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BOX 13
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Rev. 318 PUTNAM COUNTY DEPARTMENT 00-E
ua. Division of-Envlronmental Health Seces, Corm
rvi
CERTIFIC F CONSTRUCTION COMP
Located at ._
Owner /applicant .Name. —
Melling Address'
Separate Sewerage System hallt by / 1 1 naoiesst
Consisting of WJ5 - -- Gallon Septic Tank and -k-
Water Supply: Public.Sapply.From qq Address or: _Private Supply Drilled by lv: A ��le- Address ';1n� )( �1- D �I�►�j
Banding Typo T� Has Erosion Control Been. Completed?
Number of Bedroolms "cam Has Garbage Grinder Been,InstanedY
eg
Other R airements
I certify that the system(s) :a listed iervinq the above premises were constructed essentially as shown n the plans of the completed work ( copies
of which are attached), and in accordance with the standards; rules and seg lationa, in accordance wi the iled plan, and the permit issued by the
Putnam County Department Of Health.
Date �� /� - -� Certified by A' w�^ P.E. R.A.
Address D 4'
Any person occupying' premisas'served by'the, above system(s) shall 'promptly take such action as may necessary to secure the correction of any unsanitary
conditions resulting from such usage ApproveI'of the'.seperate rewitape system shall become null and void as soon as • pub(;: Unitary sewer becomes
available and the approval of the private water supply shah'become null and-.void when a public water supply becomes available. Such approvals are
subject :t /o modification or change when, in the judgment of the Cornmissionak of Health, such revocation, modification or change' Is necessary.
Date z 13 TRIO
.AM CAL
/�i
_
WJ•,LL l.VP1rLL11V1V 1CL:rVAl
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
.Office Use Only
r}-
WELL LOCATION
STREET AOURESS: WNIVI71,�Al9kkf0lvl Y TAX GRID NUMBER:
` �� 3
WELL OWNER
NAME. ooaess:
Z G s
BIVATE
PUBLIC
USE OF WELL
1 - primary
2 - secondary
ESIOENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O
MOUNT OF USE
YIELD SOUGHT —L,_ gpm. 1N0. PEOPLE SERVED -3_ -, / EST. OF DAILY USAGE O� gal.
REASON FOR
DRILLING
nREP E EXISTING SUPPLY ❑TEST /OBSERVATION [:]ADDITIONAL SUPPLY
C�.pF�UPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL ft.
I DATE MEASURED �_ PT Yuv
DRILLING
EQUIPMENT
0 ROTARY O0CRESSED AIR PERCUSSION ❑ DUG
❑WELL POINT. ABLE P RCUSSION ❑OTHER (specify):
WELL TYPE
❑ SCREENED U,0AEN END CASING 0 OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH_ ft.
MATERIALS: EEL O PL TIC ❑ OTHER
LENGTH, BELOW GRADE ft..
JOINTS: O WELDED HREADED : O OTHER.
DIAMETER in.
SEAL: ENT GROUT O BENTONITE 13 OTHER
WEIGHT PER FOOT 1 lb./ft.
DRIVE SHOE ❑ NO LINER: DYES gUW
CCRRF?J
DIAMETER (in) 'SLOT SIZE
LENGTH (Lt)
=DEPTH TO SCREEN i
DEVELOPED?
`"' "'
DETAILS/
IRST
O YES ONO
HOURS
St phLf
GRAVEL PACK
Y
❑ NO
AV
SIZE:
DIAM
ACK In,
TOP
ft.
BO .OM
OEM It.
WELL YIELD TEST If detailed pumping
METHOD PUMPED ; tests were done is in-
O C PRESSED AIR , formation attached?
BAILED ❑ OTHER 0 YES 0 NO
WELL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE.
water
Bear-
leg
Well
tell
meter
FORMATION DESCRIPTION
cone
ft.
It.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land urface
-co
d�
C G ►
WATER PafAR TEMP. S
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? YES ❑ NO
ANALYSIS ATTACHED? ES O NO
STORAGE TANK: TYPEt ,6,'761y ��f
CAPACITY d GAL. O
PUMP INFORMATION Ilnn
TYPE _ �L_" 1! CAPACITY
MAKER (�.v — DEPTH �---"—
MODEL 1 Q -4r� vOLTAGbt.� HP
WELL DRILLER NAME nn �A�� (/ DATE' s
ADOaESS g o �' 1 /3 )3 SIGil7fTUR
C d,� 2 ". J, leew_
13 ion i
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heishts, N.Y. 10598
(914) 245-2800
LAB #: 93.008223 CLIENT #: 26 NON STAT PROC PAGE 1
DENNIS mALAwcHuK DATE/TIME TAKEN: 10/13/93 09:45
PO BOX 313 DATE/TIME REC'D: 10/13/93 16:08
CROTON FALLS, NY 10519 REPORT DATE: 10/15/93
PHONE: (914)-277-3192
SAMPLING SITE: HIGHVIEW DR KITCHEN TAP SAMPLETYPE..: POTABLE
: PATTERSON, NY PRESERVATIVES: NONE
COL'D BY: DENNIS MALANCHUK TEMPERATURE..: {_4C
NOTES...:
COLIFOHM METH: MF .
DATE FLAG PROCEDURE RESULT NORMAL - RAN6E
10/15/93 NF T. COLIFORM ABSENT /100 ML B=-;ENT
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WATER (WAS NOT) 7_-FA'
SATISFACTORY SANITARY QUALITY ACCORDI��-��THE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS
TESTED, AT THE TIME OF COLLECTION..
SUBMITTED BY: --------
���_���-,--_-_---------
Albert H. Padovani, M.T.(ASCP)
Director
- ELAP# 10323
RTI1MM COUNTY DEPART1✓EWr OF HEALTH
DIVISION OF ENViRON, .fiEAT,Tfi SERViCFS • _.. .
Owner or Purchaser of Building
�� l7 •i��U l i:.� i N c4 I NG
Building Constructed by
Location - Street
Manic . p lity
Building
S vision blame
Subdivision Lot 7
GUARANTEE OF SUBSURFACE S091 -GE DISPOSAL SYSM -1
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
tiie approved, plan. or approved' amendment thereto,. and im accordance, with the.. ..
standards, rules and regulations of the Putnam County Department of Health, and
,hereby guarantee to the owner, his successors, heirs or assignsr to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years i=ediately following the date of approval of the
..'Cent ficate. of.. Construct io4-.Campliance_'.' 'for _t. be._secwage disposal .systan� .: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 Environh ntal 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 utilizin
the system. -5 _
Dated this LP day of 2 19'Y72 Signa
jP Title
- Si4nature
Corporation tangy (if Corp.)
�PM 77. V . M.-InIllpffs . .
Mdress
n:t
0s M Ave . Neil 6Hy-wo- o d 14,91
rev. 9/8S
mk
Section _
Block
Lot
S vision blame
Subdivision Lot 7
GUARANTEE OF SUBSURFACE S091 -GE DISPOSAL SYSM -1
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
tiie approved, plan. or approved' amendment thereto,. and im accordance, with the.. ..
standards, rules and regulations of the Putnam County Department of Health, and
,hereby guarantee to the owner, his successors, heirs or assignsr to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years i=ediately following the date of approval of the
..'Cent ficate. of.. Construct io4-.Campliance_'.' 'for _t. be._secwage disposal .systan� .: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 Environh ntal 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 utilizin
the system. -5 _
Dated this LP day of 2 19'Y72 Signa
jP Title
- Si4nature
Corporation tangy (if Corp.)
�PM 77. V . M.-InIllpffs . .
Mdress
n:t
0s M Ave . Neil 6Hy-wo- o d 14,91
rev. 9/8S
mk
11 °36'77'W
nmew*ipw 1i1.1i -T (1N rn
too p a�
3
Z4
3
L
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< A
.0
THIS IS TO CERTIFY THAT THE SEWAGE D6PD°5AL
SYSTEM. WA0 CONSTRUGTED A5 INDICATED ON THIS
PLAN AND THAT THE SYSTEM WAS IN5PECTE0 5Y
ME 6EFORE IT WAS COV5ICED OVER- .
THE 5YSTEM WAS GON5TRUCTED IN ACCO2DA90E
WITH ALL STANDARD RULES AMC) REGULATIONS
OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH
AND THE NEW YORK STATE DEPA!ZTMENT OF HEALTH .
qr5 : HIPEK20 4 wt`LLl VkeGt7 ON 1' *0U v ey OE
}�Df'�1�'(Y" f fit%PAI��r� UY Tli�'( ('I��EUOOt'1`P Gof.1.JtJ�
°5�2x
V
1
�1G•G
a
2
58.0
1G.0
0
2
1DB.5
115.0
Q2
F
v"
5
L�
101.0
104.0
/�
O�
1�
1UU.5
x '\
'(
c
t
too p a�
3
Z4
3
L
S \
< A
.0
THIS IS TO CERTIFY THAT THE SEWAGE D6PD°5AL
SYSTEM. WA0 CONSTRUGTED A5 INDICATED ON THIS
PLAN AND THAT THE SYSTEM WAS IN5PECTE0 5Y
ME 6EFORE IT WAS COV5ICED OVER- .
THE 5YSTEM WAS GON5TRUCTED IN ACCO2DA90E
WITH ALL STANDARD RULES AMC) REGULATIONS
OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH
AND THE NEW YORK STATE DEPA!ZTMENT OF HEALTH .
qr5 : HIPEK20 4 wt`LLl VkeGt7 ON 1' *0U v ey OE
}�Df'�1�'(Y" f fit%PAI��r� UY Tli�'( ('I��EUOOt'1`P Gof.1.JtJ�
°5�2x
V
1
�1G•G
?�i.0
2
58.0
1G.0
g
1DB.5
115.0
5
101.0
104.0
/�
1UU.5
102.0
'(
100.0
101,0
8
°I�1.5
qa.0
q
158.0
151.0
10
156.0
15.0
11
151.0
155.0
It
158.0
iJ 4.0
lei
1GD.9
1540
14
560
11.0
15
51.0
(i�J.D
1 G
48.0
Sq.Ci
11
0
55.0
to
a3.0
gl.o
too p a�
3
Z4
3
L
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< A
.0
THIS IS TO CERTIFY THAT THE SEWAGE D6PD°5AL
SYSTEM. WA0 CONSTRUGTED A5 INDICATED ON THIS
PLAN AND THAT THE SYSTEM WAS IN5PECTE0 5Y
ME 6EFORE IT WAS COV5ICED OVER- .
THE 5YSTEM WAS GON5TRUCTED IN ACCO2DA90E
WITH ALL STANDARD RULES AMC) REGULATIONS
OF THE PUTNAM COUNTY DEPARTMENT OF HEALTH
AND THE NEW YORK STATE DEPA!ZTMENT OF HEALTH .
qr5 : HIPEK20 4 wt`LLl VkeGt7 ON 1' *0U v ey OE
}�Df'�1�'(Y" f fit%PAI��r� UY Tli�'( ('I��EUOOt'1`P Gof.1.JtJ�
°5�2x
PUTNAM COUNTY DEPARTNMNT OF JMAM
DIeMw s><Dil�iidl HaMA Saetlesa. Ctrl. N.Y. lOSI? to Pn�ilde
an CEM FICATB OF COM MANIM'
,
IS�OiAL sYS!®I Peed
Vii✓ o
3rAi�biw Djt :��7T c) f1i3/�%ct�bd Lat / G Tae - £ ,awe
Map
CA
� 'ta°°"'l_ ❑ erW'° o...d ypiC.. 14 ZV r-# 1-� 1--p N& a /
Q� /� , / ' .. \ /� Deft of Pn wkw Approval
Kdbg A&kn �15 O lj'-',kT T AVE: , A�_ d� G n
7J/p�
Date Subdivision Awnroved Fee Enclosed AmM nr`K ✓U v
• r r riA d ,,�. 2 .:Qg Fm Alan 0* c
MUNI Deslpo Flog G P D PCHD Notldatlon In Raali4ed W6aa FrD IS a�
sel.aa sow«ap sip= so o ad d/ saptle Twa md CO 0�0 L 2 5 ,
To M: esnafa'elad by T� TJ Address
WaMr. Sal*t - Pine Sopp4 Otsee Address
I represent -tnat n am wholly. a" FOnlPletely responsible for the.Aesign end location of the proposed system(s). 11 that the separate few di sal s slam
above described will be constructed as shown on the approved amendment there to and in accordance with the standards. rules a rpu ns o ha
County 0e00rtmsnt of HMRIy and that on corn
p»tion thereof a !•Certificate of Construction Compliance" Satisfactory to the Commissioner Of Healthwill
be submitted to the Dpartnient, and A written' guarantee will be furnished the owner. his succnfors. hells or anions by the builder; that Said bulkier will
ge.q in fOOd .OPerating cwnditbn any pert of said sewage disposal system during the period Of two (2) years immediately following the date Of the ifeu-
ange of the appeeal of the Certificate of: Construction Compliance of the original system or any r irs than ; 2) that the drilled well deweed ebofe
"ee »cateAOs Yawn oWthe app ► oired -p »n;and that Said well will M 1 al in actor nq ith the fi r uNs and rpu ns . Of the Fulham
County Department, of ✓j "� nth.
Date l!/% Signed
--��11 �L L�11 ✓� G C / P.E. R A.
Add/eIS
—1J
APPROVED FOR CONSTRUCTIONS This approves expires two yurs from the data issued unless construction of the building has been undertaken and is
revocaeN for cause or may be am"Wed o► modifie0 when considered neowry by _th Omminlonar of Health. Any change or alteration of construction
reauires a new permit. A Prn for disposal Of domestic % an�,, s e a stn NAu only.
Bev. _ a W /ace D al. �-_�.� Tit» a L1!5�
in
�uTt��4M C®uNT- mF -ALTli DEPT =30 `1r3j5 5
Road_`
Brewster, NY 1 0509" M Date � � 1 : 1.9 9 7 -
Received s ,� < 1
The:
For
k 3 Q 'HA� �i��
❑Cash ❑Credit Car-- By
�1
,cc(
co
vl- / Z l __- - -- - -- -- - -- - -
f BOG
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7AA
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
AF Li-;Z.`Or�i TO CONSTRI CT A `WATER WELL
DfNVT nwm"IrT Y
WELL LOCATION
Street Address wn Vill a Ci y Tax
Ab&dV1r-6j 29'40)V6 53
Grid Number
WELL
Name
f L
Mail
LM_r4gP, �Ll / J4�L�
Private
O- Public
SE OF WELL
- primary
- secondary
9RESIDENTIAL
D BUSINESS
D INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
U INSTITUTIONAL O STAND -BY
_
® ABANDONED
O OTHER (specify
D
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED O -5 /EST. OF DAILY USAGE &" gal
O REPLACE EXISTING SUPPLY ® TEST/ OBSERVATION CtADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
,O
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
13DRIVEN ODUG
OGRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES i/- NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: S
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1 _NO
NAME OF PUBLIC WATER SUPPLY: /414 TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION
/ (DON 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
thirti, (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: 19�'
Date of Exp' ation 19 �� �j Permit Issuing icirl
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
^ T�rr.;12m County Department of ifealth
Division of Cnv�ronmenia� Sanxra� ion
AFFIDAVIT - CORPORATE 9-INER APPLZ_CATXON
kOn i'ERM;T T . A PP-t,ICAT•xON SV3MITTED' TO -
PUTNAtS COUNTY ?IEALTf{ DEPARTMENT
1
T0: Com,lissi.or7er of Health It) the matter of application f'or
�..., r t ePreaellt
that .T am an officer ar erpYoyee of y ,
the corporation and am ;lAut•horli
ed
to act fox- L-4 I<1 as V1 ,
`(na me of COI'poratitin .,r " __ !-�
•
having off-ices ar
•H ' .`+. !�" .T 1_ �� rr �•�• �'n ~ � �. • � +T IMF r� .
Whose a£
re iden�f/��fd .''•"... fivers •g"
re
Vice- .P'resldent
Address
•" 41AZV_�AL��_ its � _
(Ndrne a- AddrL'ss}
Tres ."Urea'' x. U_ c
• ,(ur
Name and Tddress)r`
and that wal1 be individually responsible f'o� any*
o£ the- corpora tjorl 4 {ith respect to the approvaz re ' st d
seque�rit ac_rs re]ntxng •thereto.
s. l •sub -
sqwOrnf td bQf42'@ n
e this _day Signed
I.9�� TfCIe Vi (1* tF
4ta F�11ili�. .. '
N'ATALIE M. COLLETTA
NOTARY PUBLIC, State of New York
No. 4993008• : .
Oualltled in Ulster Ci
Commission �Xpir T
Corpor4te Seal ..._._-
PUTNAM •• UM DEPARDAADqP OF BEALTH /
FP • /rT
.LVISIN • F E NVI M MX � HEALTH SERVI CES r
DESIGN DATA SH=-SUBSUFACE SEWAGE DISPOSSAL SYSTER FILE 'NO.
4. - , _', � . . ---l-
Jocated at (Street) Z2g Sec. Block lot
Und-icate nearest cross street)
t-=-icipality - A-TT i= ,e-5e AJ Watershed C�TVIO
Son PEPmu-,TICN TEST mm Pzwmm To BE suag= wrm AppijamcNs
Date of Pre-Soaking— Date of Percolation Test
BOLE
C1= TIME
PERCOLATICN
P.EROD=C?N
Run Elapse
Depth to
Water Fran
Water Level
No. Ti
Ground
Surface
In Inches
Soil Rate
Start-Stop Min.
StaX4- t
Stop
Drop In
Min/In Drop
Inches
Inches
Inches
-7q'7
2
2 ��o�7/
7�8
�5
-7
7/g3
4 1
5 •
-b/ L
3 . 'q-7 L
4
2
3
4
5
-7
5z ,
7/g 7/9
NOTES: 1.* Tests to be repeated: at same depth until appmaimately equal soil rates
are . obtained at each percolation test hole... All data to'be submitted
for review.....
2.:; Depth ffeasureTents to be made frcm top of hole.
rev. 9/85-
LALI.)J. r.L.L L.u- L.a.c1 1%LA4UJ -X � Iv nr. ovncu .L.LZJJ rv.L.La r�.rrL.�.t�t•�t.�.:�ty
DESCRIPTION OF SOILS ET}OOUNTERED IN TEST HOLES
DEPTH HOLE NO. f HOLE NO. BOLE NO_
G.L.
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
'13
14 �... .
INDICATE LEVEL AT w-aica GROGN MM IS FN)COUNTE 3
IN -DIME LEVEL TO WHICH KATER LEVEL RISES A.F= BEING ENCOUNTERED
DEEP HOLE OESERVATIONS MADr. BY: DATE:
DESIGN
Soil Rate Used���y� Min/1" Drop: S.D. Usable Area Provided
No. of Bedroms 2? Septic Tank Capacity % gals.• Type
Absorption Area Provided By (o L.F. x 24" width trench
Other
Name �� , %�SSCC° • , �: C , Signatur
c o ;j z
Address Y�, �%� /L� /%� I t/� SEAL �`-- 1? ~
Zs
F"0 No. r
04578
A
9OFESSIC
THTS SPACE FUR USE BY •HEALTH DEPAEEENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
PUT NAM COUNTY DEPART MEN T O F HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant:
2. Name of Project: 3.._. Location T/V /C:
4. Project Engineer: X�A l /1LPf4 U) 5. Address: 174,
License Number: Phone: O
6. Me of Pro ect: :.._ : �� . -. -•
Private /Residential Food-Service ...Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject'*
ubject to State Environmental Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted_
8. Is a Draft Environmental Impact Statement (DEIS) required? Ilia
9. Has DEIS been completed and found acceptable by Lead Agency? ........... /o /4
10. Name of Lead Agency
I.,s.- this..rroject....in_.an. ar -pa. under - the control - -of - 1cc41-- •pl -a,n,n-4, n5 , zon'sng _ _ - - -- - - - - - --
or other officials, ordinances? ......... ............................... Yel;
12. If so, have plans been..submitted to such. author .sties ?..................... �1,,� b
13. Has preliminary approval been granted by such authorities ?iWli Date Granted
14. Type of Sewage Disposal- System? Discharge...... Surface Water _Ground Waters
15. If surface water discharge, what is the stream class designation ?........ 44
:6. Waters index number (surface) ........... ...............................
17. Is project located near a public water supply system? .................. 0
8. If yes, name of water supply A)/ 4 Distance to water supply
:9. Is project site near a public sewage collection or disposal system ?..... /1) o
0. Name of sewage system A lid' Distance to sewage system /U //4
1. Date observed: 23. Name of Health Inspector: Ul�l�/1�4GtJ1�/
4. Project design flow (gallons per day) ...... ............................... LD
L•. �2-
�. `25./`I -s �tate� Foil- u�Lar7i::. i3iscnargt.A cl- imination "Syscc:m' - (SPDESj.Fermit �rec�ui -reds: - --- :F':�`.� T' -
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? .................................. ............................... IV(,'
28. Wetland ID Number ........................................................
29. -Is Wetland Permit required? ... L. ���: !'U��:. �. L.�.� .................. �S
Has application been made to Town or Local DEC Office? .................. o)o
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 disposal;F'``
landfilling,*sludge application or industrial activity? YES or NO A) d
32. Is project located within 1;OOO - feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known - source of contamination? .....'.........YES or NO
DESCRIBE:
33. Is there a local master plan or file with the Town or'Vi'llage? ........... /06
34. Are community water, sewer facilities planned to be developed within 15 years ?.
35-.--Are -any sewage disposal- areas Arrexcess-of 15%.- slope? .......................... - -0
36. Tax Hap ID Number ........................................................... � 13,
37. Approved Plans are to "be returned to: ................ . Applicant X Engineer
If the application is signed by a person other than the applicant shown in Item.1, the.
application must be-accompanied by y-a Letter of Authorization: Failure to comply with this
provision may be 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 Hisdemeanor pursuant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
TAILING ADDRESS:
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Goulds
z5uolmersible
Ram—
Sump
• �:
=��� -��.• MODEL -
LSP03
,PARTS DIMENSIONS AND WEIGHTS
Item No.., Part Description Horsepower 1/3 6' /e DIA.
1 Casing , Voltage . 1.15 2•, /e=
2 .;:: •.;: Impeller Amps Max +
3 Sbbtidn Strainer Phase 1
4 Shaft Seal with Cover RPM 3400 1' /i' NPT
5 :, Motor CHAR
. GE
6 Bearing (Ail dimensions in inches and weights in'Ibs. Do
not use for construction purposes. Drawing is not I .
7 Capacitor to scale.) . 9 3/."
.�....._ -r.._. ,..._ __ ..... >__.__ ._.. .,5 ...: IGIAX. 5VL1T3
-O -Ring- -- - � - - -- - - - - - -.
9 Float Switch SIZE3 18".
PERFORMANCE RATING(�� INSTALLATION
Total Head -Ft.' 20 15 10 5
Gallons Per Hour 300 1200 1740 2220
,(In gallons per hour) I5
'Vertical distance from water level to st poi
discharge —plus pipe friction.
Maximum pump submergence is 10 ft.
SBJECA FAILS tkwlDPoC DIGS
11" MIN.
TILE OR BASIN
14 ".!N
CHECK
VALVE
UNION
POWER. CORD: 16/3 SJT
WITH NEMA 5 -15P
3 PRONG GROUNDING
PLUG -115' VOLT
TETHER LENGTH:
B =2" MIN. 3'/2" MAX.
APPROXIMATE
ON -OFF LEVELS:
A =6" TO 11"
A i.
BOTTOM OF FLOAT_.
1" MIN. TO BOTTOM
OF PUMP
PRINTED IN U.S.A.
APPLICATIONS
Specially designed for the following
uses:
Basement Draining
Water Transfer
Dewatering
SPECIFICATIONS
Pump:
0 Discharge size: 1'/2" NPT.
- Capacities: to 40 GPM.
Maximum head: 21 feet TDH.
Power cord:
o Heavy duty 3-wire 16/3 SJT with
NEMA-5-15 P 3-prong grounding,
plug, 115 volts.
Power cord length: 10 feet.
e Temperature: 104 °F (40 °C)
maximum liquid temperature.
0 1989 Goulds Pumps, Inc.
Motor:
• 1/3 HP, 115 volt, 60 HZ, Single
phase, 3400 RPM.
• Built-in thermal overload protectio
with automatic reset..,..,
• Permanent - Split- Capacitor type.
• Amps: 2.6 maximum.-.-.
• Cl ass F insu lation.
• Stainless steel shaft.,
V�
OM—
Separate Float Switch is
supplied with pump. .
• Heavy duty 3-wire 16/3 SJT
electrical cord with NEMA 5-
15P 3-prong grounding plug
Series-connected ("Piggy-
back" type).
• Switch cord length: 10 feet.
MODEL
'1
'',FEATURES
Corrosion- resistant cons truction.
304 Stainless. Steel motor casing
and fastners.
G lass-f i I led thermoplastic impeller
and volute
Ball, bearing construction. Both
upper and lower bearings are
greased for life. - -
M,dt6f is driTiane
extended service life and is powered
continuous operation. All ratings
are Within the working limits of the
motor.,
303 Stainless Steel shaft.
Separate float switch is attached to
the pump at the factory. Float switch
is adjustable for various liquid levels.
Easily . removed for direct pump
operation or switch replacement.
Complete unit is lightweight,
portable and easy to service.
Effective January, 1989
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NOTCS,: &10
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CQUIPMENY.
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