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BOX 12
!7-
.I .
IN
J 1
I IN
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.. % IN in is 16 IN
1
.,
01281
Rev. 31R
.Owner /applicant Name
4L
MaflingAd s�
.. . -^ 11
71
PUTNAM COUNTY DEPARTMENT HEALTH,
Division of Environmental Health Service 1 N Y .10512
L eerr Must ast Provide
P.*C.H.D.'Perml
iS-1R-,,M0? FOR Ss: .«n SYSTE:
T own -or V
Tax Map -(0 Let
Formerly Subcilvislon Name Subdv. Let
Zip_ %ZS%3. Date Permit Issued
Separate ,Sewerage System, built b,-.' (:G)'( 'J' "1716--1 1"'LL
&4ting Gallon Septic Tank and
81s' of
Water.Supply: Public Supply, From Address
NSA e Silsi Lt. Address )(04
or: Private Supply Drilled by
Building •Type 12,-G; Jet Has Erosion Control Been Completed?
Number of Ek&wms
Has Garbage Grinder Been Installed? Aid
Other Requirements
I . certify that . the . syptem(s). as'.listed serVihg the above. premises were L c6nst ctedi ess . entially as shown on the plans of t . he completed work copies
'of which are 'L attached), ttached)', iaind: in iccoidan�ce'wiih the' standards, rules and r a tio I ns, in accordance with f il P17 and nd the permit issued by the
Putnam Z
County Depa tment'Of�Health,.
Date n
h,) -7 cortill P.E. R.A.
e
Address 7-1, - 4
ri wy 4er6 V
License No.
:- F
V
by the above system($) shall promptly take such action as maybe necessary to secure the correction of any unsanitary
Any person occupying promises served
conditions . . I . 1 .1 A Dro4a'l "of the sepa!pto, "irage 'system 'shall become null, and vold,as. soon as a puW:-. unitary nwer becomes
,,, resulting from :Such usage. . pl supply 6jc(jM'
available nki" the approval; of the, pil4ati water s6pply.ihali'becorne'nu'ii and void N"en'a public water Such approvals are
subject to . mod If Icat . ion or change ',when, 16 the jwdgment of the Commissioner of Hiultti,-such revocation, modif Ication or change is necessary.
Dote
WELL UU1vLrLL!LUN ALrUAI
fat DEPARTMENT OF HEALTH
S
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use O%ly
STREET A 0 0 - RESS. TAkGRIO NUMBER:—
.41
WELL LOCATION
WELL OWNER
NAME ADDRESS:
'0 A3 NP A 01 �77,
IdfPBIVATE
0 PUBLIC
USE OF WELL'
1- primary
2 - secondary
YE"6ENT'AL 0 PUBLIC SUPPLY ❑ AIR/COND.IHEAt PUMP, :1 ABANDONED
0 BUSINESS 0 FARM 0 TEST /OBSERVATION 0 OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
AMOUNT OF USE
REASON FOR
DRILLING
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
6 NEW SUPPLY — 0 PROVIDE ADDITIONAL SUPPLY 0 TEST/OBSERVATION
O REPLACE EXISTING. SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH —ft-1
STATIC WATER LEVEL
DATE MEASURED 22�10 7
DRILLING
EQUIPMENT
0 ROTARY &(COMPRESSED AIR PERCUSSION ❑ DUG
0 WELLPOINT 0 CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED ❑ OPEN END CASING. IdOPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH tL
MATERIALS: S'TEEL 0 PLASTIC 0 OTHER
LENGTH.BELOW GRADE D tL
JOINTS: 0 WELDED d(THREADED 0 OTHER
DIAMETER in.
SEAL: 9CEMENT GROUT 0 BENTONITE 0 OTHER
WEIGHT PER FOOT 1b./ft.
DRIVE SHOE: d(yEs ❑ NO
UNER: ❑ YES NO
SCREEN
DIAMETER (in)_
'SLOT SIZE
LENGTH
(It)
DEPTH TO SCREEN (ft)
DEVELOPED?
--
FIRST
0' -.13 N
--f-1—
SECOND
HOURS
GRAVEL PACK
I YES
0 NO
GRAVEL
SIZE.
DIAMETER
OF PACK In.
TOP
DEPTH —ft.
BOTTOM
DEPTH -- It.
WELL YIELD TEST 'If, detailed pumping
w
:CM00: 0 PUMPED tests were done is in-
COMPRESSED AIR formation attached?
0 BAILED 0 OTHER 0 YES 0 NO
w It more detailed formation descriptions or sieve analyses
ELL LOG are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Dia-
peter
FORMATION DESCRIPTION
it.
IL
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm-
Land
Surface
tllo
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? 0 YES ONO
ANALYSIS ATTACHED? 0 YES ONO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
[.MODEL
CAPACITY
DEPTH
VOLTAGE HP
fMW'tW 14YATT & SONS, INC. DATE
Well Drilling 5101MRE
im�s§11 R. R. 2 Box 171A
PATTERSON, NEW YORK 12563
Yorktown Medical Laboratory, Inc.
321 Kear Street
_Yorktown Heights, RT< Y- _10598_._.._.x.
(914) 245 -3203
Director: Albert N. Padovani M. T. (ASCP)
V V, 66X/S7& e 7 /d,X_j
/v *lt lno- -v V n
LAB # 32.00 4:_ 0
Date Taken: la -,;Z7/ -V7 Time:/
. .L'stE= too= ' °d,: -_:. . -,. -3•- ....time.... •�«- -__ r
Date Reported: 0 231967
Collected By: C -yUQ�
Referred By:
Sample Location: 1- -a6z/L
Phone # F- =3
Phone #. Sample Type:
Repeat Test?- _ 1(check one)
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
Standard Plate
(Agar Plate
MEMBRANE FILTRATION
Total Coliform
Fecal Coliform
Fecal Streptoc,
Count (CFU /1.OmL)
35 °C).
TECHNIQUE (MFT)
(CFU /100mL)
(CFU /100mL)
Dccus (CFU /.100mL)
MOST PROBABLE NUMBER.TECHNIQUE.(MPN)
Total
Coliform:
MPN
Index
(per
100mL) _
Fecal
Coliform:
MPN
Index
(per
lOOmL)
OTHER ANALYSES
REMARKS (For Laboratory Use)
yPotable •
Non- potable
_ STP INF
_ STP EFF
Other:
Sample Status:
.(check each) .
Outgoing
— Na2S203
Incoming
ye"LE h °C
GT b °C
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec -.
tion of Source
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
LE = Less Than or Equal to
GT = Greater Than
N/A = Not Applicable
THESE RESULTS INDICATE THAT THE WATER SAMPLE ((WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH NEW ORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED9 -AT TIME OF COLLECTION.
For Lab Use Only:
H/C to
,., .Albert
PUTNAM COLUEY DEPARTMEW OF HEALTH
DIVISION OF ENVIROi �AL HEAL T H
SERVICES
Owner or Purchaser,of Building
WMI
Building Constructed by
Ora
Lo%cation - street
Municipality
#/ a/l
Buildin§ Type
Secti n Block Lot
Subdivision Name
Subdivision Lot #
GUARWI.'EE 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 Com liance" for `th s cret�,,_-or
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 Andersigned 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 b the willful or negligent act of the occupant of the building utilizing
Y P g 9 .•:
the system.
Dated this 2 da of C4 19 97 Signature . (21vj
/n 71- Title
- Signature
�-
rev. 9/85
mk
Corporation -
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ABC:
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_ APPENDIX C
FINAL SITE INSPECTION
LICC<AT ,OI N
T` OR S JEDIVISION LOT Q L"
�=
II.
IV .
Date
'
YES
S�NACE SPOSAL AREA
DI
a. SDS area located as per approved plans II
'section
-------'
b.
Fill - Date of placanent
2: 1 barrier LGTH WIDIH VG'. DPIH
"
c.
Natural soil not stri Devi
d.
Stone:, brush, etc., greater than 15' fran SDS area. I
--
e.
100 ft. fran Aete_-- course /wetlands.
Sc y,Gr. DISPOSAL, SYSTEM
a. Septic tank size - 1,000 1,250
`V iy CA
b.
Septic tank installed level I
I
c.
10' 'minim n fran foundation I
d.
No 909 bends, cleancut within 10 f.t. of 45° bend
e.
DISTR.IBL'IICN BOX
1. All outlets at same elevation - water tested
2. Prote--tw below frost
3. Minimum 2 f t. original soil be Nee*! bcx and trenches I
f .
JLCIION BOX'- prorerly set,
g .
TP=EES
1. Length re�--si red - � ` L,;-tr_c_�`z installed
2. Distance to watercourse meas-LLrr c . rz.
3. Insa -11- according to plan
IX
A. DiS tance center to c°}lter
5. Sloce cf t-ench acceptable 1/16 - 1/32 " /foot.
6. 10 fe--t f_an roDerty line - 20 fe-t - four_dations
7. De'th of t_en6n < 30 inches fran surface
8. Roan al?csaed for a oansion, 50%
9. Size of gravel 3/4 - 1 " diameter `I
10. Depth of gravel in trench 12" minim-n
_
__ .. ... .......
..11. Pipe
...._.. --
...
Fr:�-T QR DCSE SYSTEMS
1. Size of pure Chamber
("
2. G ier lc,.q tank
3 Aiahm, Visual/audio
10 C ll 9r--
A. Punt) e_-si -1 accessibl e TcnfiOle t0 C =-Ce
I
5. First bcx baffled
6. cle witnessed by He= t-1 DeDarttment
I A
estimated flcw_per cycle
I
,
i. _ -ruse locate cer approver plans.
sI=Leri of Jz= C TE
I
I
Well l local f as ce_ app= -v ar plans
e.
Distance f-at-. SDS _ _- xe sured
C.
C =sing; l8" a: cvec_ ace.
(�
I
C.
C:'iriaC° &-a; r.;= a= CL''_C well aCCSDL?—_�.
CVMA -M WORMA ^7'�
a. Bates prcce*lV crcct c
1i
'
b.
A11 pies -, t; ' :y w= =:i= i led
c.
All pines flush w' -Li inside of bcx
d.
Eac-vf ill materi a! contains stones <. 4" in diaweter
e.
Curtain drain installed, accordinG to plan
f.
Oartain' drain cut=all roter-ted & dir.to exi st.watercours
g.
Fcoting drains disg�Zarge away from SDS are=
h.
Surface water protection adeouate
-
i.
Erosion ccnt=o provided on slopes c- e-=te-r tLan 15 %.
_j
�� �° �� oo
p)-i
PUTNAM COUNTY DEPARTMENT OF HEALTH rt w
e V j3/86~ `A ; i 61vldon of ESsvironmental Health Services Carmel, N Y 1051? - Et glneer to Provlde:Permlt q /77
;
\� t on CERTIFICATE OF COMPLIANCE
Permit q'"
CONSTRUCTION PERMIT FOR S, AGE,DISPOSAL'SYSTEM;
Located at _� �r Town S YtL'aSo —
Subdivlsiosi Name. abd Lot q Ta= Map ? r Block tr-
�'` Renewal_❑ �Revieion
.Owner /Applicant Name !� •lam � ` a T ❑ c
Date
r ��
d_ dre t � _ ... � + _ •Town / �(
f wion
oe– op-
Bailding Typo / / / �� Lot , Area S! a FnPSecaon only, } ` Depth Volume ',s
Numbertof Bedrooms ` Design Flow:G /P/D :'( / �� °PCB Noffleidon Is( Regalred When FW le completed
Separate Sewerage System %to �nsiet�of; •"K� Genoa Septic'
To be c' onstraeted by `-�' Ad idrees `w —
1, it F' l4 Y
6
Water Suppi Public apply From { X „' A`ddress J
V
or= Private:Sapply 1)rlll y `' Address
Y 4 b
Other Regalremente
.. ;
z t
represent a .I,am wholly and completely :respon sib le for the design and location of they proposetl systems) •1) that the separate sewage disposal system
above dexritied w,ll be constructetl as shown on the'approved emendme'nt thereto' and inaccordance.wdh thests>�ndart]s ►ules and regyjations a •• e ' u nam
County„Oepaitment of Health antl that on com'letion thereof a Certtfiute of Construction Compliance .asatisfaetory to the Commissioner'& Health`will
p'
be .subrridted to`•,,the Oepbrtment;:'and a wnttentguarantee will�be furnished the ownei,: his suceessoii hors or assigns by t,he,butlder; that said; builder will
place in good opeiaiing conddlon` any part of saiA sewago',dtsposalmsystem dunng lthe+ period otttwo (2), i dmmediately toilowiry,thedate'.of tha'issu
ante• 'of the approval of ;the Cersiftcate of Construction Compliance of, t o final system or'a__n repap , t r' 4' 2) that the Grilled well.ditscribed above
S
will DelocateC esshoWnbn the approved plan and that said weltwtll belnstall i 7accordas e, wit '' a stn rd r s and r u anions of the Putnam „
t of H th
Date /� ! ✓' t( d _\ i' h .49 sm kr. ..
County;.Departm f` St ned P.E R A _
License N0
,
APPROVED. FOR CONST.RUCTI`ON This approval, expires' one year from the ate usuetl unless” nstruct'ion of the bwldmg. has been undertaken and Is
revocable °tor cause ar'maY De emended orm'odttied; when consideretl necessary by the Commissioner ofti Health n Any ehange. or alterdtbn of'construction
requires.a new permit may, disposal of',Cornestic samtar`y swage an water supply ,only
Date1.�
DIVISION OF •• U is Y• •r • M• •+S
.DFSIGN-.p TA, SH= -SUBSUFACE _SEWAGE DISPOSAL SYSTEM _ FLI.E NO..�
Owner Address
Located at (Street) K T7)_ Sec. 6 Block Lot
(indicate nearest cross street)
Municipality Watershed
Date of Pre- Soaking
Date of Percolation Test I ]I CA
NUMEA CL OM TIME
PERCOLATION
PERCOLATION
Run Elapse
No. Time
Start -Stop Min.
Depth to Water Fran
• Ground Surface
Start Stop
Water Level
In.Inches
Drop In
Soil Rate
Min /In Drop
Inches. Inches
inches
21 19 113
620 4:26 /'S
n
Im
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 frC'm top of hole.
Via- X�i�r. 9/85
.f
eab
DEPTH
G.L.
11
2°
TEST PIT DAM REQUIRED TO BE SUBMTTED, WITH APPLICATION
DESCRIPTION OF • IIS ENCOUNTERED IN TEST HOLES
HOLE NO.
HOLE NO.
3° 4 /
Corr, O G Gi 1W dl,�a
40 l
� �i,( CT h 7"i
5°
6° eclo
71 -/v P (—Q
8°
9°
10°
11° -
12°
13'
14°
INDICATE LEVEL AT WHICH GRommoTER IS ENOOUNTEmED G
INDICATE LEVEL TO WHICH WATER LEVEL, RISES AFTER BEING rUNTERED
�%���
DEEP ROLE OBSERVATIONS MADE BY: ���e DATE:
z4a
,� DESIGN /�
Soil Rate Used �� au Min /1" Drop: S.D. Usable Area Provided (� 7�
No., of Bedrooms Septic Tank Capacity /000 gals. Type (�G/? Cc
Absorption Area Provided By , L.F. x 24" width trench
Other
C
THIS SPACE FOR USE BY HEALTH DEPARTM&W ONLY:
Soil Rate Approved sq.ft /gal. Checked by
.' tl
_4
Date
APPENDIX B
OF HEALTH - DIVISION OF ENVIRONMERM HEALTH SERVICES
REVIEW SHEET - CONSTRUCTION PERMIT
DATE REVI
(Street Location)
YES OM DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log. Perc _
(36 0 Consistent Perc Results (3) Fill
Perc Hole Depth cd `
yequired
.0
O�
=_�_
'PAP N
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
pproval SSDS Adj. Lots Checked
Wqtland (Town /DEC Permit R & D)
to On DDS Plans & Permit Same
REQUIRED DEIAIIS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic.Profile - Gravity Flora
Fill Profile & Dimensions - Volume
D or'J Bax;Trench/Gallery; Pump pit details
Septic Tank - Size,.Detail
Well Detail, Service.Line if over,
Construction Notes _. .
De .gn Data: perc and.deep.results .
E�ot Contours Existing.& Proposed
driveway & Slopes' Cut - - . - _. - . .
Footing /Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedroans
.Wells & SSDS's w /in 200 ft. of Proposes( System
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1/411/ft. 4 "0; Type pipe .
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L. Driveway, ge Trees,Top of fi'
20' to Founda ' . s
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, lake (inc. expa•
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercour.
101. to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15! Well to PL
9
40 ct
5° /
6'
71 eoF
8'
9'
10'
11'
12`
131
141 ..._
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER ING ENODUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used & Min /1" Drop: S.D. Usable Area Provided
No. of Bedrogms 3 Septic Tank Capacity gals. Type (f:ac
Absorption Area Provided By L . F e m-441! i ,316. 4....n _h
Other ,/ '�/ ✓ ®° V� l /.� .%,�
Name
Address
+�.+v vr� +v++ rva� Vvu ✓+ aaia .. .+aa Luaau�+L .. ..�a VLWi• -- �_..�
Soil Rate Approved. _ sq.ft /gal. Checked by Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
FPY;TCA- '1sI�71QvT� C:OI�STRUCT AGV'A'1'ER` �ri1ELI, ... -; "�_ >.. _,." ° •, ° -, . -..: -' ... .. ' ._
w PCHD PERMIT # -O
WELL LOCATION
Street ddees
To Village C'ty ax
Grid Number
WELL OWNER
�^,-
dress
rivate
W
O Public
USE OF WELL2ESIDENTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
17 ABANDONED
1 - primary
❑ BUSINESS FARM
0 TEST /OBSERVATION
O OTHER (specify
2 - secondary
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY
❑
AMOUNT OF USE
YIELD SOUGHT_ gpm /#'PEOPLE
SERVED /EST. OF DAILY USAGEjjgal
REASON FOR
EW SUPPLY
❑PROVIDE ADDITIONAL SUPPLY
OTEST OBSERVATION
DRILLING
❑REPLACE EXISTING SUPPLY
0DEEPEN EXISTING WELL
DETAILED
REASON FOR
"'
DRILLING
WELL TYPE
RILLED
DRIVEN
DDUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO 9
IF WELL IS LOCATED IN,A REALTY SUBDIVISION, NAME OF SUBDIVISION: /Z2
Lot Nd. /e�,30 -
WATER WELL CONTRACTOR: Name Z�'_ Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES C NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
_ _.....DISTf'sNCE ._TO...PROPERTYrFROi {. -NE"��i- .TinlhTi^R° i1A1N, yj ... ._.. - _ ..._._.....
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
Q ON REAR OF THIS APPLICATION []ON SEP SHE T
(date) ( '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 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.
Date of Issue: 'Fe 'V/ 'Z'�' 19
Date of Expiration: ,, 2 6 195 ermit Is �-
Permit is Non - Transferrable
EM
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
F.._ .. �_... , •_ --- -.., _. -._.._ AFFIDAVIT .. CORPORATE-
OWNER. -.., . -
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
represent that I am an officer or employee of the corporation and am authorized
to act for
Name of Corporation
having offices at I-lea r k" 6 �1 V
Whose officers are:
President:
Vice - President:
Name and Address
(Name and Address)
Secretary:
and Ad-ure as_ , - - _.. - .. _. _... _......
Treasurer:
and that I am and will b
corporation with respect
thereto.
Sworn to before me this
of, November
Notary Public
8/84
(Name and Address)
individually responsible for any and all acts of the
to the approval requested and all subsequent acts relating
5th day Signed:
A WJV
0
19_ 86 Title: A
&4
DEBORAH L. DAUKONTAS
otary Public, SIAM e of New York
Qualified in Putnam County 0
Dommission Expires March 30, 19
Corotirat,,;.Seal
Putnam County Department of Health
lbivision of Environmental Sanitation
....AFFIDAVIT. - .CORpORA2'E•;..�INER ��PPTr �.rT nN..._, _ �..
FOR PERMIT•APPLICATION SUBMITTED TO -
:. PUTNAM COUIITY }IEALTH DEPARTMENT ! 'r
Tb: commissioner of Health - In the matter of application for.
SU 1351�RA�t �CW�C �ISLCYarL — —YS'(E
I► _ Ger-r1 r, _4'.111 Yi.,��.t-- - /-,(— — — —y-- — — • represent
that I am an officer or employee of the corporation and arrt authorized
to act for
(name .0? corporation)
having offices at
— — — — — - — _ — — — ,. _.._ .f'_�._. � _ r.. Whose• officers -are
President 5. F..(�l_ - -`_ —_
ame andridres
Vice- President
_ (•Name and Address)
Secretary _ — _ ► _ _ _ _ '
-
- (Name and Address) " — .. — -'
"treasurer
(Name. and Address)
• - U f
and that I am and will be individually responsible for any or alllactp
of :thp corporation with •res,pect to the approval requested and all- sub-
sequent acts re.lating_tlier�to. -
Sworn to before me this �ay Signed
...
of 19 7 Title
- ' N t Y Public
s
JOANNE Mr MASON
r Notary Public,-State of New YorQ f
Qualified in Putnam County D Q
Commission Expires NO. 29, 1911..Jt
i
Corporate_ Seal
'
1
PUMAM COUMY DEPARTMENT OF • E T•
:.DIVISION OF- ENVIRCNMENTAL HEALTH -SERVICES.
_. ,.___,DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSaT1IM FILE NO..*
Owner _S, • Vf cn � �<_'- %tZ u LT(�t.� V Address
Located at ( Stree I P. :V<_fQC ye Sec. Block 3 Lot '7_
( indicate nearest cross street)-
Municipality
Municipality --tbW t.._(, l' 'iTEr���� Watershed
SOIL PERCa TION TEST DATA RDOULRED Ta HE SUM= WITH APPLICATIONS
Date of Pre - Soaking /1% Date of. Percolation Test :8 ji3`7
Ruh Elapse
Depth to Water From
Water Level i
No. Time
Ground Surface
In Inches
Soil Rate...
StartrStop Min.
Start Stop
Drop In
Min/In Drop
Inches Inches
Inches
7(e
3
Z 7
4 ..
3
::, is
"ZO
Z-7
4
4:
5
1
2
3
4
5
NOTES:. 1. bests' to bd repeated at same depth until apprcximately 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 /AS
i
TEST PIT DATA MQUIRM TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. Z. HOLE NO.-
G. L.*
ZGO
ju S3a�t -4
-4 V
20
30 L.4 L6 P f jM&m -ri L L�
49
59
60
79
80
9°
10,
129 -,-q
131
141:
INDICATE LEVEL AT WHICH GROUND MTER IS EN =NrERED
is
INDICATE LEVEL TO WHICH. WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE:.
DESIGN
Soil Rate Used 8 -10- Min/I" Drop: S.D. Usable Area Provided GOO 'ZI,
No. .of Bedrooms - 3
Septic Tank Capacity .. I 0<:)%z:> - gals. Type -
Absorption Area Provided By 4 L.F. x 24" width trench
Other
Name Uuoas-r Ekait�AcGmNiG.-) ►SSJc-,,PCSignature
FOR USE BY HEALTH DEPARTMENT ONLY:
SEAL' I` �\
Soil Rate Approved sq. f t/gal. Checked -by -Date
i
7�o 7-7'%
' IB -/33
% B -/t336 B -1835
I� g i83z g -/831
.oe,E� = Z3` -�•3S Ste-' '
Z9 - °erg 2 7 ' _ �9� • 9Z
Ail
7
7 7111
N •
1 I r
00
2 1 2 IP
r <\
SaAlS �v�2
� S
Q] L I Cp I So
C6
I a0
� I \t -� orne
N '•
GOo.1oj�
�Q 56.37' y T
• SS'45 =00 E = =• --
VICTORY (50'.ide)
tr �1• OP
�• \a
SUR,VE Y OF PROPERTY
PREPARED FOR
ANNA - GARC /A
BEING
LOTS 8 1844 - 8 1849 INCL.
SHOWN ON ��
"MAP 8 OF FUTNAM LAKE
$ITUAjEIN
TOWN OF PATTERSON
PUTNAM COUNTY NEW YORK
.. _. SCALE l'= 30
Sold map filed August ly 19,;/ as Map N° 149K
James C Edgelt, the surveyor who mode
s map, do hereby certify that the survey
the property shown hereon was conjo -le,Apd
pt. 9, 1971.
New York License N23,7212
Conn. Registration N° 5632
Office of James C. Edged
Land Surveyors
93 Main Weel, Brewster, New York
Church Street. Pine P lain, New York
hole: All certifications hereon are valid for
this map and copies !hereof only ifsad
map or copes bear the impressed seal
of the surveyor whose signature appears
hereon.
Certified to Chicago 771 /e Insurance Company
for rifle N° 71 W- //06/ in accordance with
the minimum standards for surveys as adopted
by The New York Slate AssocOtion of P►ofessionc
Land Surveyors.
Legend
wires-
iron pin set — •
Jab N °7/088
ROAD
SUR,VE Y OF PROPERTY
PREPARED FOR
ANNA - GARC /A
BEING
LOTS 8 1844 - 8 1849 INCL.
SHOWN ON ��
"MAP 8 OF FUTNAM LAKE
$ITUAjEIN
TOWN OF PATTERSON
PUTNAM COUNTY NEW YORK
.. _. SCALE l'= 30
Sold map filed August ly 19,;/ as Map N° 149K
James C Edgelt, the surveyor who mode
s map, do hereby certify that the survey
the property shown hereon was conjo -le,Apd
pt. 9, 1971.
New York License N23,7212
Conn. Registration N° 5632
Office of James C. Edged
Land Surveyors
93 Main Weel, Brewster, New York
Church Street. Pine P lain, New York
hole: All certifications hereon are valid for
this map and copies !hereof only ifsad
map or copes bear the impressed seal
of the surveyor whose signature appears
hereon.
Certified to Chicago 771 /e Insurance Company
for rifle N° 71 W- //06/ in accordance with
the minimum standards for surveys as adopted
by The New York Slate AssocOtion of P►ofessionc
Land Surveyors.
Legend
wires-
iron pin set — •
Jab N °7/088
=40�(�-
54 4'' ''nn.' " fa0 t0
ao: N4 (1'M)
5,y .. f r S .3FC.l .�� 9
low 71`ENGHF1i
crrr.) .
a
1900 (1P�'. 9'e��GC •' � •s, �
• 5
Ito
Itfo1 / � 51.5'96 '
1000 GAI_
uz.
4' o� 5010 Y..C. Q Zq.•
I
104
4' 0 '50L%o pv.C. a r. r,
100 r-- 4" 9 SOLID
o ',f'DgA1- *Y,)TGM WA<i GON%f UG CD
A�iND14ATW ON TH19 f°LAU ANI (HAT .5CA�.E: 1 " =zo
r
(1`� W / TNt; 6fSj�M wA* INSPBGTCD oY M6 Meror`r- IT WAg
�. U!�-'- _ILA- -,TNE `�i7T�M GOFIfJ'UGTCt� tfil,.A.- .= ^rcpAtJGE y�ltN'�11
AUD J1E&OLATION°j Or PUTNAM GOUNIY !tPAn1Mr:NT
G✓GAI.E I'u = 20' iHt; PeW YOFK *TATS tPePA1�TMeNT p
CLEtiil FILL Coy- l'PAGTED f HL•ALTH .
lt- G4 LIP-r-S CJOTt=h
• Q" Toasoll_ -t-•I lwl. ��Y-TV L.IUE IuF --oCi
' "�Aro� s�la�E "�1'CV6Y os= Ar_avGe'c1•
AUQCtST Q
(T/>?� Z. - fovOQiG+.'PH1I_At_ IiJt =o��
� 0 1�- tFE�.V�OC15 U.YE'1C �E�Ni•QE OI <_�'F!�.�AL SV9-
V-41 6L.1., '���� 3 , I4 ®6 •. -v-g