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HomeMy WebLinkAbout0694DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.12 -1 -4 BOX 8 11••, Al ■ 'Sr so r k J . , % 11••, 0 -' re d � El SITE LOCATION OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES LN R SEWAGE TR Internal Use Only PERMIT # C�\•— Repair Permit issued in last 5 years LJ Not in Watershed Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ elegated Repair within 200 ft. of a watercourse or DEC - mapped wetland Joint Review TOWN e , 4 _ TM # Z- -IJ-1- APPLICANT ame & Relationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE ZP ' PCHD COMPLAINT # PROPOSED INSTALLER _JfC PHONE # W( a +d ADDRESS REGISTRATION /LICENSE # Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the I, as owner,agree to the itions ated on this form SIGNATURE TITLE DATE / (owner) I, the septic installer, agree t mpl wit a conditions of this. permit for the septic system repair SIGNATURE TITLE DATE 12 (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied I :n _ & 2 3 nspector's Signature & Title Date / Expiriftion D to Repair proposal is in compliance with applicable codes Yes No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 PUTNAM COUNTY HEALTH DEPARTMENT . DIVISION OF ENVIRONMENTAL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All information below must be fully completed prior to any scheduling SITE LOCATION OWNER'S NAME MAILING ADDRESS TOWN fq71—'rX54V TM # 7 ��d PROPOSED CONTRACTOR/INSTALLER (.�rs PHONE # ADDRESS REGISTRATION /LICENSE # Z1 7 V r oLW Reason for exploration: lure to surface ❑ back -up in house ❑ find limits of system for repair ❑ other (explain below) - /�- - 7e-3-1 / FOR COUNTY USE ONLY Inspector's Signature & Title Date r ntment Date: / �,.. _Time: [-VMS pt._etip S kly:excel:septic '"' :c =, I 1. �!.f 11- 11 " - .. Sheet !�- - ��I`k ,, . I of � 'PUTNAM COUNTY DEPARTMENT OF HEALTH ,� � , 1.11 Y` ; � DIVISIAib&i ENVIRON1YiENTAL IEATLH SERVICES ; FIELD ACTIVITY `REIPORT f Bf:E� t r. r �s° (��'FIr' xf I , ... I Ft t I I z.y,: f F F , 1 i .tw ,p� •71'., C r F5 i k e �'} Iff 1"; 't ` Town Sta #e Zip '' tTeet ;a't� 1 1 V 1. , SnUATOnno 8 1 pi I- r 1 i I, I HA�OE _ L. 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I IZ PUTNAM COUNTY .•DEPARTMENT OF .,HEALTH Division op Environmen al Heahh I S&r ices, Carmel, N Y 10512 CERTIFICATE OF' CONSTRUCTION COMPLIANCE FOR. .SEWAGE ;DISPOSAL SYSTEM AP�SO ... -. - TOW e Q n or Villa Located at O N Al 1�W ^d A Section Block, j� a QQ Owner Lot Separate Sewerage' System built by �� ',.o > A4T. Address Consisting of /" Gal, Septic Tank 2 lineal. Feet X • width trench Other. requirements Private SuPPIY , Water Supply: Public Supply Fro m 0. W 0 6► %.� \V Dr filled By Address Building Type b.N L-[s No, of Bedrooms Date Permit Issued 3 a A 11 Has Erosion Control Been Completed? " I .certify that.the system(s), as listed serving'the above premises 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 regulations, plans filed, and the .permit. issued by the Putnam Cou t Department of Health. Date Certified b P E. Address �. A i • ` License No `•Any person ,occupying, promises served by 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 the separate <sewerage system shall become P.Uli and v610 as soon as a public sanitary, sewer' becomes available and the approval of the private water supply shall become.nuli d void when blic water pp becomes available. ' Such approvals are subject to modification,or, change when, in.the')udgment of the mi oner, of H th, suc ; odification or change is necessary.' Date BY Title ti sfl P •, '� • e� r 'ti d„ r WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3171 Division ,of Environmental Health Services a s COUNTY OFFICE BUILDING - CARMEL, NEW YORK This repot is to.be completed by well driller and sut.r',,4ted to County Health Department together with laboratory report of analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME Herb Brodauf ADDRESS Beekman Rd Carmel N.Y. LOCATION OF WELL (No. 6 Street) (Town) (lot Number) Mt. View Dx • 7'0*",k11114.r, X Patterson PROPOSED USE OF WELL BUSINESS nX DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING OTHER ) DRILLING EQUIP MENT ❑ ROTARY CJ AIR PERCUSSION ❑ PERCUSSION OTHER ) CASING DETAILS LENGTH (feet) I 45 DIAMETER (inches) % WEIGHT PER FOOT � THREADED : El WELDED RIPE 5 O � YES ❑ NO WAS CASING GRROU LJ NO YIELD TEST 1 HOURS G.P.M. ❑ BAILED ❑ PUMPED ®COMPRESSED AIR 2 4 YIELD (G.P.M.) 51 WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) 41 DURING YIELD TEST [loot) Total drawdown Depth of Completed Well in feet below Land surface: 140 1 SCREEN DETAILS MAKE LENGTH OPEN TO AQUIFER (feet) SLOT SIZE DIAMETER (Inches) IF GRAVEL PACKED: Diameter of well including gravel pock (Inches): GRAVEL SIZE (inches) FROM (loot) TO (feel) DEPTH FROM LAND SURFACEI FORMATION DESCRIPTION 1 overburden Sketch exact location of well with distances, to at least . two permanent landmarks. FEET iv iici 0. 33 33 1.40 ledge If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE ao 3 1;30 51 DATE WELL COMPLETED,- f DATE OF REPORT i r WEL RILLER (Slgnatu ) h.n 7h rnel. i I �. BREWSTER LABORATORIES Box 224 - BREWSTER, N.Y. WATER ANALYSIS REPORT SAMPLE No. 3415 SOURCE: Herb Brodauf - hose Bibb - well supply Alt. View Road Map 186A Towners, N.Y. Sec. A Town of Patterson Lots 1, 2, & 3 COLLECTED: May 2, 1975 BY: Herb Brodauf BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method This result indicates the source of the sample was Of satisfactory sanitary quality when the sample was collected. May 10, 1975 d1 , 0 per 100 ml. Ro kwit P. E. Director C . .a !. b "_�) Ro 'a au� Owner or Purchaser of Building Building Constructed by pLAN:j ktw V!E cX Location - Street P, %J l•i c-1-� Building Type Q�S O� Municipality 14 Section 4 Block Lot GUARANTY 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 guaranty to the owner, his succes- sors, 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 de- termination of the Director of the Division of Environmental Health Ser- vices of the Putnam County 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 syste Dated thi s V^ `�� day of NM a 191 g l � � F' Si nature Title If corporation, give name and 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 � '� . FM -""41 t - �_`_ I '. - ;11 -1. - . I " . - I—- -1-1 1-k-.1_11. . _- , " - _",.-_-,,_,�,-'.-_ _'_.,V..­l ­--i-1.1 ��d..,..�-'-,-.��..�-.�--,!d"�,:��:",:-,�l�"-".,.,-"�i..,-T,�.,.A."i, -i,'i','-,"'.�-""!4."�-.!'*,��,','.,'Il�w�All�'.1 U ..''n;,.''. 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Ik �. -,,I'... , - ,, , Dy : . : Y .r `CONSTRUCTION> PE:RMI,Tf?I Z �• Located at ,Subdivision /� t r r �BuIldiltg Type 4 k � 4 Separate Sewerage System to co sfi I To be constructed by J , �-WaterjSupply Public t o >sS G a Prwate SY tt J.� :. i t r Addresl rda �10ther� Requirements '� � ��' �� c, a ' w_ .plaW in': OUNTY, DEPARTMENT`L OF; HEAL ^TH z F y �nmeriialA,Health Sewices, Carffidl N YC 10512 iSALSYSTEIVI Q; - Town or V iII$ge. / Section Bilock T r5 tfy F K Address F )artment of - - ealth 3 '' w Address ; Y F40R CONST +RUCTI,ON TFiistapprov, expii rr cause or may be amended or modrfigd when new rmit 'r.�Appr�oved for disposal of dome T Total Habitable Space Square ,Feet {Gal Septic Tank to lineal feet X .width trench' f � ;9dilress ¢mot tvx s a 4 the design7and IocaUon of the propo systems) 1) that the separate sewage Adis , a system'; d amendment, there to and m accord ce :with, thest idards rules an regu a ions o _ Putnam. .:..,: a. .. ,r a c , r ereof a 'Certif.icate of�Construction- Compliance:', isfactory to the CommIsslonerof Health will':` — IM e wilhbe furnished the owner h�s'successors, heirs assigns by the builder that said bwider will ge dlsposal system during the pprlod of two (2) y rs immediately ^following the date of fhi issu- Compliance of 'the original system or a�y.repartsthereto ) thattthe dei'iied well GescrIDed, above, vell(will'be installed in accordance with the standar rules and egulaa�`ons of '.the Putnam ' License s one year from the ate issued unless `,construe n of the building has been undertaken and is.' onsidered necessary by the Commissioner of Health qny change or alteration .of constructionf: �c� it ry se a tl /or private water - supply .only. " 4 t s1 /r Title y 6 OL n 6 O'k,41'e, J. ktJ v ts St(j. r ra. o DO C UIV11*1111".1 I.T1 111) A ,..,,,)uc,!.e plans DIn � s --l- F., n dn1t::1-L s-, J. C, t r r 'ercs, pre.so,-iked? I. n Perc test -d--PJL-,'rl Con st. resi.0-ts for 3 runs, D. 'Role tor, O.K. Corporat.e Affidavit .-[,6r, oa_,e�r than individual Authorization for er_iSinener . 1) -(. i app Jcable ,tter T3-.,c.m V!ater Su ply f .1 If variance requested­ such noted on plans &, apps. DF, PAI I S if chaqge .-Ls proposed, ) I Existing c.ont-citrs shoran Rhow new contours) i -T Slopes for dr-Iveilay cuts, etc. shown Water service line loc-ation _L ,.draln., etc. loca-tion ___ Top slope.,' bot-Itbottom slopee of fill .----1 I . ............. Percolatioi-i tests and deep test p t- location Septic tank size and conformance to std. 3 B. R. house mirii-mum 1-1cuse setback shol-711 st, D P-31-an and profile. Sr' 1111 other ;cells and .'DS closer 2 0 0 shown or reference mar-,le Property boui.-idaries (,cotes and bounds- clearly .(�-O I"- FT-i-, CjT�j P SEPARATION DISTATTC—ES I D . 1PW 10, 201 00, 501 i-51 10, 151 _L 10 .101 151 to P. L. t o Four-dation -,.ialls to Nearest well to st•eam., marcb, lake;, etc i-11cl. expansion) to Curtain drain to water line (p!Tt _-2_0_'_T_ to storm drain to large trees from f o-Lui dation to septic tank 10 pipe from leader. drain & it IL7 INITIAL SITE INSPECTION a Yes No Cgrrnents I ropertf linen or corners fovand . '. Slope of the line and trench acce ptable - -e _ _ Can estimate house location ... Over 59 fat. from swamp, ;.ratercovrse Will driveway need cut.. � — Must .trees be rernoved -note these • •. _ +� Is deep hole.representative of entire SDS area Additional deep 'roles needed. . . . . . . , , _ Sufficient SDa area available considering driveway cut,ho'se location ,separation •distances, : etc. . _ DEEP t10 r .I)ATA ... Depth : Water elevation: ' Rock elevation: • Soils description: r ate: C FINAL SITE DWSFECTIO�,I Insp. by. House located where shown on approved plane .. /�%d :(- LE••q,,b ti'iti.M WI1V• /-j 5��/ VY �� • • .. .. . . 1 1 . � 1.. Width of trench average Slope of the line and trench acce ptable - -e _ _ Room al.1.oved for expansion trenches . . , Over 59 fat. from swamp, ;.ratercovrse FINr'1.L GRADING OF SITE ACCEPTaRrB, PUTNAM COUNTY DEPARTMENT OF HP,.�A.LTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..COUNTY -OFFICE BUILDING, CARIvIEL, N. Y. 10512 ........ �..... _. DESIGN TA.SHEET- SEPA,RA.E SEWAGE DISPOSAL SYSTEM FILE N0. Owner �Ci� Address Located at (Street LainjoOlkfj 10,AAD Sec. 4- Block �i LL .� ica e nearest ss street) Municipality. Watersheds SOIL PERCOLATION TEST DATA REQUIRED TO.BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION Elapse p to a er Water ve No. Time From Ground Surface in Inches. Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 2 5 In- 5 Notes: 1) Tests to be repeated, at same. depth until approximately equal soil rates are obtained at each percolation. test hole. A11 data to be submitted for.review. 2) Depth measurements' to be. made from . top of hole. 5 a 2 5 Notes: 1) Tests to be repeated, at same. depth until approximately equal soil rates are obtained at each percolation. test hole. A11 data to be submitted for.review. 2) Depth measurements' to be. made from . top of hole. TEST PIT DATA REQJIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES INDICATY'LE'VEL AT 'WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO -WHICH WATER LEVEL RISES A R BEING ENCOUNTERED TESTS MADE BY �' �' ? �, a. Date • -� � DESIGN Soil Rate Used L Min/l "Drop: S.D. Usable Area Provided s-c 71• No. of Bedrooms .,� Septic Tank Capacity Ga ¢oF5s Absorption Area :Provided 'By ' L. F.x2411 n . o *aiat ,.:,ench. OtYfe . Name r Q . V t- I - �: �.�_ ` r r Address 1 / .. SEAL sr 38998 THIS SPACE FOR USE .BY HEALTH DEPARTMENT ,ONLY: Soil'Rate Approved Sq. Ft /Cal. Checked by Date NIA J UN W CTiqBOX ­4 N, +`t ki f— p u .:�IT. I L V, /7 ;A A - ty i� . -c- T�, _7 �'-SE#T C TANX % NHOLE 'COVER- ..a— LIQUID LEVEL CAST IRON SANITARY TEE.. PRE -CAST.CONQ 7 INF. 6'C.C.'8/W _P GRO. LEVE t EARTH -Z vj_ OA46KFILL JOINT t'!j4'. fwj. F,,f_L.w f itog L�, 15" COVER 8LD6L PAPER OR HAY �7. PERFORATED VL W I T 4 10' c D cn A L v PIPE T 7 - _ 24 WK CLEAN GRAVEL OR CRUSHED STONE ABSORPTION TREK H "'NoTtq: pco -*- dt: CON -D'IN�A RDA APPROVED SYSTEM To $ MUCTE �FCO NCE WITH THE RULES AND REGULA,Tr.ONS;:_OF'. THE -.- As FA COUNTY DEPARTMENT. EAC '+J: OF IT KFILLED- UNTIL JNSPECTED BY DESIGN 'HEA ENGINE t9,CA1 AWDEPARTMENT IF REQUIRED. EVANDAIW­ L L 1974, . + i IwAy .2 , -Y T GALLON SEPTIC TANK -WITH-A MAXIMUM y I OVEAM' p ;UTNA OU'll V BY. -.p - Wvf ya I Islam OF A;S,_Jjl�,FERENCED TO F�I,NISHEDFIRST 0'' ,.!Wv.iR0NMENTAL 7- HEAL1`4 SEW41CI I.. Rekc NOTED. Flo ISE 52 OTHERW S '4�ERftI bfZ(D'DAUF_ FOR IRLK. No. 4- 'LOT NO. Aj T r, tz so t-4 to r Drawing No. -7404 --9 4 -7 HOW) A. KC CAR. Y'-'- Xm -'tA X 'MAP NO. r ml OF Chlca 991 4 OF 'ele IRLK. No. 4- 'LOT NO. Aj T r, tz so t-4 to r Drawing No. -7404 --9 4 -7