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Re V” 3 86 °" ; PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y 10512
Engineer Meet Proylde (J r-j 3�f
P.C.H.D. Permit li—
CERTIFICA F CONSTRUCTION COMPLIANCRFOR SEWAGE DISPOSAL SYSTEM
Locsted at - . 2 - - - Tax Map -1_1.� Block I ` Lot
Owner /applicant Name ormerly " Subdivision Nam1SM ? Sabdv. Lot
Melling Address Ar "or -mp- j �� zip 0 1 N
Date Permit Issued � Z�
Separate Sewerage System built by Address b wok 4 l WIN
Consisting of Gon Septic Tank and 1 �+
all
Water Supply: Public Supply From Address
ort Prlyate, Supply Drilled by Address �_1 " i 1 �r� rl-,
Building Type � l � A " Hue Erosion Control Been Completed?
Number of Bedrooms �- Has Garbage Grinder Been Installed?
Other Requirements j t � ' �`' ►� 'l �ArtF s T'� iZ� 7F:I ui...
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the hs of the completed work ( copies
of which are attached), and in accordance with the standards, rule's and regulatio ac ordan wi f a plan and the permit issued by the
Putnam County Department Of (Health.
Date L Certified b P.E. ��R.A.
Address License No.
Any person occupying premises served by' the above systems) shall,promptly take such action as may, be necessary to secure the correction of any unsanitary
conditions resulting from such usage. > Approval of the separate sewerage system'sball become, null and void as soon as a pubs': sanitary sower becomes
evallable and the approval of the .private water supply shall become null. and void when. a public water Supply becomes available. Such approvals are
subject to 'modification or change when, in the judgment .of .the Commissioapr of H . h, revocation, modification or change Is necessary.
oats �� �� X r ey ����� ._— Titg�
WELL COMPLETION REPORT Office Use Only
DEPARTMENT OF HEALTH /
Division OfYEnvironmental Health Services'
PUTNAM COUNTY DEPARTMENT OF HEALTH
`J
STREET ADDRESS:
WN /VII =111Y TAX GRID NUMBER
101--,W,33 - /,
WELL LOCATION
e ��
NAME:
ADDRESS: jYP8iVATE
WELL OWNER
��
❑PUBLIC
USE OF WELL
❑ LIC SUPPLY ❑ AIR /COND. /HEAT PUMP . ❑ ABANDONED
1 - primary
❑ BUSINESS
❑FARM ❑ TEST/ OBSERVATION ❑OTHER (specify)
2 - secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF. USE
YIELD SOUGHT _--
gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE �® gal.
REASON FOR
NEW SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION
DRILLING
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH
��� ft.
STATIC WATER LEVEL �. —ft. DATE MEASURED
DRILLING
❑ ROTARY
COMPRESSED AIR PERCUSSION ❑DUG
EQUIPMENT
❑ WELL POINT
❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
C1 SCREENED
® n
❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH
ft.
MATERIALS: 9 STEEL O PLASTIC ❑ OTHER
CASING
LENGTH .BELOW GRADE _a ft.
JOINTS: ❑ WELDED THREADED ❑ OTHER
DETAILS
DIAMETER
:_ in.
SEAL: CEMENT GROUT ❑ BENTONITE ❑ OTHER
WEIGHT PER FOOT lb./ft. I
DRIVE SHOE 9YES ONO
LINER: ❑YES YNO
DIAMglin)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
_. SCREEN
<F ;RST. -v..
�... _
_.._
_ .... - -
..- .... �.....�
. C] YES p N0•
-
DETAILS
HOURS
sI coND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
OEM tt.
WELL YIELD TEST If detailed
pumping
LOG
it more detailed formation descriptions or sieve analyses
are available. please attach.
METHOD: O PUMPED t tests were
Vf COMPRESSED AIR ; formation
done is in-
attached?
N.WELL
ROM
CE
Water
Bear.
Welt
D'a'
FORMATION DESCRIPTION CODE.
O BAILED ❑ OTHER ❑ YES
❑ NO
tt.
' "9
meter
In
WELL DEPTH
DURATION
DRAWOOWN
YIELD
land
Surface
It.
hr.
min.
ft.
!J
4arl)
1 i
/
��'
LL
r..-.-m `-he
WATER 9 CLEAR TEMP. •
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES O NO
PUMP IHFORMATIOH
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
STORAGE TANK: TYPE
CAPACITY GAL.
A,I'E}t I.M 11ftTT & SONS, INC. DATE
Ao Ess Well Drilling s16ri3tTt1RE
e. 311 R.R. 2 Box 171A
PATTERSON, NEW YORK 12563 A*
Yorktown Medical Laboratory, Inc. LAB I CA ° `'0
321 Kear Street Date Taken: 11/:L8/87 Time: 8,1 -5
Yorktown Heights, N. Y. 10598 Date Re' d : Time:
..__..�:__. _._ __(914)245 -3203. - -:•.- :_- - -- _ ,..fit- e-- Repor -ted;
Director: Albert H. Padovani M. T. (ASM Collected By
JOE RIINA Referred By:
T 40 NORMAN PLACE , Sample Location:
Colonial Ridge, Fair Su.
ARMONK, NY. 10 .504 Patterson
Phone N
Phone # �!77 Sample Type:
L '� Repeat . Test? _ I' (check one)
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
X Standard Plate Count'(CFU /1.OmL)
(Agar Plate 0 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)_
X Total Coliform (CFU /100mL)
Fecal Coliform (CFU /JOOmL)
_ Fecal Streptococcus (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
Total Coliform: MPN Index (per.100W
t 3b
-Fecal Coliform: MPN Index (per_100mL)
OTHER ANALYSES
REMARKS (For Laboratory Use).
X Potable
_ Non - potable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each).
Outgoing
Na2S203
Incoming
X LE 40C
_ GT k °C
Other:
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tion of, Source*
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
LT _. Less Than (C )
GT Greater Than (�)
N/A = Not Applicable
LE Less than or equal to
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH NE YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT-THE TIME OF COLLECTION.
x
Albert H. Padovani, M.T. ASCP , Director
12 /85(Rved7 /87)RWE
For Lab Use Only:
H/C to
LAB OFFICE HOURS (Main Lab):
9AM -5PM, Mon. -Fri.
9AM -NOON, Sat.
1
PUTNAM COUN`T'Y DEPARTMENT OF HEALTH
DIVISION OF EVVIMNZEN AL HEALTH SERVICES
s00 7&T
�er'or chaser of Building
Building Constructed by
Location - Street
Municipality
Building Type
(0 2 4 3
ft t * Ca Block Lot
Subdivision Name
Subdivision Lot #.
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
`represent that6 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 shoran 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 " which fails to
operate for a period of two years immediately following the date of approval of the
1.
-- Certificate of Construction Compliance" for the sewage. disposal system, or any
made ade by 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 Environmental 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 bu' ding uti • zi
the system. `
Dated this day of 19 Signat
I Title
Gener Contractor (Owner) - Signature
L�� G
Corporation Name (i Corp-)
Address
rev. 9/85
mk
Corpora
0�Corp.
Address
7
Engineer th Provide Perinit
N.Y. 1051i
Lookled at ToVM
Subdivisl
ce
9wnir/AOP.�&ini Name
Date of Previo
ZID
Mailing, Town,
"im 611Y
constructed -
Address
Water Supply,: Address
rujIuc
-Or ihe'd - 0 that thee se-4iate, sewage -diispo'* sail sy'ston;. -
above described,will be constructed as,shown on ffie�aporov`ed amenelment ther ciond'in accordance with the standards, rules and:!egu1,at:ons.oT, the -Putnam
ace -.,in good ting, condition any: part.-of �said -sewage disposal _sjfste
will be located as shbiwn,on t-he'apiprove. pl n and the sald well will beAnitalled in, acc ancii wi t st d s o the' -Putnam
Cou
Sighed
Ad-
Date By
�
m
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
'- APPLICATION TO CONSTRUCT A WATER WELL"
PCHD PERMIT # p
Street Address Town/Village/City Tax Grid Number
WELL LOCATION
14- ddress C]Private
WELL OWNER
Z �Lp ,� 9'Public
USE OF WELL
W4ESIDENTIAL . O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
(specify]
1 -
O FARM O TEST /OBSERVATION O OTHER
.
2 - secondary
® INDUSTRIAL 0 INSTITUTIONAL O STAND -BY
AMOUNT OF USE
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
YIELD SOUGHT_ gpa► /# PEOPLE SERVED /EST. OF DAILY USAGE &0 gal
MEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O REFLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
WELL TYPE GRILLED DRIVEN ®DUG 11 GRAVEL ®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L,--'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAMES F SUBDIVISION:
Lot No. '3 3
WATER WELL CONTRACTOR: Name ��� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES Po" NO
NAME OF PUBLIC WATER SUPPLY:
TOWN /VIL /CITY
'- ll1S'rADTCE- TO'-PROPERTY FROM" NEAREST WATER-MAIN"
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
® ON REAR OF THIS APPLICATION �ON � ARAT SHEE r-- / L �"'
3' �� �7 —4
(date) (si nature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
-2 of Part 5 of the New York State Sanitary Code, and
provisions of Subpart 5
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 p rmit.
3. Submit a Well Completion Report on a form p ovid d b the ,P nam C my
Health Department.
Date of Issue: J�
Date of Expiration: 19-. emit Is uing Official
Permit is Non - Transferrable
0 /0C
0
s _ uuent .acts velati„
�Dtsry+ .lic
LINDA R. BURPEE
(Votary Public, State of New York
No. 4808377
nualified in Westchester County
Commission Expires a��
9 /ifs g
- po-n Jh.Ie for an-v or all acts
Corpo -s to Seal
F. Or e, _1c,�ee of �:' e _. ito . ioz ;ar,3 �. _:'t'�or�. ed
cicT for
�(ry °Jl; v' �`1i i�ft
"J . ✓� `t, -T ( C 4E,3C.
—
l -1 ' 4. 1�
i~';`, 0. s e o f ' C "e'T' S., a re
61vl /"(
Ct =t.•: E'it31
"'\ f j iF y. �_ .. %�.�. v it -C. � !�- ��- /�C.�.r I!. -•.l j /�"�� An
I�fy'�
nSp ..:
S_ C L:�... t' i
! -
s _ uuent .acts velati„
�Dtsry+ .lic
LINDA R. BURPEE
(Votary Public, State of New York
No. 4808377
nualified in Westchester County
Commission Expires a��
9 /ifs g
- po-n Jh.Ie for an-v or all acts
Corpo -s to Seal
IF -
APPENDIX B
PU` INAM COUNTY DEPAR`IMEN'r OF HEALTH - DIVISION
INDIVIDUAL WATER SUPPLY & SUBSURFACE
2 j .-50 G31)
OF ENVIRCRVENTAL HEALTH SERVICES
SEWAGE DISPOSAL SYSTEMS
; ,f '- ° L -MIEyq -SHr EEt - `CONSTRUCTION-PERMIT - -
(Street
Location)
CUMEN`I'S
=nit Application
)rporate Resolution
-ans - Three sets
igineers Authorization
sign Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
DATE REVIEWED:3 2� Y'
BY: -JC(—
WT 3s
s/s
SUBDIVISION
Perc �0
(3) Fill
cd S X,c�
ruse Plans - Two sets
all / permit; PWS letter
ariance Request
ENERAL
egal Subdivision
ubdivision Approval Checked
-approval SSDS Adj. Lots Checked
fetland (Tcwn /DEC Permit R & D)
iata On DDS Plans & Permit Sam
EQU= DETAILS ON PLANS
>ewage System Plan - (north arraa)
sewage System- Hydraulic Profile - Gravity Flea
?ill Profile & Dimensions - Volume
) or J Box;Trencn /Gallery; pump pit details
Septic Tank - Size, Detail
Bell Detail, Service Line if over
^onstruction Notes
Design -Data• perc•- and - deep- results._..__ __. -..:.
r o -Foot 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 Rmped Pit & D Box Shown & Details i
House - No. of Bedroans
Wells & SSDS's w /in 200 ft. of Proposed System
Property rtes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 110; Type pipe -
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fi'
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, lake Unc. expa
15' to Drains - Curtain, Leader, Footing
351to catch basin, storm& kin, piped watercour.
101. to Water Line (pits -20') -
50' intermittent drainage course
Se tic Tanks
10' fran Foundation; 50' to X11
15' Well to PL
WO-11 "'ilticl�
It
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF.ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, .CARMEL,.N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.'
Owner <foL1ZM4 k6or - Address
Located at (Street fee .. Z. Block I 'Lot" (d Z 3?,
6dica e neares cross s ree
Municipality_ j��,o� Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
o e
Number
CLOCK TIME
PERCOLATION )K
PERCOLATION
Run
apse
p o a er a er Level
No.
Time
From Ground Surface in Inches
Soil Rate
Start -Stop Min-.
Start Stop Drop in
Min. /in drop
Inches Inches Inches
1
10,67- to:45-
9'(z I'll
2
10' 4s - t t� t 5-
t 9 '
3
it. t6'- it'45 30
t9 � 13ia
'LZ
5
1
o' Q-t ►�' i
4_It= Il - ►I' 47 3 <� ZO 21 tl �'l4 Z4-
1 ...
2 _
3
4
Notes: 1) Tests to be repeated at same depth until aroximatelyy equal soil
rates are obtained a,t'each percolation test hole.. All pppp data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA.REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION . OF SOILS . ENCOUNTERM IN -TEST HOLES
DEPTH HOLE NO. HOLE" *NO . ` HOLE' 'NO.
G.L.
611 _7
1$"
24"
30'►
36" ,
t
li 2"
4 �!
`8"
54 11
72,.
78. it
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL- TO WHICH WATER-LE . RISES . AFTER BEING ENCOUNTERED -.4
TESTS MADE BY'- T t7 i'e�cs `Daterab�_i?�gr7
DESIGN
Soil Rate Used Zl 30Min/l "Drop: S.D. Usable Area Providedooag, c5G®c) [K
No. of Bedrooms 4- Septic Tank Capacity Gals._
Absorption Area Provided By CQ"i L.F.x24" a/ ate
Name 3igna ure ,
Address , Z-0-3 SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal. Checked by Late
1 �
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