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BOX 13
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01450
4 P> -CO
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WELL UUMrLt_11UV tcZrUMI
DEPARTMENT OF HEALTH
Dfvlsfon bi tfivir6hiiental- Health 'Servit6'9
PUTN AM COUNTY DEPARTMENT OF HEAL
Office Use Only
fz —:2—
WELL LOCATION
ADDRESS: wNi t LACRIC11Y TAX GAID NUMBER:
- .3
JALA. , 2- , '
-
WELL OWNER
Nfiw . - — - ADDRESS: 1 9 PBIVATE
A —4 kpna 4 0 PUBLIC
11 RESIDEN'rIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS 0 FARM 0 TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
USE OF WELL
1 - primary
2 - secondary
AMOUNT OF USE
60
YIELD SOUCHT gpm./NO. PEOPLE SERVED _/ EST. OF DAILY USAGE � gal.
REASON FOR
DRILLING
[]?,EPLAC_3 EXISTING SUPPLY [:]TEST/OBSERVATION OADDITIONAL SUPPLY
VfNEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 5KJ� -ft. I
STATIC WATER LEVEL _j�6 ft.
MEASURED
DRILLING
EQUIPMENT
❑ ROTARY 19 COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH tL
MATERIALS: PfSTEEL PLASTIC 0 OTHER
LENGTH BELOW GRADE ft.
JOINTS: ❑ WELDED 6T BEADED 0 OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT "YDENTONITE ❑OTHE8
A
WEIGHT PER FOOT M' 1b./ft.
I DRIVE SHOE. MYES ❑ NO
I LINER: ri YES NO
SCREE
DETAILS
DIAMETER (in)
'SLOT SIZE
JENGTH (ft)
DEPTH TY EEN (ft)
DEVELOPED?
FIRST
'6�fs C3.. NO
Houhs
-SECOND
GRAVEL PACK
❑
0 NO
VNO
CRAVk/
11ZE:
DIAMETEW
OF PACK In.
lin
TOP V V
DEPTH —ft.
SOTT
DEPTH — IL
WELL YIELD TEST if retailed pumping
METHOD: ❑ PUMPED 1 tests were done is in-
If COMPRESSED AIR lormation attached?
❑ BAILED ❑ OTHER :OYES ONO
It more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACE
Nit
aier
Bear-
Well
Oi3-
meter
In
FORMATION DESCRIPTION
coof
WELL DEPTH
it.
DURATION
hr. min.
DRAWDOWN
It.
YIELD
9pm.
Land
Surface
63-ma) Pre-
WATER YCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
0 COLORED ANALYZED, 0 YES ONO
ANALYSIS ATTACHED? 0 YES ONO
STORAGE TANK' - :- TYPE
CAPACITY GAIT.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTA13E — HP
WELL DRILLER NAME DATE
ALBERT M. HYATT & SONS, INC.
ADDRESS Well Drilling SIGNATURE
Rte. 311 R. R. 2 Box 171A
pATTERSON, NEW YORK 12563 P&N-
NORTH AMERICAN
LABORATORIES, INC.
ANALYSIS DATA SHEET
TYPE:
PW
LOCATION:
Lot 26, Highview, Patterson, NY
REPORT TO:
John E. Garibaldi
ADDRESS:
406 Covington Greens
CITY, STATE, ZIP:
Patterson, NY 12563
DATE COLLECTED:
04 -26 -94
TIME COLLECTED:
1:05
COLLECTED BY:
J.E. Garibaldi
REPORT DATE:
04 -28 -94
LAB # :
94 -2644
SAMPLE SOURCE:
Kitchen tap
DATE
ANALYSIS RESULT UNITS METHOD ANALYZED
Total Coliform Absent COLILERT 04 -26 -94
THIS SAMPLE AS RE TED AT THI LA TORY MET
THE REQUIREMEN S O EW K STATE RINKING WATER STANDARDS.
r
I i
Laboratory Di or
NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 /914-278-7600/ FAX 914- 278 -7754
PLITNAM COUtRy DEPAFaxEWr OF HEALTH
DIVISION OF EWIR(XNZ=AL HEALTH SERVICES
e ?a-e� A_,iovA Q A
Owner Oe Purchaser of Building
Section
Block
Lot
&-&AA CqZZ"'r t &- %d t
Building Constructed by
l e W ,✓r-
Locat on - Street
MunicRn ipality
Building Type
,✓ 245? 0
Subdivision Name
7 .
Subdivision Lot #
GUARANTEE 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 Compliance" for the sewage disposal systen, 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-. utill z i rig
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental 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.
(SEE ATTACHED "LIMITATION OF GUA,1A TEE ")
Dated this day of ==F-` -- 19 -`/��- Signatur
Title
Gen a Contractor (Owner) Signature ROGER_MAYES CONST. CO.; INC.
Corp=6&� "OA6f .Corp• )
Corporatio (if Corp.) P,OUGHQUAG _N._ Y,12570
ess
Address
rev. 9/85
mk
LIMITATION OF GUARANTEE
NOTWITHSTANDING the attached statement, it is intended that the
sole responsibility of the Guarantor (septic system installer) is limite(`
to defective workmanship to the extent performed by the Guarantor (septa,..
system installer), and to defective materials to the extent supplied by
the Guarantor (septic system installer).
In addition, the Guarantor (septic system installer) shall be
responsible for the placement. of the system on the lot in accordance with
the plans supplied and approved by the board of health and for building
the system in accordance with the plans supplied..and approved'by the
board of health. However, the Guarantor (septic system installer)
assumes no responsibility for the failure of the system to function
properly if such failure is due to the design of the system and to the
extent that any materials and /or workmanship was performed by someone
other than Guarantor (septic system installer), or in the event that
anyone, after the installation, modified the installation or caused
damage to it in any manner whatsoever.
....... ......
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PUTNAM C OUNTY D E PART MENT O F H EAL TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: K) f�i izlLil/i,�t l
2. Name of Project: ._ /C:n
4. Project Engineer: 1'� i j,A). uEgo s� Z�z-= -. 5. Address: :B tr1J1✓
License Number: 15l•` C`L Phone: Z7S��61b�
6. TVDe of Pro ect:
.Private /Residential Food .Service = .._.Commercial ,
Apartments Institutional Mobile Home Park
Office Building .Realty Subdivision Other (specify)
7. Is this project subject: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? ............. SID
9. Has DEIS been completed and found acceptable by Lead Agency? ........... N�,4
10. Name of Lead Agency N�4
- tt. Ls this •prroject -1-n- an- ar-ea•-under -the control -,of-locat--planni-ng;--zen4n9i - - -
or other officials, ordinances? ......... ............................... tJ0
12. If so, have plans been..submitted to such_. author .sties ?.•................... W14-
13. Has preliminary approval been granted by such authorities? 41/A Date Granted:
14. Type of Sewage Disposal_ System Discharge...... Surface Water P""� Ground Waters
15. If surface water discharge, what is the stream class designation ?........ )/A
:6. Waters index number (surface) ........... ...............................
7. Is project located near a public water supply system? 1JD
8. If yes, name of water supply Distance to water supply
9. Is project site near a public sewage collection or disposal system ?..... )_
-0.
Name of sewage
system`/ 6) /A
_ Distance to sewage system �
1.
Date observed:
--
? -�� 23.
Name of Health Inspector: , 4 O e
4.
Project design
flow (gallons per day) ......
............................... b 0 z
m
: . 2.
2'5: Is-Stat& -- Pol- lutant - Discharge-81imination System` ( SPDES)- Permit required ?.'.
26. Has SPDES Application been submitted to local DEC Office? ............... _4
27. Is any portion of this project located within a designated Town or State
wetland ?........... ..................... ...............................
28. Wetland ID Number, .......................................................
29.-Is Wetland Permit - required ?' ..............................................
Has application been made to.Town or Local DEC Office ?. .................. L),ZA-
30. Does project require .a DEC Stream Disturbance Permit? ................... tJ o
31. Is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste disposal;`'``
landfilling,'sludge application or industrial activity? YES or NO
32. Is project located within 1;000 feet of existence of abandoned landfill, 4 ' -,"
hazardous waste site, salt stockpile, landfill, sludge disposal site or C --- _.
any other potential known source of contamination? ..............YES or NO
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ......
34. Are community water, sewer facilities planned to be developed within 15 years? 1INW- o v
35. Are any sewage dispos•al - areas -in excess of 15% slope? ........................ tia
36. Tax Map ID Number ......... ............................... ... ..........�- Z .397
37. Approved Plans are to"be; returned to: ................ Applicant Engineer
Lf the application is sighed 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
)rovision 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 I''est of my knowledge and belief. False statements made
herein are punishable as a Class A Hisdemeanor pursuant to Section 210.43 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
TAILING ADDRESS:
. r• qXWY DEPAFMMTr OF HEALTH
DIVISION OF M• E w BEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner T/) f�D� t�1 iLi i l�l Address 1 1-55 M 7�1 Q f E= . �u�f - N.
�— c -1
Located at (Street) r1 t IA V I ✓V QO 11f-�- Sec. Block 2 Lot 3 �
(indicate nearest cross street)
Municipality �iac`i ci�x3iJ r N •`�: Watershed Ij
SOIL PERCOLATICN TEST DATA RDQUIRED TO BE SUBMITTED WITH APPLICATICNS
Date of Pre- Soaking fl-_ �,74._ 1,2, _ Date of Percolation Test f _ �? 4 - 12
HOLE
NU4BM CS= TIME PERCOLATION PERC O=ON
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
2 p
3 f q , 1I �.
4
9
1
3 -
4
5
�2 2 °
e
L 3 1 D :!A- 11 2� '�d ��,�y •G�� �q yq �r
4
5 ..
NOTES: 1. Tests .to be repeated'at same depth until approximately eua_1 soil rates
are' obtained :at' each percolation test hole.. A11 data to' be suimitte3
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 HOLE NEY-
HOLE NO. HOLE NO.
G.L.
V
21
31
4'
51
61
71
81
91
10,
11
12'
13'
14'
INQICATE-14��L -GR IS. M40OU-NTIUM.-
,AT,
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATION'S MADE BY: DATE:.
DESIGN
Soil Rate Used Min/I" Drop: S.D. Usable Area Provided
No. of Bedrooms =j Septic Tank Capacity gals. Type
Absorption Area Provided By Ana L. F. x 24" width trench
Other
NEW
N1
Name IA-),- �TTZ- Signatur
Address I \41E— SEAL E:: uj
. W
4a P Er CO)
t
1,7 No. 56124
THIS SPACE FOR USE BY *HEALTH DEPARTMENT ONLY:
Soil Rate Approved _sq.ft/gal. Checked by Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO - CbRSTVUCT `A.. WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address
own illage City Tax Grid Number
WELL OWNER
Name Mailing
D (�
Addres
5 S D
OPrivate
D O Public
USE OF WELL
(I)- primary
2- secondary
Q RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL d INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /#
E3 REPLACE EXISTING SUPPLY
®'NEW SUPPLY NEW DWELLING)
PEOPLE SERVED �5' /EST. OF DAILY USAGE Leo gal
O TEST /OBSERVATION GI ADDITIONAL SUPPLY
0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DRIVEN
ODUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L_NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot 140'.
WATER WELL CONTRACTOR: Name T�Tp Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: WA TOWN /VIL /CITY
DISTANCE.TO.PROPERTY FROM.NEAREST,.WATER MAIN.:
N/
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
(DON SEPARATE SHEET
17. zo - /;t- " � -, 1
date) tfigfiature)
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- (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 m2g#er as not to degrade or otherw,`ontami surface or groundwater.
Date of Issue:
Date of Expiration Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
THE NEW Fr)UNDLAND 7'8" X 40' • 1120
16'X 40' Unfinished Second Floor e 640 Sq.
Q;
tip
0
w
f1,
f3 -1
Y -t
H
t�
c,
ca
f =:
r
``J
Pa
:I: w
CPrnnrl Floor
�_ 40' -
16'
• U ~
,�'8;,
�e
STANDARD NEWFOUNDLAND FEATURES
• Luxurious First Floor Master Suite
• Compartmentalized First Floor Bath with
Two Separate Vanities
• Formal Entry Foyer
• Formal Dining Room
• Formal Living Rohm
• Spacious Eat -in kitchen
• Fireplace Options Available
• Consult an Authorized Westchester Builder
for a Complete List of Options
• Artist's renderings and Floor Plan Dimensions are
approximate. All specifications must tie Written in the
Contract No oral conditions.
ESTCHESTER ODULAR HOMES, INC.
Reagan's Mill Road • Wingdale, NY 12594
(914) 832 -9400 m (800) 832 -3888
r IV
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property o
Located /aa%�t
(T) U �%N' Sff)\ Section --1'r. Block o` Lot
Subdivision of G7)/- Sl- e-el Jew laky"g r7lY�
Subdv. Lot .#- 2(, Filed Map #,
Gentlemen:
Date
This letter is to authorize V-ArM4
a duly licensed professional engineer r registered architect
(Indicate
to apply for a. Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions ofVArticle 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary (
Countersign
P.E , R-*---,
Ica
Address
/e, s A) 6n 1AZ q
'91 -?�( - to o ko
Telephone
Very truly yours,
f'
Signed (,
Owne of Property
1255 rna --A *ee �-
Address .
Dy' 4U 0 /0250
Town
Telephone
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH S IRFACE SEWAGE DN IS HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & S UB
REVIEW SHEET for CONSTRUCTIO PERMIT
STREET LOCATION
ME OF OWNER TAX MAP #
DATE
DOCUMENTS.
T D�ISCH—A.,RGE (OK)
P —E APPLICATION__ P DEEP HOLES LOCATED
-1 NTATIVE OF PRIMARY AND EXPANSION
IN LL .PERMIT; PWS LEI-TEK EXP: ;SHOWN; GRAVITY FLOW, Si7FF.SIZE
G � EERS AUTHORIZATION_ ED PIT & D BOX SHOWN ETAILED
ES DATA SHEET(DDS) HOUSE - NO. OF BEDROOMS
E LOG LLS SSDS'S WAN
FI'
EP LE ROPOSED SYSTEM
A<(- N TENT PERC RESULTS (3) METES & OUNDS
R HOLE DEPTH_— O - ACK NECESSARY (TIGHT LOT)
RATE RESOLUTION O E- -SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE
it�S THREE SETS__ NO BENDS; MAX. BENDS 45 W /CLEANOUT
E PLANS -TWO SETS 2� FILL SYSTEMS
:J VARIANCE REQUEST —' CL,AYB R
�/�GENERAL /' m10 FT HO ONTAL: SLOPE 3:1 TO GRADE
==SION UBDIVISION " "-=) f m FILLS CS
APPROVAL CHSc KED [SJD GAUGES
CD L PROFILE &
FILL REQUIRED ��' CID VOL
CURTAIN DRAIN REQUIRE PIPES TRENCH
Jx- ROVAL SSDS ADJ. OTS TRENCH PROVIDED
(TOWN/DEC PERMIT R & D) L�60 FT
ON DDS PLANS & PERMIT SAME _L 1 CONTOURS
1 P - 969 -NEIGHBOR NOTIFDTCATION , EXPANSION PROVIDED
,RBTPLBA SEPARATION DISTANCES SPECIFIED ON PLAN
IOJ 0 YR. FLOOD ELEVATION= - FIEIDS
UIRED DETAILS ON PLANS O L -:, DRIVEWAY, LARGE TREES, TOP OF FILL
Es
YSTEM PLAN - (NORTH ARROW) TO UNDATION WALLS
PON IC PROFILE m GRAVITY FLOW 00 TO WELL, 200' IN D.L.O.D., 150' PITS
TRENCH/GALLIiY m P- PIT DETAILS 10 .STREAM WATERCOURSE LAKE (INC.EXPAN)
NK -SIZE, DETAIL 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
AIL, SERVICE LINE IF OVER , .�� n�.0 -WATER LINE (PIT
CTION NOTES (GRU (DER RATE) eEr 50' INTERMITTENT DRAINAGE COURSE
!DE ATA: PERC AND DEEP RESULTS 00 FT. RESERVOIR, ETC.m 150 FT. GALLEY SYSTEMS
ITO - OOT CONTOURS EXISTING & PROPOSED SEPTIC TANKS
D AY & SLOPES CUT_ "FROM FOUNDATION; 50' TO WELL
WELLS
TING /GUTTER/CURTAIN DRAINS 15' WELL TO P.L.
MMENTS:
� O
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D l M E N S 10 N .. G-H-A.2 T.
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88.0`
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140.o'
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56.5`
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