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HomeMy WebLinkAbout0588DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -52 BOX 7 y , MIT MIN IN r I` . ti 1 Z I + 'T Immill ■ or ME N L PUTNAM COUNTY.DEPABTREIM OF HEALTH a 3 1 D6lelon it Ravhoemental Hetlt6 Seevleee, Carmel, N.Y 10512 115 bilu Md5t Provide LATE Oi. Located .� ., �Q m i�►-s e�'" l:� r-i Owner/ .ppel t Named Inaval% 17:'.v i MIS Aadrese w d/ Lt relUt u Fee Eincl:osedM A)nount S / CE FOB SEWAGE DISPOSAL SYSTEM own r VQIaSe .. Tax Map - — ock L,ot Formerly SWxUvhdm NaiueL%J ILo. JV ZI. Subdv. Lot # Date Permit Issued` _! Separate Sewerage System built by c? • . _� cS�p't__G �Gf STP/J rl S Address 7 w Consbting of Gallon Septic Tank and / ��' �%1�1 ;e, Water Supply$ PubUc Supply From Address � �. _` , +: on - Private Supply Drilled by Address CIUY '� �� r f 1 +�1 S . NY Building Type ' � Lot Size Has.Erosion Contrn.l RPPn rnm 9 �. Number of Bedreome �: Has Garbage Grinder lieen InsWW? n Other Requirements Y10 O tom° I certify that the system(s) as,listed serving the,above"piemises 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 reg dons, in accordance with 711ed lan, and the permit issued by the Putnam County 'Depetme Of alth: _. P.E. Oats � CertifiW by Y' R.A. Address + S License Me. ((J Any person occupylnq premises saver -by the above systems) shall Promptly take, such action as may be necessary to secure the correction of any unsanitary conditions. resulting from such usaga.. :Approval of the separate sawerapa: (hall t»oome; null and void as soon as a pubito sanitary saww/ beconvo available I and the approval of the. p►)vata.water:iuDPly shalhbacoma null it' voW wben a public -water Wpply e.00mes avatlabN. liueh .epptovals an subject to modif lion rrr Mange when. In the juaement of tM Coln ,isNO _ MMlth w lion, modNieatbn N ehenge Is neeawr Oats LL. `7�% 9Y TItN } 1� �„ ►� W X WL' LL I,VPlt LLI IVLV 1u,rvt�t DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADDRESS: CMWNLNILLAGAICIIY TAX GRID NUAtS - ,d T SI fit, ti .�0 WELL OWNER NAME / ADORES D / `�' Q�Q j 19 PBIVATE 0 PUBLIC USE OF WELL 1— primary 2 - secondary 114ESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM O TEST/ OBSERVATION ❑ OTHER (specify). O INDUSTRIAL ❑ INSTITUTIONAL ❑. STAN D -BY ❑ MOUNT OF USE YIELD SOUGHT _ 9pm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 1!e7o. gal. REASON FOR DRILLING MIK'EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION ❑ REPLACE EXISTING SUPPLY 0. DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 4 ft. STATIC WATER LEVEL _ � o ft. DATE MEASURED �ls DRILLING EQUIPMENT ❑ ROTARY ❑ C90PRESSED AIR PERCUSSION ❑ DUG CJ WELL POINT ABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED 9KfEN END CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH ft. MATERIALS: CREEL 0 PLASTIC D OTHER LENGTH.BELOW GRADE tL JOINTS: ❑ WELDED EYrHREADED ❑ OTHER DIAMETER ❑OTHER WEIGHT PER FOOT 17 IbXt DRIVE SHOE: COESr ❑ NO LINER: CJ YES SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it DEVELOPED? REN 6 Y-ES ONO HO URS O GRAVEL PA YES O N GRAV SIZE D OF PACK in. TOP DEPTH ft. BOTTOM DEPTH it. WELL YIELD TEST If detailed pumping r METHOD: O PUMPED it tests were done is in- O CO RESSED AIR , formation attached? 04AILED O OTHER ; -O YES ONO UY �LL LOG 1f more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE water Bear- ing We1l Dia- Deter FORMATION DESCRIPTION CODE. ft. tL WELL DEPTH it. DURATION hr, min, ORAWDOWN YIELD BFm. Land Surface pe S.® ("It. WATER EAR TEMP: QUALITY O CLOUDY HARDNESS — O COLORED ANALYZED SO NO ANALYSIS ATTACHED? ES ONO I I �j I STORAGE TANK: TYPE /dy'fI CAPACITY d GAL. fJ WELL DRILLER NAME ADDRESS 3 6 j� ✓��,J SL IG pAT/ E� u r j-0jg- PUMP INFORMATION � CI � TYPE `s i/ s CAPACITY MAKER DEPTH MODEL VOLTAG "U" HP 1.. PUINI M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Co, -nwHII Mill 6ty E, IJpMN.t Owner or Purchaser of Building T- A J r S PO n.) S Building Constructed by Location - Street /S 61 a o Section Block Lot CeAQz,A�_r, 12/17&�5 E52T .TES Subdivision Name P,4 f Ye- ,t S on �2 Municipality Subdivision Lot # Building Type GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTE'ri UJO represent thatUL awholly 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, rifles 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 immediately following the date of approval of the "Certificate og 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 Environmental Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate uns caused by the willful or negligent. act of the occupant of the build�pg ut,,Alfz n the system. _ Dated this day of - C—� �-19 9 Signa Title f� (Owner) - Si nature 1 1117 Cl/ Corporation Name (if Corp.) C,N o n ,I L AeLj !C. //C. Address N. y 1 p,�V 1 rev. 9/85 ink Corporation Name (if Corp.) Address Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -2800. Director: Albert H. Padovani M. T. (ASCP) T_ DENNIS MALANCHUK P.O. BOX 313 CROTON FALLS,NY. 10519 L J REPORT ON THE QUALITY OF WATER LAB Date Taken: 6 (.2 61 qO Time: /n1 Date Reld: 6 1.2 �.Lq M me: Date Reported: Collected By: fl I riyi c Fu,, k PO /Client ;# Referred By: Sampling Site: 2 Phone .( ) INORGANICS (mg /L) MICROBIOLOGICAL 1001E _ 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 PH SI A S ELLANEO S _— Color�(Units) _ Conductance (ohms /c) Odor (TON) _ Turbidity (NTU) _ 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 KEY FOR TERMINOLOGY CFU = Colony Forming Units IT = < = Less Than GT = > = Greater Than NA = Not Applicable SA = See Attached ',TNTC = Too Numerous To Count REMARKS COMMENTS For ab se (For Lab Use) SAMPLE TYPE: (Check One) Potable _ Non- potable OUTGOING: (Check Each) HNO HC13 _ H2SO4 _ NaOH ZnOAc — Na2S203 _ Other: INCOMING: (Check Each) LE 40C GT 4/hE 200C _ GT 200C pH LE 2 _ _pH GE 12 Other: THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS ' (WAS NOT) (NA) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO M NIWYORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT T OF SAMPLE gCO ION. _ 'THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) T THE SATISFACTORY CHEMICAL I STANDARDS OF THE NEW YORK STATE DRINK - ING WATER CODES, FOR E TERS TESTED, AT TFiE TIME OF S LECTIONo 7 /87(P- %rsd.1 /90)RWE FINAL SITE riSPE'C' =CN L�at - nsr_::- Bd by a 'm ff OR sz DIl _SIC:] z C 7I� DISPOSAL P G'- v a_ SDS are- jc=- e as per amroved ola-IS b. F-: 1 sa r-• ? ca - Da t_ os plac=-Irle-lt 2.1 barrio' . LGTF w H AN - .DPTf1 iT 4 -U C. 17atur-- sC.L P_CL_ d_ Stone, brushl, e_c_ , ere =tar tiara 15' fran SDS a- -Ea-e- 140 ft_ f-c: WEt_r �e�rCe!weLl ants. DISPOSAL SYS 1.000 1,250 b. Septic t -_*i:Y i _` =l 7Z—H IS e1 C_ 10, In in TI um == f cuncH tim G_ iC goo bcrL °- ^_Cut Gi t * 10 f`__ cf 45'3 _ , ' � -C e. D"5TRI.EUTITCN ECK _ li C: r tP r � — — same eiova � - -�C 2. Prot =C=­_, = 1:e1c frost 2 -- Cr1CiP =1 son, h=T-`•veen �CX �'=G t= 'c'?C�eS f- j uNCTTCN E,:" -- orcc =r? v s== C. !ff-s 1. q Z Di c:t_r to Cs t°r -tEnca .s. =Ccem cf ac==' able 1/16 - 1/32 "/-CG`. _E. 10 t_ __ _ uLrC:e-rty 1 i re - i Dec-E c= '= ch < 30 J_nc +e= f- an �� =_c- 8. Rc<au allcw 50� O Siz_e of C =!L 3/4 - 1+lt a?G1cG�r l o . re th cf, c ='Zi a In Tr anch 12" M _n 7 Tr11T 11. Pile Erg crL='' h. PT_2�T OR DCS ^ c, c r�rc \ 1. Size of Z (::c:� 2. Over=1cw t= l k 3. P! awl, v_=` j /aud ii c / P-mr) e=El li, ac=sssi'r l e mp-nnol° t0 CicC° • Firs t.. L-CX G__! ea 6 eve e w : -- -= cf' by E °= l th Denar `Tic ^_L eS ' � TLSGtl '! Geri Per cvc. e a_ E-.use a=Orcve; p b_ IN- rser cf beE.='Ocmns V. aE r-er acnrove plans ft C_ Casing 18" a:_cvc crc^e- C_ S "�`i -o �r= _c= arCL'i:G iti'c i i cCC= �^l °- a_ E--Yes prozez'_v crcut b_ All piers r, =--;.=a11y bac�ili , C_ t1_l pices f ��� + wit Z ins ice of bCx c_ Ea kf; I I s, t__al ccr_t *ns stones < 4" in di`net- e_ C "-tain Sr=i _ ins`,_ l ^ten acc ^,rdinc to vl n f- ` ='t ? n Gtr=_ C ?Lall prctact -_; & C1r. t0 EYiS `- Svct�rC:�u c_ . c'•xt2. na era:-_= c _ =c ^.arce awav f =an SDS area mace wet- CrCt=`` _C 1 cQE.(L'c' -L= 1. +�- -VS;CZ C::. =-! Crc-i? Cad cn SiGCcs Cr.=te�r t!'la- _ 1 �� ���.p�, tl�vuX 'I � H /lll q 0 3'. 3� P� l U 0 Putnan. ,ounty Departme nt of .Health Division of Environmental Sanitation Notary Piiklie BONNI< J. 601I keuq oub6c. &MO of N.% ymk - Owchm CGUtRr my cemmbsb" krp'M 4A A 195 i • Corporate Seal .... ......... ... s •: DEPARTMENT OF HEALTH L� 7 Z 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 # /-/'- /i WELL LOCATION Street Addr ss Town/ SQ LY t'i Y l v� 2, 't Y G age- Tax Grid Number Lc — 2— 1 WELL OWNER Name Mailin Add ess t- 1d 46 / /�'r V2 e�4 �.1 rivate ublic USE OF WELL 1 - primary 2 - secondary ^ _RESIDENTIAL O PUBLIC SUPPLY -(] BUSINESS 0 FARM O INDUSTRIAL U INSTITUTIONAL Q AIR /COND /HEAT PUMP p TEST /OBSERVATION ❑ STAND -BY O ABANDONED 0 OTHER (specify, O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE' -gal 0 REPLACE EXISTING SUPPLY p TEST /OBSERVATION Q ADDITIONAL SUPPLY NEW SUPPLY NEW DWEL ING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED - REASON FOR DRILLING A r ! , WELL TYPE MRILLED , 13DRIVEN ODUG GRAVEL. D OTHER IS WELL SITE SUBJECT TO FLOODING? YES _1 I NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: (.c_4 Lot No. WATER WELL CONTRACTOR: Name D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __1,-'-NO NAME OF PUBLIC WATER SUPPLY: A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: /V / LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE q RON SEPARATE SHEET (date) (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 pr by the Putnam County Health Department. Date of Issue: 1 6 19 � �,e4 rmit ssuing is a Date of Expiration: 19 Permit is Non - Transfer able �� �PY� H.D. File Yellow copy: Building Inspector Rev. 10/88 Pink Copy: Owner Orange copy: Well Driller p= aENDEC 9 1•'.- Tn•rf_� �.."- -•�Tm: L:�Z �.1�Sir CF �7.L � — Dr%T''IOI Clr~. ENV: C` +'rtF `rL .L �5:..:1_�.ii �:�1L D� c. c Zr� �-vtlr DIS -- S-L, E•�r %�[_�r, S^tt_'i' =: SuP °L1 it �n,.:.i�l•.F .s: C'''�ISi t -c= =CN pt r��tTm OIL _ I I P 1 ams _ 7: rae sat=- g /'c fs I I C°_s_--n � : (7C) ,,„� �,/1 i�dc�l I ✓I i reeg ac__ Lcc Ccr=' s t_r c rP rc Pte_ E - -_ L-_ _ =r..dc R I I I Lc= Cil UL.0 i I C. _ - -; ^,uc`- '= ..�' -�'Cil NCL== (Cr_ 1G.= & 1 Y I �7�rcv ,. a1CC.c5 L'. Dr" r i0_ I I •v c -_cC I I I I r=_== -�Ci =, emc. Li I i =J f =_ t= _c='_r' -1•. I I, I Fccz Perc be i e- rr _ =G_ = .._tom- �. = �.` ¢ D w!� SllC'iV ll & r-„c.` C`_ F__._ L` T-- Tc c_ _ 10 t.z ic.- Walls 100, , wal- 1 ; 200' in D- L-C.Dr 1 =,�' r i� - trc- T = {� o r1C. Ems- 100 u s`= an", Wac =_fit. _ ! 13, to nr^_.- Run Elapse Depth to Water IYan Water Level ._ ,...._...,. No. Time Ground Surfacg In Inches -.Soil Rate ,. Stai`t Stop Min:. Start . Stop Drop In .... _. Min/In Drop. Inches Inches Inches Z Ito 2_ . 2- 2-,2— - S1 3 /6 3 ` 22. 2� 3 -3 3 ; y (= t 3 I 36 22— 1.5— -3 16 9 .. 5 AC2_: 110 - Y-3.6 - -_6 - zz E-3 .3 ' 2.J S, lZ S Z. 22 4 5 CIN 2 -. M _ "� r g.i�•.rg9 t,�.. •,off, �.� ; � • 4 5 NOI'FS: 1. Tests to be repeated at same depth until appra dmately equal soil rates are obtained at each percolation test hole. All data to be submittld for review. 2. Depth reasuren✓nts to be made - fran top of hole. 10' 12'. - 13' 14' INDICATE LEVEL AT WHICH GROUNUATER IS EN00UMEM INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING 1; UNTERED DEEP HOLE OBSERVATIONS MADE' BY: i`2� �.�U ( �, L444 ��; /- DATE: DESIGN Soil Rate Used l Min/1" Drop: S.D. U$able Area Provided �,` 06 o S, No. of Bedrooms 3 Septic Tank Capacity (600 gals. Type Absorption Area Provided By _ -q �2-9 L.F. x 24" width trench Other of NEW Y, Name f ac / ''" C Signature r t` Address 7. �t it l• SEAL // No. 5&1Z4 /91Z7 Y„tG -' /�Ci :�—��G ©AAOFES 1CISa��!r THIS SPACE FOR USE BY HFALTii DEPA ONLY: Soil Rate Approved sga f t, 4g . (pecked by Date �x � s-� i ►�� w �w Q ' 4 =►.OW AS - 1U i L.T PLAN SCALE I "- 30' AS- OUIL -. f OlMr-,NWM G IAVe -:T NO. A 0 No A ?� 50 2 3 I " 4.0 3 3� 9'�' ►3 Yl S 3 E0 23.5 6 50 SE�' IS, 5+ ZS Fo 5ra.5 5`I.S t(, S� 33 &4-' S roq' `iq' 13 <02 51.5 10 55' 014' NoT�s 1• 1'Fi th YO Cit?.F271F'^f THAY ?;Fir✓ yLWAGG dtgr'Q�tii. 9�f57�M wAy GON�'fIZUG7>rD A [,NaIGA ti 47 O!N 71-11', PLAN: P��Ii� THAT rtN Y°>7ti1 WA°� ti't?:Gft?..e�'f . Me'. DiPO1lE% tT WA�j COtGt? ONPt?. "Ct1`fftt�i GDN��'t?E)G7 tN.AGGOt?C�ANFi� WV 0 A 1`ANit'JAiz� lZi1LE?i� #412t~Gi)l%A-7EON�I` lJi; THE ry NAM ' G. Qr t o t,7N - tNr? 'C} =it✓ t tEVV' Y�11? FAZE%. t? ' tt 1 ME'%N7 O :HVPA'L t� 2. HO CA 5E 4 NE; LL LOGA- TIOINs -fAte-eN QOM SLAteV5Y t'1? t At p e-Y GUNNY`( A�50GIA"(�5 , DATEP AU&- 2, 19010. — DOHS �nl�Cl c A %11A 1 z t�.Y