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BOX 8
17--
16:01
is
00733
Rev...3 /86 PDTNAM COUNTY DEPARTMENTOFHEALTH
Division of Fbvionmental$ealth Servkex,. Carmel, N.Y 10512
Englneer'Mas Provide
P.C.H D. Permlt M
CE ATE O.F. CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL;;
Located at
Owner /spPllcant Name G Formerly
Melling Address
_ 'ITS` -TIF ' DtJ '
Town'eiFWat�
Tax Mapes Block g Lot- a4—
Subdivision Name ? - Subdv: Lot M l
Date `Permit leaned ' � 2 i 2� % � � 1
Separate Sewerage System built by LQ �N MIA Address V. 110 �b� �fJMi� 1 N.�% (0i
Consisting of 1D Gallon Septic,Tank and17�
IA
Water Supply: Public Supply From �y Address Y'
orr Private Supply Drilled by�1?��`' CH OF Address MD_ uIJ_, .G✓�I%�h�i
Building Type Erosion Control Been CompletedY�
ti
Number of Bedrooms GI' ' Has Garbage Grinder Been Installed? D
Other Requirements'
I, certify that the systems) as listed serving the. above premises were;constructed:edsentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules 7rej ations`,'in accordance with th%,!5pd plan, t permit issued by the
Putnam. Co t Deplartmeepmt Of Health. Q /
Date /� �r ► Certff(ed by R.A.
___Tr --'—
Address "'. License No. 1TJ I
Any person occupying piamfas served by•the above sysiSM(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting (r!r such usage. Approval -of the separate sswerage system'shall becorne null and vola;es door as a pubs;: sanitary Nwer becomes
avallable and `the approval of the,p►(vate water supply shall become null and void when a' public water 'supply bscomes'avillabN. Such; approvals are
subject ,to'moditieation or Change when, <ln the )uggment of the COMMISsloner Health, weh revoutktn, modlfleitlon or change Is necesury.
Tit
Date er
��s
WELL COMPLETION REPORT
3 /7b
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL. NEW YORK
This report is to be completed by well driller and submitted 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 Q �n
f= ?5 �ah�T ,I I A G �uLE
ADDRESS � /„ t C* 6-'Frz { GJ" r_
� .J e' ' 1!r G1l"f
LOCATION
OF WELL
(No. 6 Street) (Town) (Lot Number)
1 ( m 0 �J
PROPOSED
USE OF
WELL
�. DOMESTIC ESTABLISHMENT FARM TEST WELL
j
SUPPLY C INDUSTRIAL CONDITIONING OTHER
DRIVING
EQUIPMENT
(j COMPRESSED CABLE, a OTHER
ROTARY AIR PERCUSSION �!i PERCUSSION (Specify)
CASING
DETAILS
LENGTH (tea() s
I r sl Ot�
1
DIAMETER (inches)
/I
'WEIGHT PER FOOT
' y
Aj THREADED []WELDED
RI O
YES ❑ NO
CASING
YES NO
TI EST
HOURS G.P.M.
1
D BAILED ' PUMPED COMPRESSED AIR J 1920
YIELD (O.P.M.)
AO
WATER
LEVEL
MEASURE FROM LAND SURFACE — STATIC(SPecifyfeet)
(
DURING YIELD TEST fleet)
70 )
Depth of Completed Well ^�
in feet below Land surface: � /1)
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (leaf)
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (inches) FROM (feet)
TO (feat)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact face t/017 of well with distances, to at least
two permanent landmarks.
FEET to FEET
L d—
'VIC
w-�
If yield was tasted at different depths during drilling, list below
FEET
GALLONS PER MINUTE
a�
ATE WELL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature)
MAYOR
STANLEY J. ESPOSITO
Klaus Weirether
RR3 Lake Shore Dr.
South Salem, NY 10590
CITY OF STAMFORD
DEPARTMENT OF HEALTH
888 WASHINGTON BOULEVARD
P.O. BOX 10152
STAMFORD. CT 06904 -2152
private well water report for Big Elm Rd.
Collected by Boris Churyk from the direct from well
Test colle ted on 04/26/93 at 10:00:00 AM
Joseph E. Kunt Analyst
TEST PERFORMED
Bacteria tests
Total coliforms / 100 mis
non-coli form bacteria
Fecal coliforms
E. Coli
Total plate count
Iron bacteria
Enterococcus
Other observations
#0695 -92
ANDREW D. MCBRIDE, M.D., M.P.H.
DIRECTOR OF HEALTH AND MEDICAL ADVISOR.
977 -4399
ROBERT H. MURRAY
LABORATORY DIRECTOR
977 -4378
April 29, 1993
-YOUR VALUES - RECOMMENDED LIMITS
A
less than 1
not applicable
0
0
suggested less than 250
absent
0
RESIOLTS REPORTED 04/29/93 :
Water MEETS State requirements for bacteriological potability.
PUTNAM COUNTY DEPARTMERT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Mr. and Mrs. Robert Q. Mar uley
Owner or Purchaser of Building
Wald Construction Co.
Building Constructed by
Big Elm Road
Location - Street
Patterson
Municipality
Single Family Residence
Building Type
Section Block Lot
i� 7- <5�i.
NA
Subdivision Name
NA
Subdivision Lot #
GUARA= 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 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 was
caused by the willful or negligent act of the occupant of the building utilizing
the system.
Dated this > day of 19 Signature
Title
General Co actor (Owner) - /Signature
el
Corporation Name (if Corp.)
Address
rev. 9/85
mk
T �L
p vJ iv ;t K
7 ors/ ADAP1S . CvAvs%
Corporation Name (if Corp.)
�oX 30 E R-S A/_/
Address
K
I as ma that 1 am wholly and completely rsponsiele for this dasgn and location of the - proposed }yfbm(Q. 1) that the Opwate awe a di '�11 st Nor
Mono deurieed will N constructed as Mammon the approved amOndmant there to and in accordena with the standards, ru1N a rape
County Deportment of Hnnh. and that on canple6on.theroof a - Certificate of Construction ComplMmoa" ratisfaetory to the Comml N MwtMted N we DepartnwA.ond a written gmarwKae will tit furnished lha Owner..kif tticawws. hears or assgha by the twkder. ri 1W
in tfoM .eperatlq aall/NIM ally tlwt of -Cold swap dklposal . System Owing the.Owbd.Of two (2) yhrs Immediately t0ftwk» t Nwr
alter of: t11t1. do~ of the rCutllkate, of Coefl►itetbn CoMpoianee 'of. the orlsktal,sy/t•m a any reM Ifter"ol 2) that t drom
wM N IoeatN N Morw ON tM approeM plan and l hat eskl waM Milf N'NMaS1a0 accordonee Mi l ►Y Its f ttl� ►Y1Mm
Cetmty DepeA//���lwtt of IM"k.
oo
Oaa / lfJ -�! l ligow F.E. IIIJ&
V.
-'Addraw� "' " ` LICOnM N
AFFf10VEO FOR CONiTAtJC?IONi This approval eaFira two "the date issued unless construction :of t ildkq has ben undertaken and is
is for eausp or way ti ; amended or modified when eon ►y OY t olnlhhYOnar of - "With. A y c nM or Migration of eonstrtl~
BOON" a 'MM - ►mil..' p tioae/ 160, dHMrl- o•: domNdk a - ti watw pp only.
$ii2nnV. By f//•► TRW
DEPARTMENT OF HEALTH
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 # L L
WELL LOCATION
Street Addre
Town/Village City Tax Grid Number
WELL OWNER
Mai], in Address
I &ICI )il
rivate
UU Public
USE OF WELL
primary
secondary
RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PU C SUPPLY IR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
❑ ABANDONED
O OTHER (specify
O
AMOUNT OF USE
�y
YIELD SOUGHT 17 gpm /# PEOPLE SERVED) ..5T /EST. OF DAILY USAGE 8 6L Sal
❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION GIADDITIONAL SUPPLY
EVkW')SUP LY 4NEW DWELLING1 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
L?s
WELL TYPE
RILLED
®DRIVEN
®DUG ®GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1Z NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETC6�ON SOURCES OF CONTAMINATION PR D
SEPARATE SHEET
(date) (signature)
.,Z 'M
PERMIT TO CONSTRUCT A WATER WELL < C
This permit to construct one water well as set forth above is granted under the pro4siG- ,Cs�7 -j -r
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that witiAn F I?
thirty (30) days of the completion of water well construction, the applicant shall:d
_i
1. Pump the well until the water is clear. ^` C
2. Disinfect the well in accordance with the requirements of the Putnam County%geaj� M
Department attached to this permit. Ul n _<
3. Submit a Well Completion Report on a form provided by the Putnam County HeaRh 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 manner as not to degrade or of erwi a contaminate surface or groundwater.
Date of Issue:
Date of Expiration 1 Z 6 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
WE
2-r_
PUINAM COUMY DEPARTMENT OF BEALTH
DIVISION OF ENVIRONMENTAL HEALTH SEWICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Address 1 & oLT
Located at (Street) �,' . Sec. dock _Lot. _
pp
(in to nearest cross street) T 3 a�
Municipality G 1I f4 &GYM Watershed �0 �
Date-.of Pre- Soaking Date of Percolation Test lo�
HOLE
NtF,JBER CL= TIME
PERCOLATION
5
•
PERCOIATION
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
C1 61 ' So - i0'. 2o �' 3o
%4 �3��
�`�
±O
5
2 1 - D'
3 � 0.5D _ :, 2 5�$ 11 A 11 "-12-o
4
5
2 ID' 2 - 10 ;52
64 .616
4
m
5
•
h
°
rte-• ' m
2
3�M
u► ) ..
4
NO�I'F5: 1. Tests . to.. be `repeated at same depth thtil ' appr'd4mately equal soil 'rates
are obtained at each percolation test hole.. All data to* be suimitttd
fora review::; -:
2. .,Depth measiireiints to., be made from top of hole.
rev. 9/85...
TEST PIT DAMAREQUIRED TO BE SUBMITTED W1ITH. APPLICATION
DESCRIPTION OF • •• ERE• IN TEST : •
DEPTH HOLE NO. HOM NO. i HOLE NO.
G.L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNURNMR IS ENCOUNTERED -- - - _
INDICATE LEVEL TO WEUCH WATER LEVEL RISES AFTER BEING ENOOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: �% . /l%r,Gc,j /S 7i DATE: /� • oZ - /
-- -. DESIGN
Soil Rate Used #& -[p 0 Min/1" Drop: S.D. Usable Area Provided
No. of Bedroans 4 Septic Tank Capacity 1,A90 gals. Type
Absorption Area Provided By qv-' L.F. x 24" width trench
Other F, OF NEH,���
Name P i nature ' #%
-*j + - - - -
g
Address SEAL
THIS SPACE FUR USE BY HEAT:rra - UkXAKLMLUX UNLY: .
Soil Rate Approved sq.ft/galo< Checked by Diate
I .
PUTNAM COUNTY DEPARTMENT OF HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
Name and Address of Applicant: �% �•a.
2. Name of Project: 3.._, Location,:T/V /C: :.:7
4. Project Engineer: ee3 1 5.' Address:
License Number: Ptione:
Is OV ).. ::�:: l,h Ji..�.i�t.�;., I.-
6. !VTP_ P o ect :•',- ''. >a ;t,1c x T, -.� ~ .. , :.. ..
riva te /Residential Food-Service �..R. :. Commercial t
Apartments Institutional M6bile Home Park
Office Building Realty_ Subdivision `Other:(specify),
7. Is this project subject - :to State Envieonmental.Quality Review'(SEQR)? ==
Type Status (Check-One)-' Typel..'s. Exempt
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? ............... 00
9. Has DEIS been completed and found .'acceptable by Lead Agency? ...........
0. Name of Lead Agency 44
.- -Is this project in an area under the control of - local planning, zoning,
or other officials, ordinances? . ......... ............................... AM
2. If so,-have plans been submitted to such authorities? .................. .:.
3. Has preliminary approval been'.. ranted•by such authorities ?..,,!i,,:�L;Date Granted:=
'�1f.3:4�?{!Jf•'„r" ::s.!:n.. �'.t�.:r:.i.'1 :�j''.1 ��k:. f. ! •i•.�.�•� 1 .. :: -.... '` ": .'(•. .:.. ::�. .• ..
4. Type of Sewage Disposal.System Discharge...... Surface Water :Lground-Waters
•
5. If surface water discharge', what is the stream class designation ?........ A �
6. Waters index number ( surface)....:.*,....: .... ...............:.:.::.......:..
ter supply system?
T. Is p roject located near a. ublic wa
3. .....
..:.... :...:.
If yes, name of water supply IL)1,4- Distance,to..water supply
).'Is project site near a public sewage collection.or disposal.system ?..... . A)O
). Name of sewage.system - /4- Distance to sewage system
. Date observed: /off o� �q 23. Name 'of Health Inspector:
1. Project design flow (gallons per day) ...... ............................... 8�
2-
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?...
26. Has SPDES.Application been s . ubmitted to local DEC Office? .............. 4,6
27. Is any portion of this project..-located- within -a -- designated -Town or State
wetland? .................................................................. Ado
28. Wetland ID Number ........................... x)41
29. -Is. Wetland Permit -,required?' "..-,,;,-.,....'.- 0000.6.** ......
i,. o A-
Has application been made,to-Town or Local..DEC Office? ......................
30. Does,. proj9ct __req4_!.rq._A. DECStream. Disturbance Permit?. , ............
-775
31. Is or was 'Project site: used for agricultur-al.activity.-involving applicatiorl
of pesticides to orchards or other crops, solid or hazardous waste disposal�-r
landfilling, 'sludge application or industrial activity-9. ......... YES or, kO"::" :6
'
32. Is project. located .-within: 1-,V00 '-feet..of existence of-
aban'doned landfill;'
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? or NO
DESCRIBE:
33. Is there a_..Iocal master plan or file with the Town or Village?
34. Are community..- water, sewer, facilities planned to be developed within 15 yea , rs?
35. Are any sewage.. disposal areas in excess of 15% slope?
36. Tax Map ID Number
37. Approved.Plans are to be returned to: ... ...... o Applicant.. Engineer
rf the application is signed by a person other than the applicant shown in Item.1,.the.
application, must:-be.-.accompanied by�aLetter_ of. Authorization Failure to:comply with this
provision may be grounds for the rejection of any submission.
.r hereby affirm, under penalty of perjury, that information provided on this
form is true affirm, the best of my knowledge and belief. False statements made
here in are pun ishab le as - a - C lass A Misdemeanor pursuant to Sect ion 210.45 of
the Pena 7 Law.
1)4IGNATURES & OFFICIAL TITLES:
[AILING ADDRESS:
E DISPOSAL
TED ON THIS
15MCTEO 8Y
F NKPA�lGE LATIONS
HEALTH -f of HEALTH .
2tzY ��Ut:Nno��
EutrAm Coumft Departmf
jivision of Environmental
- Ppr6ved as noted for conj
spplicable Rules and.Regu:
Aitnam County'Realth Depa3
Y ?, r,JojLl n1 M�N51ofJ GH���
i
5�
t �•
4
I
101
�
�l0
1DG.5
1D1
112.5
q
1 11.5
130,5
II
1'�2.
123
I
14&
1h2
1�
150
14�
t�,
163.5
iG4
101.5
lob
22
8
1 t 3
LAURENT ENGINEER G
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
RANDOLPH W. LAURENT, PE. (914) 278-6108-(FAX) 278.2658
HARRY W.NICHOLS. JR., PE. CONSULTING SITE ENGINEERS
April 5, 1993
Putnam County Health Department
Route 312, Geneva Road
Brewster, NY 10509
Att: Mr. William Hedges
RE: Proposed.SSDS
Big Elm Road
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing S. -1 "As -Build Plan ", dated
3- 30 -93.
2. "Certificate of Construction Compliance for Sewage Disposal
System ", dated 3- 30 -93.
3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal
System ", dated 2 -2 -93.
4. Well Completion and Well Log Report.
5. Water Analysis Report.
6. Money Order in the amount of $200.00 payable Putnam County
Health Department.
If there are any questions concerning the enclosed, please call.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
jJ. c1166 o-Qo
Harry W. Nichols, Jr., P.E.
HWN:bd
91091
enc.
cc: Mr. R. MaCauley w11 copy ea.
Rev. 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
P.C.H.D. Permit N
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM MV9: / 00
-t-'— 2 Town
Located at ", � LM 'GAIL Tax Map_u- —Block z Lot _
Owner /applicant Name d Formerly Subdivision Name— Subdv. Lot p l
Melling Address �IP G� �6 g 0 Date Permit Issued 2 2�
Separate Sewerage System built by i/Qti G Qi7A� GdP157 . Address 0• egg �%D� �JDM� N•`% (D���
Consisting of Gallon Septic Tank and q0�-- �T�G��
Water Supply: Public Supply From �y Address
or: Private Supply Drilled by u l Address
Building Type _Has Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?
Other Requirements
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 reg ations, in accordance wJktJkth d plan, t permit issued by the
Putnam Cow t Departme /J ^'t of Health. /3
Dab O��Gr , `�� f-r� Car by 1 �11 ,,r r.
Date
Address 1vf; �a0 N' �'6 License No. �u
Any person occupying premises served by the above systems) 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 null and void as soon as a pub;;: sanitary lower becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Commissioner of Health, such revocation, modification or change Is necessary.
Date
By
Title
jJ r
rl
r
i
i
•0
PUTNAM COUNTY DEPARTKENT OF HEALTH
DIVISION OF ENVIRONMENTAL'HEALTH SERVICES
Mr. and Mrs. Robert C. Mara„1ay .
Owner or Purchaser of Building
Wald Construction Co.
Building Constructed by
Big Elm Road
Location - Street
Patterson
Municipality
Single Family Residence
Building Type
?2 �2__ 2�
Section Block Lot
NA
Subdivision Name
NA
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 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 Environirental 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 . sys tern.
G
Dated this day of ��- 19 !.� Signature ru- � "4,
;7Z Title
General Co actor (Owner) - Signature
Corporaationn Nam �e�(if Corp.) / X'
2 Z, Z, ess
rev. 9/85
mk
0 VV iv E t�
L- AW701V RDAP1S (-OrvSi_
Corporation Name (if Corp.)
30X301 3C)P1
Address ) O S` 5 1
K
,,aIPLETION REPORT
6
PUTNt'%POUNTY DEPARTMENT OF HEALTH
. ,ion of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
This report is to be completed by well.driller and submitted 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
It- 11 kT n AG
ADDRESS ' & it G N
G G i3
LOCATION
OF WELL
(No. 6 Street) (Town) (Lot Number)
((�� m Fes' l}-rr 5'RSd(Lf
PROPOSED
USE OF
WELL
BUSINESS
.DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
❑ SUPPLY (._� INDUSTRIAL �❑ CONDITIONING ❑ O(Specify)
DRILLING EQUIPMENT
❑ ROTARY
� AIR PERCUSSION ❑ PERCUSSION ❑ ((SSpsEy)
CASING
DETAILS
�LENGTH (feet) t DIAMETER (Inches)
oC0 90 I� )I
WEIGHT PER FOOT
THREADED ❑ WELDED
2-ki-VE SHOE-
YES ❑ NO
W
2
$CASING QMUTED?
YES NO
YIELD
TEST
HOURS G.P.M.
❑ BAILED ❑ PUMPED )t2,,J COMPRESSED AIR 1-12 1?
YIELD (G.P.M.)
A0
WATER
LEVEL
MEASURE FROM LAND SURFACE- STATIC(Specily feet)
(
DURING YIELD TEST fleet)
a 70 (
Depth of Completed Weil
in feet below Land surface,��
SCREEN
DETAILS
MAKE
LENGTH OPEN TO AQUIFER (lent)
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED;
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (inches) FROM (teat)
TO (lest)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact locallon of well with distance$, to at least
two permanent landmarks.
FEET to FEET
�I
� r �
N 1 i
1
-
'
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
//.
C� L/
DATE WELL COMPLETED
DATE OF REPORT
WELL DRILLER (Signature)
/MD
u
'n D
4-``s MAYOR
N LEY J. ESPOSITO
IA
Klaus Weirether
RR3 Lake Shore Dr.
South Salem, NY 10590
CITY OF STAMFORD
DEPARTMENT OF HEALTH
888 WASHINGTON BOULEVARD
P.O. BOX 10152
STAMFORD. CT 06904-2152
private well water report for Big Elm Rd.
Collected by Boris Churyk from the direct from well
Test collie ted on 04/26/93 at 10 :00 :00 AM
Joseph E. Kunt , Analyst
ROBERT H. MURRAY
LABORATORY DIRECTOR
977 -4378
April 29, 1993
TEST PERFORMED -YOUR VALUES -
RECOMMENDED LIMITS
Bacteria tests
#0695 -92
Total coliforms / 100 mis 0
ANDREW D. McBRIDE, M.D., M.P.H.
non - coliform bacteria
DIRECTOR OF HEALTH AND MEDICAL ADVISOR
Fecal coliforms
977 -4399
ROBERT H. MURRAY
LABORATORY DIRECTOR
977 -4378
April 29, 1993
TEST PERFORMED -YOUR VALUES -
RECOMMENDED LIMITS
Bacteria tests
Total coliforms / 100 mis 0
less than 1
non - coliform bacteria
not applicable
Fecal coliforms
0
E. Coli
0
Total plate count
suggested less than 250
Iron bacteria (
absent
Enterococcus
0
Other observations
RESULTS REPORTED 04/29/93
Water MEETS State requirements for bacteriolo
i� cal potability
a vv�-.
X10
1
1 ?r0 G4hL,.
L1
O
t'utnam County Department of Realm
;division of Environmental Health Services
tpproved ndted for conformance. tith
• ipplicable Rules and Regulations of.the
+utnam County Health Department.
PROJECT.
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r,4"-1 'f E,:: 0 ri N Y.
CLIENT
t20071!� 1?-T 1�/.
1611 c-Nf!�rzrLY �T�T
LAURENT ENGINEERING
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
(914) 278.6108
CONSULTING SITE ENGINEERS
DRAWING TITLE
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SCALE'
DATE .
DRAWN BY
CHECKED BY
JOB No .
DRAWING'No
in
K ,J"T
iA WN
X110 -t1
4s'1
'Woo
So;
"it wh- n
i.
-n otboon
Ai A lot
110 STAIN"
to-
'Woo
So;
"it wh- n
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-n otboon
MOM RANSOM".
110 STAIN"
to-
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T
PUn4AM COLWY DEPARTMENT OF HEALTH
DIVISION OF ENVIROZI E AL HEALTH SERVICES
Mr. and Mrs. Robert C. Marauley
Owner or Purchaser of Building
Wald Construction Co.
Building Constructed by
Big Elm Road
Location — Street
Patterson
Municipality
Single Family Residence
Building Type
/1,14. I l
Section Block Lot
/`:' -/7 -9;
NA
Subdivision Name
NA
Subdivision Lot #
GUARANIEE OF SUBSURFACE SES�aGE 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 o.r,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 nne which fails to
operate for a period of two years immediately follcswing the date of approval of, the
"Certificate of Construction Compliance" for 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 occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environiriental 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.
r
Dated this day of 19 ! Signature 'w �' J 0-rrA ^&
Title
General Co actor (Owner) - Signature
Corporation Name (if Corp.)
r
ess
rev. 9/85
mk
0WiVEJ�
L- AW i 0n/ A1)AP1S 60Al -<
.Corporation Name (if Corp.)
lox30`1 3nP-I ERS,N_/
Address S`. S 1
F
DEPARTMENT OF HEALTH
fad s i m i l Givisior: of Environmental Health Services
T R A N S M I T T A L 4 Geneva Road
Bre :vse
New York 10509
Te!. (914) 278-6130 Fc (914) 278-7921
to: Nancy Smith
fax r: 278 -4865
re: .Records Retrie v al
date. 6 , d' I I '� .
paces: 1 ,including tr_is cover sheet.
BRUCE R- FOLEY
Ar"; Public H-.3!.% Di
This is to request that t^.- followL --ig records be retrieved from storage:
Record: 0u: - Box i Your Box
Circle one: _
Commercial Addition Repa r Realty Subdivisio Ind. SSDS
Other
n macow.4
Name or � ni�gin2. l Owner (tf avz. _bla .,
Street: Town 0(-,
Ta /— Year
x Map r
D?
Other identifying information:
Special Instructions:
5si1
P �I
p 1
s
yy0 , )i-
Frcm the desk of...
Kathy Graap
Account CIeek
=� P team County Heath Department
4 Geneva Road
Brewster, New York 10509
w�
914 - 27130, ex`. 153
Fax: 914 - 273.7921