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Home My WebLink About0585DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -49 BOX 7 1101 go 'owl I IL ml 1' T j'16 , IN al laTmol � 00585 a .t �* W WL' LL UU111rLL11U1N 1CLruml DEPARTMENT OF HEALTH Division Of Environmental Health Sorvices PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADDRESS: 7f ffW__N /VIL / I Y L J TAX GRtO NUMBER: �'j-,� 0't cr N ( LJ E Z_ a 3 1 ' z- WELL OWNER NAME: ADDRESS: N A_ LL (De L) Cjz p ❑ PaIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary ESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑- ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT. /S gpm. /N0. PEOPLE SERVED _ / EST.'OF DAILY USAGE Zr gal. REASON FOR DRILLING SUPPLY 0 PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH Z 2::L ft. I STATIC WATER LEVEL ft. I DATE MEASURED 7AA& DRILLING EQUIPMENT ❑ ROTARY O CgNPRESSED AIR PERCUSSION ❑ DUG O, WELL POINT ABLE PERCUSSION O OTHER (specify): WELL TYPE O SCREENED EN END CASING. ❑ OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH _ fl MATERIALS: EEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE fl JOINTS: ❑ WELDED READED O OTHER DIAMETER in. SEAL: ENT GROUT O BENTONITE OOTHER WEIGHT PER FOOT _Z _ Ib. /fL DRIVE SHOE. 124�- O NO LINER: O YES SCRE D E LS DIAMETER (in) SLOT LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? RS7 O YES ONO HOURS SECOND G ❑ YES ❑ HO SIZE: DIA OF PACK .__ in. DEPTH ft. DEPTH ft. WELL YIELD TEST If detailed pumping t METHOD: O PUMPED i tests were done is in- O COMPRESSED AIR , formation attached? e AtfO O OTHER ; ❑ YES ❑ NO WEL� LOG It more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing well Oia- meter FosmATION DESCRIPTION CODE. ft fl WELL DEPTH ft. DURATION` hr. min. DRAWOOWN ft. YIELD gpm. Land Surface z A 11� WATER 111,06EAR TEMP. QUALITY ❑ CLOUDY HARDNESS`, O COLORED ANALYZED? 10Es ❑ NO' ANALYSIS ATTACHED? OeTfS O STORAGE TANK:' TYPE CAPACITY GAL. PUMP INFORMATION TYPE cS CAPACITY INO DEPTH MODEL VOLTAG� 'U WELL DRILLER NAM E �{J U�� OAT l ADDRESS 3 &l %� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROiNZflMAL HEALTH SERVICES G0lf,nWA11 14i 11 6r.0L% im C4,t Owner or Purchaser of Building 4,j s No ."I 4L -S Building Constructed by So en k L S e, f h C1, d C. Location - Street Afye_2S0n Municipality Building Type is Section 6 a! Block Lot CdALL �2/1p&j5 C%S -TES Subdivision Name !�,j Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM Li represent thatUL aVCwholly 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 tFiereto, 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 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 (96 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 buildi g ut/.}l±z nV the system. Dated this i0 day of ^ U 6 i 19� Title (Owner) - S gnature n 0 V#i /l d �� /o v,a�., t 6.4-/2, Corporation Name (if Corp.) DD Address A). Y. 1 p 9D 1 rev. 9/85 mk Corporation Name (if Corp.) Address WAS Yorktown Medical Laboratory, Inc. 321 Kcar Street Yorktown Heights, N. Y. 10598 (914) 245 -2800 Director: Albert H. Padovani M. T. (ASCP) F DENNIS MALANCHUK P.0.BOX 313 CROTON FALLS,NY. 10519 ILk B f,` Date Taken: :? u Time: Date Re'd: Time: r; Date Reported: 9C' Collected By: Irko, I rAYA PO /Client # -� Referred By: Sampling Site: 0 3� j!h v, euo bet, . a-Le. C a1r n ou n *\ I b Phone ( ) L J REPORT ON THE QUALITY OF WATER INORGANICS (mg /L) MICROBIOLOGICAL (CPU/IQ0mL Alkalinity Chloride _ Copper _ Detergents, MBAS Hardness, Calcium _ Hardness, Total _ Iron Lead Manganese _ Mercury _ Nitrogen, Ammonia _ Nitrogen, Nitrate Nitrogen, Nitrite Phosphate, Total Silver Sodium _ Sulfate _ Sulfide _ Sulfite Zinc _ Standard Plate Count (CFU /1 mL) Membrane Filtration Method Total Coliform_ Fecal Coliform Fecal Streptococcus Most Probable Number Method Total Coliform Fecal Coliform _ Fecal Streptococcus - Presence /Absense (PA) Total Coliform P A PHYSICAL IS ELLANEOUS KEY FOR TERMINOLOGY DH (S.U.) CFU = Colony Forming Units Color (Units) IT = < = Less Than Conductance (uhms /c) GT = > = Greater Than _ Odor (TON) NA = Not Applicable _ Turbidity (NTU) SA = See Attached TNTC = Too Numerous To Count REMARKS COMMENTS For ab Use (For Lab Use) SAMPLE TYPE: (Check One) Potable _ Non- potable OUTGOING: (Check Each) HNO —_ HC13 HSO _ NaOH4 ZnOAc _ Na2S203 Other: INCOMING: (Check Each) LE 40C GT 4 /LE 200C _ GT 200C _ pH LE 2 _ pH GE 12 Other: THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) j (WAS ITT) (NA) OF A SATISFACTORY. SANITARY QUALITY ACCORDING TO YOW 1 TAATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) (NA MEET THE SATISFACTORY -CHEMICALL /QU�L Y STANDARDS OF THE NEW YORK STATE L DRINK- ING WATER CODES FOR E)P ERS TESTED, AT THE TIME OF SAMP COLLECTION. /,-/ � pavq ? /R "7(PvsdI /90)RWE I.. V. v__ Li 1. FINA1, SITE Di 1SPE'CT -CN Date L l/ CWTa� P q —q �� ;t O SJEDIs7ISICm1 ' e 3 I ' eA crr� Sr -M_G DISPC SALT PG-'? I` I a_ SDS area lc eE as per aLmroved vians E. 10 f= - r:- = - fcunEa - -ici c = =uit prCC ='"t + 1' - 20 fc b- F-i? 1 se,--,- i cn - Date of place-n-ent I 7. Lert:-! c= t-e,ch < 30 znches - =an 2.1 barrl er . I= W'II H AVG.DP h E. Rccn a11C.':e✓ fcr EY"..an-sicn, 50; C_ maturall scil IICL s =_:LE sd I 9. Size c= 3/4 !7- d_ Stcne, bra =, etc_ , Creare_r t'Icn 15' f_Cti1 SDS ara=_ U R� =+ ;"2 C C' Vel in t_ a ch 12" e_ 1(0 f t_ f_c: Hat_r ccLr_e / wetlands= e_.ds I __T SL: DISPCSA.11, crc-r�n (� I a. sect; c tank s_-- 1,00 1,2[0 2. G- e_rf1cw b. S_ctic tG*ic levell I . P l a_�-n, V== �/auaii c I C . ! ' IIliII? TIiL?I �= :=.1 i CLII:r. =. L ? CII I d. P= eas__: ac== s -sible II- '^Cle to cicC° • G_ 1c' °0 ° her_ -C-s , c l °^_CU•L within 10 f =_ cf d; ° and e. DISTR2= L- T'ICti� I I 1 P11 cutler at same el evati cn - water t °sue ='c:V I I s P-ot, fres t I �'=G t=en :?ES ECL � a_ E use ICC- E r_r at: plc -ri5. f. jUNCTICN F.': i : urCC^rZ Dist=nc_ rtc wat =Cct-s- Iez-s ire Tnc = -i1 `-^^T ^iTC iC D1�� 1 —4 DiSL P_C? to C°rLer E. 10 f= - r:- = - fcunEa - -ici c = =uit prCC ='"t + 1' - 20 fc 7. Lert:-! c= t-e,ch < 30 znches - =an E. Rccn a11C.':e✓ fcr EY"..an-sicn, 50; 9. Size c= 3/4 !7- U R� =+ ;"2 C C' Vel in t_ a ch 12" e_.ds I __T I h- PaT OR DCSE 1. Size of t::. c:a =-L'bpr ' 2. G- e_rf1cw . P l a_�-n, V== �/auaii c I I d. P= eas__: ac== s -sible II- '^Cle to cicC° • S First rcx h: f =ter I I 6. Cycle w_* _ -_= by Health esti TZ1at d =_cN ce c,, �e I I I ECL � a_ E use ICC- E r_r at: plc -ri5. b. \cre- of t—'-=LS a- Wz- 1 lcc=t_ aE pc'" aCBrcve- plans I I I b_ D� —tancs f_S. S.6 are= Meas•LLrea ft_ I I I C. __LnC 18" a2"C�,e C-Za^_e_ I I I G_ _TIC° dr-- = arc= Hie! ? a. F=ps prcce=_ r c"cut b. P'`'' Fires C_ A I pices fIL -s, with inside of bcx G_ �� i l 1 IC. =C_? c ccnta i7_° s tC;I7E5 < 4" In C? cTilcC_ e_ C= it -z n c-�i_ in-stalled accordinc to' plan -_ C_T -�in ar_ cu-11 protect & C'_r'_t0 E`CiSt.wct�rCCLL=E [" �•rt'4 nor C t�CT C�5 crc= ' , . :;W__ I ".. = _ Imo' I 1 h_ S�,__ac_ wz== c.:ct� =�cn ad��t= t i 1 _ i =oSiCn CCU ! Cr=.CE_ Cn 's LGres C:.—L—r 1`7 1 Iva" q/o/To 3' sop, 1 M :c1 PUTNAM COUNTY HEALTH DEPAIMAW M •DIVISION -OF 'ENVIRONMENTAL - HEALTH -SERVICES John M. S.mnons, M.D. Deputy > >Ccmmissioner of Health := FIELD'ACTTVITYREPORT Sheet �: of. / t :INSPECTION.. , NAME �i �C �:i%l .` %(.� . Orig.. Routine ADDRESS � ( �C �: E/� Sal , Orig Complain i+! (_ �I / !/ Orig.- "Request. No Street Town ?M. No. r'. Canpharice, Complaint Comp MAILING-ADDRESS. ': ^,'" _ 'Final;_ P.O. - Box : =Post Office, Zip .Code_ _ Group :Illness :. Construction . TELEPHONE _ inspect ion PERSON : IN CHARGE Field, Sampling . Only OR INTERVIEWED F-1 eld,=Conference° Nacre and :Title DATE FACILITY�F other $TYPE TIME ARRIVED - TIME LEFT Explain FINDINGS:Y ��^^ a i s- _ k � t T'EGEPHONE . INSPD�POR' Signature and Title °• PERSON IN C HARGE ' OR :-INTERVIEWED::. I, acknowledge this Field Activity Report...SIGN&TURE• 6/86 TITLE 1 repnaant eh6t t am who11Y and'complatmnr rotpon4iplo fp► th louitiOP1 of, tha proposatl system(sa l).tthat rho; repo rat ®'iiwase ®is�osil ysf.m Opce N fha o0o►atlrt0 eonditeon Onpr ®s+rt o4 ,toW 89Wi0i di�otsl syttam+durirtg the Oar1oA.o4 terso'tap yeakwPesdl6tsiy .folttimlPe®a118QOt004;8h0 iseae- a000e -of the .appo*ii of-14 ho-�tWkato ;o/ Conitvudbn; Com011ance OP .tQeo OPighaIJW;tein oa 4a11y.fai m, . t ,'Gto a) that the dr.ilmd well dewfim 860we ia1M a loca4oa as ON" on tm &O&GkYm plan and that said'0 CIA In "Go . -'In accoNanoe xriQh the fartda dfi: ruRaa`;and r�u�ona �Ot rho ;'t►i�tnam Coll V Otl$mftwNalt Of.,►Aeilth E.' Comm It 9a S� n - �Zb r License No rr AIT.ROVZD ROO COP/5Y/BUCTIOP7� Yrii6: aOwoaet;oxOMea tens om the. data issued unloss coi4wtiL of the touild" .h6s bean undertahan and is 'MrOCitlM,tor cause at Wray bm_arNindad OP`., mod111e ®1ph0n.00 '� ry "t1y;t11O1.COmfPrlBfiOnal °OP F./ca0tP1. ,. iieny CnaRga Or altsaation. 04 construction nn,� Alum 4", a n®w parinw, AOOPOV 1 OpP @Po000a1 Of; domattk n and/or - aYo wetaP �rt�h/ Tito. i DEPARTMENT OF HEALTH L v T '3 ! Division of Environmental Health.Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. .10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Town y-• Tax Grid q �w o �, Number WELL OWNER Name /I Mailing Address EXPrivate Z46 Gr ecru ublic USE OF WELL 1 - primary 2- secondary IiRESIDENTIAL BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP D.ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify U INSTITUTIONAL O STAND -BY C3 AMOUNT OF USE J_ "`gal YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE - ❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 13. ADDITIONAL SUPPLY QLNEW SUPPLY NEW DWELLING Q DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING -c c WELL TYPE DRILLED QDRIVEN ODUG QGRAVEL C] OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Cor- i,",01 KLr,1gr__ LS.7'4Jc..r Lot No. WATER WELL CONTRACTOR: Name / r3 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: x/ / A TOWN /VIL /CITY -ITT DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ❑ON SEPARATE SHEET qC1_,4"" (date) ignature) f PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted tinter 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 prov by the Putnam County Health Dep rtment. Date of Issue: 1 �� 19 V° e tvr 19 milt Is-suing is a Date of Expiration: I 1A Permit is Non - Transfer; ble Whits copy: H.D. File Yellow dopy: Building Inspector Rev. 10/88 Pirk Copy: Owner Orange copy: Well Driller p .�:P =IDS{ 9 P V-r^.�_� r� -� n*•,- Dc-�a_ �., ; r CF lip "'- - DI / -I -:101 ( EtiL =MT." =.L E -�� : i 1. CZS ar Suty.Fr� �ts'�' DiSrr7.:L SiSLctii c uP v: r� J.C:�� 4rt•:�: �Z & (Name C_ -2? NO ( MC" - 'l_�t_cn Fey Cam__ sa . —,c_C_i Ca =_c 'ac_e Lcc C .i �iS L. Pe F. Per` E: CE_ t7 C� var. anc_ C1:= L ' -- = a. cry'• SS S D cr v iY; '= `aC: /C -=�+T .Tr; r (mac. -`-..r L- }C+_�c.•'_K - S.:_� -.../ Nct e_ ar E. Dr: -iYGV Sic_ Cj- Pere Sc L� =- �01 °_S Tccz- -� Fee _ C. �- crom & D:{- .C:iCwu & Ca =il Ecuc Ctic c 4 Es^- 1 _ 1 - 200 cf Dom- �. —•-E.D: EY " c� c P Cyr "� =c5 & N E- F 10' tc _.L Dr_ve air, L'':- Tr-27E YT`'= Gr 20 to 100' t" 4�:_l; 200' 100' t✓ _ tie. St- =.�,1, Wac =r -=-- 13' a -ti -ter Fcct' 3. f1^ -'.a Sin, s_ -T - _z, -i_= � wat =r =- 10' I � I I I i A'1) I I I I I I i I i I I I I I - r---= __- �60 z = = -=- �c cc-L•c�_ I _ I I li. L I V I/ I F= FfS i 0 fill, i� not =c I I _'i srec Ee=LlCc'_Cae =0 v= _ fle=e r=__er-,rci =, e =c_ I ✓ �� I I � I V n/ - 'l_�t_cn Fey Cam__ sa . —,c_C_i Ca =_c 'ac_e Lcc C .i �iS L. Pe F. Per` E: CE_ t7 C� var. anc_ C1:= L ' -- = a. cry'• SS S D cr v iY; '= `aC: /C -=�+T .Tr; r (mac. -`-..r L- }C+_�c.•'_K - S.:_� -.../ Nct e_ ar E. Dr: -iYGV Sic_ Cj- Pere Sc L� =- �01 °_S Tccz- -� Fee _ C. �- crom & D:{- .C:iCwu & Ca =il Ecuc Ctic c 4 Es^- 1 _ 1 - 200 cf Dom- �. —•-E.D: EY " c� c P Cyr "� =c5 & N E- F 10' tc _.L Dr_ve air, L'':- Tr-27E YT`'= Gr 20 to 100' t" 4�:_l; 200' 100' t✓ _ tie. St- =.�,1, Wac =r -=-- 13' a -ti -ter Fcct' 3. f1^ -'.a Sin, s_ -T - _z, -i_= � wat =r =- 10' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE'DISPOSAL SYSTEM FILE N0: Owner:rQ tZ�.SP�LtC. Address 455 GEi.st¢At. �+.1�,,'SG►R.SD�CL.t��/. �. ssAL �. QQ. Located. at (Street ge>4wu 'KT. (_(oQ Sec. �5 Block dlea e nearest cross street3 9 Municipality �ATTev-.0 Watershed C1ZC!'Ctai�1 . SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Number CLOCK TIME PERCOLATION PERCOLATION Run apse No. Time Start -Stop Min. Depth to Water From Ground Start Inches Surface Stop • Inches a er -Ieve in Inches Drop in Inches - Soil Rate Min -An drop �s 2 1:00 - V 5-5 . ;):00 4 3:or -359 5$- 3t�.._._.. 5 . �� 1 1D A'6-- 1•a°1 44 5 - •• Notes: 1) Tests to be repeated at same depth until a roximatelyy equal soil rates are obtained at each percolation test hole. All data to be stibmitted for revl ow . pth measurements to be made from top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. MOLE NO.. HOLE NO. G.L. 6 °1 12" 1811 24" .3011 36" 42" 48" 54#1 6011 72 '° 7811 PA 11 � � 0-- � � INDICATE LEVEL AT WHICH GROUND-WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TEZ`i°S MADE BY _R.VV.L. Date DESIGN Soil Rate Used 2 ® MirVl "Drop: ` S.D. Usable Area Provided 'S006 �.F. No. of Bedrooms 3 Septic Tank Capacity 1O00 Gals. Type Absorption Area rov a By g L. :_L. F. x24" ewe renc . I Address L . — SEAL' a ,;y z W (�A -TTFp Savt /! S/ THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq.'Ft/Cal. Checked by ctl- INDICATE LEVEL AT WHICH GROUND-WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED TEZ`i°S MADE BY _R.VV.L. Date DESIGN Soil Rate Used 2 ® MirVl "Drop: ` S.D. Usable Area Provided 'S006 �.F. No. of Bedrooms 3 Septic Tank Capacity 1O00 Gals. Type Absorption Area rov a By g L. :_L. F. x24" ewe renc . I Address L . — SEAL' a ,;y z W (�A -TTFp Savt /! S/ THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq.'Ft/Cal. Checked by 045UN�'� ® _rw-*r4 Date 0 Patnan. -ounty Department of Health ' Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT.APPLICAT•ION SUBMITTED- TO PUTNAM COUNTY HEALTK DEPARTMENT TO: Commissioner of Health - In the matter of application for` _ _ _ -... • represent. : that .I am officer or employee of the corporation and ain; authorized' to act for. Co .-n wd (f . e enact0o'Itc.corporation) � }' having offices at ��v� • eh,e� �.- j — " Whose officers-are President — ��v1 Zv.� _ <nf S4-x dT D ame ana a — — — — — — ddress� .: . Vice- President..:.. Secretary ., -- «- - - - --- (Nam and Address)_.:.__ Treasurer • .(Name and Address) and that I- am-and will be individually responsible fon any or all of the-corporation with respect to the approval requestgd and - all -hub- sequeAt aets relating -thereto. = i Sworn' to •iie'foi a iae this . ``� da . . • �_ y Signed of Alev 19� Title P sid t• = Notary PuUlic 60NNIE J. DAVJ$ lJdaq PUM C. gut# d Kft ywi - o. try ce�nn E *am t;orporare Seal PL TNAM CCUN Y DEPARIMIEWr OF PLY & APPEWIX B - DMSICN OF MWMRCUAE= HEALTE SERVICES REVIFW .S= - CONS'L�=ION ME= VcTiie of Cwnerr) (Street Locaticn ) DA BY: Dccav= Permit Application Corporate Resolution Plans - Three sets Engineers P_ut'horizaticn Design Data Sheet (DCS ) Deep Hole Lcg Consistent Perc Res;i _s Pe_rc Hole Depth DATE RE', • :vr'� : �+ I �1 SuEDIVISICN Parc Z;o (3) Fill . C-; (a House Plans - Mwo sets We-'! Fe-' i t; -� 'IS Variance Reruest C "fir, L 1 Subdivision Subdivision Approval Cie--k Fzc -a. _•rcval SSLS Ad . Lots Ci:an': WET? and (Tcw-n/DEC Ps=i Z R & D) Data Cn ODS Plans & Psrmai t Sa =e REQ J= D=- A TT c CN PT. :NS cevaae SvstVem Plan - (-or_h a..r_cw.) S:.Vge Svstaq HvdrauliC PrCf__e - Fill Profile & Dim ` nsicns - V-----= D or J Box;Trencz /Gallery; _Pl=m W pit de -ils Septic Tank - Size, Derail Wel ! Detail, Service Line if cve= Ccnst"ucticn Notes (grinder rte) Design Data: perc and deep res,:l:s Two- -Foot Contours Existing & Prcr -csed Driven y & Slopes Cut Fcotin�Gatter,Curtain Drains (discharge CK) Pero & Deep Holes Lecatad Representative of primary and e-v ansicn Expansion Area;showm;gravity ficcq,stif ..size If Pzmxd Pit & D Box Shim & Der —ailed House - No. of Bedroans Wells & SSDS's w /in 200 ft. of Proposed Sys- Proce_rty Metes & Bounds House Setback Necessary (Tight lot) House Safer - 1 /4 " /ft. 4 110; T_�pe pipe No Bands; Max. Bends 45° w /c_eanout SEP=ON DISTAL'QC...S SPECIF= CN PLAN Fi elds 10' to P.L., Drivc-vav, Urge of f: 20' to Foundation Wads 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stra.am,, Watercourse, lake (inc. ex--E 15' to Drains - certain, L�cer, Fcoting 35'to mtc:1 basin, Ovate -rc -u= 10' to water Line (pits -20') 50' inte_*nittent drainage ccurse Seotic Tanks 10' fran Foundation; 50' to w-ell 15' Well to PL �yi F iM i tj TIA .1 Parallel to coj;;'�"Xs 11 f J Mo 200 f t. res EM Em DA BY: Dccav= Permit Application Corporate Resolution Plans - Three sets Engineers P_ut'horizaticn Design Data Sheet (DCS ) Deep Hole Lcg Consistent Perc Res;i _s Pe_rc Hole Depth DATE RE', • :vr'� : �+ I �1 SuEDIVISICN Parc Z;o (3) Fill . C-; (a House Plans - Mwo sets We-'! Fe-' i t; -� 'IS Variance Reruest C "fir, L 1 Subdivision Subdivision Approval Cie--k Fzc -a. _•rcval SSLS Ad . Lots Ci:an': WET? and (Tcw-n/DEC Ps=i Z R & D) Data Cn ODS Plans & Psrmai t Sa =e REQ J= D=- A TT c CN PT. :NS cevaae SvstVem Plan - (-or_h a..r_cw.) S:.Vge Svstaq HvdrauliC PrCf__e - Fill Profile & Dim ` nsicns - V-----= D or J Box;Trencz /Gallery; _Pl=m W pit de -ils Septic Tank - Size, Derail Wel ! Detail, Service Line if cve= Ccnst"ucticn Notes (grinder rte) Design Data: perc and deep res,:l:s Two- -Foot Contours Existing & Prcr -csed Driven y & Slopes Cut Fcotin�Gatter,Curtain Drains (discharge CK) Pero & Deep Holes Lecatad Representative of primary and e-v ansicn Expansion Area;showm;gravity ficcq,stif ..size If Pzmxd Pit & D Box Shim & Der —ailed House - No. of Bedroans Wells & SSDS's w /in 200 ft. of Proposed Sys- Proce_rty Metes & Bounds House Setback Necessary (Tight lot) House Safer - 1 /4 " /ft. 4 110; T_�pe pipe No Bands; Max. Bends 45° w /c_eanout SEP=ON DISTAL'QC...S SPECIF= CN PLAN Fi elds 10' to P.L., Drivc-vav, Urge of f: 20' to Foundation Wads 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stra.am,, Watercourse, lake (inc. ex--E 15' to Drains - certain, L�cer, Fcoting 35'to mtc:1 basin, Ovate -rc -u= 10' to water Line (pits -20') 50' inte_*nittent drainage ccurse Seotic Tanks 10' fran Foundation; 50' to w-ell 15' Well to PL ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL.HEALTH SERVICES �I COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO: Owner:rm,p Addresses 455 Ce*xx4A&. 4 .5'F_.: Sc�►Q.SflAtL t�t_�__. �. Located. at (Street _ wi►�.� <<.`. V.Y.. h Z', . Q _......,....Sec a 15 Block kinq1cate nearest cross street) Municipalit Watershed CJZCrr .k SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS::... 31010 Number CLOCK TIME PERCOLATION . PERCOLATION apse Depthto WaEer Water-Jev e No. Time From Ground Surface in Inches Soil Rate ' Start -Stop .. Min. Start Stop Drop in <,. : Min. jin drop Inches Inches Inches Qs 2 :��_ ��6 51 as a5 31 zo 1 C)45 2 .3a �. a :, 45 I 4D 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 submitted for revl ow . ' ► •xith measurements to be mgde from top of hole. r ,;. ;.:.:.:: ;� ,- TEST PIT DATA REQUIRED TO:.BE.:SUBMITTED WITH APPLICATION .<.:... DESCRIPTION ' OF SOILS 1 i13NCOU TERED 'IN TEST HOLES'- DEPTH HOLE No. :.. ' HOLE ' NO , ...:. :.. _ . ;...HOLE NO. G.L: • 6" �c-pso r� 2 300 _. _....... _ 42" :.._ ... . 54" 72" i INDICATE LEVEL AT WHICH GROUNDWATER- -IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES•AFTER BEING ENCOUNTERED TESTS MADE BY . It-W t l.... Date G I gs Soil Rate Used 7.0 Min/1 "Drop: S. D. Usable Area Provided S® O O �.F. No. of Bedrooms 3 Septic Tank Capacity 1600 Gals. Type Absorption Area Provided By it.f _L. Fa x24" w1 t, renc . i Address L SEAL(;- ay ,z °► t�# m W THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by_ A N0.045�8, ��s�UFES51v N� e �r� Date 4 ..� y - ..vr't° �. { fi • uu, wt 'w h1tiP t .." Y + 1 ,rr a' ! 1 - �r. rr I�r��F fi'�`�' �;Kr, 4'r� -'�.r 5� "� k11 .� h •,:MJr.,.S:iP t�l�,�q >,..xr x . f . J 2. 3 2 IPOO 6rAL'. w oo = atKWT100 7 f2 04 (o'AhN 4 g yUntGfION 0,q)( T�f P o QL 17 It gojt%y 1 -rIA I-v 1 ,�, TD Ae:� INo(GA1 Mfi iii ��I aGco�naNc GOU Nip' bf 2. Nauss . A�JOriI p�'(� x. �t- 2a' (5H 1J4j llli,li c - I 1 T1-+/:kT THE SA� �Y�T A4�, tN121GaT1;0 ON Tkl* rI-,A q AN40 THAT THE ✓'{S��M W', z` Me f3r--f%e)r4i� IT WAS ove-l4. THe SYSTe" w aGGO�pa NcC W ITFI At-L GOU1�T�( �r;f �I�TM��1T O� I�1%AL'(N pNi� 2. HUt15� yJ�I.L 1,oGaTcaN� T� j��N rrom *Urzvr,Y i 3 47' 4 52 S3' 14 *et,57 5 *g' 15 8'Z.5 e�,� 61 �3' C,4 ) I & 7 �5' 8 Z. 5 1-7 f7 .� 1 �.5' I b ; ?.5' 3q ' 1 5�.�� 73.5 11 123' I t o ' to 50.5 71.5' 20 c - I 1 T1-+/:kT THE SA� �Y�T A4�, tN121GaT1;0 ON Tkl* rI-,A q AN40 THAT THE ✓'{S��M W', z` Me f3r--f%e)r4i� IT WAS ove-l4. THe SYSTe" w aGGO�pa NcC W ITFI At-L GOU1�T�( �r;f �I�TM��1T O� I�1%AL'(N pNi� 2. HUt15� yJ�I.L 1,oGaTcaN� T� j��N rrom *Urzvr,Y i