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HomeMy WebLinkAbout0264DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 5. -1 -30 BOX 3 00073 ,� 16 �� ir .. r' 00073 T 1, CER CATE.,OF.CONSTE 1"t6d4*76; ; ILI OwnTrZappficant. Name - Mailing Ad". , 4)� PUTNAM COUNTY DEPART [Malin of Environmental Health Si OMF(iruli ZIP 7777 )512 Separate Se*enge System bufft.by Addres LISP G on Septic Tank Consisting of Co C). Water _Supply: Public Supply from Address Private Supply Drilled by &Clfffit�A C1,,,U;-Ad ress Q&A412 Po-i or.— M B4Odl, -Type g Control Been Collioleted? Has Garbage Grinder Been Installed? Number ofBedroonts 061 qther.Requlpknieno: f certify that the syat*,(s) as listed serving -the above premises -were - constructs nti 11 as shown' the 1 f. the completed woik ('copies th 't which attached); "d in accordance .0 with the siandarcis;, rul0s:and regfiatlyny accordance Wi iled plan, and the perinit'iisued by the Putnam county Depa rtmsnt 0 Health. , 3 z%-7 ?1 C-A,- by S E. R : A oate > Address _ License No Any parson . occupying promises served by the above system(s) shall promptly take such action as may.be riocasury -to secure the correction of any unsanitary conditions resulting -fr from such . . - use . ,usage. . Approval of -the - separate sewerage systern'Shall become null and void as soon as a Oubt: unitary sewer becomes available ,in -a ,water supply shail'69come null "�o public water supply Such �Oprovsis are ;hHen a ply bacpmes available. d the al o ., th private .. .. . I - ­ I .. I I — . "I . , -, - - �v h in� the u me, t S�Ojeit* to m I W or c angs when,­­ -j-dq It of h evocation. modification or change Is necessary. Title Date 3 BY 10 it W Y WELL UUl"1rLL11UN M.MrU.A! DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNA4 COUNTY DEPARTMENT OF HEALTH Office Use Only Lla_= 5 BEET AOOAESS: wN /vI ! 1 Y TAX GRIO NUMBER: o IJeGN a � o � WELL LOCATION WELL OWNER NAME: ADORES a f�$oi oL� !l�,5�3 /� BIVATE ❑ PUBLIC E OF WELL primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /CONDdHEAT PUMP O ABANDONED ❑ BUSINESS O FARM O TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL 0 STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED V__/ EST. OF DAILY USAGE_ gal. REASON FOR DRILLING 06NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA ' WELL DEPTH 3ab ft. STATIC WATER LEVEL Of ft. DATE MEASURED DRILLING EQUIPMENT O ROTARY COMPRESSED AIR PERCUSSION O DUG ❑ WELL POINT ❑ CABLE PERCUSSION - ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH ft MATERIALS: STEEL D PLASTIC O OTHER LENGTH.BELOW GRADE ft. JOINTS: WELDED ❑ THREADED ❑ OTHER DIAMETER 6 in. SEAL: O CEMENT GROUT • BENTONITE OOTHER WEIGHT PER FOOT �Z lb./ft.. L DRIVE SHOE ES O NO LINER: O YES ONO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED? FIRST ❑YES ONO SECOND HOURS 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 i tests were done is in- • COMPRESSED AIR , formation attached? • BAILED ❑ OTHER i ❑ YES ❑ NO WELL 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• It. WELL DEPTH it. DURATION hr, min. DRAWOOWN ft, YIELD gpm. Land r r R.'n 4 3. WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? ❑ YES ❑ NO STORAGE TANK : • TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP W ELL DRI" W , WELLDR'ILLING .II4G ADDRESS Clapp H:III; Road slGhATURE �, LaGC8pAf vI11e, {.`N , 12540 �Q Andrews Welldrilling, Inc. Clapp Hill Road LaGrangeville, New York 12540 (914) 223 -3375 Fax # (914) 227 -6988 OUR REGISTRATION # PC -143 County of Putnam July 2, 1992 Department of Health Division of Environmental Health Services 110 Old Route Six Center Carmel, New York 10512 REF: THOMAS J. RAVESON Well Completion Report TO WHOM IT MAY CONCERN: Please be advised that we had made an error on the static water level reading in the well completion report for Tom Raveson, North Birch Hill Road, Patterson. It should'have been 30 ft instead of 257 ft. Please' enclosed a copy attached for your records. Sorry for any inconvenience this may have caused. Sincerely yours ANDREWS WELLDRILLING, INC. Valerie J. Andrews Vice President cc: Tom R nclosure n �, .' * �c W �4 wc.iru— oivr�i LL' ilV ►7 ►XL'ry ►tl '• DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION WREET ADDRESS: wN I TAX GRID MUraBEA ) r INN- 914,_" —3 d ool WELL OWNER NAME. ADDRESS: la'`J�G3 oo c.[. /� �� < �� HIVATE rOPUB LIC E OF WELL - primary 2- secondary RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ABANDONED O BUSINESS O FARM. O TEST /OBSERVATION. O OTHER (specify) O INDUSTRIAL O INSTITUTIONAL O STAND -BY O MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED V_/ EST. OF DAILY USAGE& 6 gal. REASON FOR DRILLING XNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ID REPLACE EXISTING SUPPLY ❑ DEEPEN EXISAF WELL DEPTH DATA yyELL DEPTH S ft. STATIC WATER it. DATE MEASURED �i°21 a DRILLING. EQUIPMENT O ROTARY )S(COMPRESSEO AIR PERCUSSION O DUG O WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED O OPEN ENO CASING, OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH fL MATERIALS: P6TEEL O PLASTIC O OTHER CASING DETAILS' LENGTHRELOW GRADE ft JOINTS: WELDED 0THREADED OOTHER DIAMETER in. SEAL: O CEMENT GROUT ' BENTONITE OOTHER WEIGHT PER FOOT DRIVE SHOE: ES O NO LINER: O YES O NO SCREEN DIAMETER DETAIL (in) •SLOT SIZE LENGTH (It) DEPTH TO SCREEN (It) DEVELOPED? FIRST o TES ONO HOURS SECOND GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE DIAMETER OF PACK In. TOP DEPTH tL BoTroht DEPTH It. WELL YIELD TEST It If detailed pumping P P 9 METHOD: O PUMPED i tests were done is in- • COMPRESSED AIR , formation attached? • BAILED ❑ OTHER DYES ONO WELL LOG jf more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bar- inq Well Dia' deter FORMATION DESCRIPTION cool. It. IL WELL DEPTH It. DURATION Itr, min. DRAWOOWN It. YIELD qGm. Land Surface r /sue / _ �b WATER ❑ CLEAR TEMP, QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES ONO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER M CAPACITY DEPTH VOLTAGE HP WELL DRILL OATEi� Aooat:SS �j Clapp Hill Road 1 y -,, 1aGrangeville, N.Y. •3315 1- ` v� 7.17- WE R011=71.. 1 v • ('�() 4 DEPARTMENT OF LABORATORIES AND RESEARCH \ t l VALHALLA,'NEW YORK 10595 BACTERIAL EXAMINATION OF DRINKING AND TREATED WATERS Lab No. W � �. PWS ID. No. Bottle No. 1tLt Vl . J Lab No. Ent Date Coll'd. Time b n Time Set I Q Q Time Submitted `1 JL� 77 �: 1 Tests (circle) SPC, oliform P /A, oliform MPN, eca, 'Other �y ^l �� Coll'd By Agency Coll'd For f COII'd From: (Name) _ Address Nv9�rl (street) Identification of Source RAV N TWo nhL 'T Q rRtN P R Tr F P-'s 0 (First) N WELL ( (City, Town, Village) Sampling Point within Premises P A Lx- ET AT \ 1tL1, 14FAI) OTN A f, (Zip Code) (County) Chlorinated? Yes _ No _ % Free mg /1 Total mg /1 'pH RESULTS OF EXAMINATION OF WATER P /ATest/100 ml. MPN /100 ml 1� Total Coliform Total Coliform E. Coli - Fecal Coliform Standard Plate Count Other Bacteria Per ml (48 Hr) These results indicate sample ( s, as not) of Reported by: Date satisfactory quality when sample was collected. Ann -Marie Bury +, `j -1 COUNTY OF WESTCHESTER `" ' t DEPARTMENT OF LABORATORIES AND RESEARCH. Hammond House Road Valhalla, New York 10595 August 13, 1992 Area Code 914 524 -5555 To: Dr. Thomas J. Raveson Route 4 Box 6 South Quaker Hill -Road Patterson,' New York 12563 Bacteriological Examination of Water 1 Coliform @ $10.50 ea. 'DA T V1 $10.50 IJM� .. ANCT _ . RA "JO I✓ o .s . t Own or Purcha �_t.of Building ps RA go Building Constructed by lymp 04Z 40 Location - Street AA ii�`gj 9 iv l�1 J Municipality BiTilding Type -- -- - Section SubJivision Name Subdivision Lot # li[ _kt ,NIEE OF SUBSURFACE SFCgCc DISFl lip SYS i 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 pericd of two years i=,ediately following the date of approval of the "Certificate of Construction Compliance" for the savage disposal systai►, or any repairs made by me to such system, except where the failure to operate properly is caused by the willlfcl or negligent act of the occupant of t:,:e building utiiizin=l the 1-stem. The unldersigned further agrees to accept as ccnclasive the dleterwdna -ticn of the Director of ? t e Di eaServices o Division of Envircr_m�ntal Hlth Sf the Putnam County Derartment of Health as to whether or not the failure of the system to cparatQ ,7as caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this N c� i day of L)L-r 19_q4 Genera_ n actor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 rak Signature ,< _ Title U k/ /moo f Corporation Name (if Corp.) Address v Block Lot Subdivision Lot # li[ _kt ,NIEE OF SUBSURFACE SFCgCc DISFl lip SYS i 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 pericd of two years i=,ediately following the date of approval of the "Certificate of Construction Compliance" for the savage disposal systai►, or any repairs made by me to such system, except where the failure to operate properly is caused by the willlfcl or negligent act of the occupant of t:,:e building utiiizin=l the 1-stem. The unldersigned further agrees to accept as ccnclasive the dleterwdna -ticn of the Director of ? t e Di eaServices o Division of Envircr_m�ntal Hlth Sf the Putnam County Derartment of Health as to whether or not the failure of the system to cparatQ ,7as caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this N c� i day of L)L-r 19_q4 Genera_ n actor (Owner) - Signature Corporation Name (if Corp.) Address rev. 9/85 rak Signature ,< _ Title U k/ /moo f Corporation Name (if Corp.) Address cat= c,*4L CR LZT rc DIS__ cf piac�­It 2:1 barri c -==-1 sci nct_ s E-rus-H, j r ft we. arc= f::Cr. wc_�=� T CEA Z. SYS Jet 1 I '� (� c: EL t: c w Z:11-n- 10 f7 - c e �_� -__ C, rrCEZ cc-k - SCI ,:.-:CN c r: L Ez" - �: T=om.= � _ /-- ; __ _ i i _- �� >�;1� _Lanc7t: -{- I _ _ `,�_ If 7 i rn - _l J Ln c=n' _r�a CZ 1/32 E_ 10 < i -7ch=:= s=aSE C C i 7,�.. Cf j: Es h. Pa-f-D CR EC-`^* S-Lze cl: V= C)Ver-- ------------- 4. arm F t:cx _rS-t E. orcle wz hy L '1 ��- `-`'0L i i t r-:er C V=e c ---: C. cas n, C -= E_ we ,71 --z--- C_ C:=s n e c f ma a c2r;.-,­__s sl-< 4" c- ` tL2 pla-li C �z ri G_'_'_' C_ cr -,: E a;a r:r, area Z.--ct-Inc. ­- -r v c C=- C-1 S! cz:=_E c_ — _ �.ALa.- ..DISTAA1f�S._/�IZE _I'1 :E9�Q2ED F`Fi?OM F1KED�11�7:T.5.. _ _ �.- -- i —i nr4TEP�NJF3E STettCruitE ,J�14.SE1iiAL<5__F2�M_ , .. _ ;: j :. .. , �_ ZUP��v =U��S EASEMEtJ'T L1Nir5 t52 (STif�fL RaINTS ° -: , 21: -MAP- I5.[NTEN,C- `f0- IJL1T�.: ?H� WCATIoAI. -... QFZHe- - SAtiITAKV' p15P0SAt- SYSTEM AND WELL wlrH Tr4E STRucrum, AMD SHDULL) NOT BE. U5ED :FGV A[vY_0THE(2 R)WPOSE 3) DI STANCE :. F27M THE WELL- TD IT* NEAP -EST (ATERA I_ _. IS C�REQL�2._ -tHAAI ..100_EEET _ L Pf# A P, G D e; F � So'.o' l l4 io LAWRENCE LE PERE PE. !4 2.'. 5d7 I 8o 1S 3 Sara 1210 /cox I i 4 sr' o" 123'2" I f 7 s Go'ro 529 lto A) 71415 IS To CeP_TI(�/ THAT THE SEWAIvE DI • JI`STrJ 1 WAS - - L, AS Il.ivi :.i' viy iii; 1rG -. PiAtJ "..ANiU TFitii" i.ic SY�iEJ i W,S iN'�F c1� BY hic IIG6'o`IIIiZ "� I -r-WAS covc m OVER 7NE SYSf+:M WAS' pr'Da CjDMSTK:UCT`C1j.IN ACL0P-CAmCE WITH ALL STANDAP-b OJLa5 AND F-E6ULATI0I,JS OF THE PjjIjAt, COLi41 "4 [,f--PAKTMENT OF i4E:A&T AND THE Ntkl YOLK STA i� HEALTH T�3APTMEtM'T" s TOTAL LA_1.16TH OF Tze;y -utS, A5 rNdTV.LLE», - (PWAt,s SqG Ff. .._ I. TAX _MAP. _tes%r. Jr`+now of Toe, PIXZCZL IS -.-1-30 ' Putnam County Department of Health Division of Environmental Health Services Approved as noted for conformance with applio Rules and Regulations of the. Count ealth Dep�aartment. Z�z24 S g ^ature A Title Dat& 1312 -7 �C 9 a Al a s i GL.�N T- nLA►J VIE W 1,_Sor 7 zoo'." T.43o1 - - -- I'1•Sx l8�5.1 — S 9 . � AS - QUILT' PLAN{ "{ LAWRENCE LE PERE PE. !4 1S 42('1 /cox f 7 529 lto 40 'D z► 39 0" 48'0" Lz 424` 23 49 S' 51'0•• ?J 5C o' S4,3 - THan A s S. R.Av-scA-1 . a r TL: AIoR.TM armL4 k" rt A, - - jDw /� O❑ PA7rera5or..7 . PUTNA..% "w" "zw 4var- AS - QUILT' PLAN{ "{ LAWRENCE LE PERE PE. P.O. 90% 326 CROTON FALLS, N.Y. PUITIAM ODUIfff DWARTAUM OF HEALTH _ `\ .. DMdm H@d& S•e�. Caw!. ICT 1!512 18� MFIIAPi(� etl�trkeaweaW� _ F0= t6WAGIO:DIflOSAL SYSi>�1[ . , P at GYRW- ; . a +nw ra.. �; S. ...> Let / 3.4,. Tu Map HMek >t etwail ❑ Devhka ❑ Date et Ftevl•u "APPeoi'tl ti1rA lyais Atlit+ee �ioUl�i. Q.�a.{ri✓ f�.Lf �ec:cf Tmrr P°�i'�Qricr:,.' �y� �_ ZIp � ZS� 3 qtr Subdivisioii'Appro'v:ed WA :Enclosed ".Amnint .. (1.iooesla wee .Let A.ea Fib Irlaae�•r e[ Mieetir Dee1Fn Flo G' P D � � . ce 4 C FCHD [�ofbC.tlaa `d'Devohred whoa I+m d c.-ptatett • ' 8epinM.SeweeaAa $7e1emil M eepiit et Sgptle Tama,. Ti.be ewe4s1W 621-1 Adders Wa1�r SWl4= ' ' Aids.St� Frel, - _' Addien ,' n kC : TM+--tro Si ip DetBed.6yli� Ober lfa�iti.wta , 1 ►epopnt'tl at I. ant wholly and "compMhly ra"nslble.foi4M Wsyn alW `klfition of tA'e Proposed systam(s) 1) aMt thi "apuah �aw di sal:�i stNn above described wi11,0e.o "st get d as shown on the •po►ove0.amendrnent there to and in "accordance with ter stanq&!dS, rum a rgu am of - am ' I:ouMy .aifaprtment. ,of hlwRh ;and that oo a "otnOletiott;tha►eof a !tt:�rtifiut�,of,'COnstructton Compltanee' tiitisfaeto►y to�tM- Co�nmissbmof tieiRRwill " lai "Winked -te the `bijidineut, and 'a written guarantee will ba'furnisliii ter owia►, hii mi ceaors, heirs or °a aigna oY the builder. that .s•id buiwGw wlll, ll c" _in 96" Operating oortdpbn any ppt of said aawa dMpatal system during the'perioq: of two 2) yearn Umnediately fO110siritlg to" data of the isew fit". Of the'`apptoval, of ter Cwtifkate if Coneiruction ComplMnce of-6 �, or I .>+ystem o►, any �gnNs tMnto 2) that the -drilled well described ;ado" wile :Oe IOtaled as Mowp on'ter aop►e»d Pun rive that. s.a well will sa In INA_ eeorWnee "with ter,. st S. '.eels and iesuLlons of` the Vutnam " county DeWrti am of "aelth D/ Signed �!% .pE !' RA - r a� new _ . ; /O. iI �. / -75 , : Addre Lkena No ..� .. APPROVED ROR CONSTRl1CT10N ThN;app ► owl expires lwo years ;from the date Issued unlm construction of ;the building has�'eean uniekiken,.ana is revocable fou,cavae or maY be anl•rWeO or,modHled when eonsWeree neeesaar 'by the.:Commissioner of 't/etltN. .Any eMrpe of •naatbn of eoentruetbn uMN • nwr permit... Appore0 fa disposal of domestk sanaary lmw .and s rivate water supply only. Data I.0 � Rev -7 �+ 1088r./G / /�� :' �/'�$ ---�� j Title 0 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL � .2 �� PCHD PERMIT # WELL LOCATION Street Address l o' 14 Town/Village/City Tax Grid Number gt"-j R o,. f.-1-30 WELL OWNER Name — © j Mailing Address 'ise; OPrivate p' "®." ''v_ QuQlw ULU P44eesw.. P-4. O Public USE OF WELL Al - primary 2- secondary JS RESIDENTIAL O BUSINESS 13 INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP D ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT :Sr gpm /# PEOPLE SERVED /EST. OF DAILY USAGE goo gal REASON FOR DRILLING Ll REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 12-ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING caju sx",4 A Nox4a WELL TYPE ®DRILLED DRIVEN DDUG GRAVEL. O OTHER IS WELL SITE SUBJECT TO FLOODING? YES P( NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_07A Lot No. WATER WELL CONTRACTOR: Name V n kw®wr► q_f 7XZ4 11iri. —Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES_NO NAME OF PUBLIC WATER SUPPLY: jJ 1A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: > 4iac�o LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED (36Sjaaj POP- *A4"%aQwC-S ®ON SEPARATE SHEET (date) (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 third- (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 drilling operations be contained on this property and in such a manner as not to degrade or otherwisq_contaminate surface or groundwater. Date of Issue • -:2 19_�-�`-��� -��-� Date of Expiration 19 . Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PC -1 P UTNAM COUNTY D E PARTMEN T O F H EAL TH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: Thomas �.!•eso•, 56 3 2. Name of Project: 731orno.s J P-a—esorr s;fio 3. Location (DV /C: Pe'tt 's._ 4. Project Engineer: tA.,A now 6,G Pei- r P.L_ 5. Address: License Number: &17So (9«() Cr�uLs IVy Leff-, 9 Phone: 2,73 -2.51) 6. Type of Project: X_ 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)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. N 9. Has DEIS been completed and found acceptable by Lead Agency? ........... &J /A 10. Name of Lead Agency NAY+ 11. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............. N is 12. If so, have plans been submitted to such authorities? ................... PO NOT 13. Has preliminary approval been granted by such authorities ?lta4vlaa -Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water X Ground Waters 15. If surface water discharge, what is the stream class designation ?........ _ 31A 16. Waters index number (surface) ........... ............................... N.10 17. Is project located near a public water supply system? .................. Po 18. If yes, name of water supply &J fiF Distance to water supply P/p, 19. Is project site near a public sewage collection or disposal system ?..... N a 20. Name of sewage system 13/A Distance to sewage system N A 21. Date observed: PAX 23. Name of Health Inspector: N�13 $ 24. Project design flow (gallons per day) ...... ............................... °° 2. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 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? ......... ............................... ........................ No 28. Wetland ID Number ....... ............................ ......... EVA 29. Is Wetland Permit required? .......... .. ............................... N Has application been made to Town or Local DEC *Office? ................... lulot 30. Does project require a DEC Stream Disturbance Permit? N o 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO PAD 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 po DESCRIBE: 33. Is there a `local master plan or file with the Town or Village? ..:........ N o 34. Are community water, sewer facilities planned to be developed within 15 years? Po 35. Are any sewage disposal areas in excess of M slope? :....................... NC7 36. Tax Map ID Number ......................................................... S. — 37. Approved Plans are to be returned to: Applicant X Engineer If the application is signed by a person other 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 perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Pena I Law. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: /�� Rox 324. crof6- Filts 7 A-=-- Of C,. 7-_" I nC.=-. we T.= C CE S A--. D= C\ E OR VC C.CS` Nctes I, T.ic-7�ct Czn -Cur" —r:= -r-ravarcl-7 SISC=-S C-Zt C 'Pit & D Z--x & N-c- Stec: w/:n 2Cn Se c 'NE C s M c'- ic No Cl =7 C-r 10' t0 =-.L- 20' tz) ;C,- WE-1— i0ol to W=al; 20o, ia D. .0 -D, 150' P 100 to Sz:::-eam, 13' t:2 Dr-::- T.:--= 10, NO !�7L ccns--<tan� Perc I nC.=-. we T.= C CE S A--. D= C\ E OR VC C.CS` Nctes I, T.ic-7�ct Czn -Cur" —r:= -r-ravarcl-7 SISC=-S C-Zt C 'Pit & D Z--x & N-c- Stec: w/:n 2Cn Se c 'NE C s M c'- ic No Cl =7 C-r 10' t0 =-.L- 20' tz) ;C,- WE-1— i0ol to W=al; 20o, ia D. .0 -D, 150' P 100 to Sz:::-eam, 13' t:2 Dr-::- T.:--= 10, :. PUTNAM COUNTY DEPAIMUM OF BEALTH DIVISION OF ENVIPMENTMI, FILTH SERVICES _._._...::__._....... : _.......... APPENDIX I DESIGN DATA S=- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Govt �rn.ct I/a►. d tv 0"er Th.o►,:ws f. Raa.eaa`.: Address So. Q✓a,�t,. N•.L( A0414 pa..' le "sa, Located at (Street) Sec. S. Block 1 Lot 30 (indicate nearest cross street) municipality ��.'j"�'e�rsw, Watershed Cfv+mv1 SOIL PERCOLATION TEST DATA //RE DUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking 11-19-13 Date of Percolation Test HOLE NUMBER CIOCR TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Frcm Water Level No. ~ Time Ground Surface In Inches Soil Rate Start-Stop Mina Start Stop Drop In Min /In Drop Inches Inches Inches I 1 /0- ?5- 21.5 2,75 10,9 14r,� /v 2 1: S'B 21 ?1 lb 2.5 iw /2,p /.V 3 2; 3c 3 0� I S.�S 2t,Z3� 2.5 iv J2,0 4 1:5-5 /$. IT 2 0. ? S 2 / :-5.f 2 : ZS 17.0 i9. S 2.6, Iu N 3 Z.27 2: 577 9.5 2.5 jai luo "Y,a 4 5 2 3 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 ne surenents.to be made fran top of hole. rev. 9/85 PUiNAM OOUl1I'Y DEPARIMIIQT OF HEALTH , DIVISION OF HEALTH SaVICES _._._...:: __ . _...... _ APPENDIX I DESIGN DATA SHEET- SUBSUFACE S&gAGE DISPOSAL SYSTEM FILE NO. Corr�rw.e.l Vw�,.d 4e. . Gone,- Address . So. Qva,kt r %Z04A mesa% Located at (Street) Sec. S• Block Lot 3n . (indicate nearest cross street) Municipality ��.`�'' rsw. Watershed Cr*+PA SOIL PERCOLATION TEST DATA RBOUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking 11 • `31 [ _i4+M� Date of Percolation Test J1 9 -•9 e HOLE NUMBER CI1JC'R TIME PERCOLATION PERCC XTION 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 i 1 1: 2a ?S 2 �. 5 2.75 Ili /o,9 2 1;5121#21% 18,25 2). 21.5 2.S IN 3 2; 3"0 I.-Do iz.o �N 4 5 2,,s ,A, 2 ,5S Z,5" it'd t .0 AAjA1 /M 3 4 5 �1 tj 3 4 5 NOTES: 1. Tests to be repeated'at same depth until approximately eqLal soil rates are obtained at each percolation test hole.' All data to* be suLmutt?d for review. 2. Depth measurements.to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WIM APPLICATION DESCRIPTION OF SOILS ENCOMEMED IN TEST HOLES DEPTH HOLE NO. Qr HOLE NO. p Z HOLE NO. G L 1: gs - a 4,4 S ar 21 31 coo,, +0 41 51 Se t I d" -tel-kc, 61 71 go io, 121 13' 14' mimm LEVEL AT waica GROMMATER IS ENCOUNTERED +e.^LJ INDICATE LEVEL To waicH WATER LEVEL RISES AF= BEING EbKVJNTERED QJA DEEP HOLE OBSERVATIONS. MADE BY: e- P"c- DATE: DESIGN Soil Rate Used Min/1" Drop: S.D. Usable Area Provided 362.4 for No. of Bedroans 4 septic Tank capacity M50 gals. Type co, C Absorption Area Provided By L.F. x 24" width trench 701_90M Name Pewi P3vX& L-6 r6g-w Signature PjMress SEAL CjZ4 rpvj S11 THIS SPICE USE BY HEALTH DEPAR3MW ONLY: Soil Rate Appr_%red sq. ft,/gal. Checked by Date Thomas J. Raveson March 16, 1992 Putnam County Department of Health Division of Environmental Health Services Carmel, New York 10512 Delivered by Hand Re: Permit #P -2 -92 Gentlemen: With regard to the above listed permit number, plans submitted to you by Lawrence LePere, P.E., P.O. Box 326, Croton Falls, N.Y. dated December 5, 1991, and your approval to place fill, dated 1/27/92, please be advised that as of today's day the perimeter clay barrier and the 900 cubic yards of material for the SSDS have been put in �. place. In compliance with note #21 of the approved plan I am hereby notifying you of the date of placement. If you have any questions please call me during the day at 914 -279- 7534, or' evening, 914 - 878 -6471, or wri.'te me at the letterhead address. cc. Mr. Robert Brill Brill Excavators Pawling, New York Sincerely, J Route 4, „Box 6, South : Quaker Hill`.: Road, Patterson, NY 12563 914 - 878 -6471 'r TEST PIT DATA MWIRED TO BE SUBMITTED WrM APPLICATION DESCRIPTION OF SOILS ENCaRriERED -IN TEST HOLES DEPTH HOLE NO. Rt HOLE NO. p Z HOLE NO. G.L. 6' "FOPso' i 21 31 41 51 61 71 81 go 10, 121 131 141 1(111f;WV*zW I I k% W, (I " lr-05-d 1.14 4o ® 44`6'-sl INDICATE LEVEL TO WHICH WATER I= MliS AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS. MADE BY: DATE: DESIGN Soil Rate Used Min/1" Drop: S. D. Usable Area Provided 562.4 Pr' No. of Bedroans 4 Septic Tank Capacity I ZSO gals TA:)e C.4h, c,- a. Absorption Area Provided By SO'+ L.F. x 24" width trench Other Name � A-wP3VC.0 L-GF(39-tr 'PC. Signature. V PA[dress ow- '3 SEAL C"ralo For," THIS SPACE F USE BY HEALTH DEPARTMENT ONLY: Soil Rate Appr-ved sq. f t/gal. Checked 'by'.' 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