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HomeMy WebLinkAbout0201DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 4.15 -1 -3 BOX 3 1, ,' .T 1` i4 1. f r 1 r 00010 -IN UST -�-DEPART -OF HEALTH -PROVIDE - -Town or Villa- go WL 73 M separate sewerage system built by . gfecm H10-- C0KjrekqCTDP—S Address R9 4. f).6k kt-Y' septic Tank and Water Supply: Public Supply From V Private Supply Drilled By 60y'C-) Address -7 � � No. of Bedrooms Date Pormit'istued His Erosion Control Been Completed? Has garbage grinder been installed? I'certify that the system(s) as listed serving the above premises were.constructed essentially as.shown on p ans of the completed work ( copies of . which are attached), and in accordance with the standards, rules akd regulations, in accordance with t�h f ed plant and the permit,issued by the Address License No Any person occupying promises served by the above systern(s) shall promotly.'take such action as may be necessary to SeCuke'the corrodlon of any unsanitary conditions resulting from such usage. Approv' - &I of the sep4rate-sevveraq I a. . sy iie . m shal , I - become -nfill and iOW asi-soon at a pu 1 blic sanitary "War becomes av liable and the approval of the private water supply shall boc6rne null and vold I when 8:pu�lic wat4i supply becomes avallabW Such approvals are s6tject to modification-or change-when; In the Judgment 6f'ihG.Co'MmlSsii0n&r �of- Healthi such revioica. n, modification or change is necessary. Title _'�gv.o/o � -4 _ N WELL UUnFLE'11UN Krlruml DEPARTMENT OF HEALTH Division Of Environmental Health Services COUNTY DEPARTMENT OF HEALTH Office Use Only -- WELL LOCATION STREET AOURESS: TOWN/ YII I I Y TAX GRID NUMBER: �U R 1 DG - PA7TERSON WELL OWNER NAME: ADDRESS: ,D *� S ,0V..1 �tI DUTGHEk H0/nE-5 "� - 60X 73 / /a�(,�3 epBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary )(RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM O 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 9 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH a3D ft. STATIC WATER LEVEL ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY KCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. WOPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH ____52 5' -1t MATERIALS: 1R'STEEL ❑ PLASTIC D OTHER LENGTH.BELOW GRADE ft JOINTS: ❑ WELDED I!!rTHREADED ❑ OTHER DETAILS DIAMETER in. SEAL: CEMENT GROUT ❑ BENTONITE ❑ OTHER WEIGHT PER FOOT Ib. /ft_ DRIVE SHOE�YES ONO L1NEA: ❑YES �CNO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (1t) fJEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO HOURS SECOND GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEFM ft, WELL YIELD TEST ' I( detailed pumping MEJHOO: ❑ PUMPED tests were done is in- COMPRESSED AIR , formation attached? O BAILED ❑ OTHER :OYES ❑ NO 1PIFLL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE water Bear- ing Well Dia- meter FORMATION DESCRIPTION CODE ft. ft WELL DEPTH It. DURATION hr. min. ORAWOOWN It.. YIELD gpm. Lance Qom! //,31�°CrirnJ / ,S !� z.n a'c:e.cize% WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ❑ NO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAME 4?41 emu p� .1 DATE r- AO RESS S S1G 7:}( Q /AleL l4�� i� PUTNAM COUN'T'Y DEPARTMENT OF HEALTR DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building Building Constructed by LyT #7 ©u9.rf�c /I �l Gf Location - Street Municipality Building Type / Section Block Lot VUAkt2 /F /-66Q�; Subdivision Name Subdivision Lot # GUARANTEE 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 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 �� c', 19 . ��� '11Y °'' 4 neral 06itxactor ( (Jwner) - Signature Corporation Name (if Corp.) Address % rev. 9/85 mk Signature ������. %is✓'` Title Corporation Name (if Corp.) t Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights. N. Y. 10598 (914) 245 -3203 Director: Albert H. Padovani M. T. (ASCP) i DUTCHER- HOMES. ^ . R.R. #4, BOX 73 PATTERSON, NY. 12563 L J LAB N CA.005786 Date Taken: 11./4/8 Time: 8: ?0 Date Re' d : 1.1/4/87 Time,: 10 Date Reported: NOV- 09=7 Collected By: Referred By: Sample Location: Aitcllerl Tau 9 Quaker Rdge Estates 1jatterson, INY Phone H - Phone # Sample Type: Repeat Test? _ I(check one) _LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA X Standard Plate Count (CFU /1.OmL) (Agar Plate @ 35 °C) MEMBRANE FILTRATION TECHNIQUE (MFT) ,rte X Total Coliform (CFU /100mL) 0 _ Fecal Coliform (CFU /100mL) _ Fecal Streptococcus (_CFU /100W MOST PROBABLE NUMBER TECHNIQUE (MPN) _ Total Coliform: MPN Index (per.100W _ Fecal Coliform: MPN Index (per lOOmL) OTHER ANALYSES REMARKS (For Laboratory Use) X Potable _ Non - potable _ STP INF STP EFF ._ Other: Sample Status: (check each) Outgoing — Na2S203 Incoming X LE 4 °C _ GT 4 °C _ Other: KEY FOR TERMINOLOGY RDS = Recommend Disinfec- tion of Source TNTC= Too Numerous To Count CON = Confluent ( =TNTC) LT �. Less Than (� ) GT Greater Than (> ) N/A Not Applicable L2 s LARR than nr enual to THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH NE YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT-THE TIME OF COLLECTION. J x Albert H. Padovani, M.T. ASCP , Director 12 /85(RvsdT /ST)RWE For Lab Use Only: _ H/C to LAB OFFICE HOURS (Main Lab):.. 9AN -5PH, Mon. -Fri. •. 9AN -NOON, Sat. I' . 1717. V. 4- - FRIP_L - 'TE LN E ION In= _tea by rr � OR SUrDri SIG. LOT a I YES Nyl 5 DIS- '--AL P -REA a- EDS arc- 10C= L...a as Ear ancroved plans b. Fill sactica - Date Of placCr =nt 2:1 b�r�ieY . LGT Q W P_VG _ DFfi ' c_ T.y, -^i sci1 not s icced + I - I d_ 5wne, brush, etc-, er==_te_* tzcn 15' SLS �*-�_ I i e. 100 -ft_ fran wat_r ccurs_ /reset! and.. I a.ot_c t=nk -- - 1, 000 1, 2 b. C. 10' ff l nLnam fcL'- ^_C t'_cn I I C_ Ik Q0� bends, Cl-- ="'_CL't wi`n_n 10 fc_ Cs -5° b- I e- DIS QTETjTlCLN EC.K I 1. A-1 -1 cull ts at- SaT.c e v t? cn test ' 2. Protscted b—z' 0, f_ct 3. K .' Lr7a= 2 ft. crici rill soil t_tWe__ ire t=erc _es I e S f . J � = ?,, CN FOX a- 1 L cz r u_� 2. Distz-:nce tc watEirc=se 3. L -Is`=l l= j ec=r:5- rc to plan I I a Distance canter to cantar I 5. Sicce of tranch accen`able 1/15 - 1/32 6. 10 f r f_= trctar -ty lime - 20 f� - fc =caz— cn_ r I 7. Cemt:-i cf t en_ch < 30 i_iche_= frail s-=_ace 8. Rccm allawad fcr EY-_ =n =icn, 50% ( ` ) a J . Size of c —avel 3/4 - 1 ;" Giamet_- 10. CcDtn Or c —ravel im trnrach .12" IILiILT- m, I I L. Fi :.e ends crc- I h . FCAT CR LOSE SlrST- -s 1- Size of pt_-1 C=-Lzer 2. CGZT=1ca tank 3- p'amon, visu'=l /a" -'c d P= easily Ira ^dal ° to Grade V I I 5- First bcx bGffl — I 6. Cycle wi-Lnesse. by Ee=_l h Dema-rtccnt e=ti_rat flees r� cJC1e FOUSE a- Ecuse lace _---: pe✓- accrcvel plarls. b. N -L =Ler Of a�WeLl 1Ccatfi as ce accrc)ve- D1ar'c b. Distance fran SCS a-r=—= ina s'�eJ ft- C. Casing 18" al:cve Grade_ ( I Q. S=- -ace ZraiP=Gc c?"CiLr - we-'-! accast able- I I I a_.7 . 4Kt7F��5"r_0 a. Bears Lrccerly crcut b. P11 pies -rL; ally bccK =i1? c. P? i_es f1Lh with i-_ =ice of bcx c.. E still Irate* -ial ccntr_rs s`cr_es < 4" ir2 e. o r twin drain it = =.= -> > w accordi nc to pin f. oar �-in Grc331 cu al! prcteC` -_. ^ & d?; -to EY'at.- wct =rccurse C_ FCCtin-C C_r`i- c d' SG ^_- :Te away f -= S,S aza= I h. water prat= _cc acs =`= I I i_ � =esicr_ cva�o! prcvc_n cn slcc� cr==-= tLn 1�3. I tai I - - L r'. �1�� 4 F101A✓fG , W�1.� t� DI2IV�VJA'%: �D�,YIDtJS r c ' A& t'Fiit" 5LAWVEY ?>'f :12 TUII � ?+ >;;•: bATETD 9 I a- 0 7Y S \ 1150 &AL MAWt4� TAP 5 �P C.Uf.?AItJ bRAlt.1 T G Fi OP` \'t zo rat, MA"K'f sWn� Lf aP 2411 TRgti-c �' v � C)tooM . SANK �X 3 Roa -f o Gu��mirl awv� W5, 0 120 . i' >` w I l l 7 r :'Lr7CA�lotJ'�/�/o PNK 53'-�u 41' -0 Mxnam .Coagty Department at Heeit�. AS BU11.T .`APT IC C- (iSTek o nvinion of Swironmental Health Servioe. iST FAX i2 3. 5-V- fo y ; T:t:►1C t� NOME trlc , wroved as noted for oonformanoe with 6Ui IZ C � -1 gJ( I p,Q�=S - 70'-(o pplioable Rules and Regulations of the. ; 4 9 pUAKE. �Ib6E ATE 'u" County Health Department.. �' �'g �':.'..i.S IS T:� C? 'li} `j TI�11.T THE SECC/f.GL DISPOSAL SYSTEM WA -To WN OF pr�'fTMF,60t 1 . tf > #� .100. ? �i 19 c7" statgtttnre a tle t. (s^iJ77tUC,TrD AS INDICA IZD ON TIiIS PLAN AND O` M. ' I , , nr ME BEPOItE IT C'✓AS COVERED 1°UT.hIA n , �` ;ySttiLi W.'s INS. �CTID BY WITH ALL ti dt= env, -�O I l TIIE S'fSTER•f WAS CONSTRUCITD IN ACCORDANCE MICHq }p Ag• F 4 TIC+ RULE S AND REGULATIONS OP THE PUTNAA4 COUNTY 112' O (o e I7_PARTIAWT OP HEALTH. 119.0 sox 2 IZA`-O'` qA't m Wau. , - DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELLQ PCHD PERMIT # / F / "6y WELL LOCATION Street Address Town/Village/City Tax Grid. Number WELL OWNER Name ,[. / LD Gl/ �y Jr Address Gvh �S _-Wrivate O Public USE OF WELL t?- primary 2- secondary 04ZESIDENTIAL ❑ BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM ❑ TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify E .AMOUNT OF USE YIELD SOUGHT S gpm /# PEOPLE SERVED :3- < EST. OF DAILY USAGE gal REASON FOR DRILLING SUPPLY O PROVIDE ADDITIONAL SUPPLY '10 REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING Ool �t <.e,, o , 9/�-�c • WELL TYPE RILLED DRIVEN ODUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES _'ozLQ.O IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot NOT. WATER WELL CONTRACTOR: Name �' �� Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ND NAME OF PUBLIC WATER SUPPLY: //lrlr �.a�g TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 06N REAR OF THIS APPLICATION PN SEPARATE SHEET 20 fm te) (signature) 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. Date of Issue: i'I/d 4 -' � 74 �,' 19 Y5:�_ Date of Expiration : -`�o f/Z o 19 Permit is Non - Transferrable M. ermit Issuing f is C Autnam County Department of Health a Division of Environmental Sanitation y AFFIDAVIT - CORPORt1TE OWNER APPLICATION FOR PERIMIT APPLICATION .SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter of application for I 9 S — — - — — — — — — — — - represent that I am an officer or employee of the corporation and am authorized to act for _— JJU�CIft _ — — — — — — — — — (name of corporation) having offices at .Y) Q� AS Z r7Ts2So n/ It'll — 1Rj6- j — ___________ Whose officers are President - - - -/� ! — LUG6�� s -- -- - — — - — — N a ame n Address) Vice - President ._ _ _ __0_H_t) UCH 1�J_ _ _ _ _ _ _ _ _ _ _ — U T (Name and Address) _ _ Secretary _ i9 _ (Name and Address) Treasurer----=- LJ�IL��_N - - --- -- (Nafine and Address) and that I am and will be individually responsible for any or all acts of the corporation with respect to the approval requested and all sub- sequent acts relating thereto. Sworn to before me this day I Signed of C IZ:C f( 19� Title — PReSlbZ kJ7 — — — — NotECry Public W® Ux NO ql X10) �,glltied in Dui , ,/ P� gyp' fission ExP�res �I � Qv'(l`� 0 n f, ` Corporate Seal PUTNAM COUNTY DEPARTMENT' OF HEALTH -. DIVISION OF HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SV.TFXq REVIEW SHEET — CONSTRUCTION PERMIT DATE REVIEWED: l Z BY: (Name of Owner) (Street Location) Cmmm YES NO DOC[Il�IE M G /47 Permit Application Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other use Plans - Two sets fuse - Letter ��""`'7 Variance Request REQUIRED DETAILS ON PLANS Sewage System Plan Sewage System Hydraulic.Profile - Gravity Flow Fill Profile & Dimensions.- Volume J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes Design Data Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area Expansion Area;shown;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House - No. of Bedroans Wells & SSDS's w /in 200 ft. of Property Located QC Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake Unc. expan) 15' to Drains -C rtain,Storm,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' fran Foundation 50' to Well 15' Well to PL QMM AL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked etland (Town/DEC Permit R & D) lx� I Data On DDS Plans & Permit Same 9 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 'DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO . Owner 1�J_rCA52. 4�4 en ZqC= Address Located at (StreetiD�cec.. Block Lot n ica e nearest cross s ree Municipality 77i-t %F�scJ Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH,APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION „.. Run apse p o- Water Water Mve No. Time From Ground Surface in Inches Soil. Rate Start -Stop Min. Start Stop Drop -in- - Min. /in drop Inches. Inches Inches 2 2 i; sd Z Z7 I 3tv . 2 3 10 10:41 .3'7 Z3 I 3? 7� 2 . :.. 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. DEPTH G.L. 6" 12" 18" 2411 30" 36" 42" 48" 5411 60" 66 72" 78" TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOTIZ ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. IL r. INDICATE.LML AT WHICH GROUND WATER ISENCOUNTERED �- INDICATE LEVEL TO WHICH WATER LEVEL RISES_AFTER BEING ENCOUNTERED TESTS MADE BY Date DESIGN t . Soil Rate Used3L-4j Min/1 "Drop:. S.D.,Usable Area Provided No. of Bedrooms Septic .Tank Capacity 1000 Gals. Ty Absorption Area PrZovided By L. F. x24 x j6"—.. wi P Ah6C Sri 3((2o l u. � � i �E� ������ �t:� ��e� Na—me ( EL igna ure � Address SEAL 1 <; 14 8,14 r- THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF.HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date IF Re: Property of �Jyr4#t5.7e 4, Located at /A flo? (T)��7 �Af Section Block Lot Subdivision of,��� Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professional engineer or registered architect (Indicate to apply for 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 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned•. ' eP'. R.A., # Address Very truly yours, Signed Owner of Property Telephone ' i Address Town Telephone 60 bo 0 0 " s ry 1 5 �' LO -� Q� 125, 540 sq. ft.:% 3 fr Y .' l \� WOOD DECK, ( Under constr ction }' c - STORY FRAME OW; LUNG >F CONCRETE WALK''' LL l N 60 °29'00 "W 3 a L - / 3.58' 30.00 tiJ Y x''=225. - QUgKER 1.9e - -- - -- --- - - - - -- •.� UtiUtres -_,\- TITLED FI)VAL PLAT SNOW /N6 QUAKER RIDGE ESTATES, i t OWN OF PATTERSON, PUTNAM COUNTY, NEW YORK, )0' TOTAL AREA 6/.978 AC.; DATED JAN. 24,1984l ; U APR /L 5, /984," FROM THIS OFFICE. k:. �� �� Ol �. ��, ^i C \� �\ �� V W �� I1, � - t� W'� 1 pY`6 � J Q nV 11 S _ 1 --{ � ��.[1 4T 3 t5i � r - ,. ,.. ,. _ ...�.. f. .�.i ,� �t 7. - - � .. �� �� Ol �. ��, ^i C \� �\