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24. -1 -85
BOX 9
I I A I
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L - I N16 Ni-
00777
Rev. 3 86 PUTNAM COUNTY DEPARTMENT OF HEALTH U
i Divislon of Environmental Health Seeylces, Carmel, N'Y 10512
En per Mast Provide g
ilcoP CH D} Permit q
CER VCATE 00,CONSTRUCTION, COWLLANCE FOR SEWAGEMISPOSAL SYSTEM
ea'
Town oFYWag
4
Locdted Tax Map Bock Lot
Owner/ Iicpnt Nente . Formerly Subdivision NameSabdv :Lot M�_
I Mailing Addreiae LA ZIP Dste Permit Issued
Separate Sewerage System.ballt by -17 Address ..,_TAY•
Consisting of Gallon Septic Tank end G�'�yJD L•'1=:
Water Supply: Pdbllc' Supply From Address
or: V Private> Supply Droved by A'f T 2 , I ILL AdArese
gufldb2g TyPe 1 1-1 T Has Erosion. Control Been CompletedY `� 5
Number of Bedrooms Has Garbage, Grinder Been InstaUedY
Other Requirements
I certify that:.the system(i) as listed servinO,the above premises, were constructed essentially; as shovn'on' the plans of the completed work ( copies
of which fire attached);'and in accordance with the standards; rules and ;e u atione, in dccordance with e'f led p n, and the permit iaeued by the
Putnam County Department Of Health.
Oats / �G'�., / J Certified by . ` P.E. v R.A.
Address v License No.� .
Any person 'occupying premises served �Oy the above systems) shall - promptly take such action as may be necessary to secure the correction of any imunitary
conditions resulting from :: such, U,4gG. . Approval, of the, separate aewera stem shall become Pull and voltl as soon as a publ% unitary wwer becomes
9e >y
available and the approval .Of the, private water. supply shall become null and. v kt ; when a public water supply becomes available. Such approvals an
subject to mo leatiori `or Change• when; in' the: Judgment:of the m al of MealtA; such lion;: rood n'or change la riaeasafy.
Oats v - BY Title
ti
C� ,-✓�i
„
J ►�
�W Y04
WLLL k,vrir Lrji LVy 1NX!KviXt
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH A I
Office Use Only
„� z g�-4'o
WELL LOCATION
STREET AOURESS: WNI I / 1 Y TAX GRID NUMBER:
Q � A#CjzS0jj �-�
WELL OWNER
NAME: AO RESS:
"A4
PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
[RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT _ S gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE K01)
. gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY []TEST /OBSERVATION ❑ADDITIONAL SUPPLY
fTEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY KCOMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING rff/0PEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH a L_ fL
MATERIALS: eSTEEL ❑ PLASTIC ❑ OTHER
CASING
DETAILS
LENGTH BELOW GRADE_ ft.
JOINTS: O WELDED THREADED ❑ OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE OTHER
WEIGHT
PER FOOT � Ib. /ft.
DRIVE SHOE YES ❑ NO
I LINER:OYES NO
SC
DETAILS
DIAMETER (i
'SLOT SIZE
LENGTH (1t)
DEPTH TO SCR (ft)
DEVELOPED?
FIRST
S ONO
HOU
NO
r
GRAVEL PACK
S
O NO
GQAV
SIZE:
A
OF PACX in-
TOP
DEPTH ft.
BOOM
OEM It,
WELL YIELD TEST If detailed um in
I p p 9
METHOD: O PUMPED 1 tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED O OTHER ❑YES ❑ NO
�I�LL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
8ear-
ing
Well
Dia-
meter
FORMATION DESCAIFTIDN
taota
ft.
fft�.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
ft,
YIELD
gpm.
Surface
'
`
dS
/0
WATER CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME DATE
ADayRT M. HYATT & SONS, INC-r ,(3
Well Drilling y�
'Rte. 31.1 eQN RNEW YORK 2563 o '
al ov
R
321 Kear Street
f Yorktown Heights,. N.Y. 10
(914) 245 -2800
Albert H. Padovani, Direc
LAB #: 93.007845 CLIENT #: 1378 S
NpNpNMMNNNNNpMMIN NNpNpNMpNIINM %CAI IJ•.VMNNwf N wV /J pwJNNNMNNN�
ALAN. ROSS D
25 BYRA "'LAKE RD A�
ARMONK, NY 10504 R'
Pi
SAMPLING SITE:
:
COQ.' D BY: ROSS
NOTES ... :
.S.p MNw..NNNpNppMi. wl1
DATE
OLD RT 22 WATER TANK
BIG ELM SUBDIVISION
ALAN
yNpNNNNpNNIVNNIV Nw4 Nw /NNNpNNN NMNNNN.y
FLAG PROCEDURE RE
07/08/93 MF T. COLIFORM ABSENT
PROC PAGE 1
MNNwJNpNNpNNNNIV wJNNNNNNNNpNNry
/TIME TAKEN: 07/07/93 09 :11,:i
/TIME REC'0I 07/07/93 09156
RT DATE: 07/08/93
E: (914)-279-5180
SAMPLE TYPE..: POTABLE
PRESERVATIVES: NONE
TEMPERATURE..: t 4C
COLIFORM METH: MF
'ppNNNN NI. ---- ---- -- NNNN.N
NORMAL RANGE
ML ABSENT
COMMENTS:
BACT THESE RESULTS .INDICATE THAT THE WATER A (WAS NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDI HE NEW YORK E:TATE
AND'EPA FEDERAL DRINKING WATER STANDARDS. k THE PARAMETERS
TESTED. AT THE TIME OF COLLECTION.
SUBMITTED BY:---- __�..._� -----.
Albert H. Padovanis M.T.(ASCP)
Director
ELAP# 10323
PUMAM COUN'T'Y DEPARTMERr OF HEALTH
DIVISION OF ENVIRONLMENAL flEALTH SERVICES
pwn or Purchaser of Building Section Block Lot
905y
Building Constructed by
Locatio�nl - Streef \/
municipality
Alh )L u 1
Building Type
/�, Subdivi ion Nam
_ ►2
Subdivision Lot
GUARA= OF SUBSURFACE SEPtAGE 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 Departrnent of Health, and
,hereby guarantee: to the aaner, 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 systen, 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 system.
Dated this day of 19 �3
�oss Al
Geneial Con actor (Owner) - Signature
Corporation Name (if Corp.)
25- 13 i9l �
Address Al- \j/
rev. 9/85
mk
Signature a< LOI�jt,&4 &0 �6. �
Title P�v�
�1�_
Corporation Name (a Corp.)
a S- 0
Address
�. o� CONEWAPOL
V Dlflilta9 [dwY9lnanldBa9iDfanlla9.Cf.a I T 14M w O'hwW_liwti/ Pww"R IMAM
' f
i
;, .. 'yaLE'JUDUi•yJ.rilyaa- 'A'KUL Vr cu- :.- .v. -,ri -= - -.. .. ... -..._ ..:. cc c. wm.
�++rs sYi•� i n E'h1 TI t.� Aw. / ro s.tu.ay
' Iltitiae 1 �9i99r - r ' .` � ° Dulp'FMw G P D1s7 t ®NN�eill� b Mv�
v.�.._ ,
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�-
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opM9et'that 1 x111 whONy N10,COTOMbh rNponslON fp tM a9}i�n irnd btatlon ot, tM, p►OisoMd syst9nl(ys 41 that the sl at9 di YI Nh' •
NOro.RppiOaA wlll'M iji t* lttoi,si down op tho avorovod arn111iAm99t tliw410:81W ^ in iccOrOnc9 with tM stamlardt,;ruNi • ratty
pwlty: OMar1111aOt of 'HOKIN,aM that 011 eanONt1",tMno/ 4'vertifieita Of Construelbn Con101Nnw f W.ssctoiy to the C0111n11a/IOItM of. HwIthwin
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"• Ito M t ..MAN 9on/Rlon, of >fii/ niraM �igofal :syfaln.Aur" the PWW.of two (!) 1�s Nnnlwl0teew folloriny tMisto o tM Null.
hap N tM ;q/r�w1 M tMCortMleoN. of C"Anrction .ConitNNlKO' . oi1�NN1'tyrtMl o� any r thorotot i) that tlw ArKId.win "Me" 1160449
l M bwt9K tl atteww M•tIM aMrOarM men aM that as wtll wIN Instil M " t ►tK. rY1a ano rgZi� 5fns the PutMle
t'` %wMy //0�, Mt1h9h1 et IIMRR '
AMr�al V �7 //�'r t� p` ri 6 /O� icomi
,.
E.
I- AP fOR COMTRUCT10N} TkN aN►owl 9a011p twe yYr root tM �t Is111aA unNws tonitrlletfoe of, tM twiwilq lwts 09on ;unMrtaken ana U .
nMOtMN for ea11M M nNy M`ai1MI1Y/, a. niarHNA wh9n ry OY ,tM e11ssN11ar 'of MIMKIi ° Any cMnp o' iKaratloii Of eonle►uctbn
fe"Wir" • 09►iw 1011 oNroaN:M AOwNitk a M woob ontY
Title'
0
m
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 Vf 4s / V
WELL LOCATION
. Street Address /� Town Vi11a a Cit T Grid Number
QL %� 07-6 O�li i /�7�S1J � � -� �% s o�
WELL OWNER
Name Mailing Address
SUS 1j-L19R) ��5 pJ` /,�i /I�Or���'
MTrivate
0Public
7 E OF WELL
primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
E) BUSINESS O FARM O TEST /OBSERVATION
13 INDUSTRIAL M INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT b gpm/ # PEOPLE SERVED 3- S /EST. OF DAILY USAGE 0 0 gal
O_�PLACE EXISTING SUPPLY ❑TEST /OBSERVATION 16 ADDITIONAL SUPPLY
U NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
•DRILLING
C_6
WELL TYPE ,
DRILLED DDRIVEN 13DU6 GRAVEL.
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: L Z m
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 SKETCHt4 SOURCES OF CONTAMINATION PRO
(ZION SEPARATE SHEET
(70
(date) signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted ender 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 pro d by the Putnam County
Health Department.
Date of Issue: l 19
Date of Expiration: 2 19 Permit ssuing c a
'2
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Rev. 10/88 Pink Copy: Owner
Orange copy: Well Driller
pUlIMM COUNTY DEPARTMEW OF HEALTH .
DIVISIQN OF ENVIPLR4RUAL HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NJ..
Ares //� Owne RIP N•y Jo sv.
Locatea at (Street) All. Z 2 f3 1•c> ,FE'G N�1 Sec.. Block .5 ; Lot
.. ..... .. (indicate nearest cross street).
nmicipaiity PO T l k R Sa al/ Watershed Q I?o.1 -a
SOIL mqp=m TEST DATA RDQU?RID TO BE SU&fff= WITH ' APPLICATIONS . .
Date of .Pre - Soaking ' // Date of Percolation Test
HOLE . —.
2JL�'IDEft • . CTACK TIME • - .. PIPRCO CN PERCOLATION
Elapse .. Depth to Water FYom Water Level..:.....
. ::. Time Ground Surface.., In. Inches :,..:...Soil Rate
Start Stop. Min. Start . Shop Drop In MinJln Drop
�'L . Inches - inches Inches .
3
2g-'' . zsy 11 .
- Z
'/ Z 1,
4
4
.5.
Zd
1 2;2s- Z:ss
.; 30• �
Z4`
7� %s"
Q 2 2'SS- 3:Zs -.'3v
2�4 ..
251Zr
3
2g-'' . zsy 11 .
- Z
'/ Z 1,
4
4
.5.
Zd
1 2;2s- Z:ss
.; 30• �
Z4`
7� %s"
.. ��" - � l8
-LJ 2
3 ,3; 27 - 3:.57
; 30
2¢''
2S %L°
1A „ . Z o
5
P
NOTES: 1. Tests to be repeated at save depth until approximately 'egml soil rates
are obtained at each percolation test hole. All data to -be sutmittbd
for review.
2. Depth measure rents to be made from top of hale.
rev. 9/85
10 —W,47-�517 E Coll
lit.
121
131
14"
INDICATE LEVEL AT WHICH GROOM= IS
INDICATE IZM.TO WEICU WXTER LEVEL RISES AF M BEING
DEEP ROLE OBSEMMMONS MW BY:
DESIGN
Soil Rate Used Z o Min/1" Drop: S.D.. Usable Area Provided
No. of Bedrocms Septic Tank Capacity' gals. Type
Absorption Area Provided By •572 L.P. x 24". width trench
Other
Nam PC.
maress 71
�N�O
THIS SPACE MR USE BY MUSH DEPARTMEWr ONLY:
Soil Bate Approved N.ft,/gal. Checked by Date
0451
THIS SPACE MR USE BY MUSH DEPARTMEWr ONLY:
Soil Bate Approved N.ft,/gal. Checked by Date
p(MUN COUN'T'Y DEPAiMTD�ZT OF BEALTH .
DIVISION OF ENVIRORMML EiEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.,
Owner 'S f� N... Address 2 Y�/� �7 tAr,� RIP .404 o.C/1� AIX.
Located at (Street) �(�� Z Z 13 hf, f_G w� - .. sec.. �- 9 Block :. S Lot
(indicate nearest cross street) .
itunicipaii.ty F/J rl e /2 Al .So Watershed Q 6 IV
SOIL pnCMATIM TEST DATA PMOMED TO BE SUEM� W= APPI,I=CNS
_..._........_. -__ _......... _
Date of Pre - Soaking // Date of Percolation Test
HOLE .
Na�BER Q TIME - - -. PF..it00LATION . _ .... PERC OLMON
Run Elapse ... - Depth to Water Frcm ... Water Level ...:.
No. Time •, :- Ground Surface,. In, Inches :.....:Soil Rate
i� .Start Stop. Min. ..: '• Start .. ... �:. Stop Drop In . Min,/Tn Drop
(,� �'L • Inches Inches Inches .. .
4
2
20
4
4
5 .
5
NOrTFS: 1. Tests 'to be repeated: at same depth until appraacimately *equal soil rates
are obtained at each percolation test hole. All data to' be submitted
for review.
2. Depth measurements to be node frcm top of hole.
rev. 9/85
B 2 .0-11-56- 3: Z G ,. 3
20
.3 1:27- 3:s7 -311
2f�'
ZS /L°
'lz �! '. .. Z o
4
5 .
5
NOrTFS: 1. Tests 'to be repeated: at same depth until appraacimately *equal soil rates
are obtained at each percolation test hole. All data to' be submitted
for review.
2. Depth measurements to be node frcm top of hole.
rev. 9/85
DFPTH
HOLE NO_ �I
Address
SEAL
G Lt
"'
..'. .. .. . _. .
.ter .':� -�. �.e,•.y
.. .. ,. .
No• 0451��r�,��
6'
71
HOLE NO.
Si QTY 34IVZ2,
of cG R Y
91 ......: %�!Io7G /N� @ 3 %0 Mom //VG e 3'=or�
10' wATe�'q G ` o'' Wig neW �' o
ll,....
INDICATE LEVEL AT WHICH C,ROONDRAM IS ' -o 1= 7o
INDICATE LEVEL TO WHICH W= LEVEL RISES AFTER BEING & NDOUN7�ID
DEEP HOLE OBSMAWIONS MADE BY: Cl'66- 1�17C HC o c k DATE:
DESIGN
Soil Rate Used - /l - 2 0' Min/I" Drop: S.D. - Usable Area Provided Sov v
No. of Bedrocros Septic Tank Capacity /2_57.0 gals. Type c
Absorption Area Provided By -.572 L.F. x 24" width trench
Other —of N E W
_ .N A A.
Name Li�iUR it/T ,c/G /� ,Eli' /.V4
/ASS oc. , f? G. Signatur ,._1 _. ,�,Jy - , ,
Address
SEAL
N
t
P4 T 14W6 y i(! -l/ �x
/ 2 S. W, 3 \�,pR
No• 0451��r�,��
THIS SPACE FOR USE BY HEUM DEPARTM= ONLY:
—�
Soil Rate Approved
sq.ft/gal. Checked by
Date
NOTES: 1. Tests 'to be repeated at same depth until. approximately 'equal soil sates
are obtained at each percolation test hole. All data to- be suimnitted
for review.
2. Depth Reasurements to be made fran top of hole.
rev. 9185
pUjjMM CnCJM DEPARniF OF HEALTH.
M1 _
DIVISION OF HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFAC.E SEWAGE DISPOSAL SYSTEM
FILE
Owner 5f /�, :. Address Z Y /F/j p7
Located at (street) Al.;. Z Z 1.0 , f-G m..
sec.. 9... Block ..
S . Lot
(indicate nearest cross street).
0
mmcipa .ity > l-1 K l2 SJ,r�/
Watershed Q r?o 16 IV
SOIL DATA RDQU11W TO BE SU& r= W= APPLIC AMCNS ..
Date of Pre - Soaking • // Date of Percolation Test 9 1/l
. e 9
N C j= TIME
PFRC)OLATIDr1
Elaps e Depth un ... to Water Frcm
..... ...
Water Level... _:.:
.... ,.. .
No. Time :, . , Ground Surface. :...
In .Inches .......; .. ;:....Soil
Rate
� Start-Stop. Min. .:. Start .. ... .. Stop
Drop In
Min/In n/In Drop
(��: �2
Inches Inches
Inches
.Z:2¢
q
2 a:ss- 244 254-
F3
%Z', :
zo
3 3�Zr° z-57 /2
1 yZ,
Za
4
..
ri
3 3; 27 - 3: S'7 ; 30 2 �'' 2S /y°
'JZ �'.
7-0
2
3
4
5
NOTES: 1. Tests 'to be repeated at same depth until. approximately 'equal soil sates
are obtained at each percolation test hole. All data to- be suimnitted
for review.
2. Depth Reasurements to be made fran top of hole.
rev. 9185
DESCPJPTION OF 60 I i 5 k(VI UULVl1 •n rr , yy �".
DEPTH BOLE NO. 4 HOLE N0. /� HOLE NO.
G.L.. .
s Z
B'ouiti GCiA'e
L]C.
5, L. .0
6',
7,
8'
109 wATEiT c
11• ... �o�fC @- Cc� o��
12'
mo
CGA
/�'IOT7G r. /6 t 3'
V✓A T,EW
/(/,- rroe%
13'
14,.
INDICATE LEVEL AT WHICH GROMMM10M IS E= 4 -o 7-6 G ! o ''
INDICATE LEVEL To WHICH WATER LEVEL RISES AFTER BEING II�7�tJNTERID ¢ o '� jo lo'-o "
DEEP EOLE OBSERVATIONS MADE BY: C 66- *is NGo c be DATE: _ -1,016 s a(?
- DESIGN
Soil Rate Used Mp - Z o Min/1" Drop: S.D. - Usable Area Provided So v v
No. of Bedrooms `f Septic Tank Capacity /Z So gals . Type
Absorption Area Provided By 5-72 Z.F. x 24" width trench '
Other r� �pF N E W
Nam 440fFavr ••
�c/G/,(% 4 kl SS , P Si natur 4' a lAr i
Address 3 fAl%rl�G 7. SEAL
�� D�
P2 TT)6W6 v ,cam V' / z 3 ,�0p No. 0461
ES
THIS SPACE FOR USE BY BEALTH DEPAME= ONLY: �^ -
Soil Rate Approved sq.ft/gal. Checked by Date
1.. „r
114
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