HomeMy WebLinkAbout0389DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
13. -3 -26
BOX 5
IN
11111 A191
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PUTNAM;COUNTY DEPAflTMENT OF HEALTH
Dlvislon'otFmvl�onmengl Hedth 5ervl . Gemel,`NiY: li
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PUn COUN
M TY DEPAMIEWr OF REALM
DIVISION OF ENVIRONMEZZM $EALTH SERVICES
Owner or Purchaser. of Building Section Block Lot
Building Constructed by
_!�omr_m
Location — Street
Municipality,
Building Type
. G�-Q WA��
Subdivision Name
:11
Subdivision Lot v
GUARANTEE OF SUBSURFACE SERAM DISPOSAL SYSTa4
I represent that I am wholly and completely responsible for the location,
wor)aiianship, material, construction and drainage of the sewage disposal system
serving the above described property, apd that it has -been constructed as sho�m on
the approved. pl. . an or .approved amendment thereto,_ and in. accordance .w it , h., the.
standards, 'rules and: regulations . of :: the'. Putnam County Dot of Health;.
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 i=ediately 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.willfiil or negligent act of the cccupant.of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environ.�ntal 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. A / 1.7
Dated this ( day of _ 191,4
po�
tera l . f viol
Corporation Nare (if Corp.)
l�n Al &V44
Address
rev. 9/85
mk
Signature
Title r�
Cdr cation Nam (if ifc:orp. )
es Ile y
WILL UUr1rLL11U1V 1c1',rUic1
* ,F DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADORESS: TowNivILLAGLICHY TAX GRID NUMBER:
Cornwall Hill Patterson, NY Lot #11
WELL OWNER
NAME: ADDRESS:
Cornwall Home Builders, 155 E. Main St., Brewster, NY
❑ PRIVATE
❑ PUBLIC
USE OF WELL
1 -primary
2 - secondary
-a RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY p
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) [) DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 305 ft.
STATIC WATER LEVEL —3-0— ft.
DATE MEASURED 11/10/93
DRILLING
EQUIPMENT
tt ROTARY I@ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING fl OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH 1.31 ft.
MATERIALS: ® STEEL O PLASTIC O OTHER
CASING
DETAILS
LENGTH BELOW GRADE 130 ft.
JOINTS: O WELDED O THREADED O OTHER
QIAMETER 6 in.
SEAL: 9CEMENT GROUT ❑ BENTONITE OOTHER
WEIGHT
PER FOOT 19 Ib.l1t.
I DRIVE SHOE ®YES ONO
LINER: DYES :W0
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST t If detailed pumping 9
P P
METHOD: O PUMPED I tests were done is in-
t
XXCOMPRESSED AIR ! ormation attached?
❑ BAILED ❑ OTHER ; ❑ YES ❑ NO
1P1�LL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
suaFac.
Bear-
Bear-
ing
well
Dia-
In
FORMATION DESCRIPTION
pGE
tt.
tt.
WELL DEPTH
ft.
DURATION
hr. min.
DRAN100WN
ft.
YIELD
gpm.
Surface
Lll
Lng__ in overburden clay & bou
de
Hip
rock
at 401
305
4
285
6?
k set casing, grouted,
131
305
Dr'll
ng in rock granite.
WATER ❑ CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY - GATE.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME P.F. Beal & Sons C..
4 Putnam 193
Ave. .
ADDRESS SIGNATU
Brewster, NY 10509
� I �li �
i
® � i 11
!i:vr:w;v +I Vrl vri wiwlvriv +l W;wiw;w:y'rlw�v'r:y +:w!�
y
THE REQUIREMENTS A)F NEW
Laboratory D
DRINKING.WATER S
ctor
I:.
NEW YORK STATE ELAP CERTIFICATION NUMBER::: 11218:
CUNAMONS, RTE 22,
BREWSTER, NY .10.5091/.9! a -2MI
s I
r
t
,
..
4I RT. AMEBIC/ N
R
EAU -YRATO DIES, INC.
THE REQUIREMENTS A)F NEW
Laboratory D
DRINKING.WATER S
ctor
I:.
NEW YORK STATE ELAP CERTIFICATION NUMBER::: 11218:
CUNAMONS, RTE 22,
BREWSTER, NY .10.5091/.9! a -2MI
r r�su P.r .
. a.ICE nfPWATR OP ooh
❑ .
2.
sa+rs rM_�L
Nobr at Bed
t�ae.te-
.rat A.e. LA62Aet'
Deshp Flom G P D
SeMe.ta Sew_ tae�e srlta a, oe�t e[
T�
be Addreq
Wow Smir. PtiWOe SWl1Y Ftin Ad.dmn :
on, �/_Atwalilil snub D aw
otr.r Reqd•••:a
1 represent that t am wholly and completely responsible forahe design and location of , the Proposed system(:); 1) that the separate seers di sal t slam
above described will be eonstiubtid as slwwe m o the approved amendment there to end in.SiCOrdance with the standerok rules and regulations or
na
County Department of MMIt and that on completion tinareof a tC"llicata of Construction Compliance!' satisfactory to the ComMli"ner of 'Mwlthwill
a spemRted to tM`:Dapartnrerst and -a . weittirl gwrantN will be ' "furnish ldihe owner, his Iuccassors, heMS Oreuigns by the buildei' diet Yid bulkier will
pli" b pod operating condltbn any °;pas of said , sewage disposal iysteni during the pirksd of: two (2) Yaa'S ImMedietely following tltidate of the u.u-
afiee of the app "sal of tM,;Certificete of, Construction Compliance of the original system or•any repairs t Stet 2) t t the drilled well described above
W N 'be located ii, shown on the approved plan and that sold well will M instal in 'aceordaiias with ter 9ta , ds, ulos rpuiarioni of the Putnam
County Divartnlemt of kek
Date �' / : Signed A P.E. R.A.
T c ,!� ,i
Addiess�1' L1riY�� V License NoG I `�
APPROVED FOR CONSTRUCTION:.Tnis approval axpiras two years ' /►om.tha date •issued unless construction of the building has been undertaken and is
revocable for use or may be aii►erldad or modified when Considered, na"tYry by ,the Commissioner of Health. Any change or alteration of construction
requires a permit. A proved for disposi1,of domiidki sanitary iike aye o: Orate- r pply only.
10/88 Data BY Title
-s.
.. .......,. s - - . -.¢
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL �D C�
PCHD PERMIT #/ �5'l✓
WELL LOCATION
�,, Street Address
o Village Ci y Tax Grid Number
WELL OWNER
Name
,.� F_
Mailing Addres
� 5 7 l L) 5
rivate
O Public
USE OF WELL
(I)- primary
2- secondary
® RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /CON; /HEAT PUMP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
O ABANDONED
0 OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT i gpm /#
❑ REPLACE EXISTING SUPPLY
RINEW SUPPLY NEW DWELLING
PEOPLE SERVED .5-6, /EST. OF DAILY USAGE b02 _gal
❑ TEST/ OBSERVATION Q ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
)
�'
WELL TYPE
®DRILLED
DRIVEN
[]DUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES G✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:i��NL1IALL t2i��r
Lot N6.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L,-'NO
NAME OF PUBLIC WATER SUPPLY: , /k TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
13ON SEPARATE SHEET
s
_ � r
(date) (s ature)
V
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
thirti, (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 otherwise contami to surface or groundwater.
Date of Issue: 93 9
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
PiJTNAM COUW'TX" I7 EPA,RTMEZVT OF
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant:
I5r2 A I N) EE
2. Name of Project: grP<-7 j�2 3.._._Locationa/V /C:
4. Project Engineer: W `( [ill, • `fi= 5. Address: '?�,�
License Number: 56 Phone: ?,I
6. _T_YP�e 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 Review (SEQR)?
Type Status (Check One) Type I.. Exempt ✓
Type II. Unlisted.
y .•
8. Is a Draft Envir'o'nmental- Impact Statement (DEIS) required? ........ t�1U
9. Has DEIS been completed and found acceptable by Lead Agency? ........... ►J /A
10. Name of Lead Agency rJ /b
ti. Is this project in an area under the .control of -local planning, zoning,
or other officials, ordinances? ....... .............................. I.)d
12. If so�nhave plans been - submitted to such . authorities ......................
13. ;Has .preliminary approval been granted by such authorities ?�j� Date Granted:
14.-,•Type ofRSewage Disposal. System Discharge...... Surface Water Ground Waters
surface water discharge, what is the stream -class designation ?........
:6. Waters index number (surface) ........... ............................... n1 /A
:7. Is project located near a, public water supply system? N G
8. If yes, name of water supply Distance tow water supply ,
project site near a public sewage collection or'disposal. system ?..... IJo
,0. Name of sewage system K) ZA Distance to sewage system
i . Date observed: 23. Name of Health Inspector: 14 t t- Vii►. -
4•- Project design flow (gallons per day) ..................... �d
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. QD
26. Has SPDES Application been submitted to local. DEC Office? 011A
27. I's any portion of this project located within a designated Town or State
wetland? ...................... ................ :........................... �)�l
28. Wetland ID Number .... .................... ...................'........... -0/4
29. 'Is Wetland Permit, required ?' ............................................. Q0
Has application been made to Town or Local DEC Office? ................... 11,�Ai�
30. Does project require 'a DEC Stream Disturbance Permit? ................... Q0
31. Is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste disposal;``'.
landfilling, sludge application or industrial activity? ........ YES or NO rt.ly
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 K)D
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? NoWO
35. Are any sewage disposal areas in excess of* 154' slope? 90
36. Tait Hap ID Number ........... ........................... .. ... .......... �i._ • -IZ1 69
37. Approved Plans are tobe. returned to: ................ ' App-licant _/ Engineer
If the application is signed by a person other than the applicant shown in Item.1, the.
application must be- accompanied by y-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
fora is true to the best of my knowledge and belief. False, statements made
herein are punishable as a Class A Xisdemeano'r pursuant to Section 210.45 of
the Pena 7 Law.
SIGNATURES & OFFICIAL TITLES:
.AILING ADDRESS: '�`�"�I"zf �J� tai
PUIMM COUNTY DEPAFM-ffNT OF. HEALTH
DIVISION OF ENVIMMMAL HEALTH SERVICES
DESIGN DATA SH ET- SUBSUFACE SEWAGE DISPOSSAL SYSTEM FILE NO.
Owner ��� — ��` Mdress
Located at (Street) Sec. j% . Block %5 Lot 2�0
(indica near t cross street)
t- =icinelity �'��T % OtJ Watershed o
,OIL PERMIA.TIC N TEST DATA P3W= TO BE SUFxMI= . Fv=, APPLICATIONS
Date of Pre - Soaking Date of Percolation Test
SOLE
NLw3M CLOCK TIt PERCD=CN PERO7D=C?.q
Run Elapse Depth to Water Fran Water Level
No. Time Ground Surface In Inches Soil Rate
Start -Stop Min_ Start Stop Drop In Mi.n /In.Droo
Inches Inches Inches
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 suhmitt�d
for review....
2. Depth measurements to be made fran top of hole.
rev. 9/85
10
2-
3
22 2�
q
4
.5
6
v
3
4
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 suhmitt�d
for review....
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRID TO BE SUBMITTED WrM APPLICATION
DESCRIPTION OF SOILS ENCOUNTMM IN TEST HOLES f
DEPTH HOLE NO. I HOLE NO. HOLE NO.
C
1
2
3
4
5
6
7NDIME LEVEL AT WWMCH CROUNDWATM IS ' ENC OUNTERED �� I
INDICATE LEVEL TO WHICH MTER LEVEL RISES AFTER BEING ENMUNTERED
DEEP HOLE OBSERVATIONS MADE BY: t� DATE:.
DESI&N
Soil Rate Used Min/1" Drop:. S.D. Usable Area Provided ,
No. of Bedrocros Septic Tank Capacity J gals,, Type � G
Absorption Area Provided By L.F. x 24" width trench
Other
Name Signature..
�E `( W . N I c- - o � Tfz- .
P s
Address �11�Lra C��1�/ SEAL �TQ
ix
W
THIS SPACE FOR USE BY HF ILTH DEPAMMM ONLY:
FESS\dNP
Soil Rate Approved sq.ft /gal. Checked by Date
9
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2 � oprovad as noted for corforman a h
aplicable Rules and l.egulations of the
'ut - County_ He De tment.,
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PROJECT
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1�iaT'f G�hoN
CLIENT
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DRAWING TITL
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No. 56-J.'