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HomeMy WebLinkAbout0567DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -31 BOX 7 qrM .. NJ `, ' ;� I r op ru N � ■■J NMI IM6 14 1 f �4 4r r IJAL i 00567 P Division Owner /applicant Name Melling Address. Separate Sewerage Systembuilt "by_ Consisting of 6 Jai %r \VO�srui. �i -: Subdivision Name Snbdv Lot Ih Date Permit Iasned Water. Supply:. Public Supply From Address ors ►� Private Supply Drilled by `i'Q`I` f GJOfJGJ N (/ Address 1 i �? �• 7io h*X 111A Butldiag TypeGJ.�7� Erosion Control Been Completed? Number of Bedrooms Has Garbago. Grinder Bee. Installed? N D Other- Regn4ements I'certify that.the.systeii(s) as listed serving the above premises wake constructed essentially as shown on the piano of the completed.work ( copies of which are attached), and in accordance with the standards, rules and re "u ations, in accordance with e ill plan, and the pe=mit'issued by the Putnam 'County,Department Of Health. - - Date (r -T���` Certified by_ '.,, Address'p.. License No.� I " Any person occupying premtses'aerved' b'y the above_system(s) shall •promptly take such action as may be necessary to secure the correction of any .unsanitary conditions resulting from: such usage: Approval of tne, ssparafe sevverage'systiin. shalt Decoma hull and void as loon as a pub:'-' sanitary sever :becomes available and the approval of the private water supply shall become nulland void when a public water supply becomes ivsilabkL Such approvals are subject to 'modification or change when, in' the judgment of the Commissioner of M4alth, such revocation, modification or change Is necessary. Date .:iG�+ / �� /.: 1 'BY �� �_�__ Title L='_ IP OIl.''. nn�mT TmTr%wj DL.In/1D r -� WL,LL UUr1ri1Z1J_v>4 LNX:rvni DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only ,p STREET AOURESS: wNivtl ! I Y �Ot TAX GRID NUM §ER: r P WELL LOCATION WELL OWNER NAME: a ADDRESS: ASsH" -T� - �a�E �� T 4c.1C (IE P8IVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary m RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑. ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT —5— gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ❑ADDITIONAL .SUPPLY ffffqEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH QATA WELL DEPTH -74 ft. STATIC WATER LEVEL _ _ ft. DATE MEASURED %6 DRILLING EQUIPMENT ❑ ROTARY YCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION 0 OTHER (specify): WELL TYPE / ❑ SCREENED ❑ OPEN END CASING �f OPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH —�— ft MATERIALS: 9STEEL ❑ PLASTIC ❑ OTHER LENGTH BELOW GRADE' —- ft. JOINTS: ❑ WELDED IYTHREADED ❑ OTHER DETAILS DIAMETER 6 in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE O OTH R WEIGHT PER FOOT . _Z7 . lb./ft. I DRIVE SHOE WYES ❑ NO LINER: ❑ YES NO SCR Eli DIAM R (in) -SLOT SI LENGTH DEP CREEK (ft) DEVELOPED? DETAILS FIRST ❑ Es 0 NO HOU S O GRAVEL P K ❑ YE ❑ NO GRAVEL SIZE: DIAMETER OF PACK in- TOP DEPTH ft. BO Oht DEPTH It. WELL YIELD TEST If detailed pumping METHOD: ❑ PUMPED 1 tests Were done is in- • COMPRESSED AIR , formation attached? • BAILED ❑ OTHER ; ❑ YES ❑ NO LL LD C1 -If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE. Water §ear- ing Welt Dia- Deter FORMATION DESCRIPTION CODE tt. tt- WELL DEPTH It. DURATION hr- min. DRAWOOWN It. YIELD gpm. Lurtace 6 , �M WATER IKEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? ❑ YES ONO ANALYSIS ATTACHED? O YES O NO / STORAGE TANK: TYPE ,Y�� cw! CAPACITY :�10 C—alkin Drau"AL6 GAL. PUMP INFORMATION TYPE -� - �F CAPACITY 7" MAKER it DEPTH n MODEL S2 - � 4 VOLTAGF� HP WAI ffff VHYATT & SONS, INC. DATE l �, ADDRESS Well Drilling SIGirA7tiRE Rte. 311 'R. R. 2 Box 171A �° PATTERSON, NEW YORK 12563 pv (r, *4 3/89 �/ a1w - ENVI N-M..ENT-A.LtLABWORKS , P.O. Box 733, Marlboro, New York 12542. y BOTTLE NUMBER BACTERIOLOGICAL EXAMINATION OF WATER ELAP ib* 10824 CO DATE AND TIME COLLECTED DATE AND TIME RECEIVED SOURCE OF WATER CHLORINATED �SY 6 °' _� 3 Li t. I NOD YES D ppm EXACT COLLECTION POINT SAMPLE COLLECTED FROM TELEPHONE # -T'ar►4- , PUBLIC SUPPLY D PRIVATE SUPPLY -- Z (p ti E� 00 NAME ANDlOR LOCATIONS OF WATER SOURCE: REPORT TO BE MAILED TO La. 2L �-1 � .rt.� C^� d 1�➢E:: v\L\ z S � v i �c� -� � oid-r4 Ha L-w to RESULTS OF • BACTERIA/ ML AT 35•C TOTAL COLIFORMS / 100ML OTHER TESTS REMARKS ABSENT METHOD OF EXAMINATION P/A 0 MPN 0 MF O Colilert.jp INTERPRETATION OF THESE RESULTS INDICATE THAT THE WATER WAS OF A SATISFACTORY SANITARY QUALITY IN RESPECT TO THE ABOVE TEST, WHEN THE SAMPLE WAS COLLECTED. REPORTED BY �� DATE 6/8/93 y 02 -24 -1993 09:53RM FROM LAURENT ENGINEERING ASSOC TO 1 DrVISION of ENVIxa� t, HMTH SERVICES Owner or Purcbaser -1of Building Buffd_ing Constructed by lrocation - Street hmicipality C.-. CON Iry W 000 V a At � Building S`ype Section Block lot CoCZNwA\\ V`N"S E5�95. Subdivision Dame ZS Su xi- ivision Trot # C41ARA= OF SUBSIMFACE SAGE DT.SPQ&PL SXS ai I represent that X am wholly and completely responsible for the location, wo4monship, material, construction and drainage of the sewage disposal system serving the above described property, and that it has -been constructed as sham 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 i mned.i.ately following the date of approval of the "Certificate of Construction, Compliance" for the sewage disposal system, or any repairs made by we to such syste=m, 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 detein in tiara of the Director of the Division of Environip�ntal Health Services of the Putnam Coanty 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 Z 4 day of 19, C1 Signature General. Contractor (Owner) -- Signature N E-LV,`..E S 1, u l cic2s L• Corporation Name (if Corp.) pddres - - rev. 9/85 ok ess soft 00 14 qt lei l% DnIP FMw G P D twaW ftwomp S!mbm to exit d- - Gi 8�Ile 11nk o Rev. n o op DEPARTMENT OF HEALTH Division of Environmental:Health Services 4 Geneva Road, Brewster, New York 10509 (914) 218 =6130 APPLICATION TO CONSTRUCT ,A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Town V- 1+a E-ity Tax Grid Number WELL OWNER Name Mailing Address A%Anj''E .5� C,604� ors PE-r- 5KIL N =i . 105Ci ti -s �\ PC -1 P UTNAM C OUNTY D E PART MENT O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: 2. 4. 6. 7. Name of Project: f E�ZiSn SS7� 3. Location T/V /C:1.1T8T�'1Gf�i Project Engineer: 14Af -g-4. f�f.'-1-I�U_9 X, 5. Address: 73 ��� 4� � �c� 01. License Number: Phone: `eIJcr 79-r, Q) Type of Project: — Private /Residential Food-Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.., Exempt t.� Type II. Unlisted 8..Is a Draft Environmental Impact Statement (DEIS) required? ............. NO 9. Has DEIS been completed and found acceptable by Lead Agency? ........... t 10. Name of Lead Agency 11. 12. 13. 14. 15. :6. 17. 8. 9. :0. :1. Is this project in an area under the control of-local planning, zoning, or other officials, ordinances? ......... ............................... a If so, have plans been .submitted to such .. author hies ?.................... /►' Has preliminary approval been granted by such authorities? Date Granted: Type of Sewage Disposal System Discharge...... Surface Water ,ZGround Waters If surface water discharge, what is the stream class designation ?........ Waters index number (surface) ........... ............................... Is project located near a public water supply system? .................. U If yes, name of water supply Distance to water supply Is project site near a public sewage collection or disposal system ?..... /V G Name of sewage system Distance to sewage system IVA Date observed: 23. Name of Health Inspector: 4. Project design flow (gallons per day) ...... ............................... 8,06 9 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. 26. Has SPDES Application been submitted to local DEC Office? l+ 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... 28. Wetland ID Number ....................................................... /v 29. Is Wetland Permit - required?' .............. ............................... Has application been made to Town or Local DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? ................... 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 G 32. Is project located within 1;000-.feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or J 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? �Ztjl 34. Are community water, sewer facilities planned to be developed within 15 years ?_ 35. Are any sewage disposal areas in excess of 15% slope? ........................ 36. Tax Map ID Number ........................................................ 23 i 37. 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 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 Xisdemeanor pur uant to Section 210.45 of the Penal Law. I/ / 1 e SIGNATURES & OFFICIAL TITLES: 23 l/ Vq- r� \--lJ fj-, i {AILING ADDRESS: 'S PUTNAM 03= DEPARMilM OF HEALTH DIVISION OF ENVIROR%ffWML HEALTH SERVICES DESIGN DATA SH=-SUBSUFACE SEWAGE DISPOSAL SYSTEM F= NO. Owner t -� c )Egg, 5A� T Address 5 � C'f- Q4P- L-/,T) r Located at (Street) 4AM P-194i4e Lpo ,j Sec. � n Block Lot (indicate nearest cross street) ,,=icivality EAT-r� Watershed SOIL PERCOLATION TEST DATA PJD7J= TO BE SUBMITTED WITH APPLICATIONS Date of Pre--Soaking �e,� - Date of Percolation Test �r- /a HOLE N94BM CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level. No. Time Ground Surface In Inches Soil Rate Start-Stop Min. start Stop Drop In Min/In Drop Inches Inches Inches 2 Z-V7 - a:ao 9-2 AA- H 0 2 1�2 4 5 2 3 4 N=: 1.* Tests to be r0peated'at same depth until appradmtely equal soil rates are' obtained at each percolation test hole... All data to'be suhmitt�d for review. 2. Depth measurements to be made from top of hole. rev. 9/85- TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS IN TEST HOLES DEPTH HOLE NO. j G. L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' HOLE NO. HOLE NO. INDICATE LEVEL AT WHICH GROUND ATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: A LL/L- DATE:. DESIGN Soil Rate Used Min/1" Drop: S.D. Usable Area Provided 50o.6 5,f. No. of Bedrooms _ Septic Tank Capacity SZ gals Type Absorption Area Provided By 4p6 L.F. x 24" width trench Other Name j Z - Si g natur i lid Address 75 SEAL ° ��m�, t� X124 • �;; THIS SPACE FOR USE BY -HEALTH DEPAQNLY° Soil Rate Approved sq. .. , PP ft /gal , , Checked by Date m �C \9 > \ �T rA G�DU t2T a S J s �R �3 I'1l�O 4,A GJ�t'T lC� /6, ice: I� 1 N� � N� 1 O 1�( GK ��� (I N �T• THIz IS TO C812TIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED A5 INPIGATED ON THIS FLAN AND THAT THE SYSTEM WAS INSPECTED E3Y ME BEFORE IT WAS COVI:IZI;D OV5K- . THE 515TEM WAS CONSTTZUGTED IN ACCOKPA1�1GE WITH ALL STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH AND THE NEW Y,7KK STATE DEPARTMENT OF HEALTH . N o1"1✓ : HOli'�Vt✓ A Ar2 Lt1GA -TlaO � 1p,��t �d rfleOM It Or 1°r;qI°j�-rvTY " t2,16,-r,;n 2 _ I I.1-1,145 , r1of�rA[ze , 1 -5Y 0UwNr-Y AYv'oI,IA-Tev- , 1,.,S7. /15- 103 b4 g 135.4 103. � q 1�1-v 1D1.� 10 141,2. 112 I2 5$.Z r23•b l� 61 -M-b I� 6,1.7 $ THIz IS TO C812TIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED A5 INPIGATED ON THIS FLAN AND THAT THE SYSTEM WAS INSPECTED E3Y ME BEFORE IT WAS COVI:IZI;D OV5K- . THE 515TEM WAS CONSTTZUGTED IN ACCOKPA1�1GE WITH ALL STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH AND THE NEW Y,7KK STATE DEPARTMENT OF HEALTH . N o1"1✓ : HOli'�Vt✓ A Ar2 Lt1GA -TlaO � 1p,��t �d rfleOM It Or 1°r;qI°j�-rvTY " t2,16,-r,;n 2 _ I I.1-1,145 , r1of�rA[ze , 1 -5Y 0UwNr-Y AYv'oI,IA-Tev- , 1,.,S7. _ ------------ / / f % / I l I \ 1 ; j 1 1 I I I 1 / 1 I I I / I I, PROP05 `i-P 1 / I I I / 1 1. .11 1 1 \ I I \ \ I I R- 4C SITE. PROPEL PATT E IZ TAX MA SS D, DESIGN 4 E3EDKC SOIL RATE APPL. I CAT A550RF REaull PROVI TEST HOLE • I ; o RP. dFO�LE�� Q PT Q T. P.