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HomeMy WebLinkAbout0613DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -21 BOX 7 �INI:il �' Is ; r so 0 r , ra Is 114111 1 I's i ML 610 J 4 Ime ` E I -�i I ,.L .� I 00613 ^-e.s -s—.- �w.+,c _. .. ,., ef�rs.?:Tw-= a r.;T^s t•• -.'.; t ^""^s'F'� •: *� : -�:.. - Rev. 86 PUTNAM COUNTY DEPARTMENT OF:HEALTH . l Division of Environmental Health Services; Carmel, N.Y. 105'12_: Mast de �'- Eri(n.1j Provide Z.J P C.H D Permit q –� -- — CE TE OF CONSTRUCTION COMPLIANCE .FOR SEWAGE DISPOSAL SYSTEM. �/�� _ 9 . <T Town or V Located at `' �" Ta: Map B J10ag Lot %d 4 S c -3 Owner /applicant Name r� I✓P� Formerly Subdivision Name ` Sabdv. Lot q J Mailln 'A`ddrese h �P Date Permit Issued Separate, Sewerage. System built by �y/ Address � �,-i Conslefin of Z 0D o Gallon Septic Tank and g . . Water. Supply: ` Public Supply From Address or Private Supply Drilled by Address V. Banding Type Has Erosion Control Been Completed? .Number of Bedrooms, Elm Garbage Grindeir.'Peen Installed? Other Requirem. ente I certify that the,aystem(s) as listed serving the above'premasea were con structed•esaential as shown on the plans of the completed work, ( copies of which are attac ),, d in accordance with. the.standarda; rules and re ions, i co dance with. the'fi*r plan,'and the'permit issued by the _. Putnam Ecunty D rtmen - -Of Health 0 d Certifie Y T P.E.yC R.A. Oats, �� 2-0 4 � 2 zi �S o� a Address, License No Any person,oecupying premises served by the above systems) she1F'.prompt take ch action as may be necetu►y o assure the correction of my unsanitary conditions resulting from such usage. ADDrovai :of the, separat seweid syitem shall become null and void as n as a pub(': unitary sewer becomes available and he approv I of the private water supply shall Deco a null void he ', a public-water supply comes available. Such. approvals are subject do m' ifiru r ha a when, in the judgment of t m Goner' ea' , such o m Ifleatlon or c qe Is necessary Oats By Tit 1 ADO /L. T='T T 1 n^XAoT L+R+TnM DVnnDT .t iC Y * WELL LOCATION W jlJ AJ V WL -- --- aw DEPARTMENT OF HEALTH Office Use Only • Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH STREET ADDRESS: wNlVll / ltY TAX GRID NUMBER :... ' lYIf�Iv Uj,! c� WELL OWNER ME ADDRESS: � ,Or Arenr/lAvet- C' lhAllt1' e-d 0 PUBLICS USE OF WELL 1 - primary 2 - secondary �RESIDEkIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED - / EST. OF DAILY USAGE gal. REASON FOR DRILLING tKNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DEPTH DATA • WELL DEPTH !, ' ft. �' STATIC WATER LEVEL e,,ft. DATE MEASURED /.2 LC/ DRILLING EQUIPMENT ❑ ROTARY 5( COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING. KOPEN HOLE 1N BEDROCK O OTHER CASING DETAILS TOTAL LENGTH 2 1 tL MATERIALS: STEEL O PLASTIC O OTHER LENGTH .BELOW GRADE — fL JOINTS: O WELDED XTHREADED O OTHER DIAMETER in. SEAL: O CEMENT GROUT O BENTONITE ]OTHER WEIGHT PER FOOT lb./ft. I DRIVE SHOE ❑ YES NO UNER: O YES O NO SCREEN DETAILS DIAMETER (in) SIZE LENGTH (1t) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO HOURS SECOND, GRAVEL PACK O YES O NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH tL BOTTOM DEPTH ft. If detailed um in WELL YIELD TEST p p 9 METHOD: O PUMPED i tests were done is in- (COMPRESSED AIR ,formation attached? O AILED O OTHER ; ❑ YES C3 NO WFLL LOG it more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE Water Bear- i ^9 N1e11 D'a- In FORMATION oE5CR1P710N CODE. tt it. WELL DEPTH ft, DURATION hr. min. DRAWOOWN 1t. YIELD gom. Surface A)v L NO- WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE kx-le (1 )(1_0L CAPACITY GAL. WELL DRILLER NAME rnNS 10 1; S S o A�GiOYR`ES�SY_1jriur•)t i .1 1) iV' �I tf SIG? AlRE PUMP I FORMATIONf TYPE (,� fLi�f�a 1 e CAPACITY MAKER DEPTH 90 MODEL — vOLTAGET1'' HP Owner or Purchaser of Building 1 ('7 6 � & 6-; 9 � , �)/W- Building Constructed by Locati n - Street 1 M e..' madg, , Municipality IA64 A� Building Type Section Blocks % r7"' Lot )�9 is , � ;� l Su vision Name If Subdv. Lot # GUARANTEE OF SEPARATE.SEWAGE SYSTEM I represent that I am wholly 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 success- ors, 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 initial use of the sewage disposal system, 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determin- ation of the Director of the Division of Environmental Health Services of the Putnam County Department of Health as to whether or not the fail- ure of the system to operate was caused by the willful or negligent act of the occupant'of the building utilizing the system. Dated this day of /Z)dv' 19AE�� Signature Title Corporation Name if corp.) L� -P Address THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health Yorktown Medical Laboratory, Inc 321 Kear Street Yorktown Heights, N. Y. 10598 1� f f (914).-24S-3203 � 2c0n3 a A �l k ohCt i L? _j LAB N Collection Station Used: Carmel V Peekskill Mt. Kisco _ New City _ Date Taken: Date Received: X30 Date Reported: 3} Collected By: $Tp ;44 1 ALq -e� Referred By: Sample Source: 78 0q LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER GENERAL BACTERIA 7y Standard Plate Count per 1.0 ml (Agar plate @ 35 °0 MEMBRANE FILTRATION TECHNIQUE (MFT) — Fecal Streptococcus per 100 ml _ MOST PROBABLE NUMBER TECHNIQUE (MPN)_ Total Coliform: MPN Index ner 100 ml Fecal Coliform: MPN Index per 100 ml OTHER ANALYSES THESE RESULTS INDICATE THAT THE WATER SAMPLE. ( AS (WAS NOT) (NOT APPLICABLE) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO HE NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Albert H. Pado.vani, M.T. (ASCP), Director LEGEND RDS = Recommend Disinfect- ing Water Source < = less than TNTC - Too Numerous Too Total Coliform per 100 ml_ Fecal Coliform ner 100 ml — Fecal Streptococcus per 100 ml _ MOST PROBABLE NUMBER TECHNIQUE (MPN)_ Total Coliform: MPN Index ner 100 ml Fecal Coliform: MPN Index per 100 ml OTHER ANALYSES THESE RESULTS INDICATE THAT THE WATER SAMPLE. ( AS (WAS NOT) (NOT APPLICABLE) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO HE NEW YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Albert H. Pado.vani, M.T. (ASCP), Director LEGEND RDS = Recommend Disinfect- ing Water Source < = less than TNTC - Too Numerous Too Putnam County Department of Health Division of Environmental Health Services Approved as noted for conformance with ;applicable mules and Regulations of the . F VieL`' I 3 f b c 3 e>:aRoc� -t hbusE - �lo�Y�B� A / � IOW 7. C&N4. SFPn C, TANK �5 53 r9 A N k D. A -M\1LJ N4 1A-rA , P,C-. 7A)C MAP, -73-3 LOT 3 s'UrsD. MN -C747io / E41-Tr 46 Ij BRET7 1IAUF.P- A .B 5WpnC- TANk ""LS 44 Gg 7'C7'N. E3O x FA D (1) -74 (FR) 101} (91) 2 ;642) TO NF) 109 (Ff 1 3 (3) 86 RY) /IY psi 4 (�q RZ (10 119 (lot) 5 (sj 9 G oq) IzI U 10) G (b) 104 G 14) 121 (tit,) 7 ( '7) )3'f (► -a) c 3 e>:aRoc� -t hbusE - �lo�Y�B� A / � IOW 7. C&N4. SFPn C, TANK �5 53 r9 A N k D. A -M\1LJ N4 1A-rA , P,C-. 7A)C MAP, -73-3 LOT 3 s'UrsD. MN -C747io / E41-Tr 46 Ij BRET7 1IAUF.P- AA (lV 4 j VL/ S /I'L1 . � OVL •t 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 NO. ff �` Owner f t' -�� 6 �• Address ("WIAAf Located at (Stree t) C. � A G`1lb� ij i I Sec . Block Lot J .� near est cross s reet Municipality �G� Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Run apse Depth to Water Water Level No. Time From Ground Surface in Inches Soil Rate Start-Stop- Min. Start Stop Drop in Min. /in drop a Inches Inches Inches 1 9 310 '01 a-V -Z-0 zSr 7-1y 2 36 z� l 5 1;go,3 F -30 -- via 50 � �f- 23�r Notes: 1) Tests to be repeated at same depth until rates are obtained at each percolation test hole. for review. 2) Depth measurements to be made from top o i i �� approximatelyy All data , o be s e F0 f hole.p,, ✓1 :5 �y8 r s N b�pr q P Cou yFq` rj Y Notes: 1) Tests to be repeated at same depth until rates are obtained at each percolation test hole. for review. 2) Depth measurements to be made from top o i i �� approximatelyy All data , o be s e F0 f hole.p,, ✓1 :5 �y8 r s N b�pr q P Cou yFq` rj Y TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES ,i DEPTH HOLE NO. ` HOLE NO. HOLE NO. _ G.L./ _. 12" /ice Xozup f - 18" 24" . i 301 �. 36'•� 42" / 4811 60" 66" 78.. 84 "_. . INDICATE LEVEL AT _WHICH GROUND WATER IS ENCOUNTERED VVQ-1 '- INDICATE LEVEL TO WHICH WATER LEV RISES AFTER BEING ENCOUNT T J • ' TESTS MADE BY __._. v: �� }�- Date DESIGN Soil Rate Used '1� Min4/1 "Drop: S.D. Usable Area Provided 71 No. of Bedrooms j Septic Tank Capacity Gals. Type Absorption Area Pro ded By L.F.x24" width trench. \Z'u Y�' 'j:A c ©ke sionai Name1.i. E-y- igna ure Address �C �.. �y ir-G S THIS SPACE FOR USE BY HEALTH DEPARTMT ONLY: �'sy 410. °'the 5ta�e Soil Rate Approved Sq. Ft /Cal. Checked by e I a. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEIvIAGE DISPOSAL SYSTEM FILE NO. Owner Gguxe C g 2eT1_# /f ( &- Address Plea Saoi7- Wa C& i.oa P Located at ( Street C Mop H vS A Sec. Block Lot 3 Sica e nearest cross.s reet Municipality 10CL#eySci-P1 r77 Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIPC PERCOLATION PERCOLATION Run Eiapse. Depth to Water Water Level No. Time _ From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches ►j 3s ►_s L ��. 2�b�3 3 21 3 ®� X® r �e 1 2 5 Notes: 1) Tests to be repeated at same depth until aonroximately equal soil rates are obtained at each percolation test hole. All data to be submitted " for review. 2) Depth measurements to be made from top of hole. 3s ►_s L ��. 0 7Vy 3 21 3 ®� X® r �e 1 2 5 Notes: 1) Tests to be repeated at same depth until aonroximately equal soil rates are obtained at each percolation test hole. All data to be submitted " for review. 2) Depth measurements to be made from top of hole. Address SEAL " . j * f THIS .SPACE FOR USE BY HEALTH DEPARTP 1 T ONLY: J�' C No. 5''11� � PROFESSI NPR. Soil Rate Approved So. Ft /Cal.. Checked by e TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION . DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. 02` HOLE NO. G. L. }� S�� � t 1 4-i y 5.6 t) . 6" Tci�I� If 12" 4-4 low 4j, Le :, Sr l vGlI2- 18" 2411 3011 3 6 If 48" 60" 7 �. 84" _.. INDICATE LEVEL AT H QROUND WATE IS ENCOUNTERED INDICATE LEVEL TO RH RISES AFTER BEING ENCOUNTERED TESTS MADE BY Date co Soil Rate DESIGN Used Min/l "Drop: S.D. Usable'Area Provided No. of Bedrooms Septic Tank Capacity 10-O Cals. .. Type Cdfit.C,,,_ L.- Absorption Area Provided Byj�L.F.x24" >< wiILthtrench. Address SEAL " . j * f THIS .SPACE FOR USE BY HEALTH DEPARTP 1 T ONLY: J�' C No. 5''11� � PROFESSI NPR. Soil Rate Approved So. Ft /Cal.. Checked by e � ��, (" }� 1. • N� RCArl I `I PROPOS 5p w \' PkOf OSEI) ..FI LL I t SeCTIoN PROVIDE %00 cu `1DS - - A ,t 2.0. 3 - -PILL L4 All" �f -roPO67RAP[J/ OhrE�j oefoe)E211 SvQve-y mkvp DATED MAY 31, M5 BY 8URGlESS P,+;oWISSiOMAL L4ND 5URV£Y -IN4 CARA&L ?_ ll/Y• lusaz 845 co.7. Subt LOi MOTE: