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HomeMy WebLinkAbout0456DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13.07-1-35 BOX 6 Fir ` T 'L LE ' I 1, rg , 00265 n rte• -:_- _ x 'ITT — -- Rev:'. (, PUTNArd COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y 10512 Engineer Mast Provide P.C.H D ;Permit # CERTIFI A OF CONSTRUCTION COMPLIANCE. FOR SEWAGE DISPOSAL SYSTEM f� Town Located st T����.. Ta: Map. Z Block_ _Loth ks :JBa" R 1% ��C S� [ / Formerl Subdivision Name Sabdv Lot q Owner /applicant Name ..-r, ----1 Y , . .. Mailing Address _Z 3 cZ4-M--- c-SAgat ZIP Date Permit Isau 190 Z. nd Separate Sewerage.System built by "S - Address Consisting of �°y on Septic Tank and J` Water Supply: Publlc•Supply From Address or :. ;K__ii Private Supply Drilled by 4 Q t`�' _ u Address Building Type r, t d � - - Has Erosion Control Been Completed? Number of Bedrooms - Has Garbage Grinder Been Installed? Other, Requirements I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and r latione, in accordance the.filed plan, and the permit issued by the Putnam County Department si Of Health. � Date / z-9 l2 c9cr t;ertifle P.E: V. • Q A r� ` ia��ll Address Lf1� Q License No. 7O Any person occupying premises served by the above systems) shall-promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the 'separate`seweiage system shall become. hull_and'void as soon as a puW% sanitary sower becomes available and the approval of the private water.supply shall become -null and void when a public water.supply becomes evaliable h . Such approvals are subject, to modification or change when, in the judgment of, the commissioner' of tosith such revocation,, modification or change, Is necessary. Oats /'/1� �_ — %� g R/ 1 Title . �� -� a ' 4c W $ WALL VVL'1rL1'+11VLV Rr•r.,1.1 DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only I WELL LOCATION N/vl I Y STR T ADDRESS: TAX GRIO NUMBER: " T v+�' + A i p WELL OWNER NAME: p ADDRESS; ,/�SF�fI �L�i'�5� /Ti " -3 .5% C�- �•;+�i4r�� y j /3 6 ❑PUBLICS USE OF WELL 1 - primary 2 - secondary M11ESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑- ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL ❑ STANO -8Y ❑ MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE Dal. REASON FOR DRILLING W SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/ OBSERVATION O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL -, DEPTH DATA ° WELL DEPTH ® ft STATIC WATER LEVEL ft. DATE MEASURED �°? / DRILLING EQUIPMENT oc ❑ ROTARY O GOO ESSED AIR PERCUSSION ❑ DUG ❑ WELL 501NT ABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED 94PEN END CASING. ❑ OPEN HOLE IN BEDROCK 'O .OTHER TOTAL LENGTH ft. MATERIALS: 9,01EE ❑ PLASTIC ❑ OTHER CASING DETAILS LENGTH.BELOW GRADE_ ft. JOINTS: ❑ WELDED 141411READED. ❑ OTHER DIAMETER in. SEAL: MENT GROUT ❑ BENTONITE ❑OTHER WEIGHT PER FOOT Ib. /ft. DRIVE SHOE S ❑ NO LINER: ❑YES SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (It) DEVELOPED? IRST NO HOURS kEpfD ' GRAVEL PACK ONO GRA ^--- ZE OF PACK in. TOP DEPTH it. BOTTOM DEPTH It. WELL YIELD ST If detailed pumping t METHOD: GOUMPEO ; tests were done is in- • COMPRESSED AIR , formation attached? O BAILED O OTHER ; ❑YES ONO �a�ELL LOG It more detailed formation descriptions or sieve analyses vY are available, please attach. DEPTH FROM SURFACE Water Bear- ing well Dia' In FORMATION DESCRIPTION cooe. tt it WELL DEPTH It. DURATION hr. min. DRAWOOWN It. YIELD gFm. Surrface D An ` xv'e WATER EAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? S ONO ANALYSIS ATTACHED? S ONO STORAGE TANK: TYPE CAPACITY GAL. WELL DRILLER NAME 6 q //4 1/ 0 ADDRESS 13 0 ��� . , 5tq � va'ojo PUMP INFli MA71UN . '; .. ` WK d V CAPACITY ti DEPTH d MODEL VOLTAGHP 19 PUTNAM CDLUEY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building Building Constructed by �au-,� 311 Location - Street Municipality Res ;r-, I'l-C. C-, Building Type ?i f ! a y Section Block Lot Subdivision Name Subdivision Lot # GUARANM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, wor)ananship, 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 systan, 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 Environinental 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 1— _ day of ,e 19 9--V Signatur e s Title General ntractor (Owner) ---:'Signature Corporation Name (if Corp.) Address rev. 9/85 mk , Corporation e (if rp.) Address Yof own' 'Me own Inc. LAB # _ CA. 00597:3 321 KearStreet. Date Takens Time: Yorktown Heights, N. Y. 10598 �� Ti (914) 245 -32 Date Rc d. me: Date Reported Director: Albert H. Pad ovani M. T. (ASCP) Collected By:,: C4,u,t Referred Byi kt ('4S Sample Loc tion. S r-00k4 /4 �- 13 AT Phone # L� Phone Sample Type: # Repeat. st,2 (check one), otable LABORATORY REPORT ON THE BACTERIOLOGICAL' QUALITY OF.WATER :. _Non-potable _ STP EFF GENERAL BACTERIA Other: Standard Plate :Count (CFU /1.OmL)' to (Agar Plate @.35 °C) Sample Status: (check each) MEMBRANE FILTRATION TECHNIQUE (MFT) Total. Coliform (CFU /100mL) Fecal Coliform (CFU /100mL) Fecal Streptococcus (CFU /IOOmL) MOST PROBABLE NUMBER TECHNIQUE (MPN) Total Coliform: MPN Index (per 1.00mL) Fecal Coliform: MPN Index (per 100mL) OTHER ANALYSES REMARKS (Fo.r Laboratory Use) Outgoing Na2S203 Incoming �LE* 4 °C. GT 4 °C KEY FOR TERMINOLOGY RDS = Recommend Disinfec- tion of Source TNTC= Too Numerous To Count CON .Confluent ( =TNTC) LE = Less Than or Equal to GT = Greater Than N/A = Not Applicable THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. x1—_ Albert H. Padovani, M.T. (ASCP, , Director For tab Use Only:_ ,_ H/C to r . AP-°E IDIX C FINAL SITE INSPECTION � D TION e I i �— C WNER jr :"41T, "41T # �} TM SIMDIVISICN LOT v NO j. IT. IV. 4I. C SEWAGE DISPOSAL AREA a. SDS area located as per approved plaris , b. Fill section - Date of placQnent 2:1 barrier. LGTH WII7I'H AVG.DPTH �- c. Natural soil not stripyed d. Stone, brush, etc., greater than 15' from EDS area. e. 100 ft. fran water course /wetlan' , SDPAGE DISPOSAL .SYST M a. Septic tah]k size - 1,000 1,2`0 b. Septic ta.^k, installed level c. 10' minimm fran foundation d. No 90° beads, cleancut within 10 ft. of 45" bepd I I ` J i e. DISTRIBUMCN BOX 1. All outlets at same elevation.- w ' er test 2. Protected below frost. 3. Minimum 2 ft. original soil bey � ^. and trenches f . JLZvC'I'IOI4 BOX - properly 52t c. 1P =HES / 1. Lzugtz red si reds - LE &L:,l installed (Qcc�> 2. Distance to watercourse measur d f`. I 3. Insta11ed according to plan 4. Distance center to c- -,iter / 5. Sloce cf trench acceptable 1/16 - 1/32 " /foot. 6. 10 feet fran roDerty line - 20 feet - foundations 7. Depth cf trench < 30 inches fran s _Fac` 8. Roan allowed for e ransion, 50% 9. Size of gravel. 3/4 - 1j" diameter 10. Depth of gravel in trench 12" mininum 11. Pine Erc:s moped h:. P'� OR DOSE SYSTEMS 1. Size of pL7-m chamber I 2. Overf.1cw tank 3 P1a_rm, visual /audio 4. Ptma easily accessible Tznhole to c._de 5. First bcx baffled 6. Cycle witnessed by Healt-i DeDaxtr:ert I estimated flow per cycle I l �7C:- _. 'Ecuse lccsted cez auumved plans. I I Y �,• .. I=Ler of b oars ( I J as C=- : ed Plans C. Distance f_aim. S ^ =�-_-- xe..sured =_ C. Casino 18" a:.;vey= C. S' rrace arci well acceor_ r__ CV"E RAj., , WOR&%51S ?� a. BcxeS prEcellliv Cam" CUzec. b. P11 pipes -r i-?1y c. All oires fius:, wi tZ inside of bcx d. Fzc'dill Irv--- ter ccntains stones < 4" in diameter e. Curtain drain ins talled according to plan Kl_ S f. Curtain drain cut=all rotected & din.to eYist_wat urs -1 ( G. Footing drains discharge away from SDS ar=:. h. Surface water protection adequate i. Errosion cone =o prc;Hded on sloces creat`r tron 15�. will'Ge- locate cou Dep `DaEe` .AOPROVED- revocable for requirer a Rev, 1/87 Dat PUTNAM COUNTY DEPARTMENT OF'HT:ALTi, Rev. . 3/ 86 `r' Dlvlelou of Erivlronmeritel Health Servlcee Carmel, N Y ' 10511 Engineer to Provide Permit q on CE1i171C TE OF: MP CE ;; CONSTRUCTION PE FOBS E DISPOSAL SYSTEM. Permit q m `� �a► TT'�Rs e�2 Located at 15_lL�'� Z Town �,;:.. Sdbdlvlelon Name Sabd. Lot q T p_ Block Lot enewal - Revision Q Owner /Applltiaat Name �d�S dolt P1 aske e U v� j, Date of Pre one pproval 2 p'" J 3 . f' /� t^ S%tr -e � / Town- MaWng Addreea' . . j Building Type di Lot Area `�+ FIII'Secdon Only. Depth Yolnme Number of'Bedtroome Destgo Flow G /P /D -ice F#CBD NoH9cation Is Repaired When Fill to eotnpleted Separate Sewerage System to:conalet of Lo y GaH.on Sepdc To be oons4pdW by * he lei - Address Water SaPP1J Paibllr Supply From Address + or: Private Supply 1)tided by Other Regttlremente I represent that 1 aiin. wholly and Como et ely:responsiblefor the des,gn and.Iocation of :fhe, pioposad system(s):, 1) that the separate sewage disposal system above described will be constructed, as shown on the approved. amendment there 4o and in accordance with the standards; rules an regu a ions O e u nam County Department of Health, and that,on completion thereof a Certificate <d,f Constru;tion, COmpliance satisfactory to the Commissioner Of' Health Will be submitted ao' the Department,•and.a written guarantee will be furnished the owner his suceelisors,,:heirs or assigns by the builder, that said builder will place in good operating ;contlition any ,part of :said,. sewage ; disposal system durmg,thaperiod of'two;(2) yeari lmrhediately followi4 _the'dete of. the Issu. ance .of the approval''of the .daitificate oi'Construction' Complience.•of the original system or any repairs thereto ;•2) that the drilled well'described above will be located as shown on the approved plan and that `said well wiil e, Iled in ccordance wit a ,standards. uies and .regu a ions. of the Putnam County. Department of.Health )/ Date���br�(��% R.A._ .� 73 ra fit' ijqpr S0 . f�% 7cQ Address License No APPROVED.FOR CON_ STRUCTION:' This approval expires'one year from the date issued unless'construction of the building has been undertaken and Is revocable for cause or may be•amended'or motlifled when considered nicessary by the Commissioner of ,Health. 'Any change or.aiteration of .construction repuires a r�ew permit: /f Approvetl for d /lisDOSaI o1 domestie ianitsry sewage, at w�only. . •Date 0�,�rG�ii� GL- 8 y Title y, Vz PU1'NAWCQtJP1'fY ®EPARTMENT t0F HEAL'TIi Pezmit a b _ r. 'Ve Division of Enwronmenia'l Health Services Carmel 1V: 4Y 10512. CONSTRUCTION PERf1lIIT FOR SEVYAGE DISPOSAL SYSTEM /L down Located "at �� 9 Tax' .Ntap 2 �elook" tot 5 ' : • '. :. }, .~ a ? Subd Lot q Renewal .,< Revision Subdivision Owner /Address - ate f Previous App J,,p royal t >.i3 f� Gam i • BuUding -:Type Lot Area ' �� FilY'Section "Only ❑ «. ' P C. ,H D Notification Re wired I •Number of Bedrooms Desiyn Flow c /P /D`� 9 r Separate;- ,Sewerage "System, to cohs�st of ��� r Gal Septic Tank antl - To be .constructed L.9 11A P Address �- s Water Supply `Public SsuPPlyf F om �Pnvate Supply tosbe dn11Gd by Other RegOirements L 1 represent that I:am wFiolly and completely responsible for the es�gn; and IocaUon oi,'the proposed system(s);. 1) thit'the'separate sewage-disposal system s . above described ill, constructed as show,h on theapproved amendment thee to and'in accordance with thestandards,rulet an regu a_ions o e Putnam.',* :. . k, „County department :of Health, 5 +and that n "compiet�on thereof a '; t ertificafe, of Construction Compliance •=satisfactory. to the.•Commissioner of Health will {,Tx -roc tie sutimitted;.to `the ;Department,- and a'._4vr�tteri gir rante °_v�ill be'Yurnislied the owner his`successo►s,.heirs oc.assigns by the'builder, that'said builder will place :in' good operating eo idd!op any '#it,,ot said sewaq'q disposal system; during the, period of two (2) years Immediately following thedate_oi the issue Vance ot,- the`', approval' °of' he Cer4iticate,oi Constructionompliarice 'of.the onginal'system 'or any repays thereto2) that the.drilled,well described. above - will be�located`asshoyvn o the app_rp` it plan and thpt said well wil be" stalled in accordance -;with t andards rules' and regu a i� ons.' of the Putnam Count Department of Healpt�h Date�C Sig d' P. E - RA tvV License No _T�SCCI�� �c - 'APPROVED "'OI. This`approval,expires,,one year from the date issued unless construction` of the "buildmg ha - , s been, undertaken antl is revocable for cause or'may be'.amended +oramodified °when considered` cessary by the, C m_issionerof Health: Afiy .chanye',or alteration of :construct ion - ►eq61res',a new - permit •'`Approved for, disposal o /;:domestic mt sewag and /o riva water` only.- ^' i ti -1, AW T � ��, " .'Rev 9 tle 0 DOCIJI,TPITS REVIEW CIiI;CK SIII,,T House plans 0. K. Dr_sien data sheet Peres presoaked? Kin., 30" perc test depth Cont. results for 3 runs D. Hole lor, 0. K. Corporate Affidavit for other than individual Authorization for engineer Utter from Water Supply if applicable If variance requested -such noted on plans & apps. IMccts' Str9 . R:marks • I es , No , i IWA I DF,TAILS (if change'is proposed,) Existing contours shown (show new-contours) ?� Slopes for driveway cuts, etc. shown Rater service lire location I� Footing drain, etc. location I Top slope, bottom slope of fill ► Percolation tests and deep test pit location I i Septic tank size and conformance to std. ► I 3 B.R. house minim= �► i House setback shown i Y. I Distribution box ftg. below frost All water within 50 ft. of PL shown , Plan and profile SDS ........... I I ..... All other wells and SLS closer 200' I shown' or - re ;"erence made Property boundaries (metes and bounds - clearly s van; 1 SEPARATION DISTANCES SPECIFIED ON PLAN I .10' to P. L. ?0" to Fotuzdation walls ' )0' to Nearest well 30' to stream, march, lalce, etc. incl . expansion , L5' to Curtain drain 10' to water lire (pits -20 G .5' to storm drain .01 to lar-c trees ! :0' froill I.011111dItioll to - sopLic tank I .` , to pipe from leader drain & . foot ntl drain MO KO d s F, pc^� `>12 �rEF S w� Ca�v RS3 K dV S I✓ i o 'f; Fl +\) K- �"2�.1•�Co-f l0/ ao;. 00 , 10/ /S l�/ PU'I'NAM COUNTY DEPARTMENT OF HEALTH DIVISION, -0F ENVIRONMENTAL HEALTH SERVICES - COUNTY OFFICE BUILDING, CARMEL,_ N. Y. 10512 DESIGN DATA SHEET- SEPARATLE SEWAGE DISPOSAL SYSTEM PILE NO.._____� OwnerNg �; '%i-- Address 29':33 'r2%, C-15 ..� ► _. Located at ( Streeto 3 Sec. Block Lot indicate neares cross street) Muni.,,;ipality�vs Watershed- t� SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICAT40NS FT-4 r� 4 i,• 2'.q4 3', P -J.. 4 Number'. CLOCK TIME ` ' PERCOLATION = .. PERCUTION an E.epsa o ZEF.errT er voT- No. Time From Ground Surface'in Inches Soil Rate Start -Stop Man. Start Stop Drop in Min. /inn drop Inches Inc-hes Inches FT-4 r� 4 i,• 2'.q4 3', P -J.. 4 - �... 3 –Notes:, 1) Tests to be ,repeated. at same depth until apppprox;.matelyy e ;ual soil . x�iites are obtained.at. each percolation teat hole. A11 data to be �tizbmitted I'or- review. 2) Deptli measurements to ..be,. made from top .of hole.. M. 4° TEST PIT DATA REQUIRED TO BE SUl3MTTTFD idITH APPLICATION DESCRIPTION OF SOILS ENCO' N` ERF.D IN TEST HOLES ys:; DEPTH, HOLE N0. TIOLE NO. HOLE NO. G.L. 6" -YO 11 J I 3! 11 __ ....V11 ,1 4;.2 4811 7211 198 --- ,l8„ p 4 Dear of °utirY 84'! HF,gt�H INDICATE. LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TVN) CH,.WATER LEVEL RISES AFTER BEING ENCOUNTERED TESTS MADE BY tA- U���� Date Jam. -l� -� Soil Rate Used Min/1 "Drop: S.D. Usable Area Provides§ M. of Bedrooms 3 Septic Tank Capacity Absorption Area ProvIUR By,�� L. F. x24" - - -- gig,' 3� �'-����;a re ! (fit er iVame _ , E07 tTi Address . ku 'Le t2z,gv, f f Jv THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY*.' f. Soil Rate Approved Sq. Ft /Cal. Checked b Date; w W? .0) N 05 14� 5R to 1.32 "OW ^fit-A N 33' 39' 2&' Er: Iz, IN � w m N 2 ti 5 6 r71�T. Pox 5ot,Iv SY sT EM &SP - bu I L,-r ✓GA(,E: I" = 20' 20 2/ 22 23 2� 2c 1500 eA �. 2� ✓EPtIG TAt IV- 0 50 L- . o T2ENGH� -o{P) t10N O � � 10 � It 1(0 11 0-()NGtIoN EnO/, CTY F7.) ►ANDRID NOTES rOR R6SID� TIA . - � SSDS . 350 AREA TO OE FIELC> STAKEC� AND cgRt?O>vED ?O PRVV>N TM$ 'Dpi✓�AT10N ©K 5TOK4&O .DP HEAVY EQUII?MENT fN YNI✓ At2E T 5805. SYgT'EM TO �� ►KgPEGTE© 8Y THE DI;r�t�N I�iGIN��R A . TO PONAM COUNTY NI;At -Tm' DEpAl2tM�id1" AI%'fEl� IN 51A:I�LA7IDN ANANO PKZIOR ' 0 DAGKFIL:L. - O FIU. FLOOTC ELEV. 198.00 UV. IQco.5D L. TA►.1K A5- OU1I,T 1�IMfiNSIDN GI -tAtZT N° A b NS' P� - 1 b I 100.5' CO5.0' I� 90.5' 35.0' 2 107.5' G19.S' 15 J &.o 1,0.5" 3 115.5' 75.5' 1(0 10 3.0' 4 1230' 80.5' 17 109.5' 5e�.o' 06.0' 10 11 G .0 ' 5%. 5' 6 1?f I. o ' 9,2.y, 10) 122.0' 66.0' p� G A b 7 53.0' 05.01 20 %5.5' .S 0°9.0' °%1.0' 21 10 1.0' 42.0' V7.0' 00.0' 22 10 -7.0' 48.5' to 100.5' 10� 5' 23 113.O' 55.0' II I IO.o' I 1 (.0� 2-t 1 1°0.0' GI.S' 12 1 1 �.0' I l �I.O' 25 l 2G•O" C�°�.p , p p A G 56. Ate - I I:'( NI 0 f -. TH 115 TO G I✓ 2'( I F `( TH L �(G✓TEM �lVAS GON�T 2U� THIS pL-AN AND -THAT TH O'f M 13 t�012 e �C�T�M WAS GON STR.� WITH ALA, �TANJVA.2G 12 D;:� TH>✓ r,0-NAM GOUN'T` ANI7THEi NFW YOeV- 5'fA- NO %: HOU,�-71i I.00ATIOk �R- oPE2T-( P2�PArz�� F I-AI I I..+f i. .i 1 i0 1UUt^_TlO1J .. . ' SOX 0Lj Lc nlCc O4 [�A GtCAVEL _ i. !r d8*50t�P'�'10�,1 I. r �. I I..+f i. .i 1 i0 1UUt^_TlO1J .. . ' SOX 0Lj Lc nlCc O4 [�A GtCAVEL _