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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -83 BOX 9 I 'm ' I f !7- :4, J L 16 I 1 :, I i7' DoT, il sp ■ 00775 Rev. 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Serviced, Carmel, N.Y. 10512 q Engineer Must Provide / P.C.H.D. Permit q -- -�` RTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM �� : esn n own or V e at l .GV y'. Tax Map_ Block Lot _ Owner /applicant Name Formerly Subdivision Name_ Sabdv. Lot k Melling Address Zip Date Permit leaned � r w Separate Sewerage System built by U in Consisting of �' �% Gallon and Water Supply: Public Supply From I r Address 'by 1,764 eA � ItJCJ( 61 Address � " � �+ r Al y �r: Ptiv Supply Drilled ,I T —. Tr / I B��g Type Has Erosion Control Been Completed? i✓C Number of Bedrooms Has Garbage Grinder Been Installed? ✓� Othar Rwnui►emenin I certify that the system(s) as listed serving the above premises were con aEltions, d essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and reg in acc rdanca with the filed Man and the permit issued by the Putnam County Departments Of Health. Date _ [ Certified by 7 A 011 Address license No. Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the cor►ectlon 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 sower becomes available and the approval of the private water supply shall become null and void wh pply becomes available. Such approvals are subject to modification for change w /hen, inn the Ju ent of -the Commission T tjpl revocatloq, moalnatlon or cnangs Necessary. Date. �/' L.L— BC ` / —� / Title �� D R3 PUTNAM COMM DEPARTMENVOF HEALTH DIVISION OF ENVIRONLZEMAL REALTH SERVICES Owner or Purchaser of Building Ao f A /Q' IL, Building Constructed by Location- Str t Municipality ' Bulld�n9 Type Section Block Lot 7�`(-I [ c Subclivigion Name Subdivision I t # GUARAWEE 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 sham 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 detezmination 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 9�0 day of 19_2f- Signature Ro55 iG41- 6nc,. Title bon X14 Generay ntractor (Owner) - Signature Corporation Name (if Corp.) rev. 9/85 mk �T.49 Corporation Name U: Corp.) ess I I AM C �n pG f" S- `�' WELL COMPLETION REPORT a � Office Use Only DEPARTMENT OF HEALTH Division Of Environmental Health Services Y04 PUTNAM COUNTY DEPARTMENT OF HEALTH e2 - STAEEi AOUAE55: TOWNIVILOUXICITY TAX GRID NUMBER: WELL LOCATION � � WELL OWNER NA : � ADDRESS: OjS vl � 5 (<.rv1 �, o� !2� t9S0 U.p81VATE O PUBLIC USE OF WELL 1 - primary 2 •secondary RL RESIDENTIAL ❑PUBLIC SUPPLY ❑AIR /CONO. /HEAT PUMP ❑ABANDONED ❑BUSINESS ❑FARM O TEST /OBSERVATION O OTHER (specify) C3 INDUSTRIAL ❑INSTITUTIONAL ❑STAND -BY ❑ MOUNT OF USE YIELD SOUGHT S^ gpm. /N0. PEOPLE SERVED EST. OF DAILY USAGE SUU gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ❑ADDITIONAL SUPPLY ®NEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL _a�:L ft. DATE MEASURED DRILLING EQUIPMENT ❑ROTARY 1Z COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT ❑CABLE PERCUSSION ❑OTHER (specify): WELL TYPE ❑SCREENED O OPEN END CASING tA OPEN HOLE IN BEDROCK O OTHER TOTAL LENGTH ft_ MATERIALS: OWSTEEL O PLASTIC O OTHER CASING DETAILS LENGTH BELOW GRADE SO ft. JOINTS: ❑WELDED [ZTHREAOED ❑ OTHER DIAMETER �in. SEAL: CrCEMEN7 GROUT O BENTONITE ❑OTHER WEIGHT PER FOOT -tj 1b./ft. DRIVE SHOE: [YES ❑ NO LINER:OYES k§NO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (Il) DEPTH TO SCREEN (It) DEVELOPED? FIRST o YES Arta -HOURS SECOND GRAVEL PACK OYES ❑ NO GRAVEL SIZE: DIAMETER OF PACK in, TOP DEPTH K. BOTTOM DEPTH h. WELL YIELD TEST � If detailed pumping METHOD: O PUMPED � tests were done is in- COMPRESSED AIR , ! ormation attached? O BAILED O OTHER � ❑YES C3 NO It more detailed formation descriptions or sieve analyses dY ELL LOG are available, please attach. DEPTH FROM SuafACF. water Bear- In9 well Dta' in FORMATION DESCRIPTION tonE WELL DEPTH It. TION hr.: min. DRAM /00'NN It. YIELD gpm. Su�ace {� SOS � St�S lv Sc� [qtPWL � 5 vv WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS ❑ COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? OYES ONO STORAGE TANK: TYPE CAPACITY GA>;.. PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP WELL DALLIER NAME' OAT ��e�UuCd iaw .PLC Co L,9�t lo ,c AooAESS1 P,hS vG'�SZ StGtdATUAE Ct�,6v1 � � j� `(94 -k -3 ca4 -k -3 ca4 NORTH AMERICAN � LABORATORIES, INC. CERTIFICATE OF LABORATORY ANALYSIS LAB ID NUMBER: 95 -5773 CLIENT: Ross Alan 25 Byram Lake Rd Armonk NY 10504 SAMPLING LOCATION: Sink: Lot 6, Courtney Ln, Patterson NY COLLECTED BY: R. Alan DATE COLLECTED: 09 /20/95 TIME COLLECTED: 11:35 AM DATE RECEIVED: 09 /20/95 DATE OF REPORT: 09/22/95 ANALYTE RESULT* UNITS MAX CNTMT LEVEL ** METHOD ANALYZED Total Coliform E. Coli Absent Absent Mustbe "Absent" Must be "Absent' Colilert Colilert 09 /20%95 09/20/95 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. 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 EPA codes). 618 Clock Tower Commons, Brewster, NY 10509 / 914- 278 -7600 / Fax 914- 278 -7754 i . r PUTNAM COD[ftY D!ARTME ' OF IMAL'18 1 Y, DFYw �f ISnkwMW HarM6 Sae�b�, � N Y 1i.W , w C1�1 18 11411,1110 VMS Paitall # 11 C ONSISUCTIM PElW NOD.SOWAOE DEPOSAL SYallflll Pae!k Iiocafed M 7/ Q ap! 'tea kLIA Tax bop elaak 1 vat tea. __0. o Date at Provloaa ApOmsd - 50 d viS, Fee Enc osed'® GLot Area ` Fm settle, oeb, se>•ilS 'rip• Ntwiae eI . DWp Flow G P D PCB Nod aWm k Yequbi4 When FM k oompMted Sepoeale Setteeep Sara: to ee ilt et t'1f�iwBw Sapda Twit ••a 1�e M ewr4tit bd 67 l l -� AtWeu�_- Wooer s4opbs - Brlre Sept Feep Addeeee arrPehraee Sepal Ddrkd by �aa•�•• " Olher lLq�eMeMe 1 represent':that Tam wholly and completely niponsitiN for. the design and location" of ter proposed systo.m(f); 1) that the a rab few di W s stem ebor. d' uagied will be constructed as shown oif the approved amandrnent there to and in aceordanoa with the standards, rules a rpu of County • Department I of ,'Q%*Rh. and that on eon►plotion thereat a '•Catifkate' of Construction Cornplianw satisfactory to the CommisalonM o1 MMRhwlll Oa submRted• to ter Oepejtnwnt, and a .wrHtat; Ouaranta will;" furnishod the..owner, his succopors, hews or assigns by the bulkier, that said builder will pow@ in gabd OPa►atirtg .eorlditfon any part 'oi said eaMiag� rlispoYl system during the pabA of two (_) years ImnNdletNy fallowing the date of ter Isau- afrte :of ter appoeof. of the,Certif kate of Construction Corn_iaoce .of the ,aiginat systenr,or any rooks. hereto; 2) that the drilled wail deforlbed above srMl be,l0eatti0 �s Mlois!ri on tlu,approlied,plen;anq that Yid well will tai Ins!" in "acco=Iviith ter. eta r fu sand rpu ns of the -Putnam County Depaitmarrt, of Maaltli Dab L! Stanad RE Adds 06*4 S License N 2 APPROVED FOR CONSTRUCTION: This approval expires two Vasil from.the date i unless construction of the building has been undertaken and Is revocable for ausw or maybe amended or m6ditie0 when Considered necespiy`by the Commissioner of Health. Any Charge or alteration of construction Muwes w pami Approved for dhpoaal of domfrstk saMtary Weee a o any. 10/88 Oab�C %:�C. . B Tit } DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL /00, �-� PCHD PERMIT $ WELL LOCATION S treqX Address Town Village City Tax Grid Number OU 1, WELL OWNER N e Mailing Address rivate D Public USE OF WELL (S>- primary 2- secondary 1:2 SIDENTIAL D BUSINESS D INDUSTRIAL ❑ P BL C SUPPLY O IR /COND /HEAT PUMP O ANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT _O j gpm /# PEOPLE SERVED. -�5 /EST. OF DAILY USAGE &,V gal 13 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION GI ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL REASON FOR DRILLING .DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ODUG GRAVEL. O OTHER IS WELL SITE SUBJECT TO FLOODING? YES V" NO WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_ Lot WATER WELL CONTRACTOR: Name iE7_12 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: NZA TOWN /VIL /CITY DISTANCE TO PROPERTY__FROM_.NEAREST WATER MAIN:. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED /�. ON SEPARATE SHEET (date) ignature) 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. .ndwater. - y��-f- Date of Issue: i' 19 Date of Expiration 19 57- Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 1=;1U1JC1\TA1M (_1C>TJ11T03C_y, K_> "all t-f)E 11-T 1_UEA1T_1'rX_X APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: I Av-wo V_ Name of Project: 3..-, Loca tion(pc: Q 2. 4. go 7. Project Engineer: �ALVJ2''( W. 5. Address: mi"r-agr .0T16f_:% o 4 ww'-POW0 rqAJ:;, License Number: Phone: Type of-Project: —Private/Residerftial* Food.Service .—..,...Commercial`,: Apartments Institutional M6bile Home Park Office Building:. Realty Subdivision Other (specify)-_-. Is this - project subject to State Environmental-Quali.ty -Review (SEQR)? Type Status (Check one) Type I.-. Exempt ✓ Type IL Un 1 i ste.d. 8. 1. s a Draft Envir'o'nmental Impact Statement (DEIS) req u.i red?.. ------ 9., Has DEIS .bOen completed and found acceptable by Lead Agency? /A 10. N.ame of Lead Agehcy 11. Is this•project in,an- area under the control of•local plan'ning, zoning, or other officials, ordinances? .... : ..................................... tilil .12. If so, have plans been-submitted to such.author.ities? ..................... 13. Has preliminary approva�l' beengranted by such authorities? N/A Date Granted: 14. Type of Sew*age D*isposal. Sys'tem"**Discharge ......... Water v Ground Waters Surface 15. If surface water discharge, what Is the stream class designation ?........ 01/A :6. Waters index number. (surface) ;7. Is project located near a public water supply system? .................... S. If yes, name of water supply W A Distance-&water supply .9. Is Projec"t Site near a public sewage. collection or disposal system ?..... IJa ..0. Name of sewage system Distance to sewage system A Date obse*eved: -7- Z4, 91 23. Name of Health Inspector: M Project design flow (gallons per day) ........ .............................. boo r2 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 ? ..................... ............................................. r.)�l 28. Wetland ID. Number .. ............................... oL4 29. -Is Wetland Permit required?'......... ...... ............................... _Tip Has application been made to Town or Local DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste d isposal�` landfilling, sludge app Tication or industrial activity? ......... YES or NO �,)v 32. 33. 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? ........ or NO IJQ DESCRIBE: Is there a local master plan or file with the Town or. Village? ... ......... h 34. Are comm, unity water, serer facilities planned to be developed within .15 years? UN INAOa) 35. Are any sewage disposal areas in excess. of* 15.4u* slope? ..,..._....._.,- .......:..... X10 36. Tax Hap ID Number .......................................................... . -�- 37. Approved Plans are tobe; 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 maybe 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 Nisdareanor pursuant to Section 210.45 of the Penal Law. /f n SIGNATURES & OFFICIAL TITLES: IN 1v,AILING ADDRESS:- P.1- "11,FtIAM COUNTY DEPARTKENT OF HF�LTf': DIVII ' .. l OF HEALTH SERVV. a DESIGN DATA SHEET- SUBSUFACE SBgAG'E DISPOSAL SYSTEM ... FILE NO. Owner AOOss - q4,q / Address zsQYl?414 ZA/'ER,P ^/y Iosb¢ Located at (Street) z DA to Sec. Block Lot (iridicate nearest cross street) Mnnicipaiity 1� TFf?S /t/ Watershed CRo % o Al ,OIL PERCOLA2 CN TEST DATA REQUIRED TO BE SUENiI'PrID WITH APPLSC TIC.NS Date of Pre- Soaking Date of Percolation Test HOLE NLFSBER C� TIME P-ERCOLA` CN PII2COr=CN Run Elapse Depth to Water Frcm Water Level No. Time Ground Surface In Inches Soil Rate j !G Start-Stop Min. Start Stop Drop In Min /In Drop Inches Inches inches 3 Z:So- 4 5 4 5 1 2 3 4 5 1. Tests • to be repeated at same depth until approximately equal 'soil rates are obtained.at each percolation test hole. All data to' be suhmitt�d for review. 2. Depth'rieasurements to be made fran top of hole. rev. 9/85 DEPTH G. L. . 2' 3' 4' 5' 7' 8' 9' 10' . 11' 12' 13' llh25(!i- LY. '--VN LA' bUIJ -0 uv ,» , ., _, HOLE NO. ( HOLE NO. HOLE NO. IV,, )?6 C / 01? W4 IF _ 14' INDICATE LEVEL AT WHICH GROONDNATEII IS ENMUNTERED �t /opt /F INDICATE LEVEL TO WHICH ..WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: % ?�A a, _ DESIGN Soil Rate used Min/1" Drop: S.D.-Usable Area Provided �= No of Bedroans f� Septic Tank Capacity Z S° gals. Type Absorption Area Provided. By j;_0 13 L.F. x 24" width trench ESP ri(c� . Name // V115:5�17 �itiG /� /.= E/? /i� /� 4j 3 =C. , P C_ Signature �- • � �'� Address 011 i55 SEAL M I'r TeW 10 r r No. 124 THIS SPACE MR USE BY HEALTH DEPART ONLY:. "z- ►^`' Soil Rate Approved sq.ft /gal. checked by Date 0 'c N 0 60 'G F/ = 7 „ �'E; �S� fir_ 7" I � pp `•• � .9g �O .�p�L o 1` 1 let I � �l . , , - , - - , - � - , , ` � I - � __ , -, .,�l ..l. I_ i I . :z. , -",- - i:�� , -_ , -- "" ", "', , — .9 , - - -. � .. _ - — - I - � , ,__ - , , !!�, ;-�. -I _�, � , �-- , li;i ,--, -� '. ,.;�,- - �- --_,. - �, I-, -1 � �. 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