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;Owner /applicant <Ni
MaWng;Addie"' -,'
'SeparaterSewetage
- ConeleHni
i a }r
Watei.sg4 3'=-
Bioding ' pe
' :Nt�mbei._of Bedroo
Other Reyairemetal
'I certi'fy� that tfie
'oP'wh ch are:ett &c
dI,Fatnam- County
Oats
Any person oecuDY
• 20nditions issuftinq
avaiblable ao ".n ind;,the_al
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Lleina No. =LCa
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106M
-
PUTNAM COLUN DEPARTMENT OF HEALTH
DIVISION OF .ENVIRONMENTAL HEALTH SERVICE-9
� t r- aoLAr---7
Owner or Purchaser of Building
BuildlIiiIng Constructed by
Location - Street
te 3 :3.2
Seet449R- Block Lot
T M
Subdivision Name
Municipality Subdivision Lot #
Building Type
GUARAN= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
wor)ananship, 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
- "Cerl- ficate- --,-f-- Constrtic },ion - _Compliance" for the swage 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 system. - -
Dated this day of 199
General Contrac or (Owner) - Eignature
ocou
Corporation Name (if Corp.)
0A. &y 961,
VU
Address
rev. 9/85
mk
Title cxkj A-)
�7C
Corporation Name (if Corp.)
1, 0. f"/ 96Z C� �'•
.Address
Yorktowri Medical, Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245 -2800
-- Director: Albert H. Padovani M. T. (ASCP)
T_
NICHOLAS DEPERNO
P.O.BOX 962
CARMEL,NY. 10512..
LAB # I
Date Taken:_. 1/8/91 .Time: 12pm
Date Re'd-' 1 Time: 77.77—m
Date Reported,:' ANN. 1 1 1991
Collected- BY- -N;_.eperno -
PO /Client #
Referred By:
Sampling Site: Kitcteh Tap
Haviland Dr.
Patterson.N .
L. -J
REPORT ON THE QUALITY OF WATER
Phone (914: )''278-7281
INORGANICS (mg /L) MICROBIOLOGICAL
Alkalinity
40C-- ----- - - ---- --
Standard Plate Count
Chloride
GT
(CFU /1.0 my)
_ Copper
LE 2 r
pH
Detergents, MBAS
_
.Other:
— Hardness, Calcium
Coliform & Related Organisms
Hardness, Total
Iron
Circle Method: MPN P/A
—
Lead
_ Manganese,
_4
Total Coliform
:.mercury
Nitrogen, Ammonia
—
Fecal Coliform
_
Nitrogen, Nitrate.,
Fecal Streptococcus
�-Nitrogen, Nitrite.
_
E. Coli
Phosphate, Total
--
Silver
Sodium
KEY FOR TERMINOLOGY
Sulfate
LT
= < = Less Than
Sulfide
-
- - -Su fit"e" -
NA
= Not Applicable
.
Zinc
SA
= See Attachment(s)
TNTC = Too Numerous To Count
PHYSICAL MISCELLANEOUS
P
= Present (Positive)
N
= Not Present (Negative)
_ pH (S.U.)
.*
= Also done because To-
_ Color (Units)
tal Coliform Positive
Conductance (uhms /c)
Odor (TON)
Turbidity (NTU)
REMARKS COMMENTS Lab Use
(For Lab Use)
SAMPLE TYPE:
:(Check One)
Potable
Non - potable
OUTGOING:
(Check Each)
ENO
_ HC13
_ H2$04
NaOH
— ZnOAc
_ Na2S203
Other:
INCOMING:
(Check Each)
LE
40C-- ----- - - ---- --
GT
4 /LE 200C
GT
200C
_i
i pH
LE 2 r
pH
GE 12
_
.Other:
NYS ELAP #10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE AS� (WAS NOT) '(NA) OF A
SATISFACTORY.SANITARY QUALITY ACCORDING TO ORK STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE T OF SAMPLE COLLECTION.
THESE RESULTS INDICATE
SATISFACTORY CHEMICAL UA.
ING WATER CODES, FOR P
W T E WATER SAMPLE (DID) (DID NOT) (NA) MEET THE
STANDARDS OF THE NEW YORK STATE DRINK --
TERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
7 /87(Rvsd1 /90)RWE
a ovani, M.-T. , Director
r
�� a
.t
WJILL UUr1rLL1IULV AZrUA-1
DEPARTMENT OF HEALTH
Division Of_Environmental Health'Sery ces
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office` Use Only
WELL LOCATION:'
STREET ADDRESS: WN! 1 ! Y TAX GRIO NUMBER:
3 2
WELL OWNER
NAME:
i'
ADDRESS:
A V l -Akio DL
BIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
IIAESIDENTIAL O PUBLIC SUPPLY-: ❑ AIR /COND. /HEAT.PUMP O. ABANDONED
❑ BUSINESS 0 FARM O TEST /OBSE,4VATION 0 OTHER (specify)
'❑ INDUSTRIAL C3 INSTITUTIONAL 0 "STAND -8Y ❑
MOUNT OF USE
YIELD SOU GMT- � gpm.lNO. PEOPLE SERVED /E ST. OF DAILY USAGE
gal.
REASON FOR
DRILLING
❑REPLACE EXISTING SUPPLY ®TEST /OBSERVATION []ADDITIONAL SUPPLY
'<EW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH M 5,7
STATIC WATER LEVEL v ft:
i . s �- r - _ j, r.�..A•.dd B""`M�.. � T 1�6U ,.. ` .� uAl�
P�s��oe'�sw�
R _ -
'
-
13 - Y
tii �1l.OUi�tL�3r-tizAbA
I .F ...1 r`D i '��_ ?102Crr►C I� CU ` �r.. _ ,' �ai�z ►%✓1 bZ zy, 1 l�S� 2�
w ki Hate Subdivision Qpnroyed_.�1►._(9f33 &I Fee Enclo ed 0 ` amp „nr
1t 1 jam(/ y 77 - Pf S.etMta 0� D V.i�i
1�Ii Y.t �t -' ?� ” DnIp FMw G P D f r ,PC®NNrieMIM )a s�q wi W" Pr1 Y oi�IN�f1; `
'1 WAW tires = Pure gap*,
r5 `• i ,,•,. J�'.� ,Jt`•
yet S1'r� wa.... Ste! Dstii b
0011e r.�fa•t�1.
aj►ofr+nt {Mt 1 autrwlaNy aM toeiYlotMy ►ofpo fit►b fa tM dni�n snd location of tM i
73 y' ` 1111 T
n K- W_oPOMd
G' - Nor. drwtlio0 .wiN,Ni eentiruetod as;;iiown on tlw aowewe.,nMdi„gt tMi. to an0 rA ucoid.noa wK�e M ffaeASxdst:uNS a My di nl
plM,ty pN.ttwwnt °of IrR1ti aM tiMt M eomvtrtlai tfwnof r t�a"gi�t. of Gebtt►uCltoft Coai014wor" Otiffaetory..to tM' Comm NiMOnir of MNItKwIN
S� ,k M ;o�n,Mtid to tM =O.dMt R. aM.,• wrKEfw �i,MMlfa• wIN, 0 fufnMMd tM owf�w. his fuop�w f. Mtn w = s t►y ttls twtldr► tMt uY tw11HM wIK
r wo. M'ptd NM.IY1y eo,1dKIM M1y,' OMt of, taN o>rirs>N tdNIPOYI Rrftoin dWiey tMapw.b0�,�0f twe l!)�yrMt y ,tNy�fo11t/wNy tM :.to N tM Ntzi,�,y'_
MOr M tl» aNRiiN� of tM ;CwtMkMi M Cowftwctioe Conipi�no. fof tlb a►Iyiml oa a,gr,riMtrs _ i ) t tM dillyd wN1:�drwttiM s>ioro, ,
w1K M bobd M dwww M t1b atlMOw!'td� tMt taN?wNl wNt`.M b�ti w nNWIN -tm. PutMni .
Cw„ty oiMt e1 IMYtR _s < z !�
} � � A/MROVED,FOR COftiTRNC!f10N: Tnb NM,,ow1 aim tws yY►s 1rMi M dad- �ifproA unMU eohftwc2b � f� tM tw'igin/ 1rt�bMO uMwtakMi and it '�;I
foreiMN faryaYM �! nHy M a1pwM/' "a natMNO wMn Mt y'Oy'tM Can,n11f1io11M o/ Mr 11. AA)r dy10. m tbn °of comtiuetbn
rNrMM . AttftrorM fa dNMrl of dMastlle Y frtit,Poy only If
K.
o► • irtM
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 #
WELL LOCATION
jstreet Address To Village City
Tax. Grid Number
WELL OWNER
Name
,_�ailin Ad ress
OF-3wx j&ZdgmA,
0-Pfivate
p O Public .
USE OF WELL
1 - primary
2- secondary
8- fESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY
O FARM
U INSTITUTIONAL
O AIR /COND /HEAT PUMP Q ABANDONED .
O TEST /OBSERVATION O OTHER (sDecifq
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST: OF DAILY USAGEal
E3 REPLACE EXISTING. SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY
[EW' SUPP Y N DWEL I G E] DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED.
DRIVEN .
[—]DUG
O GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: !4
Lot No:
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L,-"NO
NAME OF PUBLIC WATER SUPPLY: TOWN /.VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST.WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
SEPARATE SHEET.
L
(date) )� (s gnature)
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
thirt;r (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: #4 19 * . 11 Y&V.10
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
PUIMM • • UNT`Y DEPARTMENT OF
DIVISION OF •' •' ' IN V• HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner��_,�I.r rte- c.lA c�� Address
Located at (Street) 1 C-kQ"fl k Block 3 Lot -,>_ Z
(indicate nearest cross street)
Municipality Aj Watersheds LMe�-67
• • �I• �• • • • Y• • 9• •• 29 • : 05.41MIUMMUDISIVIAlm • • • •
Date of Pre - Soaking ,L �9U Date of Percolation Test APIz. rt- P, /3 V.
Run Elapse
Depth to Water Fran
Water Level
No. Time
Ground Surface
In Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop In
Min/In Drop
Inches Inches
Inches
1 1 0 •3c) 'moo
t 7 UP1 -
c q
17
2 f� _ BLS 'IL `1L 1-0
13
4
5
Z 1 d
2 2 0
�.3 U
4
5
2
3
4
5
�l 3 L
flo 2 t I
I-
,
NOTES: 1. Tests to be repeated'at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
_.- .DEPTH - HOIE M. HOLE NO.-- HOLE NO.
G.L.
2'
31
41
'51
61
71
81
91
10,
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE :4hO ICJ
DESIGN
Soil Rate Used 31-14 S Min/1" Drop: S.D. Usable Area Provided OQ t;P, -(R)O 1A
No. of Bedrooms _7-
.1 Septic Tank Capacity C)VC) gals. TypeJLh&aaq&
Absorption Area Provided By L.F. x 24" width trench
Other
Name M V--9AQ, 7A,- ,/ Signature
Address 3
THIS SPACE FOR USE BY HEALTH DEPARZMFNr ONLY:
SEAL
4-0
o
Soil Rate Approved sq.ft/gal. Checked by Date
APPLNM- X B
CGLU-,N C- =khm---E-NT OF f:EALTH - DIVISION OF EINtiZRO? -MaMAL >;..:=1 SFRV?=
Ih�IV7_' -L FAQ SUPPLY & SU SURFACE SAGE DISP��-L SYc'?!S
CCc��ti
Pre -1969
LF trench provided —
rruired
60 +f
t. rr.x.
aril lel to
100% e -xn. _
REV=N 5::,T - COST- UCTIGN PEEIMI's
(Street Lc,--= iLCn)
I YES I 0
I Pernit Applicaticn
I Corporate Resolution
Plans - `!Tree S2t5
I Enc; nee, -s Authorization
Design Data Sheet- (DDS)
I IDeep Hole Lcg
171--77 Consistent Perc Results
I Perc Hole Depth
Con zoL;__rs
F LL S t`S 1•S I � I
cla--l-,---riex I
10 �t. I
fill-notes
I 1
new sue.
deoth cauces I �I
100 vr. 1ood elev. I /r I
ft. -reservoir, etc.
House Pl s - rIL-W0 sets
Well P--- Tut; t; P ;'3 1e t t;.r
Variance Reauest
G'- - LT,
L- gal Subdivision
Subdivision P -ooroval Checked
Dc- apprc%al SSDS Adj. Lots Checked
+:et-land (T--3;, ,. /DEC Permit R & D)
Data On DDS Plans & Permit sara
P.=QUT r'' DS ON PLM \S
Sewage System Plan - (nort_n arrow)
Sewage Sy t-en Hydraulic P_oFile - G_ = -. =ty Fl,-w,
� 1 Profile & Di_,-- nsio -s - Volz -e
D or J Bcx; Trends /C?llery; ?u-n? pit
Weil Detail, S✓rvice. Line i f over
ConstrUcticn Notes (grinder rate)
Design D-=-"-=-: oarc and deeo results ...-
TwtFobt ContO: -"S ESc_sti ng & Pr.7DCSec
Dr' -y �' e S QUt
.cam
II 1'C = ' °S LJV.t
Representative of prii7ay and e,:--an-_on
Ex�pp-rlsi on zze ; shown; gravi ty flow, sL =. size
If Pa—u--ad Pit. & D Box ShaAn, & Det i - e3
Haase - No. of Bedroa -s
Wells & SS'--S's Win 200 ft. of ProocS= .Z.ys :.=is
Property & Bou-n s
House Setback Necessary (Tight lot)
House Sewer - 1/4 "/f L. 4"0; T,T^° pi--=
No 3erds; Max. Bends 4:-)* w /cle a.aou t
S`°PR.PTIONI DISTAN -=- SPECLFIED ON PL'-_N
Fields
10' to P.L., Driveway, Large Trees,^p of
'• ._11
20' to Wails
100' to Well; 200' in D.L.O.D, 1501 pits
1001 to Straa,m, h-a4ercoe -o-se, Laka (__.c. ex an)
131 to Drains—Curtain, Loader, Footing
� Z-0 CrtCl baSln,Stor7)^.rain,D1C w'_- D_- ''CO'�5 °_
10' to Water Line (pit- = -20')
50' inter -:ni ttent d_ra? n--`e course
S=otic Tanis .
10' Fran Fo=ndation; 50' to well
1s' well to ?L G
s/s
SU— .v!SIGN
Per`
(3) Fil;
cd
id
11>1
I r-2
-( K.
19 -0
1,+t-0
1
30 -0
I ?q-d
3
4r2-0
49 -0
57-0
"_0
100, 'I' L, tAA4t,.,,4;Zy
5r-9n(_ TX41-'-
466'
-13
t 55'
3
qs'
oK,
I ot4
id
Putnam County DePartmOnt Of Real - th
Division of Environmental 116aith Sary I ic
-ormance lilt." as noted for co"f
APP and R.g.j.tjons Of the
aj�,_- jjulc� %an
ap 0 1th Department.
coax
Ds 0
S nature Titl
f
q-
4y,
do 6
dodt41
rlt
J
!00
�D' AU 61
'1TIFY TI-!&T iii, SEWAGE DISPOSAL SYSTEM -Is '0 0
E .0 04 °h
_rHIS is To, CL.' THE 0,
CONTRUCTEDAS INDICATED ON THIS PLAN AND THAT Ess A
BEFORE IT WAS COVERED OVER-
SYSTEM WAS INSPECTED BY ME IN ACCORDANCE WITH ALL
THE SYSTEM WAS CONSTRUCTED
THE RULES AND REGULATIONS OF THE PUTNAM COUNTY
DEPARTMENT OF HEALTH-
11>1
I r-2
-( K.
19 -0
1,+t-0
1
30 -0
I ?q-d
3
4r2-0
49 -0
57-0
"_0
Putnam County DePartmOnt Of Real - th
Division of Environmental 116aith Sary I ic
-ormance lilt." as noted for co"f
APP and R.g.j.tjons Of the
aj�,_- jjulc� %an
ap 0 1th Department.
coax
Ds 0
S nature Titl
f
q-
4y,
do 6
dodt41
rlt
J
!00
�D' AU 61
'1TIFY TI-!&T iii, SEWAGE DISPOSAL SYSTEM -Is '0 0
E .0 04 °h
_rHIS is To, CL.' THE 0,
CONTRUCTEDAS INDICATED ON THIS PLAN AND THAT Ess A
BEFORE IT WAS COVERED OVER-
SYSTEM WAS INSPECTED BY ME IN ACCORDANCE WITH ALL
THE SYSTEM WAS CONSTRUCTED
THE RULES AND REGULATIONS OF THE PUTNAM COUNTY
DEPARTMENT OF HEALTH-