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631- 589 -8100
35. -4 -22
BOX 15
01701
Separate;Sewerage,Sysiem bailf•by
Conslsting of
Water Supplyi . Public Supply From Address
or: ✓ Private Supply Drllled by 1 M)6 - dreas
Bullding Type f72�/-T/ _Has Erosion Control Been Completed?
Number. of Bedrooms Has Garbage Grinder Been Installed? •
Other Re
qulrementa
I certify that the system(s).ias listed serving the above premises.4ere
of which are attached) , and in accordance with the,'sfandaids, rules 'and
Putnam County Depar entxr� Health.
Date 1- �- Certified by.
as as shown on the plVed n of the completed :work ( copies
in accordance with the n, and the permit issued by the
P.E. ' R.A.
Any person occupying premises servedby the above system(s), shal(promptly take :such action as may be nscesury to secure the correction of any unsanitary
conditions resulting from . such usage. Approval' of the separate'sewerage:syi6M shall become null and void as boon as a pub(:: unitary sewer becomes
availathe snd the approval of the private' water :supply shall: become null and veil when a public water supply becomes availsbW Such approvals are
sub)ect to _modification or change when, in* Judgment .of tlie'Commissloner of' Healtq, revocation, modification m change Is necessary.
Date f2::e�j� ��15 By � � ----mac Title
1
I .
a
,Putnam County Department of Health
Division of Environmental. Sanitation
AFFIDAVIT CORPORATE OWNER APPLICATION .
_ FOR PERMIT. APPLICATION SUBMITTED TO
PUTNAM £OURTY }[EALTH DEPARTMENT ! :�
T0: Commissioner of Health - In the matter of application for
represent
that I am an officer or employee of the corporation and arrr authoraied:
to act for�t�
(name of corporation)
s
having offices at y_a �_ oJ_?
Whose- officers -are
Presidentp S }f C ,L0000,�-� �,[ reE�
ame and-Address_)
Vice - President (o G�c t}vi7/
-' (NRme and Address) _ _ _ ^ .
Secretary �� 1 C- o G — � --:9t_ —/ _ _
(Name and Address)
Treasurer
_ _ (Name- and Address)
P and that I am and will be individually responsible for any or all :act¢
• of the corporation with•respect to the approval r quested and all•sub-
sequent acts arelatin' •theretoo'
Sworn to before me this / � day Signed � _ _ _ _ � _ _
. _
of 198 Title
otary Public
ANNE B. COhRiDAN
way sw�at *W Y*
�r ContnisN�, my
Wrelr?� is .
ReA Nn =e71
tM887439
up�qr=4� Pew
Corporate. Seal
9
j
WELL COMPLETION REPORT Office Use .Only
DEPARTMENT OF HEALTH
a.
Division Of Environmental Health Services
w O PUTNAM COUNTY f DEPARTMENT OF HEALTH
STREET'ADDRESS: wNlVl / Y W'GRIO NUMSEP
WELL LOCATION
Steinbeck Estates, Farm — — rket Rd., Patterson NY
NAME:, ADDRESS: PBIVATE
WELL OWNER MONROE HEIGHTS DEVELOPMENT CORP., PO BOX 970, CARMEL,NY ❑PUBLIC
USE OF WELL KKR ESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND.IHEAT PUMP ❑ ABANDONED
1- primary O BUSINESS O FARM ❑ TEST /OBSERVATION .0 OTHER (specify)
2 - secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 3 - 5 / EST. OF DAILY USAGE 500 gal
REASON FOR RkNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY D TEST /OBSERVATION
DRILLING O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA ' WELD DEPTH. 700 ft. STATIC WATER LEVEL 2 5 ft.1 DATE MEASURED 6/17/88_
DRILLING ❑ ROTARY x9r-COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE ❑ SCREENED ❑ OPEN END CASING. MOPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH 100 ft. MATERIALS: x® STEEL O PLASTIC O OTHER
CASING LENGTH.BELOW GRADE 99 ft- JOINTS: O WELDED x® THREADED ❑ OTHER
DETAILS DIAMETER 6 in. SEAL: tiCEMENT GROUT O BENTONITE ❑ OTHER
WEIGHT PER FOOT 19 lb./ft. DRIVE SHOE EMES ONO LINER: O YES ONO
SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (f t) DEVELOPED?
:... DETAILS FIRST O YES ONO
GRAVEL PACK O YES GRAVEL DIAMETER 70P BOTTOM
O NO SIZE 11 ' OF PACK fn. DEPTH ft. DEPTH 1t:
. TEST pumping Yy �L� LOG ft more detailed formation descriptions or sieve analyses
WELL YIELD
If detailed are available, please attach.
METHOD: O PUMPED i tests were done is in- DEPTH FROM water Well
Q COMPRESSED AIR r formation attached? SURFACE Dear- Dia-
meter FORMATION DESCRIPTION cooE,
O OTHER OYES -ONO ft., BAILED it Ing I
WELL DEPTH DURATION DRAWOOWN YIELD Surface 90 HARDPAN & BOULDERS
it. hr, min. ft, gpm.
90 200 M DILM TO HARD GREY GRANITE-
400 1 30 400 1
200 375 PINK & GREY GRANITE
600 2 15 600 1 375 580 BLACK & GREY GRANITE
700 6 - 500 5 580 700 GREY & PINK GRANITE
WATEit XG CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
_. O COLORED ANALYZED? =WES ONO
ANALYSIS ATTACHED? WES O NO STORAGE TANK: TYPE Diaphragm
PUMP INFORMATION CAPACITY 82 GAL. 26
TYPE s sible CAPACITY 5 WELL DRILLER NAME MILL DRILL C A 20/88
MAKER GOULDS - DEPTH 460 ADDRESS Putnam Avenue SIG
MODE L7PW,041 - VOLTAGE210 HP 1._ Brewster, NY
R bert i , es en
�26�sri�TAL
Building Type
GUARA= 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 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 me-which fails to
operate for a period of two years immediately following the date of approval of the
.. "Certificate_ of_.Construction . Complianc:e° ,for. the...sewr_ age -dis sal. system; . 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 Environinntal 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. A .1 _ W
Da this
day of --1-
19 OO Signature
7
i _
.� _ _ - -,93e_ O
_A Title +
(Owner) -
1 ca
Corporation Nam (if Corp.)
_P0. 13Dv- cam" MAFZ,
rev. 9/85
mk
l l��- 1I aril!
III
+ ELLIS A. TARLTON LABORATORY
• " DIVISION OF ELLIS A. TARLTON, ENGINEERS, INC.
CHEMICAL 34 PLEASANT STREET DANBURY, CONN. 06813 -2328
PHYSICAL
BIOLOGICAL P.O. BOX 2328 203 - 748 -7903
WATER - WASTEWATER
METHODOLOGY
APHA - EPA - ASTM
NAME AND
COLOR
--1
SOURCE OF SAMPLE Water Supply
ADDRESS OF
'
Mill Drilling Inc .
Concentration
Stelnbeck Estates
PERSON. TO
Brewster, N.Y. 10509
RECEIVE
Putman Avenue f-:
Lot #5
REPORT
Brewster. N.Y- 10509
DATE OF COLLECTION 7/22/88
DATA
COLLECTED BY Mill Drilling, Inc.
Hydrogen Ion
COLOR
TURBIDITY
ODOR
CORROSION INDEX
DISSOLVED SOLIDS
Concentration
LANGELIER
(pH)
RYZNAR
NTU
Mg /L
Alkalinity as CaCO3
Fluoride (F)
Bicarbonate
Nitrite
Mg /L
Mg /L
Mg /L
Alkalinity as CaCO3
Chlorine Residual
NITROGEN
Carbonate
CONSTITUENTS
Nitrate
Mg /L
Mg /L
Mg /L
AS
Total Hardness
Conductivity
NITROGEN (N)
as CaCO 3
Ammonia
Mg /L
Mg /L
Micromohos /cm
Mg /L
Iron as Fe
Mg /L
Mg /L
Chlorides as CL
Mg /L
Manganese as Mn
Mg /L
Mg /L
Detergent as MBAS
Mg /L
Sulfate as SO4
Mg /L
Mg /L
The arithmetic mean of all standard samples examined per month using the membrane filter technique shall not exceed MEMBRANE FILTER TEST
one - colony •por 100ml. - Coliform• colonies- per-standard sample shall not exceed 3/50ml, 4 /100nfl- 7/200fi1, or 13/500m1" "` Collform Colonies /100ML
in: (a) Two consecutive samples; (b) More than one standard sample when less than 20 are examined per month; or (c)
More than five per cent of the samples when 20 or more are examined per month. 0
AT THE TIME THE SAMPLE WAS SUBMITTED:
1. The results of the analysis of Phis sample were satisfactory and met requirements for a potable water.
F] 2. The results of the analysis of this sample were satisfactory for a potable water but certain of the chemical or physical constituents were high. These are as follows:
1
D3. This sample was not satisfactory since it did not meet the bacterial requirements for potable water. The presence of organisms of the coliform group in a sample of potable water Is
undersirable and, while not necessarily indicating the presence of any disease- producing organisms, does indicate that such contamination might survive to the same extent. The
presence of organisms of the coliform group may also indicate that the treatment was not adequate at the time the sample was collected.
D4. This sample was unsatisfactory as a potable water because certain chemical or physical constituents were above acceptable limits. These are as follows:
COMMENTS
The bacterial analysis showed no organisms of the coliform group at
the time the sample.was collected which indicates the water potable.
Certified 69&. ..........X„I.l._.:C...... ........... .................� ".`.�T.�`:�]/
Fi--,,�
IL.
A
Q
✓� FINIAL SITE LNSPE'CTICV Date
Ins ctei by
;CAT: �0�1� °
`�4 fi OR S'JEDIVISICN LOT a
S ^i[?GE DISPOSAL A -MA j
j —=
b. Fill se --ticn - Date of placenent -
----
c. Natural soil not stripred I
I --
d_ Stone, brus:, etc. , greater than 15' from SDS area.
e. 100 ft. from wet er course /wetlands.
S��u -- DISPOSAL, , SYSTU4
a. Seotic tank size - 1,000 1,250
b. Sentic tank irst=lled level I
I I
c. 10' mini= f=cn foundation I
I
d. No 90° bends, cleancut within 10 f`.. of 450 bend I
I
e. D I STRIEL'IICti EC-X
!—.All out! ets at, same elevation - water tested ,
,h '
2. Protect--- �c:a frost I
I I
3. M- nim= 2 -- origins soil between box and t`nc-!es
E . JUNCTION ECX -- prcrerly set I
I I I
1. Lena�`h r _r=te - -
-
2. Dist :Pace tC war zccurse measur u
3. Ins=�ler acrdinc to plan
4 Distance canter to canter I i
it
5. Slone car trench acce-o le 1 /1'0 - 1/32 " /acct. I I
I
6. 10 feet f_ -a Drcre- --L,7 line - 20 f� t - foundati cns I
7. Dertn cr `nc.-� < 30 Lnches fran surface
8. Roan allcxad for exr�nsicn, 503 I
°. Size of c _t;el 3/4 - 11" diameter
10. Dept* or c =vel in trench 12" m�-nimun I
11. Pi re ends cpced
�. PD. -T.OR -DOSE S-�ST��S .1. Size of c�= mina -
-
2. Overflow tank I
I I
3. Ala=, vis- ca
4 Pump east =; accessible manhole to grade
5. First box
6. Cvcle wit,e=sed by Health De�rtment I I
I
estimates =1cW Cvcie 1
IV. H
CL.
b. �;�-ri of beer �.s
V. iEEL
a. Well local as rer approved plans
b. Distance fr=, SIDS area meassred ft.
c. Casing 18" aLcve grade.
d. Surface drair=_ce around well accentabie.
VI. _ OVERALL WCPJCLm- HTZ
�. Ecxes procer_v grouted
b. A? i pines .fir ti ally bac1cfilled
c. pipes flue^, with inside of box
c. Fackfill material contains stones < 4" in diameter.
e. Certain drain installed actordinq to plan
L Certain drain cut*all protected & dir. to exist.waterc
c. Footing drai:^s crscharce away from SDS area
1. Surface water protection adeouate
E__os.ion crnz: provi d� on slopes greater t`z ri
77777-77�
7,
TUTNAMA
on CERMCAM OF CO
/
place, in g8�d.-6,peritirig' co-iniflill6n .'any -part -of sa.d-sawa
son.'Co or
Date
Iddrss-
sl
Date y
" system(s); 1) that the separate sawage,disposal system
x6rdance with the standards, rules and regulations of the Putnam
his successors. heirs or assiI by.'the �uildei, that' said buiideir Will
License No
ny change or Alteration of c2nstruction
i VS11 /I Title
~
V" •. DEPARTMENT -OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3.641
APPLICATION TO CONSTRUCT A WATER WELL �%g.1��
PCHD PERMIT OP-17-0
WELL LOCATION
Street Address
o Village City Tax
Grid Number
WELL OWNER
Name
P owe'45 PaSRG
Mailing Address P. 0
r Co.
M-Pfivate
O Public
SE OF WELL
- primary
2 - secondary
UKUSIDENTIAL
O BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
D INSTITUTIONAL O STAND -BY
® ABANDONED
O OTHER (specify
0
AMOUNT OF USE
YIELD SOUGHT
c�j gpm /# PEOPLE SERVED /EST. OF DAILY USAGEj,,)DQgal
REASON FOR
DRILLING
MEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
&DRILLED
DRIVEN ODUG
®GRAVEL
®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L,"" NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 5zlFu& c- y Ri u_.,
Lot No.
WATER WELL CONTRACTOR: Name '5 Qs -Q'eff_H i &IC-0 Address
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWNIVIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �-A&
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED,
ON REAR OF THIS APPLICATION 5 N SE ARA SHE
fty Na AIL-,
0,_s�fignAt-ULCI
ture)
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 pro i e y P t unty
Health Depar nt.
Date of Issue: 19
Date of Expiration: 19 ermlt Issuing fic a
Permit is Non - Transferrable White copy: H.D. File
Yellow copy:., Building Inspector
Pink Copy: Owner
__ 2 87 Orancra mnv< WAl l nri l l ar
am,
APPENDIX
Pumm aX=Y DEPAR24ENT OF REALM - DIVISION OF EfflnMENML BEAM SERVICES
INDIVIDUAL MM SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSva
(Name of Owner)
REVIEW SHEET - CONSTRUCTION PERMIT
DiUE
( Street Location)
DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc.Hole Depth
W�
s/s
(3)
House Plans - Two sets
Well ✓ permit; PWS lett
Variance Request '
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wet-land (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flora
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder notes)
Design Data: perc.and deep results
Two-Foot Contdurs misting &'Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shcwn;gravity flow,suff. size
,If Pumped Pit & D Box Shawn & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & Bounds .
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEP -WTION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expa.n)
15' to Drains - Curtain, Leader, Footing
351to catch basin, stormdrain, piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
\
�S
60)( --rw
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