HomeMy WebLinkAbout0740DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
24. -1 -17
BOX 8
An Nis me WE
Nis
NNN
N
INN ' .�� ���
IN IN
ri IN
IN 0
'.
00740
_Yom
P to �t
� ... n .' .IBS ...
I certify tliat. the sy tea(s) :as 'listed:.serving.tMImove preaiiae "s were
of which ere attached):, snd,'in accordance wiih':the itendards 'nilea a
PRtnmu Count' Do, snt Id,
'Health
Data, Ce►tifk+d
f ;Adtlress :
Any;;pason,'oecupyinp premim; awed °tiy the above ><ystem(s) sli ll;p►om
conditions resulting, from such;usape :;,approval' of tM`gparNh sower
availeble mq ,the aPO!oval of `EM D►ivafi water wooly shall become' nu
subJact to enod# tlon o► ehaiye when, in the - )udanNnt , of thp:
r
3
l By
89
�aoamslon nam �+ Wrs.�_� n:
S'15d 4,to t #'
DaPermit Issued' V-
L=,, —
aAddr0im t+ -_ _rte
I
n�T.ah as °� � :>'�tl.� • : �'lA `?� �'[�►Y�i^1
Addreee
J
Address
.i'lias Efbs brl r6nfrn7 Raan T•'.mm�1 Afi`arl9.
Been Installed? c
constructed esgenlially`ae shorn fans of the camPlaped cork (copies
nd iegiilationa;? o cold ce`vitfi` et pl", 'and the permit °issued' -by the
.P.E. A.A.'
G LlosnM _No.
Dtly taka such atKbn as may"necussar o Meu►e the eo►nctlon of any unanitary
aDe,system?ihall Meome null and vokl as.aoon;as a oubv:.ImnRaiy mew.m becomes
and void when s vratdi supply beconNs available.. Such spy ovalr. we
Hilo
of_;M Ith, rwocatbn; Ifkatbn oR d�an4e Is neeaesary
r
Tltk+
CERTIFICATE OF LABORATORY ANALYSIS
LAB ID NUMBER: 95 -6928
CLIENT: Key Realty
93 Gleneida Ave
Carmel NY 10512
SAMPLING LOCATION
COLLECTED BY:
DATE COLLECTED:
DATE RECEIVED:
DATE OF REPORT:
Kitchen tap: Lot 7, Country Hill Rd, Patterson NY
R. McGlasson
11/08/95 TIME COLLECTED: 10:00 AM
11/08/95
11/10/95
ANALYTE
RESULT* UNITS
MAX CNTMT LEVEL **
METHOD
ANALYZED
Total Coliform
Absent
Must be "Absent"
SM18(9223)
11/08/95
E. Coh
Absent
Must be "Absent"
SM18(9223)
11/08/95
This sample, as submitted-to- the --laboratory, and as compared to the New York State limits"-for- -drinking
water quality for the tests performed, was:
ACCEPTABLE. NOT ACCEPTABLE.
Laboratory d� 4
�� •
NYS ELAP #11218
CT Lab Approval #PH -0171
*Underlined results are unacceptable according to health department and /or US EPA codes.
** Maximum Contaminant Level (maximum permissible concentration allowed by health department and /or US E13A codes).
618 Clock Tower Commons, Brewster, NY 10509 / 914- 278 -7600 / Fax 914 - 278 -7754
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or Purc haser of Bu' ding Section Blo6k Lot
Moo
o
Building Type
C.'►
Subdivision
v7
Subdivision tot #
GUARMM 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 .. Construction Compliance" for the sewage..disposa1. 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 bukIdimg utilizing
the system.
Dated this day of 19 Signaturej�'
Title v f.
General Contractor (Owner) - Signature
Co ra ion N (if Co .)
Corporation Name ( if Corp.) C� �— /�lu'�� f %1 5.
Address
rev. 9/85
mk
a
. r
WELT, COMPLETION REPORT Office Us—e0—n. lti -
DEPARTMENT OF T?EALTH / q
Division Of Environmental Health Services
x,11_...._ .. ...
PUTNAM COUNTY DEPARTMENT OF HEALTH
- -- -- Sj�iEci A UHESS: N v U TAX GAO N /UhISE,2: +
...:ICs. T 1rJlj
aooA - -
IF !�Ll. R SIDEiv'T1AL ❑PUBLIC SUPPLY ❑ AIR /COUD. /HEAT PUMP -
❑ ABANDO1' ED
❑ BUSINESS 0 FARM ❑ TEST/OBSERVATION ❑ OTHER (spec.fYl
...�', a -Y ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
i If USE YIELD SOUGHT __S__ gpm. /N0. PEOPLE SERVED �I tJi. OF DAILY U„AGc� - _..._.
-
FOR NEW SUP FLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST IOBS°RVAT!0G t
1Nc 0 REFLAC'c EXISTING SUPPLY C3 DEEPEN EXISTING WELL
(A WELL DEPTH ft. STATIC WATER LEVEL t� _ft- DATE MEASURED
C! ROTARY 161 COMPRESSED AIR PERCUSSION C1 DUG
I-- WEL L POINT ❑CABLE PERCUSSION ❑ OTHER (specify):
C3 SCREENED ❑ OPEN END CASINu ,OPEN HOLE IN BEDROCK ❑ OTHt R
... , A I. o
-TOTAL LENGTH i H r6 � #L MATERIALS: "STEEL ❑ PLASTIC r 10TH".'::
r:::
_LE:NGTH .EELOW GRADE — ft. JOINTS: ELDED ❑ THREADED �J !-T t i!
01AMEfE t __ 91 in. SEAL:q2EMENT GROUT ❑ BENTONITE
- WEIGHT PER FOOT ._ 1Z lb. /It. DRIVE SHOE ES ❑ NO LINER: [.1 YEE:
01AME FER (in)_ _ K nT SIZE I LENGTH (ft) DEPTH TO SCREEN (it) _ DE E'L0 ?EO"
!� YES 0
...._._. --
DIAMETER ...�,� EC3TG111 .__....._..
OF PACX in. DEPTH —_!t DE;'C..K _.._
ri'A..�.. it more detailed formation descriptions or sieve anaryse:
WELL LOG are available. please attach.
DEPTH FROM water well
SURFACE _ ear. Dia- FOR ATION DESCRIPTION . .
u g In Inglar
i
Slrlzce
GRAVEL
D 0 SIZ_.
.!I—'Al T ST I It detailed pumping
(.1 i.UMF -0 i tests were done is in-
"�;:=i AIR ; formation attached?
-i' r] OTHER C] YES 0 NO
DURPJIO,V DRAMOtYtt YIELD ~'
• hr. nin. !t. 9Cm•
STORAGE TANK: TYPE P
CAPACITY GAL.
wEL.DA 9MM -) WELLDRILLING INC. + ��
AOOFESS ��U V1�Clare Hill Road SIGIIXM
�_
TEMP.
HARDNESS _- -__ ---
"T OR1O
A,%,LYZE0? ❑ YES 0 N
PSIS ATTACF:ED? 0 YES ONO
;11ATION
CAPACITY
DEPTH �. _..._
STORAGE TANK: TYPE P
CAPACITY GAL.
wEL.DA 9MM -) WELLDRILLING INC. + ��
AOOFESS ��U V1�Clare Hill Road SIGIIXM
�_
pa g Stibdivisldn =A
[a 'A
6edv Floir I
G JD
510"ll, Splivellbb sy0kinig to commofte, of IM.Sam Spd, T.0 mWL-'
:Te
wow SW67. 0.611i Sw* ;F,*4&
oil
-T,
0disirm-gWe 0 b VS U4
ijeoreserit that am wholly 'co 1-
'abovi.describ4d Will 't ad simmiWo-n t6 �ppr' Ain�mentthere-to and in ac
Owfity 'DePari"i Of "Mitill' oi-constrw
, corn"",�
11». "Mitted to lift's DePartmentj'- ands .'*rItten #Ajarantwrw.be'.iurni 'i-the o'".1
In , vioi-. 6inciftWn sv*alp_.,oispool *spjie iluring.the I
l
W64 located A ontiti46P;roved Wand, hot jaid'.iWell,will di Instal led cco
60uniV
Date S
'Addials
Cr.2A u iii
go
i URN , 3F ; W'r*u5l-" 4-m"
rouloner of,14401thwill
'. thatibid Aijilder will
10 the date of the lau-
s wall desoriiied . '.-
Inl Of 'Ithe' PUtner"
.p . E.. mA.
APPROVED FOR 'CONSTRUCTION :T6 s', I XP "t"Ye!s f!om,tp
unNU coristiuct of: th buill!n; M, bon'ncwt'ken ana Is
revocable for cg4se or mavii rnir� Ified'vefien considered nooiiiiioy missionsi:41! Malik AAy' chanipe or alteration, of construction
. — __a_ � or , modified Py, the��
reaukes I POW permit. 'A for-di* Sol of Jldorniii ic lunittr only.
WPVW
Date Title :f>
`10 88 By
.1101117.1111 couiqr a
0ilCZnUFfCA2t0FC0NMUQ4C19
$MAIN -DiVIDISAL,
Tol"
"Note
2,
p
hie
Da W of Pmvbui A
pa g Stibdivisldn =A
[a 'A
6edv Floir I
G JD
510"ll, Splivellbb sy0kinig to commofte, of IM.Sam Spd, T.0 mWL-'
:Te
wow SW67. 0.611i Sw* ;F,*4&
oil
-T,
0disirm-gWe 0 b VS U4
ijeoreserit that am wholly 'co 1-
'abovi.describ4d Will 't ad simmiWo-n t6 �ppr' Ain�mentthere-to and in ac
Owfity 'DePari"i Of "Mitill' oi-constrw
, corn"",�
11». "Mitted to lift's DePartmentj'- ands .'*rItten #Ajarantwrw.be'.iurni 'i-the o'".1
In , vioi-. 6inciftWn sv*alp_.,oispool *spjie iluring.the I
l
W64 located A ontiti46P;roved Wand, hot jaid'.iWell,will di Instal led cco
60uniV
Date S
'Addials
Cr.2A u iii
go
i URN , 3F ; W'r*u5l-" 4-m"
rouloner of,14401thwill
'. thatibid Aijilder will
10 the date of the lau-
s wall desoriiied . '.-
Inl Of 'Ithe' PUtner"
.p . E.. mA.
APPROVED FOR 'CONSTRUCTION :T6 s', I XP "t"Ye!s f!om,tp
unNU coristiuct of: th buill!n; M, bon'ncwt'ken ana Is
revocable for cg4se or mavii rnir� Ified'vefien considered nooiiiiioy missionsi:41! Malik AAy' chanipe or alteration, of construction
. — __a_ � or , modified Py, the��
reaukes I POW permit. 'A for-di* Sol of Jldorniii ic lunittr only.
WPVW
Date Title :f>
`10 88 By
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New-York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL /�
P C H D PERMIT i/ — /, %C
WELL LOCATION
Street r
s Tqt% Village City Tax Grid Number
I�a Z
WELL OWNER
am
il' M&P-JA Addres
W'
rivate
O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY
D ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
/�,,
YIELD SOUGHT �� gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGEA&6 .Sal
E3 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 12. ADDITIONAL SUPPLY
AMW SUPPLY NEW DWELLING1 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
ODRILLED
DRIVEN
ODUG
GRAVEL
O
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ENO
IF WELL IS LOCATED 7N A REALTY SUBDIVISION, NAME OF SUBDIVISION:
► L� ,�4�S Lot No. �
WATER WELL CONTRACTOR: Name 44 r4hi_jn..*ts' Address: La4L4aAe jje,_rjfi ij9'^ ;
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES
NO
NAME OF PUBLIC WATER SUPPLY: %4— TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
- I - 1Nr1� _
LOCATION SKETq1rN H & �URCES OF CONTAMINATION
SEPARATE SHEET
(date)
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 contamina dace or groundwater.
Date of Issue: 'A 19� —'
Date of Expir ion 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
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(91'4) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCAn
PF.RMTT AX 117-RA
WELL LOCATION
Street Address
CoutiTR ILL RO p,
To Village City
P TE so
Tax Grid Number
2- -1-17
WELL OWNER
Name
7- PL -ZA
Mailing
i5A LT
Address
®Private
O Public
SE OF WELL
primary
2- secondary
® RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION ❑ OTHER (specify,
U INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT
5 gpm /#
PEOPLE SERVED 8 /EST.
OF DAILY USAGE al
REASON FOR
DRILLING
❑ REPLACE EXISTING SUPPLY
IN NEW SUPPLY NEW DWELLING
❑ TEST /OBSERVATION
13 DEEPEN EXISTING WELL
13 ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
AIL=W 000SE
WELL TYPE
®DRILLED
DRIVEN
ODUG
0 GRAVEL.
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES �_NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: COUNT12Y HILL EnTATE-5
Lot No. —' T
WATER WELL CONTRACTOR: Name T, Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION ETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(da e) (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.
2.
3.
Pump the well until the water is clear.
Disinfect the well in accordance with the
Department attached to this permit.
requirements of the Putnam County Health
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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: /� �/ 19� �.
.9f L--
Date of Expiration 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
i of mmnliwAu
n of, t14 Now
sw6ei.d6wol
' .... -. .. �. ..-.. r. :... .., w.. _ ........nc..,.w.. �.�y. �..r a>..:: t "a ., r.�av ;,; -.... .., n �,#:c .W.......,, ,. ... -r ., ... -• ';�)�:. � ?-:^�"w...a.gy :..p; ✓.+�... 0' -'=7
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
o Village City Tax Grid Number M
WELL OWNER
N
A
Mail' Address
_ D,-DOX
®.P'tivate
( 5 e— �,� �� 0 Public
USE OF WELL
primary
Y- secondary
M- IfESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY
0 FARM
M INSTITUTIONAL
❑ AIR /COND /HEAT PUMP 0 ABANDONED
0 TEST /OBSERVATION 0 OTHER (specify
0 STAND -BY O
AMOUNT OF USE
YIELD SOUGHT 43;-_gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE 6007 Sal
13 REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION Q ADDITIONAL SUPPLY
a-KEW S PLY N DWELLING 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
'DETAILED
REASON FOR
DRILLING
C
WELL TYPE
DDRILLED
ODRIVEN
ODUG OGRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
o
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name _lCi Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1/' NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:,
LOCATION SKETCHH & &SOURCES OF
Lld�� SEPARATE
(date)
CONTAMINATION PROVIDED
SHEET
signitu
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
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
During all well drilling operations, the applicant
any and all water or waste products from such well
property and in such a manner as not to degrade or
Date of Issue 7C 19
Date of Expiration 19
Permit is Non - Transferrable
3/89
shall take appropriate action to assure that
drilling operations be contained on this
otherwise contaminate surface or groundwater.
Permit Issuing Official
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
wtiter rrbaa 31111111 .rtes
on >L ate Sowb: DdBsd: by
r
OIMc d
1 ripresenhtMt 1 am wholly and compNttly retpoelslblt for,tM dttgn and location of tha proposal •yst�m(s) 1) 'that the separate saw di sil steal
abovi.descrOW will be.constructed is shown onahi avprovau amaridment the[i to end in accordance with thwstalidaids; rules ano paquial na o nam
w''au MI
oGce in.,
M1Ci_Of 1
wxt f» to
COUMY l;
DOW
revocable to
nauN
Rev.
10/88 °ate
iKh
Address
FOR-'CONSTRUCT
.Cause of maybe al
1w ptrmit. po!o
in
Istmcilorl.Complianp" fatisfactory,to tAa CommiplonN Ot MwKAwill
lar ,his tucaaiort;�_MNS or "iffi,ns,ey the buiWar,3Mt _sill buUger will
the p• be of two (2) : 1mmaliatNy following thidate•of the isau-
systeni' o► a fipiif ' it ) that the drilhid' welt disl ribid above
w tM s<
IS uN; 'and, ray4latlo" ; of • the Putnam
px. Qw RA. -
l.icinfe
wed "unliss cojjsti6ction� of tiie Building has Oasn'undertaken and is
ornmiisioner. oit.kiiith. `Any change or alteration of construction
;p iva., water.• supply Only. •
Titer �'
�faee: �h.lo�d :NMMk»! nAur
.tyt njM eo"Olsn any girt ot Ny'tMdata M,tM NwN !
o.a o1 tt »' aMfeaayl of tM CartMkito M CoriRnrctbia Can0lMnp o1 .tM ay 1 ty am, or taey.raM t 2)•taat tM d►Nla wall Naatrtltad sfoao
`wdl M loaataal'as,alwr -em too sMrooM 96 am that takl.wN1 wI11 fN Instal w tnai' r Ms'in0 r »ins of the hAMIn
COwty W/ortnlim of, WORK
P.C. '/✓ Qltr►. —
Address. N,
APPROVED FOR COMTIMUCTlomi This approval aspires live s ro n M eats ;ISSwd ,unless eonftructgn .of, the bulldif* has ban uneataken and U
rwreaiMq /a WrM a fray N aelanMd or rnodMtad whan'eo y ey tfN Isfi011a1 "`of HURIL, Any Chan* or. a tqn of construction
wNiMM a new It. fapl Olaroaat subOb Doty
.W Oo�nAk a •; �f j� �✓
Rev ..
Q p!a
TitN
u
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0.310
APPLICATION TO CONSTRUCT A WATER WELL n
PCHD PERMIT #
WELL LOCATION
Street Address Town/Village/City Tax ' Grid Number
C.011r'-E aNw go, . P PrfTe2s--w-) Nov 24-1-1-7 014
WELL OWNER
Name
52 1,A -4A
Mailing Address
L;-ry PI►sr,, aej�- b2. f.n 2 ►GA'fow AA
Wrivate
13 Public
USE OF WELL
1- primary
2- secondary
V11RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
b INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT 5 Rpm /# PEOPLE SERVED B /EST. OF DAILY USAGE &O0 gal
E3 REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY
VNEW SUPPLY NEW DWELLING) 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
N V �-bu5f
WELL TYPE
DRILLED
ODRIVEN
EIDUG OGRAVEL
O
OTHER
IS WELL SITE SUBJE& TO FLOODING? YES _ Y NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: CA yATZ q I- wk, 5S_T_ CS
n Lot.No.
WATER WELL CONTRACTOR: Name �j�• Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES No
7X
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH` SOURCES OF CONTAMINATION PROVIDED
pt1ON 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
thirt3� (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 drill operations be contained on this
property and in such a manner as not to degrade or oth wi con tami a e surface or groundwater.
Date of Issue: 19�
Date of Expiration 6 19_ Pe it Issuing Official
Permit is Non- Transferr ble White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
rT- „1 ,�. ""'"y_ -J'; � i4f*"'_'r'.'.'.L: r'"� �•�".�^*z"7'+.'1'^^ �".' �K� `'.�.p` �_"^._... -` '�•- -1 -'.' f.. f '.Y'. .1
t•. �� FQflIA#[ COQlfI'Y DOlA!lf�t.OF �AC� ,` `G -' b Paarv93eltiatult B
\qj\ Oleld� e[ �tAet>•��ta1 BnY�'&nkee.'�1tsa1. !LY GOBI?
es C�BO�ICAfli iDD? COBOPLIAl�B
FOB[
F='WWA= ONVOUL fldlM
Gr
Rivkka
oaiiriA/io.a lln r 41,
n. ar` �.. ,1 9
Date g���d{��ision 'An' nioved " Fee .Enclosed o ..Amn„r;t
••r+�s Ski rn i-t � , 6t Arm- f � 'FS sum, o b DVA vab
Ntaeiry
Flow G P'• D� F( ATNOleilla� m d Wba. Fm la om
pet
Sw►aa�p S�iM� w on" ti[ .Stplk hi
-110
w ee.�Y.aN+ y R Aalur;.e
wa.r swan F,liie 8�lb''F,
1 n>Dnsent':that 1 am wholly.- eompbte ►etpon N'foi tM deiiyn ane button of ,t" pr000 system(Ui 1) that tna ra' trots aew ' di fal ' 'ttNn
aboire OMe+i0e0 will
be construct40 as snown,on tM,aOp!" an+eiWment theri to ana :in accordance with the standards, rules a reyu ns o ; the putnal"
County 'Opartment o1 ° MMRh, aro that'on- eomPletjon th"Of a ?�Certific ti "of Construetloe'CorriPlianei" satisfactory to the Commipbner of HUM" Will
M suernitte0 to ;tM fNpMtmmt ;and - a wr.Itt" livarantee witGbfe fUrniYi O tM_owM►, his ricaaois, MNS a:aoi0ns t►Y the tfuiida, that 'said OuiWe► will
PMCP'U goon opratih/ eondpbn any Part o1,•YW sawaiiN dis0oY1 syR.m Ourup tM,pwiod of
two (21 year, hiitnwatehr followln0 tM,d.te of the {ttu-
Mice of tM_;aPparat of the CMtNkate of Construction Compll'ina of'the oritinal system or any ''r trmatoi 2) that the drilled WWI dUcriMd,a6ovo
'am" on the aPYrowd'Wan 11"'that Yid well will tN InstalNA in ra rda a. wit r4 Ns 'and se7q lOns of to i Putnam
COtiMy rtmelit' of fNatth: :.
OaN Sil'ad P.E. __ RA.
Haar T License NO
APPROVED . OR CONSTRUCTION: TnN I,exPMN two yeah from the date •ifsue0 unless construction f tM pui101iq .naa tioen undertaken and is
row6aele fa cause a ;may e6 amendwd or modified when` "considered n.e.w►y Oy the Comnrissiomr 'of_►foatth: Any -'change or alteration of construction
F"UNea a ' Permit OIKOV� fp .di 1 of domedk unitary sewa�e and ►i N wvatteerywpPlY only. -
'1 88
i
m
.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO.COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # ft _?6
WELL LOCATION
Street Addr ss
To Village City Tax Grid Number
hV
Name
Maili g Address
04"rivate
WELL OWNER
� "" _2
> > i 9J, 7
Alt Public
USE OF WELL
G RESIDENTIAL
❑ PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP
6ABANDONED
1 - primary
0 BUSINESS
0 FARM 0 TEST /OBSERVATION
0 OTHER (specify,
2- secondary
0 INDUSTRIAL
b INSTITUTIONAL 0 STAND -BY
0
AMOUNT OF USE
YIELD SOUGHT
S� gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 6100, gal
REASON FOR
SUPPLY
0 PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION
DRILLING
❑REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
DETAILED
MW
Hoig,&-
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DRIVEN ®DUG
®GRAVEL
®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:, (! e)L/n ml /Ah / Z5P,* 5 _
Lot No.�
WATER WELL CONTRACTOR: Name, Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED /
[]ON REAR OF THIS APPLICATION �ON S
7
(d to (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 s.hall: ,
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.
Date of Issue: _ c� � 19 '
Date of Expiration: 19 Permit Issuing Official
White
Permit is Non - Transferrable copy: H. D. File
Yellow Buildin In tAr
2/87
ooPY• g -k--
Pink Copy: Owner
Orange copy: Well Driller
1� PUTNAM COUNTY DEPABTIYIENT OF HEALTH
Dlviebn of Ste_ vkeo Cilemel N Y 4062 CE>:17�F[�CATEtI► Pao �Pe�mit iY
F.nM COUNTY ''He'dth
on O LLINCE
CONSTBUCiiO PERMIT FOR SEWAGE DISPOSAL SYSTEM Permk `�
, �•
Locatett at /
ewn e a �y
Sabdlvlobn Nam / abd. `Lot iY / Ta: Map /, J Bloch
/ Beftewal Q)' B�eyvlelon�❑
`I' owner /Applkant Nome /%�Q %71� �d Qf� 7•� 8 /.O �'
Date o[ Previous Apptro
M�Wng Add.
Building 'ly, Lot Aeea `9 f7G FIII Sectlon d
O r Depth Volume
Number of Bedrooms ` Design Flow G P D D e PCHD.NoHBcadoi s Begtilred Wben Flit Is completed
J
Se Sew " e S tem to oensist of GoDon Totlt,an
Jr
Address
To be oonatt 116W b
Woter Sioply 0,60 , ly Supp From Address
r
on -Prl ate Sltppir DOW by Addreoe
Otbei BeOu iemente
I'reDresent that 1 am` wholly and completely responsible foYthe desiyn`andllocation ot. he} D!oPOSed sy tem(s): ;1)'` that the separate' sewage disposals stem
above desCiibetl will be constructed asshown,on the approved amendment there to and in accordance with he standards; rules an regulations o 0 u nom
County Department -of Health, ;and'thston completion thereof s 'Cart ii�cste_ of construct on "ca" satfifactory to the Commissfoner,of :Health will
be submitted to t1ie.Department :.and 'a, written .iuirantee will �be,.fu►croshed, the owner his,wccessws,:lroirs or aiigns by the builder, that said buildei will
ptacai,in-good operating condition any. part of ,said sewage disposal systsm:during�ihe peiiod,of two (2j'ysar madiafely foltowing tliedite of.tha,issu-
ance' of.the; appioval of .the.: Certificate.. of- Construct,on'.COrrtpliance of the ,orginil, system or any ' pairs,th 0 t 2) that the drilled well, described above
will be located as shawnbn the app►oved,plsn.and that said well will De "Installetl "in cc a • with e'stan tl rubs and regu a ons .ot the 'Putnam
County eWrtmsnt`ot- Health
Oats,e
A'defress - Lleense No
O
APPROVED FOR .CONSTRUCTION This app gval expkr two ears ?from '!,*-date issued unt6si construction of the building has been. undertaken 'and is
revocable for "cause ormay'be amend' tl or modified wh6n` considered necessary` by the-Commissioner.of'Heilth.,' Any change or sitarattfon Of construction
requires,a new pe mil. ADPCr�oved for disposat:of domestic ssnitaiy sewage; ante.w pplonly..
/181 Date `j� /'X 8Y Title —`
C cry/• p��
y /_—
ti
H.
,7 - --
2V. 386 Dlvlslon of Enviro nmental.
s PbTNAM COUNTY DEPARTMENT OF HEALTH
ILealth Services. Carmel.-N., Y.1051 ?' . Engineer to Provide Permit #
on CERTIFICATE. OF COMPLIANCE e O
\ ONSTRUCTION,PERMIT FOR SEWAGE DISPOSAT "SYSTEM,
Permit #
at t�Uw�'TiZ.0 FNI_1� Town or Village
'Subdivision Nam r^u- �T Sabd: Lot # ' Taz map., _ 1 Block 4n Lot S'
Owner /Applicant Name �1 &4,g A.P�I of Previous PP
Renewal_ Revlsion ❑
Date A roval
Mating Address �TZ Z V5`y)C ?)-1: --� — " . Town
Building Type' \<�.1 t-7�ti�'f �t A..t -- Lot Area at � " v `� Fill Section' 0nly Depth Volume
Number of Bedrooms Design Flow'G /P /D :CJ
PCHD Notification is Required When Fill is completed
Separate Sewerage System to consist of���"Gallon Septic Tank and ..
l-A N T P bl
To be constricted bym r ' Address
Water Supply: Public Supply From Address
of i i Private Supply :DrlIled by l r Address
Other Itequlrements
I represent tnatI am wholly and`completely` responsible for the design arld location of t e proposed system(s); 1) that the. separate sewage disposal system
above described will,be construct. as shown on the approved Amentlment there to.and in accordance with the stantlards; rules an regulations o e Putnam
County Oepprtmenf 'of .Health, ;and that on completion. thereof a .'Certificate of Construction Compliance" satisfactory to the Commissioner of Health will
be submitted to the Department „and.a wntten guarantee wil l be, furnished. the owner, his successors, heirsor assigns•by the builder,'that said builder will
place an good operating condition any',part,of,'said sewage disposal. system during the period of. two (2) years immediately following thgdatq of the.issu-
ance cof the approval of the Certificate of,” Construction Compliance of the 'original system or any repairs'thereto; 2) at the Grilled well described above
will be located as shown on the appioved plan and that Said well will be installed in accordance w' n the andards r and u a ons of the Putnam
County Departmnt e of Health....
Date / Signed „ \✓ P.E.-11 ,R.A. -
_y Address %C _ License No
APPROVED FOR CON_ TRUCTJ,ON Th�s'approval•expves -one yiaifrorri ate ad unless nstruction of a building has been undertaken and is
revocable for cause,or ay be ended or modifi 'when considered necessar i e Corrimiss' er of Heal h. change or alteration of .construction
requires a ne er for disposal of domestic sanitary sew /or piivate s 1 n
Date BY it Title
C"
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..
Owner Address JZ -7_Z. .L�
Located at ( Street k Block z- Lot 6%:1
n nearest cross street)
Municipality ��T-;� �„� Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME
1,
PERCOLATION
PERCOLATION
Run
No.
"'Start -Stop
Elapse
Time
Min.
Depth o a e� r ` water Level
From Ground Surface in Inches
Start Stop Drop in
Inches Inches` Inches
Soil Rate
Min. /in drop
17U) 3,(g
2 d S'n .
17� 0
l 20
T
.3...0 5c)
2-0 73
�O
5
.4
5
1
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 from top of hole.
TEST PIT DATA REQUIRED TO BE.SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. I HOLE NO. HOLE NO.
G.L.
6+t r c
12"
18". , I
24 " Y
301
361 co
48" 4 '
5►i I( p
.6011
M
6611
721.►
7811
.8411
d.
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERIP
TESTS MADE BY Dater 6
DESIGN
Soil Rate Used j l- �SMin/l "Drop: S.D. Usable Area Provided cg ze -5-pop q1
No. of Bedrooms 4- Septic Tank Capacity J Zeo Gals.
Absorption Area Pry By �L.F.xNll cif i
i 90 .
�u �► � A P di0� h �e 7
hC I�V �6 _
Name Si Rnat ure K 1Z77hw , a
Address SEAL.
p o
THIS SPACE FOR USE BY HEALTH DEPARTMT ONLY: "FFSS�o�
Soil Rate Approved Sq. Ft /Gal. Checked by Date
bivision Of Environmental Huh Services
TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225-3641
APPLICATION TO CONSTRUCT A WATER WELL
y�9 g6
WELL TYPE DRILLED DRIVEN E] DUG E] GRAVEL F-1 OTHER
IS WELL SITE SUBJECT TO FLOODING? _ YES �/ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:Gd�,� r
LOT NO.: -t
WATER WELL CONTRACTOR: Name Address:
IS ,PUBLIC WATER SUPPLY AVAILABLE TO SITE: _ YES
NAME OF PUBLIC -WATER SUPPLY:
NO
TOWNI /V /C
DISTANCE-TO PROPERTY FROM NEAREST WATER• -MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION. —
(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 (30Y
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 f m ovi d by
the Putnam C un y Heal t partment.
Date of Issue: 1
Perptt Issuing 03ffici 1
Permit is Non - Transferrable
L A jj,
IUWNiV1LLAGE /C11Y IAX GRiU NUh16ER,
WELL LOCATION
WELL OWNER
NAME. •
AOORESS:
t3'PgIVATC
13U6x — %Q
�. Z2_ e,�
_ � z .`
O PUBLIC!
USE OF WELL
PRESIDENTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP
❑ ABANDONED
1 - primary
❑ BUSINESS
❑ _FARM ❑ TEST /OBSERVATION
❑ OTHER (specify)
2 - secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL O STAND -BY
Cl
AMOUNT OF USE
YIELD SOUGHT
5 gpm. /N0. PEOPLE SERVED 8 / EST.
OF DAILY USAGE •( 20 gal.
REASON FOR
C"NEW SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY
❑ TEST /OBSERVATION
O,RILLING
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE DRILLED DRIVEN E] DUG E] GRAVEL F-1 OTHER
IS WELL SITE SUBJECT TO FLOODING? _ YES �/ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:Gd�,� r
LOT NO.: -t
WATER WELL CONTRACTOR: Name Address:
IS ,PUBLIC WATER SUPPLY AVAILABLE TO SITE: _ YES
NAME OF PUBLIC -WATER SUPPLY:
NO
TOWNI /V /C
DISTANCE-TO PROPERTY FROM NEAREST WATER• -MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION. —
(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 (30Y
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 f m ovi d by
the Putnam C un y Heal t partment.
Date of Issue: 1
Perptt Issuing 03ffici 1
Permit is Non - Transferrable
Putnam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE C14NER APPLICATION
FOR PERMIT APPLICATION '.SUBMITTED TO
PUTX*1 COLINTY HEALTH DEPARTMENT
TO: Commissioner of Health In the !natter'of application for
r
dpn-uquctLoiL ,permit for separate sewage system — — — — — —
I. Jerry
,Weissman, V. Pres.— — — — --- — — — — — — — represent
that I affi an officer or employee of the corporation a . nd,am authorized
to act for
..(n a me 0.7. j 6'r pziation)
having offices at Rt. 22, P.O,,Box 377,
Brewster, N.Y..10509'
Whose -offic'er's'are-
- — — — — — — — — — — — — — — — — - -- --
..President Robert Fr`g2.s�.
Trcvme En-N XdUr,7e's!')
Jerry Weissman
Vice- President
-- — — — — — CNa7me7 and Address]
Secretary
(iZW and Xd—dr7e-s7)— 7- _7
-Treasurer
(Name and Address)
...and that I am and will be individually responsible -5. y or.all acts
0
of the corporation with respect ,to the approv fe s and ..al. ..G b
.cequent acts relating thereto.
r",
Sworn to before me this day S* ed
of 19 Title
otary
I
ha R V'Ll' 11 8'. BA ?,R .
NOW') PLII)i10. StAte (A New Yoxh
Seal
44
1
PUIMM COUNTY DEPARTMENT OF HEAL - DIVISION OF ENVIRONMENTAL HEALTH ERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEKkGE DISPOSAL SYSTEMS
(Name of Owner)
cagmm
REVIEW SHEET - CONSTRUCTION PERMIT
DATE REVIEWED: 1
BY:
(Street Location)
YESJ NO DOCUMENTS
Permit Application%s
Corporate Resolution ! GJ
✓ Plans - Three sets
Engineers Authorization P-V7
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
Jf PWS - Letter
Variance Request
REQUIRED DETAILS ON PLANS
Sewage System Plan
Swage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions.- Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
Expansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
-Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
lZU"ge Setback Necessary (Tight lot)
Reuse Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100" to Stream, Watercourse, Lake (inc. expan)
15' to Drains urtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' fran Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
LOCATIONS IN5TAL-.t-ED
-"":
TH15 15 TO
CON5TRUCTI
5157 EM
Ttt gtfi5�
VT r