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HomeMy WebLinkAbout0280DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 13. -1 -12 BOX 4 Ll t r 1 yk N-1� 111.• Located at 4Z 51171//771J V—V n Owner /applicant Name • yu �+ MaWng Address �s r' . 77i� 17 sown or vumge Tax Map clock C7L , I Subdivision Name JLN'�j b�dJv. Lot q Date Permit Iseneii Separate Sewerage System built by' �'�C ' In AC4-1e !as o Address % C Ln Q s 5 Consisting of i'� y Gallon Septic Tank and Water Supply: Public Supply From Address n or: '� Private Supply DrWed bye I— � Adaeeae�T 6';%) 1 Oa�' Vex 1-71 ILK " Building Type � 5 / ! eL lj d ' Has Eroelon Control Been Completed? �S Number of Bedrooms Has Garbage_ Grinder Been installed? 620 Other Requirements I certify that the system(s) as.listed serving the above premises were constructed essentially as shown on She plans of the completed work (.copies of which are attached), and in accordance with the standards, rules and reg ations, in accord a with th file la and the permit is ued by the Putnam County Depra Af Health. i/ o(/oj( Certified by P.E. R.A. Oats /1 Address • h License No. J Any person occupying premises served by the above systemisi shall promptly take such action as may be necessary to recurs the correction of any unsanitary conditions resulting from such usage. Appro4al of the separate sewerage,'systam shall become null and void so as on as a pub( ?: sanitary tower 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, y' inn tthhe )udyment of the C6mmfsslo4er of Health, such revocation, modification or change is necessary. Date �� �r !J l / ! (j 8��� �' Title �� ffs Municipality _R I VP 1 �` Building Type 4A Subdivision Lot # GUARAN= OF SUBSURFACE SEWAGE` DISPOSAL SYSTEM �n I represent that I am viAblly 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 A,; 19 rY General Codtractor (Owner) - Signature /. Corporation Name (if Corp.) c Address _rev. 9/85 mk . Signature Title Corporation Name (if Corp.) fFf - ' COUNTY OF WESTCHESTER E 11 Rev..86 `DEPARTMENT Of LABORATORIES ANp RESEARCH VALHALLA. NEW YORK 10595' -' 5 'BACTERIAL EXAMINATION OF DRINKING�ANDTREATED.,WATERS Lab. No 3W Bottle No * ' i Cab No ENT Date Gol� r Time Time Set- f Time Submitted Tests (C'ircle) SPC Coliforrn MPN - Coliform tAembrans Fecal; Other k o u � �` # /tn Coll d by A Agericy Coll d for u 4AF,"A k `Coll d from Alams + ; �V PNmd {� gyp - . tignU y _ - Addreasf s t '01 a ga Z > lay "'Ad'1 - . (f) b'T". v l t2M Cod*) Identification of Sbu►Ce t +tt �L e s = Sampling. Point within Prem'isea Refrigerated? Chlonneled� Ves,a No, Free mgll Td!al mg %I pH r.. .. _ _ RESULTS'OF EXAMINATION 00_WATER Standrd Plate MPN /100 ml Count ,mow `Bacteria parrml (48 hr.)_ s Membrane Metho(l/100 ml. Number Positive Tubes Total Coliform _ x Fecal Col form - ��- � � Other - Shese results ihdicaie sample (was: was `riot) of t eL:Reportad by Dale; - 'satisfactory sanitary quality who a sample was 'r . 'Collected: - z _r "P kr'..,} `.'`� •.-.. ¢• = f Y . A�.��l, u ..pmt TTT/�LT nnnnnm y .e WELL LOCATION Wr,LL t.vririAr.ilvivr.,i . i Office Use Only DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH STREET AOURESS: TOWNIVICLAIZIC.1 Y TAi'GRIO NUMBEri 6U OJ.A Aq , .�1 L 3 ' 3 E '37.2,4 _ a WELL OWNER 1 ADDRESS: N � 1 £ Mhexi C- �,�, ,� PgIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED U BUSINESS O FARM ❑ TEST/ OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT -, gpmJNO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING IKNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA 'WELL DEPTH �� ft. STATIC WATER LEVEL` ft. DATE MEASURED 0�7 DRILLING EQUIPMENT O ROTARY 9COMPRESSED AIR PERCUSSION DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING ICJ ,/ OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH -r ft MATERIALS: STEEL O PLASTIC ❑ OTHER CASING DETAILS LENGTH.BELOW GRADE tL JOINTS: O WELDED 9THREADED ❑.OTHER DIAMETER — in. SEAL: ❑ CEMENT GROUT O BENTONITE OTHER WEIGHT PER FOOT lb-/ft. DRIVE SHOE MES O NO LINER: 3 YES 16NO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED? FIRST ❑YES ONO HOURS SECOND GRAVEL PACK O YES O NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH tL BOTTOM DEPTH It. WELL YIELD TEST pumping If detailed �IF�iH00: ❑ PUMPED tests were done is in- �f COMPRESSED AIR r formation attached? O BAILED ❑ OTHER ❑ YES ❑ NO It more detailed formation descriptions or'sieve analyses 1�1FLL LOG are available, please attach. DEPTH FROM SURFACE Water Bear• i�g I!ell O'a MEW in FORMATION DESCRIPTION CaoE. ft. it. WELL DEPTH ft . DURATION hr. min. ORAWOOWN It, YIELD gpm. surf ace Surf� h) CZ� -• n (`tom �. � r c, WATER eCLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE CAPACITY /' MAKER G'R"d,-10�i DEPTH ® MODEL VOLTAGE � HP w t. N DATE c% i. `�'ATT & SONS, INC. ADDRESS Well Drilling SIGrnMRE ' { ;t R. R. 2 Box 171 A'— "•sl, NEW YORK 12563 II. IV. V. VI. FINAL SITE INSPECTION Date : :�• �o Ids ted ;CATION �Gr �� �"�� , �� CWNE:R �� • !J- -�-� . G ? e� w e nR Si7RDTVISTCM •lm 1 YES No COMD S'Tr�y� DISPOSAL AREA a. S.�s area located as per armrove3 plans b. Fili section - Date cf placement 2:1 barrier. IGTH WIDTH AVG.DPTH c. U---tural soil not stripped d. S`..^.ne, brush, etc., eater than 15' from SDS area. e. 100 ft. fran water course /wetlands. ' SEvt= DISPOSAL SYSTEM a.- Septic tank size - 1,000 1,250 b. Septic tank installed level I c. 10' minimum f_an foundation d. Nc 90° bends, cleanout within 10 ft. of 45" bend L I e. D15TRIBUTIGN EOX . 1. All outlet -= at same elevation - water tested I 2. Protected below= frost 3. Minimum 2 ft. criginal soil between box and trenches I f . JLZvC CN EOX = prct>---ly set g. 1 fe--,� r=e- Length installed��/ 2. Distance to water-course me=_sured ft. (/ 3. Instal L e=' acMrdina to plan (A I 4. Distance cant =r to canter 5. Slone cf t_ a nch acceot_.ble 1/16 - 1/32 "/foot. I I 6. 10 feet f_-cm prccp--ty line - 20 feet - four_daticns Jl 7. Denth -of t_anch < 30 inches fran s-arface I 8. Rees a11e-ded for eransien, 50% ( A I 9. Size of travel 3/4 . --le diamr eter I 10. Dept:* of aravell in trench 12" minimum L. Pine ends cps h. OR DOSE. SLSTSM.S 1. Size of p=rp cha=mber 2. Overflow tank 3. Alan, vis-cal /audio 4. Pump easily accessible manhole to grade, 5. First box baffled i 6. Cvcle witne-ssed by Health De=arunant estimated flow per cycle HOUSE ` a. H -use locate! rx--- aDnroved plans. I b. hk=;nPr of bedrecros WELL a. well located as r anmroved plans I I b. Distance fran SDS area measured ft. c. Casing 18" above grade._ d. S =face drainaee around well acceot_a.ble_ OVEZ2r.-. WOR&MASi1_P a. Ecees properly arcuted b. AL! pir,is - �i a? 1v backfilled c. All pines flush with inside of box x d. E= ccfill material contains stones < 4" in diameter I e. C=-"; ain drain installed accordincr to plan f. C---fain drin cutfall protected & dir.to exist.wate-cours g. F--cr-inq drains d- scharcre awav fran SDS area h. S= =ace wate - protection adeauate i. E_osion control provided on slopes greater than 15 %. 'k All •lm 1 >Q N ®ber 4 Hedtooma Des flow 'G P g�Q S Sewbr y Si'al m to oembt ot� Z GiOpn Septic Taok o to be ooeatni ited. b " Addrese �: Ptiblk $Ltpp�y Ftam .. Addreso + FlIvste Su pply Denied by " _ . galretaena - ..a*o. gaeOt that l am wholly and'completely responsible for the Gas gn antl' -- - - - - above described will be constructed as shown on the approvetl ameridin"t i County 'Department of MMltA;. and that.on eorriplstad.thweof a cCertit' be submitted to the Department, -and a written.quarantee` will be?urni place 'in good ;ope►atuiy:conditioh any Pitt of said sewage;disposaL ; sr ante '61 the p'pro- wil_'of the Ce[tificate of Con'stiuction ;COmpiiance..of will b located al tNown,on tM aOp►oved plan and that said well wfli 0e tnstj County Department of 'Hwlth: Oate Sign" ' �anrar, - AOOrgtS ( � ar,- ia,� -a criv v r APPROVED FOR CONSTRUCTION Thn approval" two year tror revocable for cause Or May be "amended or MOWN" when consitle► neee requires a now permit. , f �p - ocdomeriYC-sa Oor tl 1/87 081. 7 t �y�iiL and in:accordance with the standards, rules and . ►agu ions o " e - .. nam Construction Cornpliancs satisfactory to ,the Commissionw. of -Health will i ownai, Nis successors, heirs or,assigns by the Builder, that said Ouitdw will ring the; period 41 two, years immetliataly following the ,this of the.lau- ginal systsm;or any repairs thereto; 2) "tAaYfhe dilited,well dosclibad.a6ove accordance with Lei— UGTfons of .the Putnam R.A. _ date issued unless Construction of the building has been undertaken and is Y ".':bOmmissionsr f Health. Any charge or altwation' of construction e vate a `i pp only. -- - -- - Title`- -- DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL n l PC_H1� PF.RMTT $ 1 =1D7'� �F WELL LOCATION Street Address G i." 514 M Atj i2v Town Tax .) Grid Number WELL OWNER Name Mailing . ©PALD R. 5 "i'i2iF��,p2, Address 15"j ..Wrivate ��e>J C�z�.5c, MI H5-3c 0Public USE OF WELL d = primary 2 - secondary gRESIDENTIAL O BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION CIINSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT Ej; gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR ,DRILLING EW SUPPLY OREPLACE EXISTING SUPPLY O PROVIDE ADDITIONAL SUPPLY 0DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING D _ t"'14000- s _rAV_ oeSr'o i;LYCvLF FA-- MiL,,( WELL TYPE MDRILLED DRIVEN DDUG []GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN .A REALTY SUBDIVISION, NAME OF SUBDIVISION: jkc:,,Ic_ PAU-C I{ t Lot No. 4A WATER WELL CONTRACTOR: Name ;p, Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES i-" NO NAME OF PUBLIC WATER SUPPLY: % TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED Q ON REAR OF THIS APPLICATION ON SEPARIE SHE T (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 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 prod ded by a Putnam Co my Health Department. Date of Issue: Z 19 d 7 Date of Expiration: 19 � mit Issuing Official Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copv: Well Driller - - - - -- APPENDIX B hv"AJI PUI'NAM CCU= DEPAR' MOT OF HEALTii - DIVISION OF ENVIROMMM HEALTH S aMCES II� )IVIDUAL W-MER SUPPLY & SUBSURFAa S'T��TPL -E DISPOSAL SYSTEMS REVIEW SHEEP - CONSMUMON PERMIT DATE REVIEWED,_{� BY: —�- (Nam of Owner) (Street Location) CON�_INI5 � NO � �U �-c p Application � Corporate Resolution Plans - Three sets s/s Engineers Authorization Design Data Sheet (DDS) S- JEDIVISION Deep Hole Log Perc Consistent Perc Results (3) Fill Perc Hole Depth cd House Plans - Two sets Well perm t. PWS letter _— Variance Request COAL . Legal Subdivision Subdivision Approval Checked Ex-a: orova-1 SSDS Adj . Lots Checked Wet-) and (Tcwm/DEC Pe=it R & D) Data On DDS Plans & Permit Sarre LF trench provided REQUIRED DEMIM ON PLANS required 3 d of t rly Sewage System Plan - ( north arrow) 60 ft. max. Se-,rage System Hvdraulic Profile - Gravity Flcw Parellel to comfours Fill Profile & Dimensions - Volume D or J Box;Tre -ndh /Gallery; Pub pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder notes) Design Data: perc and deep results Two-root Contours Existing & Proposed Driveway & Slopes Cut Footing tin Drains (discharge OK) Perc & Deer) Holes Located FILL SYS 5 Representative of primary and expansion clavbar ier Expansion Area; shown; gravity flow,suff. size 10 ft. If Pumped Pit & D Box Shown & Detailed fill n tes I House - No. of Bedroons news Wells & SSDS's w /in 200 ft. of Proposed Systems de th Qauces Property Metes & Bounds He tuck Necessary (Tight lot) o SE=wr - 1 /4 " /ft. 4 "0; type pipe 100 flood elev. No Bends; .Bends 45° w /cleanout ISTANCE`S SPECIFIED ON P�:??V ` f 0 l �i (% Fields 10' to P.L., Driveway, Large Trees,Top of fil 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. ern 15' to Drains - Curtain, Leader, Footing 35'to catch basin, stormdrain,piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' frog Foundation; 50' to well 15' Well to PL PUIMM COUNTY DEPARTMENT OF HEALTH DIVISION OF HEALTH SF.RVICFB DESIGN DATA SHEET- SUBSUFACE SSIAGE DISPOSAL SYSTEM FILE NO. Owner Do wkL-a P— S "i 2 ► FFt -F,2 Address (,; ✓S N MA N ROAD PATTERS 01V /V V Located 'at (Street) C yJ !4 MAN RQA D Sec. Block / lot (indicate nearest cross street) Municipality PATi "ERs-oN Watershed - CPO roN SOIL PERCOLATION TEST DATA, PBQUI.itID TO BE SUBMI= WITH APPLICATIONS Date of Pre - Soaking ;2-23-9 & Date of Percolation Test 2 - 2 3 - S SOLE riapse Time Start-Stop Min. Ground Start Inches Stop M4.�..V KVC1 In Inches Drop In Inches "Soil Rate Min /In Drop — -1 2'/8- Z-. 3C;, : /8 2, J7 3 to 2 Z-'37- Z : S8 ' 2! 24 Z7 3 7 7- y- Z7 4 5 . 3 2 2: 3G — Z : S3 17 -Z7 3 3 F] 5 1 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 measureTents to .be made from top of hole. G.L. 14' C) 1- 6 a 21 31 41 51 61 171 189 10, 121 131 TEST PIT DATA HOLE No. HOLE NO. Z HOLE NO., m 141 INDICATE LEVEL AT WRIC13 GROUNMMR IS ENCOUNTERED NQN,6 MMICATE LEVEL TO WHICH WATER LEVEL . RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: 11A R R Y,. W. Nlcliot—r 3R. DATE E DESIGN Soil Rate Used 6,- 7 Min/I" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity I-Z-5e) gals. Type CDIM Absorption Area Provided By 4-00 L.F. x 24" width trench Other Name,9AWDoLPH W- "UREAITAIroe-J.16. Signature 7. Address 19f1'rz-.P PRIVIC ;3EAL A -rrrp, Joly 9 i! /?- 0. No. 65124 THIS SPACE FOR USE BY HEALTH DEPAR24EW ONLY: ��ESSIO% Soil Rate Approved sq-ft/gal. Checked by Date /Al \41 /0� OP P� �PO�AI� 'oNTNlS ' 13Y M Pi WAy CON - AV-12 TY RE ATE DE - �Y OP P�TE� tz� i i eutnam County Division of Invir, Y kpproved as noted for c - applicable Rules and Be ?utnam C�aunty-Realth De "Ar"q lira X Ti tl e A5- P1UILT OiMt�NSION GHA121' N°- A t, rip W FTEtj- G0t1 2 41:0, • t'1°OP. 3 41.0' 4 'I'0 -0' _71.0, 5 41-0, 1& 10' 8.1.0. l 00.0' Iq 80.0' to 01-0., t eS49' 112.0' 12 120.0" 14]7.0' I'> 120.0" 14 120.0, IV 121.0' .14x.0' l(o l4<0.0' i +� rr"Wri;►'t7-i t- tjr- V�ATA TAKeq �t� t�LPT - MUTGHNt>c, ht�.{�IVt h101J w. LAV��rsT AEG, !� p 'HATE NAAr". F.R .a flOTIN& PKAIN /KOD� PKAIN !nt o2 Health Health Servioet ormance with ations of the tmeAt/�� rzti\/ I L II - 875 PROJECT GUSNM/�N. 1zo�.D rAW L1 N 6, 0.1<- CLIENT `, ♦ C p. }c'�t,�INGToN (tt�JSo: r7i rn 16;Atlr-0! tj G IT,f 0 . X 'Y DRAWING TITLE ,m . AANbbMPH W. LAURENT �. A- 9S20CIATES, P. C. 7:8 AIRFIELD DRIVE -0 PAT T�-@901\1 . N E W YORK 12563 914278.6108 t,ONS TING SITE ENGINEERS AS - 15U! LT PLAN SCALE 1 �� 30 ' DATE t I 28 'ct DRAWN BY 14.V-( CHECKED BY JAWO JOB No. b-1 11S DRAWING No �+ ° rrwr BUT. m "-Av - rip W FTEtj- G0t1 PIe,41°. �V 1 l.Dl Nlo t.l NG • t'1°OP. �>e1w�v wow F.R .a flOTIN& PKAIN /KOD� PKAIN !nt o2 Health Health Servioet ormance with ations of the tmeAt/�� rzti\/ I L II - 875 PROJECT GUSNM/�N. 1zo�.D rAW L1 N 6, 0.1<- CLIENT `, ♦ C p. }c'�t,�INGToN (tt�JSo: r7i rn 16;Atlr-0! tj G IT,f 0 . X 'Y DRAWING TITLE ,m . AANbbMPH W. LAURENT �. A- 9S20CIATES, P. C. 7:8 AIRFIELD DRIVE -0 PAT T�-@901\1 . N E W YORK 12563 914278.6108 t,ONS TING SITE ENGINEERS AS - 15U! LT PLAN SCALE 1 �� 30 ' DATE t I 28 'ct DRAWN BY 14.V-( CHECKED BY JAWO JOB No. b-1 11S DRAWING No