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BOX 13
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Sepiiate Sew+en'ge System bnllt:tiy
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r , WELL COMYLE'1lUN t(hruml
14
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
office Use Only
_ r- _
� -� .- �
STREET ADDRESS: WNIVI / 1 Y \\ TAX GRID NUMBER'
WELL LOCATION
WELL OWNER
Nw ADDRESS:
, r�r /� �. U C
rage IVATE
❑PUBLIC
USE OF WELL
1 - primary
2 - secondary
ESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT — gpm. /N0. PEOPLE SERVED —3 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
W SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLA UPPLY DEEPEN EXISTING WELL
DEPTH DATA -
WEL' EPTH ft.
C WATER LEVEL ft.
DATE MEASURED /`5t
DRILLING
EQUIPMENT
❑ RO Co RESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT GPOABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED EN END CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH 3! 3 ft.
MATERIALS: EL O PLASTIC ❑ OTHER
CASING
DETAILS
LENGTH .BELOW GRADE - ft.
JOINTS: ❑ WELDED READED ❑ OTHER
DIAMETER in.
SEAL: ENT GROUT ❑ BENTONITE D OTHER
WEIGHT PER FOOT — 2 lb./ft
DRIVE SHOE: ❑ NO
IJ ❑YES
SCREEN
DETAILS
_ .
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
JIIST
S ONO
HOURS .�.
ECO
GRAVEL PACK
YES GRAVEL
O NO SIZE. -
DIAMETER
OF PACK in. I
OP
DEPTH tL
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED 1 tests were done is in-
O CO SSED AIR ; formation attached?
AILED O OTHER ; ❑ YES O NO
ALL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
peat�r
ing
well
Dia-
in
FORMATION DESCRIPTION
CIOE,
ft
fL
WELL DEPTH
It.
DURATION
hr.. min.
DRAWOOWN
It,
YIELD
gFm.
Land
Surface
A00
y
I
r
WATEiI LEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? ES ONO
ANALYSIS ATTACHED? S O 0
STORAGE TANK: TYPE)0_4g &
CAPACITY D GAL. d
PUMP WFORMATION
TYPE B CAPACITY L
MAKER G v U I �� DEPTH ® d
MODEL` VOLTAGES HP
WELL DRILLER NAME ,/t/) n/ Z (✓ DATE
ADDRESS AT d )( '? > SIG
C_-
J'
a
e
YML ENVIRONMENTAL SERVICES
321 K ar Street
Yor•.-:tr +turn Hw i5hts, N.Y. 10598
(914) 245-2800
----....._---..._ A� 'C��r`_ +..He�-r'�- 3�r�Y3Ci1} - Li�i•�: �t- +i'• -. - ,.._- ---- -- --•--- -- -•-- •- .: -
LAB #: 9:3.009946 CLIENT # : 26 NON ' :TAT PROC: FACE I
DENNIS MALANC:H K DATE /TIME TAKEN: 12/09/:74 10-00
Flo BO C31"-' DATE /TIME RECD: 12/09/94 1.1,45
CROTON FALLS, NY 10519 REPORT DATE: 12/19/94
PHONE: (914)-277--3192
SAMPLING SITE.*. ZENITH B1.-DG CORP WELL SAMPLE TYPE..: POTABLE
:
HIGH VIEW PATTERSON r NY- PRESERVATIVE'S: NONE
C OL " D SY: MALANC HUI:f TEMPERATURE..' 4C.
NOTES...: C OL I FORM METH: MF
DATE FLAT; PROCEDURE. RESULT NORMAL -• RANGE
12/13/94 MF T. C OL I Fi tRM ABSENT /100 ML. ABSENT
COMMENTS 9
BACT THESE RESULTS INDICATE THAT THE WATER
( WAS NOT) OF A
SATISFACTORY SAN I TARP . :_AL I TY AC CORD I THE NEW YORK E T
ATE
AND EPA .FEDERAL DRINKING WATER
STANDARDS, FOR THE PARAMETER
TESTED, AT THE TIME OF COLLECTION..
- I i Y: _ ----------------
:11. E�h1 I TTEL E� _ � _ __ -_
Albert H. Padovani, M. T. (ASCP)
Direct -ar•
FLAP# 10 :3
jO 36 -��
PUINA.M C RqrY DEPARIMI .0 OF BEALIH
DIVISION OF ENVIROLMENTAL.PIEALTH SERVICES
36
Owner or Purchaser of Building Section Block Lot
Building Constructed by
T,ocation - Street Sulx ivisiofi Na'
c'rxlity Subdivision Lot u
Building
GLIA.RA.= OF : SM 7 -,FACE Sam DISPOSAL SYSTrc•i
I represent that I an wholly and completely responsible for the location,
worknanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has-been constructed as sho�m 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 oremer, his successors, heirs or assigns, to Mace in good
operating condition any part of said system constructed by me which fails to
operate for a pericd. of two years iMed.iately following the date of approval of the
"Certificate of_ Construction Conn),iac?(-e" for the sewage disposal s, *st-em,. or any
repairs grade 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 D' . ector of the Division of - Enviror_� e.ntal health Services of the Putnam County
Depar�ent of health as to �,htther or nit. the failure of the sysjt gin to operate vas
caused by the willful or negligent act of the occupant of the building utilizin
the system. `
IPA
Dated this aL7 day of D 19�J' Signa _ I
Title
(Ck-6tar) - Signature
,- ..
Ave'' - pet i;
Address
rev_ 9/8s
mk
Corpora
Corp.)
ls�,_L_yr �--
P-Odress
Al 3
Date of Pcevb..
Mates Adiwoa t ,) U /IA9�iir n T ✓e < Towo
s++ms T G ( 4 t -t. IM Am 3 . M swdm o l), nep* Vamoa
Naiag el aailwl>r DWv Plow G P D 8 0 C! PCHD NWIndoa k Rogdmd Wbm PM k ompMbd
Sopaamia Saw+awLd S7§k= ma Comm at -000013 Saptle Tabk bbd
To Yy,awabwemad W % tJ Adlhsua
WIAW Sob': Pilo SW* Pm Addreo
an t/ ftl+ma SW* Dlfad by '78 l.) .�..
o&W....d
I reprerentAhat 1 am wholly and completesy.►esponsiple for the design and.location of the prOPosed system(g; 1) that time separate sewapa disho_al syRem
above described will be constructed aa'shown on the app/OVad amendment there to and in accordance with the standards, rule s am�eYu ms O
County Opwtnmt of ""ith, and that on completion thereof a.11C."ficate of Construction Compliance" satisfactory to the Commisflonar of Haelthwill
be submitted to the Department. and -a written guarantee will be furnisMd the owner, his succawor% heirs or maligns by the builder. that said builder will
piece in good operating condition any part of ;Sae sewage dispoal system during the period of two (t) ,years Immediately following thOdate Of the hw-
ance of the approval of the Caft"'ca", of Construction Compliancrpinal system or any repeMsahereto; 2) that the drilhd well described a6oye
will be located as strowm on the approved plan And that ti W wall will bin accorden oa with the d rd ;�Uand regu�TiErons of the Putnam
County a Partment off keiltb
Data I-3 —9 Signed
A *in - License NO
} ri
APPROVED FOR CONSTRUCTION: This approval expires two y s from the date issued nless construction of the building has been undertaken and Is
revocable for cause or may be amended or modified when con ed n ry by the issioner of H"KIO Any change or altwatbn of construction
requires a new permit.. Approved for disposal of domestic' ary age, a water. supply
R2V. Oab 6y
Title
io /$s
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLIt,:KFILON TCj ` UNSTRUCT -cam= iiiP.TER WELL
Prun PERMIT #
WELL LOCATION
re t Address � To V_i, }lage City Tax Grid Number
1, A„`,,. — :2--3 6
WELL OWNER
Name
�t
M i 1' g Address
o
rivate
90P ublic _
E OF WELLiESIDENTIAL
primary
2- secondary
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
0 ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT � gpm /# PEOPLE SERVED C� /EST. OF DAILY USAGE B00 sal
❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 12-ADDITIONAL SUPPLY
b&TEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN ®DUG GRAVEL.
i
O OTHER
IS WELL SITE SUBJECT TO FLOODING? YES !/ NU
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name *7- AB )) Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1,-"-NO
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED y
WON SEPARATE SHEET
—� `- -a"3 i�gn�.a/ ure)
(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
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 otherw' a co tam
inate face or groundwater.
Date of Issue: Z 19 4L�- '
T
Date of Expiration_19� Permit Issuing Offi al
Permit is Non - Transferrable White copy: HD File Pink y: Owner
3/89 Yellow copy: Bldg. Ins . Orange copy: Well Driller.
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAG.SYSTEM
1 . Name and Address of Applicant: JU
33 "A-44
AU� XC1a, Cl 9,
2. Name of Project: apEej � T/V/C: 119, `J_d►so�
4. Project Engineer: 1AJ 5. Address: iK�(.�L, -�I a lll`e_{ •�J
License Number: S l? Phone:
6. Type of Pro ect:
PPrivate /Residential• Food.Service ....Cormercial ,
Apartments - Institutional Mobile Home Park
Office Building; _; Realty Subdivision Other (specify)
7. Is this project subject to State Environmental Quality Reviex.(SEQR)?
Type Status (Check One) _ Type I.. Exempt
Type II. Unlisted,
8. Is a Draft Environmental Impact Statement (DEIS) required? ............. d
.9. Has DEIS been c.om'pleted and found' acceptable by Lead Agency? ............ % ,t
10. Name of Lead Agency,
11. Is this project in ?n area under the control of-local planning, zoning,
_.... _._ or- ,o.tbe.:r-.offlc,als-,- ordinances? .... ® -
12. If so, have plans been. submitted to such, author .s ties? .....................
13. Has preliminary approval been 'granted by such authorities ?V Date Granted
�;. Type of Sewage Disposal: System Discharge...... "• Surface. =Water Ground Waters
f5. If surface water discharge, what is the stream class designation ?........
:6. Waters index number (surface) ..:: ........ ...............................
' -(. Is project located near a public water supply system? .................. No
8. If yes, name of water supply /"/°4- Distance to water supply
9. Is project site near a public sewage collection or disposal system ?.....
Name of sewage system 1V1+ Distance, to sewage system
1. Date observed: 23. Name of Health Inspector:
Project design flow (gallons per day) ..................................... 80'y
25. is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. ✓"
b d t T DEG Office
eed submitte o-1'Qca� ?
-26. Has SPDES Application
portion of this project located within a designated Town or State
27. Is any. P No
wetland? .................................. ...............................
28. Wetland ID Number ........................ ...............................
29. -Is Wetland Permit_' required? ................. .............••••............
v - --
,Has application been made to Town or Local DEC Office? ..................
30. Does project require a DEC Stream Disturbance Permit? A/C
31, Is or was project site used for agricultural activity involving application 1:
of pesticide$ to orchards or other crops, solid or hazardous waste disposal;
Filling, sludge application or industrial activity? .• YES or N0
lan 9, _ _
32. 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? .....'.........YES or NO _ /,(
DESCRIBE:
33'. is there a local miister plan or file :with: the Town or Village? ...:.......
34. Are coimmunity- watet, sewer facilities planned to be developed within 15 years? �
35. Are any sewage disposal areas-in excess of 15A slope ?_.................•••••••••
36. .Tax Hap ID Number ............. ........:. -3 7, -2
37. Approved Plans are' to' be: returned to: Applicant _'Engineer
rf the application is signed by a person other than the.applicant shown in Item.1, the:
°pplication must be-accompanied by -a Letter of Authorization: Failure to comply with this
Drovision may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury;- that information provided on this
fo „ . is true to the best of my knowledge and belief. False state.-,tents made
herein are punishable as a Class A Hisdemeanor pursuant. to Section 210.45 of
the Pena 1 Law.
SIGNATURES & OFFICIAL TITLES:
':AILING ADDRESS: L�Ye ;rJ�►- �� ��, /G�`�
DESIGN DATA S i7:AC£- -S`Si? - ,_ -DISPOSAL. SYSTEM_..
HES`i�- • - FILE_IJJ, '9z%�� -c%
G;aner 6", / i G7 �l' Address 3 3 �oy � 1 -1- /y�.0 /l.Ur/krGG e
Located at (Street) /�` i G� VI i.✓ • �r ;� Sec.. 3 �3, Block Lot 3 lJ
(indi to nearest cross streetY
• �o GJ �✓fG' watWatershed ed
Pali ty h
j 7n1C1 - --
SOIL PIIRCOLATYON -•TEST DAM R To BE .SUS WM APPLICATIONS
Date of Pre - Soaking
Date of Pe.roolat-ion Test �,�F
.&A
.HOLE
=CR TIME
PERCOLATION
off'/ —
PE RCOLATICN
-Na R Elapse
Depth to Water k7cm
Water Level
Ho, Time
Ground Surface
In Inches
Soil Rate•..
Start -Stop Min:
Start Shop
Drop in
Min/Tn DroP
Inches Ihcch^es
Inches
J
7
l =
2`�37-��
3 —
4 -
5
�Q
a z �
o�
_._.._. _.._.... l ��,d� —
,•�
off'/ —
°�y 4 _..
_ .:. _. 3...f_
7,5
2 /a•Qr - /��
4 12 lol 6� %
l�
90
i
2 `
5
NOMS: , l._ . Tests: to be repeated. at, same depth until apprmimately.. equal
so il. rates .
are obtained at each percolation test hole. All data to' be . subau.tt�d
for review.
th mea.surements'.. to:' be made - frcen top of hole.
Name
c Signature c!!
Address
G SEAL.
SPACE FOR USE BY HEALTH DEPARTMENT OMYo
Soil Rate Approved sgeft%ga1,`e Checked by :: • ... _.... ':Date
PUTNAM COUNTY DEPART)KENT OF -HP,,A-LTH
DIVISION OF ENVIRONMENTAL H2ArTk SERVICES
Department of Healtl.i, anti to si.gii all ;ior--essary paper--3 pr� my behalf in.
coTinec ion s til l,i s a L Cer ins[, -60 5upervlse s m- i d
tH6, con,5-ruc-tj.oik 0
system GIV n-,A
*.y5teM8 in -corEfor'llity %Y 'i tile provis 0 O.0 -t c -e 14'= or
'147, Educle',ioy.-L Law, the Public Hea!tI-L- Law, and the: P u -11,ti a zi i. County S A n. i -
tart'- Code.
(D
C 0 W, It e rq i gn e &i
E-1 E) I R.A. r
Add
Z-0 16)
telephone
V�i-n r tra
olgrlea A
Ow,-per of Property
Add ess 1W,4 Z-
L
1 A iA�
0 �. Ll E l7 &0 �
T''orr
4,s i - 6 �
Telephone
2-3- 5-1
Re' Property Of
Located at
(T) T 7 e c t i un; :33,
Block Z Block Lot
Subdivision of
Subdv. Lo i. 1.
e'd Map Pate
Caen tlemen.!
This letter is Q author
7
H
a duly licensed P- i -i.g ir i
e o r or architect.
a to
:to apply for a.- Construction Pexw,;:L
f o'r a "separate -serfage system, to
serve the' abo.v'o note-.d propex- Ey liri
accorclaricC, cith -the standard-4, ri'ul-ee
ox, reguldtions i:1 prom u loga t e d try
tjie- Commissioner_ of the Putnam Count
Department of Healtl.i, anti to si.gii all ;ior--essary paper--3 pr� my behalf in.
coTinec ion s til l,i s a L Cer ins[, -60 5upervlse s m- i d
tH6, con,5-ruc-tj.oik 0
system GIV n-,A
*.y5teM8 in -corEfor'llity %Y 'i tile provis 0 O.0 -t c -e 14'= or
'147, Educle',ioy.-L Law, the Public Hea!tI-L- Law, and the: P u -11,ti a zi i. County S A n. i -
tart'- Code.
(D
C 0 W, It e rq i gn e &i
E-1 E) I R.A. r
Add
Z-0 16)
telephone
V�i-n r tra
olgrlea A
Ow,-per of Property
Add ess 1W,4 Z-
L
1 A iA�
0 �. Ll E l7 &0 �
T''orr
4,s i - 6 �
Telephone
(�Jr.31am ^,un�y i?epar tm�ni' of Health `
Dzvis. o). �i .Cnv�rof,renta3 Sani>araon
AFFIDAVIT - CORPORATE U•iNF,R AP t,zcAaZON
OR ..£' F:; R:" 4AT - T;. rll, f' t, LCA'I'.z6i1��Stj- f3�f7x.1•E.o--
TO
PU NAF, COUNTY iFA LTN D�FA RTMEHT
To-' Com;tiss5•oner of NeaztJ -
xr�_ the matter df apPxicat�on f'or ,
t h a t . I a m e n o"i �' c e r .� V. � ~..Y :.; .� ., ___..,, _. ,� �..' ..� �. � �, •� , :,r e P �' e t; e tt t _•
�l or ernZa, e of y
e the .
�a act for .... corporation and am. thari,zed ' , •• ..
: (1), me Oz corporation} -
hav�ng offdc
e s at A_ _
- - /-�•; - ..•.�,•� ��_G�_,�- --�:: those
rx efd �i ^" tiers
- C�ae�� �?� Q!-� a�'�'i
�ac��.��• —wS �' 'ire
�Nane -a7'
V.ice-- Preszc�e'�t
_ ^(Name a?zd Address
Secx e�taZ,y 4> �'• , >
ana Addz'ess}
(Marne and -
and i�at x � -end w_ �i11 be indivzdt�a) -lv z•eS r
o{ the corporation 4rzril respecfi fio �hc Ronsib] e dot) any 'rl s
se
q?zent act=s relota:ns - thereto, prrovaZ requ�st�d .61Ib..r
to 'be j ;
Rorie. re this dav Sz '
i , I 19 t3 T ti ~V1��
;otar POL)IiQ, ,
NATALIE 10o. COLLETTA
NO i ARY FUELiC, St�-:;e of New York
No. 499300a,: c�
Qualified in Ulster C� /
Commission �Xpiresc
�"�Par4te Seal
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