Loading...
HomeMy WebLinkAbout0712DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23.12 -1 -37 mu '- ti ti r , rr : Rel r- rok I A 46L 00712 We* :Sapply: llc Supply FYom - tbiretae on Prly to Supply DrWed r till (a :44% Dr Big Type �25i,AOY% {1a Lot°Size �,2�. _Has Erosion fnr,firnl Rppn r.�mn7prp�a' Nmriber of Bedrooms Hae Garb /age Geinder Been Inet�lledY �t�l 1 I certify that the eyotas(e) es lisled.'eerving the atiove premises weie'oonstructed essen lly as shoin.on the. plans of the 'oompleted•,work ( copies of which ar6bttached); and in; accordance with the standards rules and re lotion in a rdance vi th f� plan, and the permit issued by the putnae Count <Depez nt Of Health �w L2.:. Certitled OY P.E. •, AA. q ,�h e nib t it.ca� 'J li a634- AAdrest (.l0ena NO. Any .pNSOn occupying D►amitas ii + ,? An "se►wd by, the above system(:) shall promptly Uke sutth attlo as may na neoeu . to aeurn the ewreetbn of any uhmnitwry conditions resulting :from such.:ustaga Approval bf -the., siparate aweiage system stall 1"Co "null and voltl as son as a putii;o anMry im0w Becomes walybls and, the_apprc4s of thi privet lwsthr.sapply;sh ll betoma null and, vof0 ,wren a.publk:.water wPWY bsjoonw wallebN, Such approvah we wtNect to lfkatbn, or change when, {n the "Jud4ment 04, tM Comnllstfoner M weaoeatbn, rnodlfkatbn or ehinp is neeewry, 3/89 °at Tali5�1 0 Re: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Property of G-V-0L.sr< vC�)lTc-, J {1c Located at �'�t,� Z o -pj !. � �,uCJ (A�')Zw4j 04% \Wbm ) (T) Section Block �) Lot. �c3� Subdivision of L >t L, Subdv. Lot # Filed Map # Date 3 i Gentlemen: This letter is to authorize . T Ic U' a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very trulyyouurs, Signed Z16Z o � �� � " - � •, Own Countersigned:n v`�, V, n n P. E. , R. A. , # C) Addr ss %,.; 's �W P - l D�S7 - Fvarf,u�A 1z 4 �-at Cavvy-pl Ajy )t L zZB- n elephone P�perty j� Address Ca V- Pl e Y AM To Ali- � 7 - -- Telephone 3:)*- -5-6' l2. g6' Co 7 %49r 36 73047 q.9 1 10 M wE►t RRsA_D ! 1°�6°J AtRLS MM v s. _ feu � Hoa.E _ � 1. I ` RIB'► * �- lA I 3 ® ' iMAP of sop-Vey LOT 10 A5 SHOW rJ. oN 5 VsDty ►s 10 to Pi.AT pF LITTLE FOOD HILL (FILED MAP N_° 2Z16�. a TcWrJ of PhTTF2soiJ WiNAM CDUWTZ, NY MA�Y 23, 1917 ,4 ' i i I er�dP, r� vny,' not 124T4 ..p - - I VW.1.14 9. *K � I S-rA woe. o (z F Q -PW7 -fl WAoCOrT profn...d C-r: wi.6ca lwg b.r~ ore oo1,Q 4, th a vo ad copy% GRa,SE Co tJCTRLAC- 0,J CORP-- ._ m�Iy .'i AAr or capK "r Ute 1-?-Ks -wet oftle SLrOgOr (3c' _ ?15- G7 -96o5 wh.ie - V"t✓cp ow eac "Woo pt cA-4 q 0-.4 S map Wx teoc e 4vM -.-4\ lbw l cr'rve� of, !/..o P'E'E-" won rl�(o� a+A O UJ 22, 1�;QP7 D W164CUTr LAND SeoQVfYt st L-Acfmcc N8 .41554 t�Aw Cs►Rmk. n.Kw Vow 9i Q - 2as -rc�g CERTIFICATE OF CONSTRUCTION COMPLIANCE Before a Certificate of Occupancy for a dwelling is issued by the local Building. Inspector, a Certificate of Construction Compliance for the subsurface sewage disposal system must first be issued by this Department.. The Department must be notified before the system is backfilled in order that an inspection of the completed system can be made. Open work inspections may be omitted only at the discretion of the Director or his designated representative. In order for the Department to issue a Certification of Construction Compliance, the following must be submitted: 1. Certificate of Construction Compliance. 2. Three (3) copies of a two (2) year Guarantee, signed by the installer, general contractor, .and/or the owner. 3. If the water supply is from a drilled well: a. Satisfactory results of a bacteriological analysis of the water, performed by a State Health Department approved laboratory. b. A Well Completion Report (PCHD form) signed by the well driller, including the results of at least a six -hour pump test. A minimum well yield of 5 gpm is required. For yields less than 5 gpm see Appendix R. 4. Three (3) sets of "as- built" plans, signed and sealed, etc., showing house location with respect to property lines, the actual layout of the SSDS and water supply facilities as they have been installed. The distances necessary to locate the septic tank, distribution boxes,. --- junction boxes, and ends of the trenches - f-rOm -two .fixed points, preferably the corners of the building must be provided. These plans must include a legend, which reads as follows: "This is to certify that the sewage disposal system was constructed as indicated on this plan and that the system was inspected by me before it was covered over.. The system was constructed in accordance with all standard rules and regulations,of the Putnam.-County Department of Health and the New York State Department of Health." "As- built ".plans must also include a title box, giving the information required on the original design drawings. Minimum size of "as- built" plans should be 82" by 11 ". 5. A Certified Check or Bank Money Order in the amount of $.00.00 payable to the Putnam. County Department of Health. After the Certificate of Construction Compliance is issued by the Department, a copy of the Certificate of Construction Compliance, Well Completion Report and approved "as- built" plans should be brought to the Town Building Inspector so that he may process the Certificate of Occupancy. 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRCVL TMAL HEALTH SERVICES 1�ro 1, S D 14 S Ir uC °ak Owner or Purchaser of Building CrJt^0f /SC t`O(/c Building Constructed by Location - Street Pa If e r 11� Oki Municipality 11 m! 4 /k/ F e �we.111,nr- Building 13.3 , l a. Section Block Lot Name A) Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL 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 successors, 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 approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by me to sucli-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 was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this &3 day of 1912 Signature Title General trac (Owner) - Signature S iLi oil Corporation Name (if Corp.) h-ee i-ca r 1* e rev. 9/85 mk &A di. � V �`' � M !� e l % (%g S iruc Corporation Name (if Corp.) 1 F ` efr/ ess ( GPPA ,4e/ 41YOs'J'I, � - `/ML ENVIRONMENTAL SERVICES,,, . w - �21 ,ear_Street' Yorktown Heis}hts, N.Y. 10598 (914) 245-2800 ! . Albert H, Padovaoi , Director- LAB #: 93.A14338. CLIENT #: 2205 NON STAT PH8C PAGE 1 ~~~~~~~_~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~=~~~~~~~~ WALLACE, DOUGLAS QATE/TIME TAKEN: 06/19/97 02:30 RFD 9 FAIR STREET ' � DATE/TIME HEC'U: 06/19/97 03:100 CARMEL, NY 10512' DATE: 06/23/97 PHONE: (914)-878-9548 SAMPLING SITE." LOT' 10 LITTLE POND HILL ESTAlES SAMPLE TYPE..: POTABLE : PATTERSUN . PRESERVATIVES: NONE CUL'D BY: SAME ` TEMPERATURE..: { 4C DATE FLAG PROCEDURE RESULT NORMAL -_ RANGE METHOD 06/23/9y M� T. COL IFORM ABSENT /100 ML ABSENT . COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCURDING�7�~THE NEW YORK STATE ' AND EPA FEDERAL DRINKING WATER STANDARD-1n, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. SUBMlTTED Albert H. Padovani, M.T.(ASCP) Director ` ` ' ELAP# 10j23 a... -4 WL'LL GVMrLG11V" rczrv>RL * DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH�U Office Use Only WELL LOCATION STREET ADDRESS: WNW I TAZ GRID NUMBER: © /-z WELL OWNER NAME: ADDRESS: r_j_ Cal,' - P8IVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED O BUSINESS O FARM O TEST /OBSERVATION ❑ OTHER ( specify) O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT --25— gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING ❑REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY ffNEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH / ��7 ft. STATIC WATER LEVEL _6 ftj DATE MEASURED DRILLING EQUIPMENT O ROTARY COMPRESSED AIR PERCUSSION 17 DUG O WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING PEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH. it MATERIALS: STEEL O PLASTIC O OTHER LENGTH BELOW GRADE C9 6 ft. JOINTS: O WELDED THREADED . O OTHER DIAMETER L in. SEAL: ❑ CEMENT GROUT O BENTONITE MOTHER WEIGHT PER FOOT I7 Ib. /it. DRIVE SHOE YES ONO LINER: CJ YES NO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (It) DEPTH TO SCREEN (It) DEVELOPED? FIRST OYES ONO HOURS SECOND GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH K. BOTTOM DEPTH h. WELL YIELD TEST If detailed pumping ME�'HOO: O PUMPED tests were done is in- COMPRESSED AIR , formation attached? O BAILED O OTHER ❑ YES G NO ELL LOG If more detailed formation descriptions or sieve analyses are available. please attach. rDEPTH FROM SURFACE. Wi1t, gt7f- Ing Well Oia. meter FORMATION DESCRIPTION coot . ftp. WELL DEPTH It. DURATION hr. min. DRAWOOWN It. YIELD gpm. Surface �? c WATEN IYCUAA TEMP. QUALITY O CLOUDY NARONESS O COLORED ANALYZED? O YES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK : TYPE CAPACITY, GAT,. PUMP INFORMATION J ?YPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP w%LiiEHYATT & SONS, INC. DATE � < � ADDRESS Well Drilling SIGNATURE 6 � Rte. 311 R. R. 2 Box 171A PAT'I'tRSON, NEW YORK 12553 3/ tSy m i Y ]/0.7" L iCiavw.uul�y �iu�'. iiiSY. UL oiir, c vJJy. ^Et, NO / \ 55DS YN17H!N % MA50NR� 7ANK DO'"'A6 77—;Z 5AO MIN. bA!- Li 0 F-AN SCALE I " = :20, R - 2:2!5ze— - �. L = 60.01, I To wa .— of ftdao .no. 70 c2ps-Uma. CC.-W. +Q- -1" El.�S IaN S_ I So =4 4 00.cs �m J. 0.0 W,L K Ste-4*(Ly �Kq . ftce 0 &rLs tmrTwA IU Ls.w i,SiKCnC- Owl X ra(CU(mr W Rf�M ga • Wx =%I •1 4ECEQ. w­ �.m Ww3,0!ts E To or ise— v 51gZ��c' LU o Ln rl ly, z F-AN SCALE I " = :20, R - 2:2!5ze— - �. L = 60.01, I To wa .— of ftdao .no. 70 c2ps-Uma. CC.-W. +Q- -1" El.�S IaN S_ I So =4 4 00.cs �m J. 0.0 W,L K Ste-4*(Ly �Kq . ftce 0 &rLs tmrTwA IU Ls.w i,SiKCnC- Owl X ra(CU(mr W Rf�M ga • Wx =%I •1 4ECEQ. w­ �.m Ww3,0!ts E To or ise— v 51gZ��c' > t�i.ESt�i FitITa IM „,e, "�6- _ Nm ber 4 Bedloema :4 Dedp Flow G P• D Fm s« ,,' PCBD Noll&"= Is B•gahed. When FM 4 completed S"Wota s• _rev Seca. a Consist of 12 5i� coo,, OP& Toot 4 R FNc.1-J To•be b7” Address Water Show. Addreve : dr! � Arv�K j'��r, �r � L7 F • � Adder Dt10ed '06M ntnt -.tm wholly and compfetoly responsible for the design` and location of the pr opo Fto y$ th rate sew" " disposal f �st�ein 1 • a• s• �� above described will be constructed at shown on the apDro�ad amendment there and in aceorda t�th stpj�f u regulations o e " uTnam - r.tatisf `'t - Couety Department of "41% and that on completion hereof a; CsrtificaH .of' Constiuctio p tc�r (, ornmisfloner of Healtliwill be submitted to; the Dapaitnlent, and a wiftlin, waif 0e furnis_tiW the+ owner, his >• halt.$— OAssigni�6 ',t Ilder, that fold bulkier flllarin, in any part of so srwsge disposal sysNm tlurhq the per t will rt (Z) W jt f. thedab of this love . :. ante of the: approval of, the" Cartitkate of Construction Comolisnee of'the' ginal tystem a ., Tepairsitfi�► pre., t eto 2) that tM: tllod well difcilbW idow ` led will be located as'shown on tike app►ovad plan and that said wall will M Instal co nce ith. he riq ns ;: -of the Putnam ' Count Y /Depa irwritaoInditbn /�1� B r3. v.E f� gSl�Yn)ed 7�+ C" zR.A.� L r 4 ✓D " Addressy..�R _ .O �t Lie sa No APPROVED FOq "CONSTRUCTION: This approval expires two`.ysan from the data 'issued. unless. ttr n �L' tnq has been undertaken and Is revocable "for cause or may be amendeit or modified whin eonsiderad recces Co missionar MTe nqa or alteration of construction .N requires e- new: perm) ., APOrovaO for, disposal of :domestic, unitary few % na s ter. w BY. TitN�' ,Rev. 10/88 ,.Oats y ro CA DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Town Village City Tax Grid Number WELL OWNER Name Mailing Address O rivate 1Do w, nj- 5 6 P14ro _fti 33o b e-fA -f-ai ( 41iot- Jj j •D.� 1 o O Public ,PSE OF WELL L)- primary 2- secondary "SIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED O FARM O TEST /OBSERVATION p OTHER (specify, b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT ,Z) gpm /# PEOPLE SERVED /EST. OF DAILY USAGE O'D al D 3gPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION Q ADDITIONAL SUPPLY ®'NEW SUPPLY NEW DWELLING) 0 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING C WELL TYPE DRILLED DRIVEN DUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES 1! NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: i(" ! f Lot No. I () WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 've"' NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY 1. DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH S SOURCES OF CONTAMINATION PROVIDED`�`� []ON SEPARATE SHEETS (date) r(s•gnature)':. PERMIT TO CONSTRUCT A WATER W` L-;- .� �OF�EVe This permit to construct one water well as set forth above i gra s n 8er 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 provided by the Putnam County Health Department. During all well drilling operations, the applicant.shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: 19 Date of Expiration 19 �Z Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 1/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PC -1 a ?� ;J PUT NAM COUNTY D E PARTM E NT OF H EA LT H APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: �(� -�C&S 2. Name of Project. 7 0 3. Location T /V /C: 4. Project Engineer: 5. Address: License Number: 2-36 Phone: 6. Type of Project: _ Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. NO ^^ff /� 9. Has DEIS been completed and found acceptable by Lead Agency? ........... NIA 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, or other officials, ordi'dances? ......... ............................... 12. If so, have plans been submitted to such authorities? .................. 13. Has preliminary approval been granted by such authorities?— Date Granted: `�"" 14. Type of Sewage Disposal System Discharge...... Surface Water ,_ 4Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. L 0.. 18. If yes, name of water supply Distance to water supply P%I-S 19. Is project site near a public sewage collection or disposal system ?..... 20. Name of sewage system Distance to sewage system 21. Date test holes observed: 22. Name of Health Inspector:�Y' 23. Project design flow (gallons per day) ...... ............................... s©© 11/93 0 4 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or State A /� wetland? .................................. ............................... (� 21. Wetland ID Number ........................ ............................... — 28. Is Wetland Permit required? .............. ............................... J Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO _ 2. a J o 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO�`'�' DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ........... 33. Are community water, sewer facilities planned to be developed within 15 years? 34. Are any sewage disposal areas in excess of 15% slope? ........................ 35. Tax Map ID Number ......................... ............................... 36. Approved Plans are to be returned to: ................ Applicant Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: p d got 1mv I a 1"1TW11kN,4104kN10VN0§;1p1,1 -� PLO' DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM . FILE NJ. i s/ Ownerpo ./%(%s,�/T /� Address &.0 O Located at (street) Ul Sfi,�- D b LD Sec. Block Lot 3 /� (indicate nearest cross street) municipality � -�(� N Watershed Y6, Date of Pre- Soaking Date of Percolation Test �: �• « •« r • • •• ) 10 Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/In Drop Inches Inches Inches I 2 3 n Sj E- 5 -9 _ -/%, M1,Yz�� 2 3 4 5 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 review. 2. Depth measurements to be made. fran top of hole. TEST PIT DATA ' REQUh=: TO' BE: SU TED. 119= DEPTH HOLE NO. SOLE NO. HOLE NO. G.L. 2' 3' 51 6'�� 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING DEEP HOLE OBSERVATIONS MADE BY:Cj DATE: MblUN Soil Rate Used 1S �� Min/1" Drops S.D. Usable Area Provided SpWF7- - No. of Bedroans Septic Tank Capacity 2,150 gals. Type CO Al C- Absorption Area Provided By "�� 1 L.F. x 24" width trench Other Name / U �Nl C'� /' Signature Address !/`�f1 y G� /� - SEAL X�A A) V ti THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft/gal. Checked by Date A o- Re: Pro Loc PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date (T)�"�/� Section �'�' Block Lot Subdivision of �% T - too/ulam' AL11- L- Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize,'%! a duly licensed professional engineer Ll� (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned: o.e...� . # �fC�L3d Address Telephone Very truly yours, Signed -�' L Owner of P operty Address A/ Town Telephone 41 Cm 7a Ole. law di pwdm e Oa: Afiir Let Am 4 wboiambeemombd DMIp � ��1 TiM IMINIF FM fib Dar b A moNtNy jo 46110 for �tm do" n g iii Ii Duls vstom , ovid kalpe:01 --stimia"'ti the Com,nbpt m if ""It" Wig II smarl"o irik.be- fWwbMA tow owl wS vs. ftimlm�%oi. oalip" by �he 116"w. 641 Sip befter W. Will duriiii'llie'timorioCof tw6oi4verf outhe Min parCof 44 'arleirAl-sw4sio Or diMed ii4ill,dievOld tMtjllld WOW be-ifWU@*C'in w rubs arA rq s I tM O-All4► 's PAU Q.A. has bow uii�aftd is INS conotruct",of tke,buiiiiloii, ilnisskmo of mmilL: Arty ?,wowS.-Or Skit Atruim' wation, of cor, ct spoov. mly.. e- DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION V,, Street Address Town Village City Tax Grid Number �. ... WELL OWNER Name Mailing Address afrivate O Public USE OF WELL " primary Z- secondary "SIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION M INSTITUTIONAL O STAND -BY O ABANDONED , ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT 5— gpm /# PEOPLE SERVED,5i /EST. OF DAILY USAGE j&Q Bal 13 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION GIADDITIONAL SUPPLY E14EW S PLY (NEW DWELLING O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING umw '—' WELL TYPE DIrRILLED ODRIVEN CIDUG GRAVEL C] OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: k i" Lot No. WATER WELL CONTRACTOR: Name "T ;T51 17 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES i '- TO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & OURCES OF CONTAMINATION PROVIDED N SEPARATE SHEET 3 (date) signa 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 provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: /-V u�.S 2 19 Date of Expiration 19!�7z Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date a Re: Property oA.- 'IoyeS 6� 72 P3 A a-&EASPA A) SW LVC f?� Located at to V ! S�A 'Do, to tleS (T) �� ZcI Section 2 a' Z� Block " . Lot Subdivision of C q tc Pond 14711 r Subdv. Lot # �� Filed Map # _Date Gentlemen: T. MICHAEL DALY, P.E. CONSULTING ENGINEER This letter is to authorize P. 0. BOX '243 _ NORCICK,NV :V. 10507 a duly licensed professional engineer or (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with'the standards, rules or regulations as promulagated by the Commissibner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise.t 'he construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the'Putnam County Sani- tary Code. Very truly yours, Signed Countersign Owner of Property P.E. R.A. Address ., T. MICHAEL DALY P.E. Ot2 f lj� C.t 1 �� -7 mfiNo t?, Address CONSULTING ENGINEER ,Town N. 0. BOX 243 N. Y. 10.587 ll l tP .Telephone Telephone P(: -1 P UT NAM C O UN T Y D E PART M EN T O H HEALTH APPLICATION FOR APPROVAL OF PLANS FOR WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: IDO L AZ Gh 63ZZ �g �,rptN,.A 2. Name of Project: 3. Locatio T, V /C: 4. Project Engineer: ::I--, , at -`r��� 5. Address: tvx Z4 3 License Number: 46468 Phone: — -0 6. Typ e of Project: Private /Resident Apartments Office Building 7. Is this project subject Type Status (Check One) ial Food Service Commercial , Institutional' Mobile Home:Park Realty Subdivision, Other =(specify) 0. to State Environmental Quality Review (SEQR)? Type I.. Exempt Type II. Unlisted ✓ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. U 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 1 0. Name of Lead Agency 1. Is this project in an area under the control of local planning, zoning; or.other officials,. ordinances? ......... ............................... 2. If so, have plans been submitted to such authorities? .................. �1 D 3. Has preliminary approval been granted by such authorities ? -- Date Granted: " 1 4. 1 i. Type of Sewage Disposal System Discharge. :'�?� Surface Water Ground Waters If surface water discharge, what is the stream class designation ?........ i. Waters index number (surface) ........... ............ .................... _ �. Is project located near a public water supply system? .................. 0 0 t. If yes, name of water supply Distance to water supply— 1. Is project site near a public sewage collection or disposal system ?..... t w• i. Name of sewage system Distance to sewage system . Date observed: 23. Name of Health Inspector: Project design flow (gallons per day) ............... ,- :OQ ....... ....... 2. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required?... 26. Has SPDES Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State wetland ?............ .................... ............................... 28. Wetland ID Number ....................................................... 29. Is Wetland Permit required? .............. ............................... Has application been made to Town or Local DEC Office? .................. `I 30. Does project require a DEC Stream Disturbance Permit? ................... �! .t 31. Is or was project site used for agricultural activity involving app -�Yk. ation of pesticides to orchards or other crops, solid or hazardous waste. dtsposa1, landfilling, sludge application or industrial activity? ........ YES! or NO 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO N DESCRIBE: 33. Is there a local-master plan or file with the Town or Village? , *.......... 34. Are community water, sewer facilities planned to be developed within 15 years? N 35. Are any sewage disposal areas in excess of 15% slope? ........................ _ 36. Tax Map ID Number ......................... ............................... .2 37. Approved Plans are to be returned to: Applicant Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant o Section 210.45 of the Penal Law. I SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: SfL��l�ocaG ltd (� l GS73 -� PUINAM COLWY DEPARTMENT OF DIVISION OF /• •' ' E Y• HEALTH SEWICES DESIGN DATA SHEET- SUBSUFACE S&gAGE DISPOSAL SYSTEM FILE NO. Owner,aj,Ljegrz2� Address fXQK 2i37 ►�� .► z. � ID 51'2- Located at (Street) << �v '�J, IZ Block -1 Lot - 3�- (indicate nearest cross street) Municipality ��- R��p1�^� Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre - Soaking 4 -1-k - 8 fo Date of Percolation Test & _ j qz -a 6 HOLE NLMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 2 it'. 33- ll'•54 2 i 24 2,:::� 3 --T- 3 11'• 54 -JZ'. 15 77,1 It, 4' ' `Z-1- 3 1 41V.L5 -ff39 C4- Z.4 14- 3 & 5 Z4 Z 3 il:b--9�- 1V2,3 -Z 4 IV t3 - I Z ,oft S4 5 1 2 4 5 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 review. 2. Depth measurements to be made from top of hole. DEPTH G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS EMXD1i RED IN TEST HOLES HOLE NO. 1 HOLE NO. HOLE NO. Via• •r 0 INDICATE LEVEL AT WHICH GROUNDWATER IS ENOOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: jg,� Q� DATE:�l2-$4� DESIGN Soil Rate Used a °l0 Min /1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity k7.,GD gals. Type Absorption Area Provided By 444 4 L.F. x 24" width trench of Name &I'ma u D A u; ex. Signature. CONSU".TING ENIr"NFER ~ Address SEAL .c 0. BOX 243 SHENOROC` N. Y. 10587 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: FSSInNA Soil Rate Approved sq.ft /gal. Checked by Date a APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DMSION OF ENVIRONMENTAL HEALTH SERVICES " INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET for CONSTRUCTION P R� m IE OF OWNER STREET LOCATION t / r DATE a. TAX MAP # D MENTS. .3 ZZE_C_`HARGE PERMIT APPLICATION ��"' (OK) - DEEP HOLES LOCATED PC -1 RESENTATIVE OF PRIMARY AND EXPANSION WELL PERMIT P �/' . AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE ENGINEERS AUTHORIZATION DESIGN DATA SHEET(DDS)% ID PIT &D BOX SHOWN & DETAILED SB _ NO. OF BEDROOMS `� DEEP HOLE LOG CONSISTENT PERC RESULTS (3) ,.,i� WELts & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM PERC HOLE DEPTH RO METES &BOUNDS SE SETBACK NECESSARY (TIGHT LOT) CORPORATE RESOLUTION tz SE SEWER - U4"/FT. 4"0; TYPE PIPE PLANS THREE SETS � NO BENDS; MAX. BENDS 45 W /CLEANOUT HOUSE PLANS - TWA" SETS VARIANCE REQUEST GENERAL LEGAL SUBDIVISION SUBDIVISION APP� .OVoW_ CHEC� — PERC RATE � FILL REQUIRED xzi' CURTAIN DRAIN REQUIRED ^ A ES FILL SYSTEMS AL: SLOPE 3:1 TO GRADE OPfH GAUGES MT PROFILE & DIMENSIONS VOLUME _ TRENCH EX- APPROVAL SSDS ADJ. LOTS CH PROVIDED WETLAND (TOWN/DEC PERMIT R & D)_ .sue 60 FP ME - MAX DATA ON DDS PLANS & PERMIT SA per [ TO CONTOURS PRE -1969 - NEIGHBOR NO CATION 1 100% EXPANSION PROVIDED LEITERBULBA SEPARATION DISTANCES SPECIFIED ON PLAN 100 YR FLOOD ELEVATION 10011F FIE WIRED DETAILS ON PLANS 0 P.L; DRIVEWAY, LARGE TREES, TOP OF FILL SEWAGE SYSTEM PLAN - (NO 0' FOUNDATION WALLS SSDS HYDRA OFILE GRAVITY FLOW 0 TO WELL, 200' IN D.L.O.D., 150' PITS D/ J BOX CH/GALLEY m P:- DETAILS TO STREAM WATERCOURSE LAKE (INC.EXPAN) SEPTIC TANK = SIZE, DETAIL t y O CATCH BASIN, 35' STORMDRALN, PIPED WATER WELL DETAIL, SERVICE LINE IF OVER 10' TO WATER LINE (PITS -201) CONSTRUCTION NOTES (GRINDER RATE) 1NTERbff TENT DRAINAGE COURSE DESIGN DATA: PERC AND DEEP RESULTS 20 . RESERVOIR, ETC.CL, 150 FT. GALLEY SYSTEMS TWO -FOOT CONTOURS EXISTING & PROPOSS . SEPTIC TANKS DRIVEWAY & SLOPES CUT �'"` / zliloll M FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELLS AMENTS: 15' W tT P.L �< �m1" Gil. C 1 N011 -v0 VJ zF DRIVE TO VISTA DOLORE5\ / I �v Y, — ;1 =- 14 411 _ lS1 w 11 1 It 11 -gal It -71 11 II , n n tP CI1 1; t7t / It It tl Il Z 11 it 11 It II� O / It u it II 11 !!0 A a 11 11: \I ►J r � �COIt 11 II 11 11 v It 11 It 11 11 I O T \ nA �� o � � � � � 'ii iT 1t '{"S to � 0 � u) 1 � .0 it 11 It 11 it 11 It 11 Il 11 11 U 11 �•_ z N 11 It 11 I 1 U 11 11 iI U .- Il It tl 11. 1 � It It It It it It kp °O� / tk 11 I t 11� � .h O 11 1 It 11 fc R � s.. z2 i