HomeMy WebLinkAbout0572DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
23. -1 -36
BOX 7
to `
' � ' t' . r ' , �I
�� t . I
r.
1 - • .. k- ir i
-.
I ' _
JL
00572
7
3 pUTNAm
COUNTY .DEPARTMNT OF
HEALTH
n of Eqy" mnen t =61, MY.
1051k2
ei Must Provide ' W
P.C.M.D.Pe
CERTIFICA OF. ONSTRUCTION COMPLIANCE FOR SEWAGE'DISPO SAL SYSTEM
A Tat Map ve- TMOi` or X,
LV.
L"4" at
OvAieir/a, Mcant-NamO -PeV61-Maif 7T Su slon Nam tibdv.%Mt-#,
P1
Date permit 7
Ini-pblAiV )�fi A) A-,
Melling Address Z11p_
ado -A)09 H—u�,L-6� /i I/
T,
Addrm 7,12p
Soparitto'ie*oiage System tat by �SWT-fa -6�1-67.tm qVl2f +��AJ
;Conslstid'g of Gallon Septic Tank and —4 L
Water Supply : Public Suolilk From Address
Q0,0 t�A �W 1, L 5� A)
ro. ya 7 a& Address
or:
BWld*i Type: —.Has Erosion Coitroi-Been Completed?_
Number of Bedroom' 4 Ris Garbage Gi inder Been Installed?
dl7 0.
Other;lleqxdrebients
I certify t"t.,th . a systeia(s) as listed 'serving - the- abo Yr --premises were 'constructed essentially as shodn c . )p thp.plans of the completed work copies
of which are attached),,,, and in 'ac6bidance with the standards, rules and lations' in accoidance rf�ian, and the permit issued by the
Putnam C e h
a .
D to P.E.
Av
rb*b_klconse No.
Address.
h� !hap.promp y maybe-riocessor to of person occupying -promises served by uch octlon_as
il, take's y any unsanitary
separate'. I
conditions rosuItInq::from'-- such uiage.-'.'Approv# . 'SeWs�a - SY null'and.
of �tt_ go stem, shall �bocorne_ void as soon as .a pub. ?: sari Itsey siwisr. becomes
when. a public water supply aromas available.
available . and the approval private water supply ,shall _ become null nun d void s6c,h"ippiovals are
. when, an. 'in t _C nor of revocationj modification or change Is ns� I C"Ury. I
subject to modi CA or hi'ludgment of-the C 0 Heal such
Date LN 'By., Title
I
UQi represent thatUx- aftCwholly 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 W which, fails o
operate for a period of two years immediately following ; the date of approval of tthe . .
"Certificate o Construction Compliance" for.the sewage disposal system, or; any:
repairs made by 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
caused by the willful or negligent act of the occupant of the build' g u Utz n
the system.
Dated this day of 191 Signa f
Title
4P ,
wrporauvn ivau�e tit t:orp. �
c> N o 1U o ,_ 4-% /-i J c. /lke.L
Address N.
rev. 9/85
mk
Corporation Name (if Corp.)
MM
A� C4r.
:.
a
_
WC.LL UUr1rLL11ULV Rr•rUAl
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use.Only
WELL LOCATION
SIRE" .AOURESS: WNlvl / i __
/�'yy� I� ,{(` TAZ GRID Nua +eEa: s.,.p�' �}
6'� / / l
WELL OWNER
NAME A "� n �- ADDRESS: a Q
%?�i1'r /hi-fi" ," G/
hIVATE
❑PUBLIC
USE OF WELL
1 - primary
2 - secondary
UPIESIOENTIAL p PUBLIC SUPPLY r-11 AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS. ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED _/ EST. OF DAILY USAGE j&_& gal.
REASON FOR
DRILLING
W SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /08SERVATION
REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH , �ftSTATIC
WATER LEVEL ft_
DATE MEASURED Z4�
DRILLING
EQUIPMENT
0 ROTARY ❑ 9101PRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT UKABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED 24PEN END CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 2 5 ft.
MATERIALS: EEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE JF_cl ft.
JOINTS: ❑WELDED READED . ❑ OTHER
DIAMETER iri.
SEAL: gai'M NT GROUT 0•8ENTONITE ❑OTHER
WEIGHT
PER FOOT �Z Ib_Ift
f DRIVE SHOE PJM � O NO
ES
9:0YESOW
SCREEN
DETAILS
DIAMETER (i
SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FI
❑ YES O NO
HOURS
SECOND
GRAVEL PACK
O NO
RAVEL
S
IAMEf
OF P in.
TOP
DEPTH ft.
BOTTOM
OEM it.
WELL YIELD TEST If detailed um in
P P 9
METHOD: O PUMPED ; tests were done is in-
O COMPRESSED AIR : formation attached?
O BAILED ❑ OTHER :OYES ❑ NO .
�IELL LQG It more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
well
D'a-
In
FORMATION DESCRIPTION
CODE,
iL
WELL DEPTH
1t.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Surface
Q j Q
L
WATER Pd6kR TEMP.
QUALITY O"CLOUDY HARDNESS
O COLORED ANALYZED? S O NO
ANALYSIS ATTACHED? 1346 ONO
STORAGE TANK : •TYPE ft►Qty
CAPACITY G% GAL. (�
PUMP INFORMATION
TYPE CAPACITY 44gj!c�/+
MAKER 6 DEPTH
MODEL Z VOLTAC rjHP
i WELL DRILLER NAME OAT
ADDRESS 30 /!?
G (Q07'D /✓ )5f&
Yorktown Medical Laboratory, Into
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245.3203
Director: ATberi H. Padovani M. T. (ASCP)
F
Dennis Malanchuk
PO Box 313
Croton Falls, NY 1.0.519
L
J
n f' _ ._
LAB . !/'
Date Taken ( 5' Time: _3Q pM
Date Rc' d:. Time: 3 o PM
Date Reported. SEP.201989
Collected'By: Dennis Malanchuk
.Referred By:,
yS�ipple Location:,
{ I G- h V1-eW
U r`►n W A l h i► I
Phone #
Phone H" Sample Type:
Reaeat Test? _ I (check one)
LABORATORY REPORT ON THE QUALITY OF WATER'
INORGANIC NON= METALS;(mg /L) MICROBIOLOGICAL (CFU /100mL)
Acidity
_ Alkalinity
Chloride
_.Detergents., MBAS
_ Hardness,.Total
Nitrogen, Ammonia.
Nitrogen, Nitrate.
Phosphate, Total
Sulfate
Sulfide
Sulfite
METALS (mg /L)
Copper
Iron
Lead
Manganese
Mercury
Sodium
Zinc
MISCELLANEOUS
— pH (units)
Color (units)
Odor (TON)
Turbidity.(NTU)
GENERAL BACTERIA
Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
Total'Coliform
Fecal Coliform
Fecal Streptococcus
MOST. PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N /A.
LT =
GT. _
TNTC=
CON =
NR. =
Not Apvlicable
Less Than ( <)
Greater Than
Too:Numerous To Count
Confiuent (= TNTC).
Non- reactive
REMARKS /COMMENTS (For Lab Use)
Potable
_ Non - potable
STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
HNO3
HC1
— H2SO4
_ NaOH
_ ZnOAc
— Na2S203
Other:
Incoming
Ci LE 40C
_ GT 4 °C
PH LE 2
PH GE 9
PH GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE O(WA (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T YORK STATE.D RINKING WATER
STANDARDS' FOR.THEPARAMETERS TESTED, AT THE OF CGLLECDNKING
THESE RESULTS INDICATE THAT THE WATER. SAMPLE (DID) (DIDN'T) MEET THE
..SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW.YORK STA WATER
CODES,. FOR THE PARA ET %%TED, AT THE TIME OF COLLECTION.
/X/
Albert H. Padovani, M.T.
CP), Director
2 /86(Rvsd7 /87)RWE
J7.
4_
b__
FDIAr, SI?'E�L�ISpECI'_r, Lit=
j
C;vza
OR SD�EDI i! SiC�I LJI' �L� — a
i •roc �k-t rrnr�:f -,-
S iPr^ DIS CSrr, PGA? 0
(`T
G_S area- 1Cr':f GS r Gr./17rovEd c1a_ns
b. F i ] se c—L i Ca - Date of piacl_=71�_rlt
L:1 barr;E~ LGLF WDZ -r! ANG_D11n-
c _ sci; nct s trircr i
bra; ec_ L-�n 15' f =an SDS
I 1
1
I
e_ 100 ft- f=-. Wa. ccur =e/ iEt: any_ I
I
_
SZ-51= DISrC�P S.�S= -,, I
Size _ 1,000 I.2�
b. se:�LZC to:
I
% goo LGr:�� � C' °�_rlcut wi tr2].n 10 f,-, . Gf 450
e. i'
1 P '• cLr! =_ at s= ms e? = -rticn
belt f res � I
7 bc rQ lcnes
jtin ;:L L hc x
I
f. j�„ CI'TCN EC=' -- Crcceri y S_=
I
I
C . r L'�+..
Dizi =nC=
1
= Lns == l _= ac- �rcinc tc�C1 -�
- S1Cce C _ �n ac = -r�= ^! e 1/ 5 - /32
0 i= - =- r_-_ t l i ^- - 20 Lam- - SC 'Lrr --_C'S
L,CJI� -} ^C= t= c'^_'" < 30
—i-
I —4—
1
S. Rccn allc ec =cr 50!-
3/
I
fit
I
1: 1rEC% -1 C C= =zi c1 in t= E_n- '! 12" u it i r-i rl
I
h. F -HP OR LC.c-
S ze Cf c_��
_ CcG'- -jcti-
I
ITani -.
C Ci cle by Ee: -: th Cfe r a L
^cEr
I
I
I I
e =tiTi�t_� cN cvc_e
b.�
I
E3 z:=a- accc rzveZ U! ans
IS _ =`te - -b_
✓
I
C_ CiEzinC 1,3" C�C..,C CiG�e
b. � ZCCS T:� �_G � 1 �� l..GC� l 1 � C`r�
(
C_ All vices f �•_ : wi z in<_ce of bcx
I ��
I
I
--
sat__al cent =?ns s -.ones < 4" in ci`rEr�
e- C_ ai n d=i n ins, led accordinc to pian
��
t. c - air a=—:n & d4 to emis`_wac-
( I
C=-- ` c- acharce away t =CII C_5 ar==
h_ - =ac- = ade=vt= I
-
+ __ ll i I
I I
Cl l_� _ • -r l.i�_L1 C.1! Jl��...c •..mac_ ___
.lea
U U
John M. Simmons, M.D.
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
� INSPF7CTION
NAME �Q/ /I �i� . - l % �o Orig. Routine
�- o/� 2 �/ Orig. Complain
ADDRESS
Orig. Request
No. Street Town Ti No. Caapliance
Camplaint Comp
MAILING ADDRESS Final
P.O. Box Post Office Zip Code Group Illness
Construction
TELEPHONE
Reinspection
PERSON IN CHARGE / __ // Field, Sampling Only
OR INTERVIEWED / C �' Field Conference
Name and Title
Other
DATE 141&2 TYPE FACILITY
i
TIME TIME LEFT �; Explain
c
FINDINGS:
INSPECTOR: ,7 " "411- � `-� TELEPHONE:
Signature and Title
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
t?IM�N9tONG1- tAl2T'
x
501, >%`APJ�O;(1•P71oN
0'
50.0'
Iq
•
Tit ->✓NG� iT'(P) ..
50:0'
'�
fit• p�
�J3.0�;
ie 14 1>I�►�
' �'
G
10:0.
g� i''
t 1�la { t� tjJP ► 40 —or TR�U
6
f32.5'
P �i. �✓`�
M�
_k.
ICJ �,�
� : °,� •
�17.p � ..
l OV..0'
F ..
Imo' Ali e
I t0.
I
el.O
Ii60.o'.
t5.
11
121.5
1�o
q5.5�
1:25:5
�7
I,Ot'..0, .
1,�,
JUNG71ON
12'Sp GAL
A 4 %a ': r r�mcoc *,
l
y�l°TIG"(?�N�
Lf4
G K�zv
1,7 77
:.. -.
4. "dl c:i.P.
ll tom,
•_
5.U1�-V FY O � IZT'(. P12.� 1°.q t2-�
t?IM�N9tONG1- tAl2T'
t
0'
50.0'
a: O`
50:0'
'�
fit• p�
�J3.0�;
ie 14 1>I�►�
' �'
G
10:0.
g� i''
t 1�la { t� tjJP ► 40 —or TR�U
6
f32.5'
P �i. �✓`�
. t 0
q(o.'✓'
�17.p � ..
l OV..0'
Imo' Ali e
I t0.
I
el.O
Ii60.o'.
t5.
5�.0'
121.5
1�o
q5.5�
1:25:5
�7
I,Ot'..0, .
1,�,
I2iGJ I l7isih FGA
ie 14 1>I�►�
' �'
g� i''
t 1�la { t� tjJP ► 40 —or TR�U
IAN-: ANN
Imo' Ali e
QO
.
1 TAR 6YF:JI
A 4 %a ': r r�mcoc *,
G K�zv
-�=-
A
ll tom,
•_
5.U1�-V FY O � IZT'(. P12.� 1°.q t2-�
,1°.!?•l>:P�
HI &HNA-( 06,VeL. OVK"r- , VAT�d ,
A V E, i `';;hv . , .
Pfe�PAt? Et7 t3'{ PJ(INit'f A54Gi:v?
N
<
CoiM
fwd:
;:aeow
!, WM A
of
' APPR�
;,iireeil
nquMi
RAV..
10/88 °j
A
0
_ .TRI
L�
Putnam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE OWNER APPLICATION-
. ,
FOR PERMIT. APPLICAT-ION SUBMITTED- TO
PUTNAM COUNTY }[EALTI{ DEPARTMENT 'r
TO: Commissioner of Health - In the matter of application for`
-- fig- -
I, represent.
that.I am officer or employee of the corporation and am.,- authorized
to act for, wq / I . �.�f4 CLAM s°tt ��!%p •— — — — _ _
namb of cor oration
having offices at'��r_��e,21 /�,�/Jg,����_
clee ` _ _ _ _Whose officers -are
President ^��j�vs- vim - -< 's -f a a�6------- - --- - --
lame an Address) .
Vice - President
—
Secretary ...—
• (Name and Address) -
Treasurer _ _ _ _ _ _ _ _
- _ — .(Name and Address) _ — —
and that I= am-and w� ll be individually responsible for, any or all aptpr
of. the- corporation Leith respect to the approval requested and- all .sub-
Sequent acts relating thereto. - t
Sworn to•liefore me this y"l day Signed —
J
of Ajohn+ 19. Title —P sid
4 A
Notary Public
BONNIE,J. DAVIS
helaq Public, State 91 'Now York
OutMae CwntY ,
MY Commission EXPires Apol 03,19 `11
t-
1
Corporate Seal
Pr 3 2 -10 :1 :1
3 :90 =1,o:tl :11
4..
5
z 10 '0 -10a ► 1-7
5
1
2
3
4
NAM: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to' be suimittmd
for review.
2. Depth measurements to be made-from top of hole.
TEST PIT DATA RMUIRED TO BE SUBMITTED WITH APPLICATION '
DESCRIPTION OF SOILS ENCOUNTERED IN " TEST . HOLES
12'.
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER. IS. IIQQOUN
INDICATE LEM TO WHICH WATER I,EVF:I, RISES AFTER BEING II1000NTEEtID
DEEP HOLE OBSERVATIONS MADE i BY: DATE: 7-
DESIGN
Soil Rafe Used X-10 Min/1" Drop: S.D. II,�able Area Provided . 0 0 D
No. of Bedroans Septic Tank Capacity _/A D gals. Type ('0 10C,.,
Absorption Area Provided By L.F. x 24" width trench
OtherF
r , P'N I c�to',��—
Name ....�R�2�T �fi�s/ �E�12 �� �S�oC ��ignature • � -� _ }Y, ,�,v
uj
Address 7� �A112�1 r✓zT7 D%O J I/� SEAL
16124
/
No.
o� 11 l✓
A9OFESS�o�?ry
THIS SPACE FOR USE BY HEALTH DEPAPMM. ONLY:
Soil Rate Approved sq. f%,%J. Checked by Date
%
,:,e^ 'z 1�
N J,
�A w Carmel X Y
-
F;
'S,
-
V
K MEW
.g
%
,Town
"S
Subdlvlt Aet :# L -Tiii r*W
it n r4
`�;".
AR
J.,
&jj : of P, Val-
,4 p
OUS,
Mao
;4
%
Sk J" y.
BalldW -g Type �C �'T� �L- Lot Area x.' �-%� .d.0 FIII Section Only - Deptlty.3 Volume
p.
Number of Bidre6iipip,
�"parmm-:Ae vikr ,S Gallon
To be cone acted br
or:PLrFvate Supply Dialed by -Z
.... .. . . ;"�,
S-4
17
:ez
V -CIA--
a diipbsal.��.Systernl'
wtiollnlT �, - -- - 9�:_ —
44 �flrreli;"Ilt,6 $;,rules
!qv�e. a JA��;;4?!.I�n.c�.'.vvi h 06 s 4p� fand.regulat ions .of: fhA utnarn
'h-- iii';c6fiiplifliSn�'theii-7 to the tomrni�5!6Air'-f, Ith Ili
be �County;� egiartment-o� I4e'4'Ith,,andVat-c eof,&!,!Certif itatq��-o
s Vil
6 �hl , : I r,wIl
t TR� - . I
submitted NoWi4i.,1his successors,-, er�� - - . .
i ate
-f
a' opera ing cononson 469,.ah'-
p ce fin, good s
i0o theiisu
0 r
anc e.,o t 0 repairs a
irs':t
;444
all
will be; located as shawn!on the
approved -ITIsaid I -
,pia
.!C'oiiniy Department of' Health .
I ssors,
o�f 'two
bove
an�, rep! 4 is a JtnaT
Dais
License No
—6
14
APP,ROVEO FOR CONSTRUCTION T h�s_approva) ;expues two 1, S, s r
romithe -daze issue 00 of ¢
f Ingelpt-alt atkn, V r q,
or,ca4sp or m ;U&
10!,"u". Pr�vT
r 4-: new -.Mrrffiit.� A/ 64 for ,c1iij)dsiI,:of. nil
q pr
aq
r
,Rev. By
1/8
Date Tate
13
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL p l�
PCHD PERMIT
WELL LOCATION
Street Addr ss
own ill a City Tax. Grid Number
U�- ED .
Imo--
I
WELL OWNER
Name.
Mailing Address
�
rivate
L 1(L
'TES �1G
'C® � 14MO&
0 Public
USE OF WELL
RESIDENTIAL
O PUBLIC SUPPLY
O AIR /COND /HEAT PUMP
O ABANDONED
1 - primary
0 BUSINESS
O FARM
O TEST /OBSERVATION
❑ OTHER (specify
2 - secondary
O INDUSTRIAL
O INSTITUTIONAL
❑ STAND -BY
Q
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE
SERVED3--5 /EST. OF DAILY USAGE gal
REASON FOR
MEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
DRILLING
OREPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
BILLED
DRIVEN
DDUG
❑
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES W-___N0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: (!fyr&,in KLL__
Lot No.
WATER WELL CONTRACTOR: Name Address::
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:, YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
<DISTANCE TO PROPERTY FROM NEAREST. WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION ONEP
jS TES E _ _j -
(date) 0 (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 provide by t e Putnam Count
Health De ar ment.
Date of Issue: 19 c
�! Date ' of Expiration : 19
ermi," Issuin ficia
Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector
:I Pink Copy: Owner
2/87 r'n- n- - T.T_'1'I I I __
nvvFmmTr n
' I �1• 1 ►
V,►. �
REVIEW SHEET - CONSTRUCTION PERMIT
DATE REVIEWED:
BY: -
(Street Location)
DOCUMENTS C P
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) SUBD1G
Deep Hole Log Perc _
Consistent Perc Results (3) Fill
Perc Hole Depth cd _
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIFZED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pup pit detail
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder notes)
Design Data: perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter,Curtain Drains (discharge OIL
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shcwn;gravity flow,suff. sit
If Pumped Pit & D Box shown, & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Sy:
Property Metes & Bounds .
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
101 to P.L., Driveway, Large Tre--s,Top of
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake Unc. i
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped water
10' to Water Line (pits -201)
50' intermittent drainage course
Se tic Tanks
10' ran Foundation; 501 to well
15' Well to PL
Notwa: 1) Tests to be-repeated at same de,th until ayyroximately equal soil
rates aro obtained at each percolation to t hole.. All.daia to be submitted
for rAvif•w.
• i nth measurernPnts to. he nvide from t op ' o.f hol r-.
D
'OF
FUTNAW COUN`!'Y "DEPARTMENT HEALTH'
DIVISION OF ENVIRONMENTAL HEALTH SERVICE
COUNTY OFFICE BUILDING, CAWE.L, N. Y. 10512
DESIGN DATA SHEET - SEPARATE
SEWAGE.; DISPOSAL SYSTEM FILE -,NO:
(n+rlerCc�1.JWAL�- I -�I�,L EST�CS
I.�•,.I .Addx!t�seZ� �p-t'�i.l,t1 -1 s�yL.,�1LA"Co►U�iI,I�Ly
Ic�r3�o
C_pVJ\,),VUL' JAALt 1?_�D.
Located wt (Stmt Wizate ' CL. See. 15'.. Hock ... tom_ .IAt
nearest cross a ree
MwLLclpQlity C LSD
:.... Watershed �.Z6T�l�,(
SOIL PERCOLATION TEST
DATA REQUIRW' TO BE SUBMITTED` WITH APPLICATIONS,
Nwnbur CLOCK TIW
PERCOLATION
PERCOLATION
—Tun kjapse
Depth to Water Wa er ve
No. Time
'
From Ground Surface in Inches
Soil Rate
Start -Stop Min.
Start Stop. Drop in,
Min. /in drop
Inches Inches Inches
1 3:4,3:4
. - ,2 . : 50
Notwa: 1) Tests to be-repeated at same de,th until ayyroximately equal soil
rates aro obtained at each percolation to t hole.. All.daia to be submitted
for rAvif•w.
• i nth measurernPnts to. he nvide from t op ' o.f hol r-.
TEST PI T DATA
IRED TO BE . SUBMIZTIM WITH .APPLICATION
F SOIIZ ENCOUNTERED IN TEST HOLES
DEPTH HOLE 140. HOLE N0. HOLE NO.
G.L.
12" .J LLCM
18"
2,►"
30 "..
3600
42"- Qoc
`,i4 N
60,,
�ack
I ND I CATS, UXE1, AT WHICH GROUND WATER IS
ENCOUNTERED
I NI )1 CATS LEVEL TO WHICH WATER IL-VEL RISES, AFTER BEING ENCOUNTERM
'PE.3TS Ku-)1K BY Date
3ui1 Rate Used
IGN
M1n/1 "Drop:
S.D. Usable Area Provided
Nei. ut' bu-druoma
Septic Tank Capacity,
Gals._ Tyj)e /
AbsurpLion Area Provi ed By L. F. x24"
—56"— nV *1d1z1-1.. renc
Nts[rx �nl.-p-
) :U /
lgria u -el
Address �'
G
., LJ
� SI:AI,`r�. � � 4 ''�i =, •''- j1
11'1115 SPACE FOIJ USE
BY HEALTH DEPARTMENT
Nllvo
ONLY: , ' x,r'l �f,;oF777jo J���i
rn
:coil hate Approved
Sq. F't /Gul.
Checked by`.' Date
<<_
C��yy @ YVO E
SEP 2 l' 1985
..
PurnrAAA
DEPT, OF OF HEALTH
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
Cornwall Hill Estates, Inc.
I, Kenneth Emerson
represent that I am an officer or employee of the corporation and am authorized
to act for Cornwall Hill Estates, Inc.
- - - -- - - - - - --
Name of Corporation)
having offices at 223 Katonah Avenue
Katonah, N.Y. 10536
Whose officers are:
President: Edward H. Emerson, 223 Katonah Ave., Katonah, N.Y. 10536
(Name and Address)
Vice - President: Kenneth Emerson & Martin Diano, 223 Katonah Ave., Katonah,N.Y.
(Name and Address)
Secretary: Janet G. Mastropietro, 223 Katonah Ave., Katonah, N.Y.. 10536
(Name and Address)
Treasurer: Lynne Diano, 223 Katonah Ave., Katonah, N.Y. 10536
(Name and Address)
and that I am.and will be individually responsible for any and all acts of the
corporation with respect co the approval requested and all subsequent acts relating
thereto. ( A�
Sworn to before me this n day Signed:
of 6�" 19
�.l.J
Notary Public
LIONEL WEINSTEIN
Notary Public, State of New YOM
No. 60. 4199160
Qualified In Westchmter Coen*? of
&*mrnLw11otr Expires Mtrcft 30.19.
8/84
Title: Vice President
Corporate Seal
" G
NfSp
_W7
I. - \�, - , . . . . . .
A
6 c
'5a`- 'E-r,Se-r -'at
IM ve