HomeMy WebLinkAbout0378DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
13. -2 -91
BOX 5
!7%.
.. ::
16 on 90 IN
� ,
IN
J 7'' I.h4
IN
'
T
` 16 rr
IL t
00187
o�
\\� COUNTY DEPARTMENT OF gEALTH PZTNAM
� DIVISION OF .ENVIRONMENTAL HEALTH SERVICES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE T STEM
PCHD CONSTRUCTION PERMIT # IJe5 7 - ry / - % p
Located at e- Town or Village
Owner /Applicant Name �9,9"VM1p/1y4-lw Tax Map 13 Block A Lot IFI
Formerl Subdivision Name
Subd. Lot # -fa'
Mailing Address 10a Z ePY 3S--Z ZV Y,
Date Construction Permit Issued by PCHD
Separate Sewerage Systenc built by 60LI-I Cahr7r, Address /�U�r��s,, /�•�. ✓.
Consisting of Gallon Septic Tank and ���� �';� �.�s�� --�. % yore .4
Other Requirements: 0ps /ti2 C�c 1 P1- w/ 5462 C.-/ d7,J -a-
Water Supply:
Public Supply From
Address
or: rd Private Supply Drilled by Address , i'ews f�.��, /V Y,
Building Type Has erosion control been completed? �c S
Number of Bedrooms Has garbage grinder been installed? 17e
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: %7 - Certified by P.E. �1 R.A.
(Design Professional)
Address,�;��Ja�,ss�c,�7�s. S��i h'r��9y�:z�. C TS,/ /� if1-Y. License # e !r,$ 9 ¢
Any person occupying premises served by the above system(s) shall promptly take such action as ma# be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment 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 a subject to modification or change when, in the judgment of the Public Health .Director, such
revocatio , odifica or change is necessary.
r,
By: / Title: il, la"4
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange-copy - Design Professional
Form CC -97
I
WS,
Received
For f
BIBBO ASSOCIATES LLP
589 Route 22
CROTON FALLS, NEW YORK 10519
(914) 277 -5805
r` FAX (914) 277.8210
TO 71
l .
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via
• Shop drawings ❑ Prints ❑ Plans
• Copy of letter ❑ Change order ❑
LL PITTIEn W TfNZA K 3WUCi" OMI
DA1L
JOU NO.
ATILNTION � '
� 0
�
RE:
J
the following items:
❑ Samples ❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
�= v 7
�
�S — � •` e".f .SAS %S'
THESE ARE TRANSMITTED as checked below:
0 For approval
❑ For your use
❑ As requested
❑. For review and comment
❑ FOR BIDS DUE
REMARKS
COPY TO
❑ Approved as submitted
• Approved as noted
• Returned for corrections
O
19
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
SIGNED: — Lot�e�".z
If enclosures are not as noted, kindly notify a of once.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
V_)t►�! 1tdt,� �6��Ow �y�IK�s7,
Owner or Purchaser of Building
fJcfic� � doao.-V_
Building Constructed by
- 1'2 5 7,r G, e � �,5;g/ �c
Location - Street
Building Type
Z,3
Tax Map Block Lot
TownNillage
Subdivision Name
Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is 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 treatment 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 Public Health
Director 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 occu he building utilizing the
system. t.\
Dated: Month &c, Day ,29 Year 1q717 Signature:
General Contractor (Owner) - Signature
Corporation Name (if corporation)
Address:
State
Zip
Title:
Corporation Name (if corporation)
Address:i�C
State Zip CAS p�
Form GS -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address: Ridgeview Est.,
Foxwood Terrace Lot 46
TownNillage:
Patterson, NY
Tax Grid # /,3 - a - I'/
N, s,
Map Block Lot(s)046
Well Owner:
Name: Address:
Dorsett Hollow Bldrs., c/o Al Finn, 15 West Hollow Rd., Brewster, NY
Use of Well:
1- primary
2- secondary
XX Residential Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion XX Compressed air percussion Other (specify)
Well Type
Screened Open.end casing „. Open hole in bedrock _ Other
Casing Details
Total length 45 . ft.
Length below grade 44 ft.
Diameter 6 in.
Weight per foot 17 lb /ft.
Materials: xx Steel _ Plastic _ Other
Joints: _ Welded xx Threaded _ Other
Seal: _ Cement grout xx Bentonite Other
Drive shoe: XX Yes _ No
Liner:_ _ No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
_ Yes—No
Hours
Second ,
Well Yield Test
_ Bailed _ Pumped XX Compressed Air
Hours 6
=d 25 gpm
Depth Data
Measure from land surface- static (specify ft)
25
During yield test(ft)
200
Depth of completed well in feet
285
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
10
Soft fracutred limestone
.10
285
Hard white limestone
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
285
25
Pump Type Capacity
Depth Model
Voltage HP
Tank Type Volume
Date Well Completed
12 /6 /gg
Putnam County Certification No.
2'..
Date of Report
12/14/99
Well D ' r (signa
NU'm: t;xact locatlori oI well wim Qlstances to at wasi two pUMMICHL 1d11U111dRCJ w uc IJrvviucu Vila avpalU%v 71AwVwj cu..
WellDriller's t1ILL LLING, INC. Address: 75 Putnam.Me., Brewster, NY
Date: 12/1Signature:
:4/99
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
ANI
NORTHEAST LABORATORY OF DANBURY
39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404
JABS (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING, INC.
75 PUTNAM AVENUE
BREWSTER, N.Y., 10509
DATE SAMPLE COLLECTED: 12/17/99.
TIME COLLECTED: 3:30 P.M.
COLLECTED BY: BOB MILL JR.
DATE RECEIVED @ LAB: 12/17/99
TESTED BY: LAB# 11471
REPORT DATE: 12/22/99
SAMPLE SITE: DORSETT HOLLOW BUILDERS, LOT #46, FOXWOOD TERRACE, PATTERSON, N.Y.
SAMPLING POINT: BOTTOM OF WATER TANK
SOURCE: WELL -NEW
.TREATMENT: NONE
TEST PERFORMED RESULT: MAXIMUM CONTAMINANT LEVEL
BACTERIAL:
Total Coliform (Bacteria)
0
per 100 ml
0 per 100 ml
PHYSICALS:
Color
0
15
Odor
ND
3 Units
pH
7.09
no designated limit
Turbidity
1.4
NTUs
5 NTUs
CHEMISTRY:
Nitrite N
<0.005
mg/L as N
1 mg/L as N
Nitrate N
1.65
mg/L as N
10 mg/L as N
Alkalinity
200.0
mg/L
no designated limits
Hardness
348.0
mg/L
no designated limits
Iron
0.097
Ing/L
0.30 mg/L
Manganese
<0.01
mg/L
0.30 mg/L
[Note: Combined Limit for Iron plus
Manganese = 0.50 mg/L]
Sodium
5.4
mg/L
20 mg/L **
Lead
0.006
mg/L
0.015***
m1= milliliter mg/L = milligrams per Liter.
ND = none detected
NTU =Units
* *Notification Level
** *Action Level
RESULTS BASED ON SAMPLES SUBMITTED: 12/17/99
SAMPLE, AS TESTED ABOVE: MPOT.ABLE or UOT POTABLE
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
Laboratory Director
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800- 826 -0105 •OUTSIDE CT: 800 - 654 -1230
Tc -i�5 P. or►
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES /
FINAL SITE INSPECTION
Date:
Street Location Inspecte y: �i pn
Owner Inspected
Town Permit # P-6-7-93
TM # Subdivision Lot # tlwl d p'#A7z,4
1. Sewaize Svstem Area
a. STS area located as per approved plans ..........................
b. Fill section - date of placement
3:1 barrier Lgth. Width Avg.Dpth
c. Natural soil not stripped: ................................................
d. Stone, brush, etc., greater than 15' from STS area.........
e. 100' from water course / wetlands ..... ...........................:...
II. Sewage System
aa. Septic tank size - 1,000 ........1;250 .......other ..............
b. Septic tank installed level., ...........................................
c. 10' minimum from foundation ........ ...............................
d. Distribution Box
1. All out ets at same elevation -water tested...........
.2. Protected below frost ................ ....... .........................
3. Minimum 2 ft.Original soil between box & trenche
e. Junction Box - properly set ........... ...............................
f. Trenches
Len required 80o _ Length installed 8 6�e
2. Distance to watercourse measured -� ;I 0oFt........
3. Installed -,cording to plan ....... ...............................
4. Slop nch a� le 1/16 - 1/32" /foot...........
5. 10 ft. om property line - 20 ft.- foundations.......
6. De Woravel h <3 i o:surface ................
7. R 0 0� 0 ......................
8. Si 3/4 - '' /z" iamete'r clean ..................
9. Depth of gravel in trench 12" minimum .................
10. Pipe ends capped ...................... ...............................
g. Pump or Dosed S stems
pump
2. Overflow ank...�. chamber
3. Alarm, visual / audio .................. ... .............................
4. Pump easily accessible, manhole to grade ..............
5. First box baffled ....................... ...............................
6. Cycle witnessed by H.D.estimated flow /cycle........
III. House/Buildin
a. House located per approved plans ..................
b. Number of bedrooms ........................S...
IV. Well q &4D rl
a. Well located as per approved plans .............................
b. Distance from STS area measured A / ft........
c. Casing 18" above grade ................ ...............................
d. Surface drainage around well acceptable ................. ....•
V. Overall Workmanship
a. Boxes properly grouted ................. ...............................
b. All pipes, partially backfilled ........ ...............................
c. All pipes flush with inside of box . ...............................
d. Backfill material contains stones <4" diameter...........
e. Curtain drain & standpipes installed according to plat
f. Curtain drain outfall protected & dir.to exist watercoi
g. Footing drains discharge away from S.TS area............
h. Surface water protection adequate ...............................
i. Erosion control provided .............. ...............................
Rev. 6/97
Slect Of
* * PUTNAM COUNTTY DEPARTMENT OF HEALTH
%'° DIVISIOIN OF ENVIRONMENTAL HEATLH SERVICES
FIELD: ACTIVITY-: :REPORT -
v
Street _ .
.Town-.- Sfate
- Zip .
,PERSON IN CHARGE
- NaThe:and Title
,TYPE OF FACILITY
f
FTNDINGS
. _ 6
8
-
h
Ic
i!
VF!�Pi
4 Q11
.
;•d
_ A , t
F ,
>
Signature and�Title
_RFAORT RFC FT `R'V
I acknowledge :receipt. }of.tlts - report
SIGNATURE;
;.02/96
- .Title.
_R_eV `.
OFF DIMEN510NS
iTEM
TA NK
I E5
-- -
45--2 1*5
METER
P
0. G.
48.3
374
cfmijr-Z-5, Wy
D-BOX
72,3*-
&M
Jel
80.3
73,2'
(7)
-# Z
06,,S'
79.2'
Igo
*3
'70.6
8+.7'i--
A-
115,3 1
1c,
-157-
#-5
jol
'r5.8
&
7 i
111.7'
107.01
6
IITI
I vu;l
Tf=-
3,
109
Tell?,
IZ-1,
1143.8i
TE-°3
',III'
W012
-rr=lw4-
Vj P- L, L-
("q-5
vevl
Te-*-5
7S' &
701
114,
TL-
9s' -
TZT.
q
/071
_J
.. . ... .......
TE*IC.)
144J
1311
A43
,171'!:
"74"
To 1 '��
-7
jP
Te. 14
Ila'
15,
TE Ito
571'45'41 "E 161.44
WELL
4-
1
r- PAVA uRK -1,3s -o QV.
I
01
Fox WOO E) T E R Fp,,,4\
gooFr 24, A*,qp
FIF-L-cs iNsTA�w-SE2: door Tj IN 06
Sy 5T Et4 IN -.51 T
A LILL-D eiy: 96 M 60N'C)Tf& VCJrL-4 THIS IS TO CERTIFY THAT THE SEWAGE+SYSTEM WAS-CONSTRUCTED
�jL.Ma5, My, jAS INDICATED ON THIS PLAN AND WAS INSPECTED UNDER MY
,SUPERVISION BEFORE IT WAS COVERED OVER. THE SYSTEM WAS
^%CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES AND
dREGULATIONS OF TILE PUTNAM COUNTY DEPARTMENT OF HEALTH
aZAND THE NEW YORK STATE DEPARTMENT OF HEALTH.
M-17, se?o c-cy-P,
Pirz-r- I AJ4.r I
OF NEpp
1.6 S
II
METER
Fox W GbD TERRACE
0'kAtZA :5V1310)."
FATrE-F50N, NY
cfmijr-Z-5, Wy
4co
- Z
lit
(7)
C14
Igo
-157-
-J.
Q11
I
01
Fox WOO E) T E R Fp,,,4\
gooFr 24, A*,qp
FIF-L-cs iNsTA�w-SE2: door Tj IN 06
Sy 5T Et4 IN -.51 T
A LILL-D eiy: 96 M 60N'C)Tf& VCJrL-4 THIS IS TO CERTIFY THAT THE SEWAGE+SYSTEM WAS-CONSTRUCTED
�jL.Ma5, My, jAS INDICATED ON THIS PLAN AND WAS INSPECTED UNDER MY
,SUPERVISION BEFORE IT WAS COVERED OVER. THE SYSTEM WAS
^%CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES AND
dREGULATIONS OF TILE PUTNAM COUNTY DEPARTMENT OF HEALTH
aZAND THE NEW YORK STATE DEPARTMENT OF HEALTH.
M-17, se?o c-cy-P,
Pirz-r- I AJ4.r I
OF NEpp
1.6 S
IZ-17-qq
Fox W GbD TERRACE
0'kAtZA :5V1310)."
FATrE-F50N, NY
cfmijr-Z-5, Wy
4co
Putnam County Department of Health
Division of Environmental Health Servioss
.Approved as noted for oonformanoe with
applic a lea d Regulations of the
epartmentr
S? Lure & Title ff.
i r�c:rvc.�n c�
f
SECTION THRU FILL FAD
o�
NTS F s
�d •: 16.44' -
g-I 1 4541" i
1f�
510
AC, .
LL
� / • O SSDS "
tNITNIN';�100'
HOUSE -. 512
SILT
3
;=ENOE
TYP,
411 1250 :GAS..
118 T. MASONRY°
506
TANK
GA5T
. .GRAM _
►^I /• S ON GoNC ' ELOYV
TLINE y ,
%
4" 8 T -- 10 / 504
/
2 SHWN
LU
lu
Q' /
i .Q.
LEADER'
- .•� ` /'�t�+ � \� / -'y� .' � t k � � � •: � FOOTING
unty Department pi.. Pee Itly DRAIN'
hviro=ental Heal S rv�e % y - '. / �a�' DI "SGH.-
noted for,.confo qc with
rules and Hegu ti t19
-Title to Q
N �.�w � ��Q�' •. gym.
x
565 t4'33 "E .. nd:
T. j
PP"OYEO.!rpR CONSTRUCTION- This III)WOys:
fr' fit v
I OXF, as two V
P' , '" two
revocable for cause rrt;*� or modified h. .0 n 11111
Of '"Y I d'i d - o ag
!"W"es a • :'Apg�!oved' of sg��: 9 mod.
Rev.
permit
10/88
0
ORWDOUANCIL "n
Ahit�4&id'bulltlim will
p tlie'date of
'Witii described above
%a of the Putnam
conslfujtiih of the liui(dinghas . beoiK urklertikon and is
if of Hult'k -:�k . ny':cha n90 or alteration of construction
r .Kipply only.
,Title
V)
�-0
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel (914) 278-6130 Fax (914) 278-7921
BRUCE R. FOLEY
Acting Public Health Director
Sean Daly November 3, 1997
Box 243
Shenorock, New York 10587
Re: Proposed SSDS: O'Hara
Lot 46
(T) Patterson
Dear Mr. Dah•:
Review of plans and other supporting documents submitted at this time relative to the above -
captioned project has been,completed. Comments are offered as follows:
`'The construction of this sewage disposal system may be subject to local wetlands regulations.
You should contact local wetlands officials in this regard."
1) Engineer's authorization has not bee signed by the property owner. Fefi
✓2) Trench cover is to be noted as geotextlle.
J3) Erosion control measures are to be shown and detailed for the house well and SSDS.
Furthermore, a note is to be added stating all erosion control measures are to be installed prior
to the start of anv construction.
✓4) Plan has not been signed and sealed by the design engineer.
J5) Remove or cross out fill settlement note. This is not applicable for fill sections 2 feet or less.
✓6) Add fill specifications, i.e., the % allowed to pass a 100 and 200 sieve.
"You are referred to Article 128.1 of the official compilation of Codes, Rules and regulations of
the State of New York, Title 10, relative to the need for approval of individual sewage disposal
systems by the City of New York. You should contact city Officials in this regard."
Upon receipt of a submission, reNised to reflect the above, this application will be considered
further.
RAVmh
watershed
Very truly yours,
Robert Morris, P. E.
Public Health Engineer
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
Sean Daly
Box 243
Shenorock NY 10587
Re: Proposed SSDS: Macaluso
Foxwood Terrace, Lot 946
(T) Patterson, TM# 13 -2 -91
Dear Mr. Daly:
May 8, 1998
BRUCE R. FOLEY
Public Health Director
Review of plans and other supporting documents submitted at this time relative to the above -
captioned project has been completed. Comments are offered as follows:
"'The construction of this sewage disposal system may be subject to local wetlands regulations. You
should contact local wetlands officials in this regard."
1•
1) Proposed contours are to be shown.
2) Current codes requires that fill is placed is the expansion area.
3) Expansion trenches are to be shown.
3) Trench detail is not correct. Minimum distance from the bottom of the trench
to rock is 5 feet and to water is 4 feet. Revise accordingly.
Upon receipt of a submission, revised to reflect the above, this application will be considered further.
Ve truly yours,
Robert Morris, P. E.
Public Health Engineer
R�vl:tn
DEPARTNIENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
June 18, 1998
Sean Daly
Box 243
Shenorock NY 10587
Re: Proposed SSTS: Macaluso
Foxwood Terrace, Lot #46
(T) Patterson, TM# 13 -2 -91
Dear Mr. Daly:
BRUCE R. FOLEY
Public Health Director
Review of plans and other supporting documents submitted at this time relative to the above - regarded
project has been completed. Comments are offered as follows:
The construction of this sewage disposal system may be subject to local wetlands regulations. You
should contact local wetlands officials in this regard.
1) Fill is to be shown extending 10 feet past the edge of the trench and then
sloping 3:1 to grade. This is required for the primary and expansion trenches.
Upon receipt of a submission, revised to reflect that above comments, this application will be
considered further.
Very ly yours,
Robert Morris, P.E.
RM:tn ` Public Health Engineer
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Property of 61i /✓%LyL 0JS- -6
Located at
(T) f�TSdr/ - !', Block 2 ., Lot
i
Subdivision of
Subdv. Lot # 7(P Filed Map # Date
Gentlemen:
authorize "A
a duly licensed professional engineer ford' - - -� ^a
(Indicate .
to apply for a Construction Permit for a separate sewage system, to
above noted property in accordance with the standards,
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf
connection with this matter and to supervise the construction of said
in conformity with the provisions
Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned: &el-n �
S_
P. E., R. A., #
/p, 0, , 'go-)( -47 P,
Address
�
',LRLv& , )uy 7
9/41 776 -- S� 73
Telephone
Very truly yours
Signed
Owner of Property
/ /--5 —//0
Address
Town
Telephone
RIP6E -IEW Df�l�/ $ .: e. c
Ln
VEWfi�Y TO - _ —_ - - -- - -- — _�_ - - - -� Q _
rti p
a C
Uj
o\- j
ulu
° *k \\ 1\ . i\ \\ \\ \\ \\ O.0
rn it �1 >
Ul
392 524° 5'21'A d 4 W r O
tP 7i tit
3: rj w `
J n
1n
m
be
uOnttied ' l to
mace sit; yo'
b no at- te app
will aiioitim'is
County
Date
APPROVED FOS
revocable for cau
mquirn a'. new.j
Rev.
10/88 0
13
the Commissioner of Heelthwill
No bulkler.,that aid builder will
j following thedliti Of the INU-
Fhe itriiiiii will."scribm above
.r — of the. Putnam
iiStruction.of.th4 building ,has been 'undeita6n and is
of Health. Any change or alteration of ,construction
uppty'Only..
Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # fll :4
WELL LOCATION
Stre t Address
own Village City Tax Grid Number
3 --D.
WELL OWNER
Name
Mailing
Addres ,private
Z a O Public
S OF WELL
primary
2 - secondary
SIDENTIAL
0 BUSINESS
10 INDUSTRIAL
0 PUBLIC SUPPLY O AIR /COND /HEAT PUMP 13 ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
d INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE � O Bal
REASON FOR
DRILLING
❑ REPLACE EXISTING SUPPLY
9-NEW S PLY (NEW DWELLING
O TEST/OBSERVATION. . 12-ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
0,
WELL TYPE
�RILLED
ODRIVEN
[-]DUG
GRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING?
YES A,-` NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: .�
Lot No. (Q
WATER WELL CONTRACTOR: Name
Address:
IS PUBLIC WATER SUPPLY AVAILABLE.TO SITE: YES i-�N0
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
MZ_N SEPARATE SHEET
to f
(date) (idifnature
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
thirt,, (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 aAanner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19��� --T
Date of Expiration 19 e-7,;—" `Permit Issuing Official
Permit is Non - Transferrable
3/89
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH
b
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of
Located at
(T) Section Block Lot
Subdivision of U bd,�Uo S 0 N
Subdv. Lot # Filed Map #
Date
T. MICHAEL DALY, P.E.
Gentlemen: CONSULTING ENGINEER
P. O. BOX 243
This letter is to authorize SHENOROCK, N. Y. 10537
a duly licensed professional engineer o„ r = teiaod
(Indicate
to apply for a*Constructioii 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.
Very truly yours,
Signed (::::P_ C:A��
Owner of Property
Countersigned:
10-T 'T�
P.E., R.A., Address
7. MICHAEL a Ali 'I" P.E. p L
Address Town
F. O. BOX 243
SHENOROCK, N. Y. 10537 � -% Sr S �-
/,,// Telephone
Telephone
I rapiesen;%that 1: am'4 Is. for the hesigh Ai� "lion of the proposed system(s); I). I . hat *the Sol Siren,
above described will be constructed sis shown on the approved amendment there to and inaccordancswK6 the standisras. ruses arm regulations or ins, ruinam
County -'Depildmint 40- H6Rl.% and that an c-iMpiatia;n thereof's .!Certaiicaite of, Construction Compllanca`* satisfactory so tim Commissioner at . Multhwill
bi, submitted to and *j� j�jjttssjj "grantee Will be furnished the ov�ftsir, his kkaNW16 heirs or an"s by the bul . IsW that said builder will
iiii, tpow-lition! siriy -pe I disposal 4�iltifn,'duknj the period Of two (1) 'ears Immediately following . the date of the Issu-
alms of th's',apli sil,:;of theCertlikate W.C, , 011'. tit c any r s thereto. 2) that this dr
,.qv onstruction Compliance a original system a Illed well describsid above
.wW be, occatei as swou".01s,ithe approved, plinind that Said *011 will'be Intl JW in h I 1� rules and reouMM51 of' Isis Putnam
` County �-_
`
Addis a -License oYJt2df
APPROVED FOR. CONSTRUCTION: This approval ex , pires two years, from the date -issued unless constructW/n of the building has been undertaken and I$
revocable I . of c I ause -6e srnfinded'orm�6dlfiissl when considered no'comr - y by. the Commissioner of I Multh. Any change or alteration of construction
"quires a new permit' Approved for.44"I of dornestle sanitary. mrsage. a ater supply only.
�
\"U88
| �' ' - - ---------�- --------' -- ------ --'--- - - - ' ' - ---- --'-- -
|
�
'
'
o
�
'vii:
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road,-Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
-_ PCHD PERMIT #t�
WELL LOCATION
Stree Address
Town Village City Tax Grid Number
WELL OWNER
Name t
Mailing
}7.
Address
tVIIA7.
ivate
❑ Public
USE OF WELL
0 - primary
2- secondary
G- RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
0 ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT__fj__gpm /#
❑ REPLACE EXISTING SUPPLY
O-W. UPPLY DWELLING
PEOPLE SERVED /EST. OF DAILY USAGE al
❑ TEST/ OBSERVATION 11 ADDITIONAL SUPPLY
❑ DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
EYRILLED
ODRIVEN
ODUG
OGRAVEL
.
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name �l :i7 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES 4___NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
IOWSEPARATE SHEET
(date) ( gnature).
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 gde de or ot herwise contaminate surface or groundwater.
Date of Issue: 1Date of Expiration 1Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: -Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
DESIGN D= SHEET-SUBSUEWE SEWPM DISPOSAL SYSTEM FILE NO.
Owner 1016aA e-v-�.,6166dress — -Rel
Located at (Street)'Ex7mik 7; it 0 Block Iot
•ndicate nearest cross street)
@) • m • DI 00) fl.'4 V (01k N V DF-1 I I ,IV V U TIM* ; rMov I MT
Date of Pre-Soaking
Date of Percolation Test
3''Q• -
ja
3 2,36— 2'6�1 i(o
Zq
SOLE
NUMSM CUXK
TDIE
LATION
PERCOEATICN
FM
Elapse
Depth to Water From
Water Level
No.
Tim
Ground Surface
In Inches
Soil Rate
Start-Stop
Min,
Start stop
Drop. In
Min/In Drop
Inches Inches
Inches
1 %*z0
Iq
7�I��4 7if3
�3id-
31��..
2 Z 9
14 71
3''Q• -
3 2,36— 2'6�1 i(o
Zq
4
5
Z.
q
-:L-
4
5
MM: 1. Tests to be repeated at same depth - until approximately equal W soil•rates
are obtained At each test'hole. All delta to' be A3bdttdd"
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
r
DoT" !�0 4 �
TEST PIT DATA REQUIM TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. to HOLE NO. HOLE NO.
G.L.
2' .l
3'
41 �I
5'
6'
7' '
8'
9'
10'
11'
12'
13'
14'
INDICATE LE VEL'AT WHICH GROUNDWATER IS EN00UNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENODUNTERED --
DEEP HOLE OBSERVATIONS MADE BY: 1 ,ty, DATE: Z�
DESIGN 1'L� �o ')4Q
Soil Rate Used in /1 it Drop: S.D. Usable Area Provided
No. of . Bedroans 4 Septic ink Capacity 2 SD gals. Type�pi1
Absorption Area Provided By L.F. x 24" width trench t
Other
Name T• MICRACL DALY P Signature �t
Address P. 0, BOX 21'INGI:R SEAL
f I)
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved -
sq. f t/gal . Checked by
T. MICHAEL DALY, P.E.
BOX 243 SHENOROCK, N.Y.
4 BEDROOM COLONIAL
5 I NGLE FAMILY RE51 DENGE
24
SECOND FLOOR -
1/8" = 1' -0"
I /0" = 1'-O"
1A
24'
G BATH DRE551 N6
L. BATH 0 ROOM
HALL
25
&)550RM
MASTER
BDRM #2 BDRM
SECOND FLOOR -
1/8" = 1' -0"
I /0" = 1'-O"
1A
24'
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
i
Re: Property o
Located at
,M
( T ) Seetie4*Block Lo t�l _
Subdivision of E- �/�.1Zf.. 4
Subdv. Lot # Filed Map # 2 ?jCpO Date)
e
:T. MICHAEL DALY, P.E.
Gentlemen: CONSULTING ENGINEER
P.O. BOX 243
This letter is to authorize SHENORnl'KJN y, �ns87
a duly licensed professional engineer or-
(Indicate
to apply for a Construction Permit for a separate sewage system; to
serve the above noted property in accordanbe 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.
Countersign /
P.E. , R.A. , # `Z
T. MICHAEL DALY, P.E.
Address P.0. BOX 243
SHENOROCK, N. Y. 10587
Telephone
Very truly �yours,
ned C1.)
Owner of Property
P. a , j? -
Address
1
Town
Telephone
S -
..__ I
P U T N AM C O U N T Y D E PART K E N T O F H EA L TH
APPLICATION FOR APPROVAL OF PLANS 1�FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: �• (�� t�AT�/'�
rV� .
2. Name of Project: 3. Locatiori(`*V /C:
4. Project Engineer: �� _ 5. Address•: x�
License Number: �� Q�w. Phcine:
6. TyDe_ of Project:
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 Rev 6w (SEAR)?
Tyae Status (Check One) Type 1.. Exempt _
Type II. Un 1 i sted
S. Is a Draft.Environmental Impact Statement (DEIS) required? ............. I•�A
9. Has DEIS. been completed and found acceptable by Lead Agency ?'...........
10. Name of Lead Agency
11. Is this project in an area under the. - control of local planning, zoning;
or other officials, ordinances? ...... ...... ................ ... - F0�-pu -09pr'
. � b
12. If so, have plans been submitted to such authorities? ............a......
13. Has preliminary approval been granted by such authorities? Date Granted: ^
14. Type of Sewage Disposal System Discharge.'?i:�'�> 6v LF' Surface Water Ground Waters
15. If surface water discharge, what is the stream class designation ?........
16. Waters index number (surface) .......................... •............
17. Is project located near a public water supply system? ......................
18. If yes, name of water supply
Distance to water supply
19. Is project site near a public sewage collection'or disposal system?......
!0. Name of sewage system Distance to sewage system
!1. Date observed: 23. Name of Health Inspector:
A. Project design flow (gallons per day) .......... C 0 ....................
2•
25. Is State Pollutant Discharge Elimination System (SPOES) Permit -required ?:. b
26. Has SPDES Application been submitted to local DEC Office? ...............
21. Is any portion of this project located within a designated Town or State }
wetland ?..... .... ... .................................................... N
i
28. Wetland ID Number ............................ ..........................:
29 Is Wetland Permit required? .......... .. .... ....
... ....................
Has application been made to Town or Local DEC Office?, ..................
` b
30. Does project require a DEC Stream Disturbance,Perihit? .............::: °... `
31. Is or was project site used for agricultural activity involving application
of pesticides to'orchards or other crops, solid or hazardous waste disposal, +� b
landfilling, sludge application or industrial activity? ........ YES or NO N
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
DESCRIBE: '
33. Is there a local master plan or file with the Town or Village? ...........
34. Are community water, sewer facilities planned to be developed within 15-'years?_
35. Are any sewage disposal areas in excess of 15X = slope? .... :................
...... �[
36. Tax Map ID Number ....................... 7.
31. Approved Plans- are to be returned to: Applicant 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 tb.,cchply 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,-..o Section 210.45 of
the Penal Law. /
SIGNATURES & OFFICIAL TITLES:-
MAILING ADDRESS:
r O
rn
rn
DRIVEWAY TO RIDGE IEN Pf;ZIVE2-'
M
� r�� Cl
> m >
Ul
U,
rp
O
Lu
uir\\
w CA
>>
524- 5'21IN
tj U
ul
-0
M
>
ILU
O C% ?a
� r�� Cl
> m >
Ul
U,
rp
O