . . . . . . _ "- Must trees be removed -note these _ Is deep hole representative of entire SDS area Additional deep holes needed. . . . . . . . Sufficient SDS area available considering driveway cut, house location, separation distances, etc. . . . . . . . . . , . ... . . .. D E E P BOLE D-8, TA Depth: Water elevation.� Rock elevation: Soils description: �. Date : . _ FINAL, SITE 13ISPECTION Ins p.. by: House located where shown on approved plan SDS located .where approved .. ...... , a 1 Slope of the line and trenc h acceptable Room allowed for expansion trenches . . . . . Over 50 ft. from swamp,watercourse . - Natural soil not stripped or SDS area unnecessarily graded ... . 10 Ft. maintained from prop.line and 20 ft. from house _ Separation of trench from house, well etc. follows plan . . . . . . . . . . . . . . _ Number of bedrooms checks . Stones, brush, stumps, rubble, etc. greater than 15 ft. from nearest trench . . . . . . 15 Ft. of peripheral soil horizontally from trench . . . . . . . . . ... . Junction boxes properly set Could surface run off from driveway, roads, ground surface, etc. channel near SDS . . area.. . . . . . . . . . Does lot drainage appear O.I. in area of SDS FINAL GRADING OF SITE ACCEPTABLE , REVIEGI CITE,CK SHLTE;T rte- -z DOCUh1ENTS House plans O.K. Design data. sheet ! Peres presoaked? 14i.n. 30" pert test depth Const.. results for 3 runs I D. Hole.log O.K. ! Corporate Affidavit for other than individual i Authorization . for engineer ! Letter from Water Supply if applicable If variance requested -such noted on plans & apps._ DETAILS if change is proposed, ) Existing contours shown kshow new contours) ! Slopes for driveway cuts, etc. shown Water service line location Footing drain, etc. location Top slope, bottom slope of fill Percolation tests and deep test.pit location Septic tank size and conformance.to std. i 3 B.R. house minimum i House ysetback shown _I 1 !l ..... • i i 1 _,aL'. F_l -i r.. .t. .. z.., . r-_i. 7 iii .i. 7� ,j ,.. A_L1. 'wa ck(=�r W-L V11ill )U 1 1, . G_+.- -Cli .)11UWi1 I ets Std. Remarks Plan SDS 'i ._..... ..................... ... ... ..... ..._....... ......I...- ..rte, /.J�- ...._... {.... .. ...... ..... .. -.. .... ._: .... Plan and prof I All other wells and SDS closer 200' fj shown or reference made ! Property boundaries (metes and bounds - clearly shown ' i _ SEPARATION DISTANCES SPECIFIED ONI PIA 10' to P.L. 20' to Foundation walls 100' to Nearest well 50' to stream, march, la 15' to Curtain drain 10' to water line (pits- 15' to storm drain 10' to large trees 101 from foundation to s 5 to pipe from leader etc. (incl.expansion)_ lap- .',f� h} � k •�._�� t _�^tr u� r.P a J � � s. -- �s � ;o, 'w ���9 `� i ,y ,� L,� �� #'�. z q f a� r y +�y i x,± '.k:- n, J,ai' oS F`*�. Sri a ,r. s ; xh P t €a..., `n�a� ft t- a' ✓sm � w' s:�.y.7 �' 'f% tj' wi 'Aft, It Ir CD 1 ^ Q l its �� v fb��tCEN eQQ�� y t f - -� _ .1 --7 4 o cy' I t � JT O W r 1 o ( C oil SITE LOCATION( OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY ss� ©V PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e., owner, tenant, etc.) DATE A0 ri/ ly ll s TYPE FACILITY � PROPOSED INSTALLER 4 k _ PHONE tf-2r"3S'6,0 pe -61?f -4 Q ADDRESS #01*S W REGISTRATION #/��� Proposal (include sketch locating all adjacent wells): 19Sf[ NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. I; as owner, or r porte a ent of er agree to the conditions stated on this form. form. r SIGNATURE TTTLE l �� �� Y I"/ DATE 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 components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X.6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Propos a roved Inspector's Signature & Title DATE COPIES: White (PC) ID); Yellow (Town BI); Pink (applicant) PC -RP 99ML It" A- omll p 1,211 �� j ( T �t� U�l- ��ih a,�,l ��� i Yl 0,0 , olou.-e, RUx -IS A,LA) f)JrOL� Are Y L— - / 7' , •r:.zs- 0,�j lDh,7 fy% E IES b" o o > _ .- � Frr. - -S6 - -'-•^{ - . G. r�r�E -ice r v s ✓e-L /�T�� /%� " 1r _ I �• I 1 a',� ��,Q � 0 0 � Iel APPROVD E AtIG 13 1973 cuull A IM MTN SERVICU _ _' _ _ _ err .rte ysrtwj : 07" - _ , fir. � yrl/'i✓ �oten/�'y' .s7Qi✓m���. • , o � �01 _ �, . �; � 3 Tiff fig -L�3 f�✓s.�cra - . /�, ��.3 ,?;'!� ,,�;�/�as , jf�seG7w %��^j"l r�i�io.4 7r7 tfacic"r1dF!1 OF Ne � �' ` S1Q` MUR h: ^.. `O i .r.�"1sf�" /.t G•>4.: .rC.+%��J'�� -s7� v /.: m .7.'_.! /C °�- 1 t - - A . PE a• / SSIO NQ�.�` ' G'7G, /`�/S /F'i�. ����-'/✓•'�l�• 111 - r • JCi1i� (Ns. _ / -cam° • : ' ch>`"x` �G r�rt% -W y'et.�,.4- ul ulll