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HomeMy WebLinkAbout1714DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -35 BOX 15 ., ti 6101 rir IL UL 01714 PUMAM.00VM b ( Division of EnvlroemenW He 3e ( p ' rmeily L'H Tak MAP ; is", ' ' Blech._Lot s5 Sabdivleton'Name S _ Sutidv. .Lot 4� U Water Supply: Public Supply From. Address , r on ,vale Supply Drilled by r` Address BulldluglType Lot Size' :Has Erosio N ®bw of Bedroome Has Garbage.Grindei_ Been metalled! it Other Regelremeete I certify that the system(s),.as listed serving the above preen ea.vere. cons ted essentially as shown on y plans the completed work ( copies of which are attached), and in accordance with the 86Mards, rules and "re l tions *, in�a rdan with th sled pl and the permit issued by the Putnam County Department Of Health. Dais % 18' CMtifledby. P.E. RA. Address License No. Any person Occupying premims' saved by the above systern(s) $hall promptly •take such actk►gss may be' necessary to secure the eorrictlon Of any unsanitary conditions resulting from such ,usage. Approval of the separate a"!n ga••systkm shall become null and void as soon as a pubis: sanitary sewer beoomea available and ths!_approval of thsi, private, water supply shall become null inil'void li in a puO1k water supply becomes avalliblk Such approvals we subject to tficatlon or Change when, in the'judiment Of ths`Ca 'Issioner of N n, mosiHlcatlon or change Is necessary. 3/89 Date TItN WELL COMPLETION REPORT DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL TYPE A O SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK ❑ OTHER CASING STREET AOURESS: TOWNIVILLAWEICHY TAX GRID NUMBER: WELL LOCATION Lot #20, Indian Hill, Brewster, New York -3 WELL OWNER NAME: ADDRESS: pyramid Custom Home Corp. , Box 451, Crompond , NY 10517 ❑ P81VATE ❑ PUBLIC USE OF WELL ® RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED 1 - primary O BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify) 2 - secondary 0 INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O AMOUNT OF USE YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR []REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ®ADDITIONAL SUPPLY DRILLING ®NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 245 ft. STATIC WATER LEVEL 30 ft. 1 DATE MEASURED 9/21/94 DRILLING 1129 ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT 1 O WELL POINT.. O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE A O SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH 31� fL MATERIALS: ® STEEL ❑ PLASTIC ❑ OTHER LENGTH BELOW GRADE 0 ft. JOINTS: ❑ WELDED ' 9 THREADED 0 OTHER DETAILS DIAMETER 6 in. SEAL: E) CEMENT GROUT O BENTONITE OOTHER WEIGHT PER FOOT 19 Ib. /ft. I DRIVE SHOE: ® YES O NO I LINER: DYES ® NO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? FIRST O YES ONO HOURS SECOND WELL DRILLER NAME P.F. Beal & Sons, In "8 / 1 4 ADDRESS 4 Putnam Avenue SIGHA Brewster, NY 10509 GRAVEL PACK ❑ YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST If detailed pumping METHOD: ❑PUMPED t tests were done is in- I ® COMPRESSED AIR ,formation attached? ❑ BAILED ❑ OTHER ; 0 YES CI NO ALL LOG It more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE tt. ft. Water Bear- Ing Well Dla- (meter FORMATION DESCRIPTION ace WELL DEPT It. DURATION hr. min. DRAWOOWN It. YIELD gpm. Surface 15 Dri lling in overburden clay & boulders 15 Hij rqck at 15' 245 6 180 82 15 31 Dr'lli g in rock, set casing,groute 31 245 1 i1na in rock granite WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? O YES O NO PUMP INFORMATION TYPE submersible CAPACITY 7apm MAKER Gould DEPTH 2001 MODEL 7 G S 0 5 412 VOLTAGE 2 3 0 HP NlalVhlm T. Beal, Jr. STORAGE TANK: TYPE Well Xtrol WX250 CAPACITY GAT,„ 44 Al WELL DRILLER NAME P.F. Beal & Sons, In "8 / 1 4 ADDRESS 4 Putnam Avenue SIGHA Brewster, NY 10509 NlalVhlm T. Beal, Jr. PUINP.i•f COJN-I'Y DEPAFMriE7I OF HEALIH DMSIOIN OP Ewi-_R \mENTAL fjEP.LTH SERyicES a,mer or -Purchastar of Building Building Constructed by At l/ C't � Location I�/-Street i Fainu.ci0-al..ity Building Tyce P -7 3 - ,93 _ 3s; 3 Section Block rot L-1 A dr Subdivision team✓ 2 Subdivision Lot GU Rk=1 OF SU_PKTR r_C✓ S90Z -E DISPQ_IzkL SXS M4 I represent that I am wholly and completely responsible for the location, wore onshin, 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 Der_arbTent of Health, and ,hereby gual.a.ntee to the owner, his successors, heirs or assigns, .to • place in good operating condition any part of said systei constructed by me which fails to operate for a period of two years iri-t ediately following the date of approval of the "Certificate of Construction Com.oliance" for the serge disposal 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 Sys tem. The undersigned further agrees to accept as conclusive the deteriniration of the Director of the Division of Envixoa';ental Health Services of the Putnaza 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 utilzznn the system. j� r— ! Dated this day o 19 Signature zq,, Title (_�_ I () ,o Y General Con trac tou (O•n;n4r_)_�- Corporation blare (if Corp.) 4.cress rev_ 9/85 MR Corporation ' (if Corp.) f o P ess . / ') .5 -` BREWSTER LABORATORIES Box 224 - BREWSTER, W.Y. (914) 855 -1930 - V�'ATE� At���YSIS r�' EPORT SAMPLE NO. 8589 TEST WELL SOURCE: Pyramid Construction Lot #20, Indian Hill Brewster, N.Y. COLLECTED: 12 / 6 / 9 4 BY: P.F. Beal & Sons BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method 12/12/94 This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 0 per 100 ml. LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road WMA Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FAQ 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS January 10, 1995 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: As -Built SSDS Lot #20 Indian Hill Road Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing S -20 "As -Built Plan ", dated 1 -9 -95. 2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 1- 10 -95. 3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System ", dated 1 -4 -95. 4. Well Completion and Well Log Report, dated 12- 12 -94. 5. Water Anaylsis Report, dated 12- 12 -94. 6. Check in the amount of $200.00 payable to Putnam County Health Department. If there are any questions concerning the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. G 0 Harry W. Nichols, Jr., P.E. HWN:bd 94004 encs. cc: Mr: J. Mirra w /enc. l�rard r n� i 6�f.ir10. rw Ya v 1.v:w eRta1 i asirt Sor . k•e a i�ar'aw/ 1 1 1 [23 try .5 I t Kim F.'sayla�e+R to P rte. ki. M e.rwzu i W, y,ale.n ■ BMM'IWA TrM AM. . of , ax KIM +..oLnra qr Jp . u. tin d¢xsar- `. r�Nb.ar m( Ii...o oo.ar IC:41 I '. C•.F'..fit,.a tkxa la t(.t.q miSmA W in•r -se P'.hl� 6. �+..nN 'rKJ iegmor MAS i.. v �e �,�..• ti . c"«aaai u r -w�eiw al -_ - 1 ,.s4+w kFa,L Ian.► a a.d _ � / ,I ' � v �' - �1._:' , V: shoe \.�d0 FarA+O![ l.ryay�81. F r +ssa ,.kb: .wa s MIZOWWA w ! °r1Nata :$ix`�a Urr+dAn<I !n, -y ,.Ld:rew 1 ropnwnt ".that I om wholly ok conipl©toly responsible for tho,dmign,and location of the proposed systom(s)i 1) that the mparote scrod o dit ofAl 4840TH above described will be constructed as shown on the approved antondmont there to and in occordonco with the standards, rules an ragu a ens o 0 no Omnty CW"w4nt of '.Hc4 lth, 'and that on eomplotion;theroof o "Cortificato of Construction Compliance" aatisfaetory to the Commimloner of Healthwill 0* subrmktod 4o t%o Oepertmamt, end a rrritton guaranto0 dill be furnished the ownd, his WCCI'iMW96 hobs oP OW16n5 by the WNW. thilt SQId bUlkler will Ito In ! opra0lln eoMition any goat of said . sowege disposol. syftfn duriM the period of two (8) years Immodiatwy fol/ot 109 th®datO Of the k3M- 06= of tko apiveml of the Certi4kato of Construction Compliance of the original .systom or any re=' Os thcaoto. 8) that the drillmd %roil desoyfcd 06000 Cm be NWatC® oa ocean on tho omovog pion and that chid wall will I Iftso tied in pFcordonco th t ondarda, rubs and rc■uIons Hof the Putnam couf tb �ort6voma of "Moth. PAX— I.A. L®ddPe4s ®i.. 71F 6 _ p >� '1— f LiCef190 R10 S 7A,G.� ARpf STRUCT1OPi: This approval oupiros two years Prom tho date issuod unless construction of the building has been undortatton and is revocable for cause or may bo oanonded or modificii.whon conside7od ne ce>sgory by the Commissionor of HMnh. Any ehango or alteration of construction rcQuivos as now porm�i4.,/�ppvovOd for ®�isppowl of domestic sanitar7 -emag ®,yid /O► DviVOto t�a4or tllpply only. lev. L0�88oALL ®y �ls —!� �/�� Title �Y.7`�'�7',E�.� CO�NT�'• ���,A.�.'����7'r' Off' )��.A.X.'�� ,:,:_,: -• =` APPLICATION' F(A-•APPROYAL`OF PLANS- FOk A' NASTEWATER' DXSPOSALSYSTEH 1 °Name- and Address of" Applicant I�a�i�'�lYa ���i 'i�ili3A i-:� v v �/ 2. Name of Project: i°�r%PDGJ�t� Gi�175 3. Location:.,T /V /.C:_:- O 4. Project. Engineer: ress. i`OD G. License Number: Phone: 6. T e' of ` Pr6 ect -: L Pr.iva�t �Re"sidential" Food.Servica {.Comercial Apartments Institutional `(?obi le Home• Park Office Building- Realty - Subdivision ,.Other- .(specify?:; 7. Is this: project; subject' to State Envi ronmental 4ual.ity.- Review,"WO) ?. , "TYOe Status (Check One).. Type I::' Exempt ✓ ' Type II. Unlisted. 8. Is a Drar "t. Environmental -Impact: Statement (DEIS). required? NU s a s,; N': EIS b'ee com n° plated and:.iound acceptable: b Lead.Agency..y," 10. Name'`of'Lead Agency :;�: • . t 1. Is- this, project • in. an area under the control _ofAocal planning, •Xoni.ng,:.; or other officials,' ordinances ?' ........ ............................... till i2. If so,'have plans been_su 1tted.to`such, author .sties ?....._...............• 13. Has preliminar .a _ -. .. , . ,::•:. �:.... ... . _..: .. ., ... y' pproval been 'granted by such authorities. M/A Date Granted: Type of Sewage Oisposa'1 :�Systern Discharge ...l.. Surface. .Water:.. v Ground' Waters ►$• If surface water discharge, what is the stream class designation ?... :.:.. /A'' '6 Waters index number (sur e).. ... , ,,, ...... project`.located near a publ is water -r su 1 s stems .. ......... , : tJ D 1 ... PP...Y . Y. 8 • If yes, narp of water supply.,. W /A Distance &water supply :9..Is..pr0j. ct' site near 'a- public; sewage col,lection.,or disposal system ?..:.. IJD .0. N?.rne.:of , sewa e- s .stem �.,..'._�..__: g.. Y !J IA" :; .1 to. sewage system :i. ;Date_ observed -' -~--- -- 23, - Nam`e`of Heal`th�Inspector:.. 4'. Pro •.. . �eCt.design: °flow. (gallons per day): . :. .......:. g00':'• :....., _ r -.,: 2• 25. Is State Pollutant. Discharge. E1 iminat.ion System; (SPDES) Permit; required?: �o 26. Has SPDES, AF been.. submitted- to local• DEC Office? �. 27. Is. any_ portion of, ,this,project, located, xi.thin:a designated Town;or State wetland ?.; -- ° .......... ;,..: :..: t .... :E 28. Wetland ID- Number..::'.. ..... :..........:``•..:�.._:.... ............. ..... . ... ►J /6 29': Is Wetland Permit•required� :' :` . °.. ° . .... .. - Has:•appl ication' been. made' to Town =;or Local DELI Office? ....... . 30... Does project='re:gdire a DEC Stream.Disturbance Permit? .. ....... o. 31. Is or Was, project site .used for agricultural activity involving;appl.ication of pesticideq: to 'Orchards or other crops, solid. or.. hazardous _waste . J sposal landfilling, sludge`_application oi-' industrial'activity? .:: YES or:NO 1v 32. Is- :project located Nithin 1;000`feet'of existence of- °abandoned' an fill, - hazardous waste _s i.te, salt _stockpile; - ,1 -andf i 11; :sludge :.disposal ;site.- or.....,..._:; ..'., _•. any other potential known source or contamination. _ ,.. .. DESCRIBE: •j: 33..:Js::there::a local master plan�or'fi -le xith"thd.Toun or'Vi llage� h . 34 ..Are'_comiunity.Water,.:sewer'- facilities planned -.to be:.developed, xi ti: hi`n 15 years? 35. Are any 'sewage disposal °areas in�'excess of i5ro slope?"'... ....... . 0_ 36. Tax Hap ID dumber 37. Approved Plans are; to••be; returned. to: Applicant, y� _. Engineer r, the application is signed by a person other than .the .applicant shown .-Ah, Item ,l,,the. 2PP ication. must be• accompanied' by -a- Letter of:Authorization:* `Failure. to'- cbnply with this provision may -be grounds for the rejectio_ n of any submission. .i hereby affirm,.. under• penalty- of perjury;• that infornat on'`pibvided 'on this fori,i ' is true to the best of ray knowledge and beT ief. -False state:rents, herein. are punishable as a Class`,4' N�sdei eano'r, Pursuant : to Sect ion .:210:45. of herein _... . the Penal Law. 31GNATURES &.OFFIC v %2iL/ IAL TITLES: � '&AILING ADDRESS: .4 1 f,:, 7i3 l _ . ... 3.- L�i;i, 9.. vim. ,,. .... .. ,,.,, _. :_ e - ... .. ..._ >•.. •.•!. y. _�., � Si tis�c _ •Y_. .. ..._ .. .. M.'S.. __... ,.. �_.... .. ... DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #P' %✓'fY,— WELL LOCATION Street Address Town Tax Grid Number r ,, vri 35 - - - WELL OWNER Name r Mailing Ad ress . ' ;gin &. Che � Private 0 Public SE OF WELL 0- primary 2- secondary J< RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL PUC SUPPLY O BLI O FARM O INSTITUTIONAL O AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY 0 ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT zjJ gpm /4i PEOPLE SERVED L /EST. OF DAILY USAGEV'S } gal C) REPLACE EXISTING SUPPLY (3 TEST/ OBSERVATION 12 ADDITIONAL SUPPLY XNEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING «- WELL TYPE ®DRILLED ODRIVEN DDUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:.,S1&-' Hal Lot No. 2-C) WATER WELL CONTRACTOR: Name ! E&D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES e�,_NO NAME OF PUBLIC WATER SUPPLY: X14- TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: � LOCATION SKETCH 5 SOURCES OF CONTAMINATION PROV DED MQN SEPARATE SHEET t�V4 ' (date) (signature) 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 otherwise contaminate surface or groundwater. Date of Issue: 19.� -- Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller Putnam .f-!^unty Department of Health := Divisior::.': :f Environmental Sanitation AFFIDAVIT - CORPORATE a4NER APPLICATION FOR PERMIT. APPLICATION SUBMITTED- TO .PUTNAM COUNTY.}(EALTH DEPARTMENT ..yyf and that I =am -and will be individually responsible fon any'or all aptp . of the-corporation wth respect to the approval requested and-all .sub- =, , t acts relating -thereto. . _. Sw rnl to - before me this day Signed of 19 Q ' Title4_ -7- _. Notary Pub ic- BONNIE J. DAYIS MAURED IN CUTCHISS C ..::.'i , 6hY CAEdIKlSS!Gt� I.7�'ii'tcS,'1U�. �1, �? • Corpor4te >Seal TO: Commissioner of Health - In the matter of application for Ds, � Q_ S; ,9 -4eA_ '.. _ ._ .. _ _ _ _. � _ _ , — 9 represent, f that .1 am an officer or employee of the corporation and am: authorized ' to act for. (x, 11 �'vN� �4r7�i'CtC /.; /�(.,� � . ^ • —(name of corpo�tion)� _ `- having offices at (, P0/V ------------ . -- _ •- . �, _; Whose officers •are -(r) ��sE -�'/ r2.l�i 3� P-L�� �w 'C,e�n7poti� N President /�% V% _< --- _ -- — — — --game anTTddress)- -" ---- - - - --- Vice- Presie ent .4�► -; ^� _ -,- r; (Name and Address) :: ,. Secretary ' _.._ _•. .. .. i .r (Name. and Address) Treasurer ' �£ ^---- '-'-'— (Name and Address) � 7 =t and that I =am -and will be individually responsible fon any'or all aptp . of the-corporation wth respect to the approval requested and-all .sub- =, , t acts relating -thereto. . _. Sw rnl to - before me this day Signed of 19 Q ' Title4_ -7- _. Notary Pub ic- BONNIE J. DAYIS MAURED IN CUTCHISS C ..::.'i , 6hY CAEdIKlSS!Gt� I.7�'ii'tcS,'1U�. �1, �? • Corpor4te >Seal S -`` ` S s,.,..�r• z h- .'.'..- ; -'£,i a oa-, �v {.S rX- t- -.'e•a e �``:,�+, rf x" a F'- •.: ia- +-'' -•� a PUTNAM COUNTY DEPARTMENT OF HEALTH �` " DMis�pp at �+vh nom tirl 136" Serk Camel: N.Y. 18512 lti,410aarft Povld permit N on CERTIFICATE OF CON N PELMIf FOR SEWAGE DISPOSAL SYSTEM Peemlt : "M E1�u rZo� -ro Located ad own Sdbdivldon Name "ff ,L11�: f3kGr t tuba. Lit iY �"� Tax Map Block Lot , `. . 0 ^2 Renewal; O Revlaloo ❑ OMM /App =- I Nestle– Date of Previous Approval Gd�MF�L N%`� Tjp l O S-.i L MB ' ,�a � � �� � � t7 _ Town , Address . Building Type Lt At81 (7 L Section o* Doptb Volumi `• Number of Bedegomr Dealp. Flow G P D j a9 0 PCHD Notification 4 Required When Fill b cismpkted it Sepgeate iiewwert- -e System to bomb" of — Gallon Sepik Twh'snd S To:be oomtruetei! by '� ': DK:7ra4LA 4 1AJ 9,V AlidrellA Water Stlp *. Pg jo $ply F " ' Addarese or =' Prwate Sapoly'DrlRed'byI Ll' l7lLi(;i.l�iy.'C�ad, 1.lNkr�1 MA Other Requirements I represent that 1 am wholly an completely respOliabN,for; the dpsign._and bcation. of the proposed syftsm(s); )) that the Separate "Wage dis oral System above described will be constructed as shown on thai,approved amendment thereto and -in accordance with the standards, rules nn regu a ions 07 • u nom County Department., of Health; anit•thston completion thhreof e'•Cerfif'"ie. of ,Construction Compliant•" satisfactory to the Colrlinlifloner of Hasithwill M submitted `to the Department and, e' wiltt•n guarantee ccisa6isi heirs or assigns by.the builder 16st said builder will pin e• in good. opwating ciiindltion any -part of,, aid aw gi dipoial systirn du►inq'"the period of two (2) yaps iminediately following thedat• of the lau• Once of the app►ovsl:of tfull ificat • of Conatruction.Compllance OI h 'oryinal system or any rioirt;th•reto.2) that the drilled will described above will b• located:as sAdwn on the eppoved`pan an' het aid well will 0e insta ff m accordan wit hr. qa rA' rules and rigu anions ;of. , the Putnam County Depn mint of Health: P. E. R.A. Data r Address , tj License No 5 i APPROVED FOR CONSTRUCTION: This atpproval expues two years,lrom the date issued unless construction of the building has been undertaken and Is revocable for cause or may be•:airiended or modified when tons ars0 n s ry. the .Commissione of Health. Any change or alteration of construction° requires a new �876 it pr for disaosaf'of domed{ a Star ag rid' r N �. pply only. o ,/87 T / /g7 Date 9y Title � Putnam County Department of Health Division of Environmental .. Sanitation. AFFIDAVIT CORPORATE OWNER APPLICATION FOR PERMIT-APPLICATION SUBMITTED TO PUTNAM COUNTY.11EALTH. DEPARTMENT Tb: commissioner o . f H6alth In. the.,matter of application for • R mjo 9_2 LL a. represent that I am an officer . or employ I ee of the corporation and am authorlied, to act for Ao�!R C. (name of corpZrialt'19n) having.offices atys"_-;f t _Whose• officers •are • A(6- 60 Y2-: 'Zd r F, President V;/d Vice-President -71 7 _CNa7me­a7nd7Kd_(fr_e_SST Secretary C-be 0I:0 1 -4-07/ (Name- _an_d*Wd_dr_es*E) Tre asurer - - - ------ ----- -------------- (Name. and Addi4e­ss) and that I am and will be individually responsible for any or alliacts • of the corp9ration with-respect to the approval requested and all' sub- ' Gequent acts rela*tin 9. tliereto. Sraorn to before 'me this day Signed of 1987 Title Public ANNE B. COhRIOAN ca" VjY Cwmrjsa6n WM0 9D 4H R 4 Corporate Seal 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 # �� WELL LOCATION Street Address Town/ y Tax Grid Number � tom_ �. ��..�.. � -Zt'r�°�!� ►.9 - °L - Z�.. WELL OWNER Name Mailing Address AD�112cA j('(5, �i7k�0rM�� Co F',p. ��,� �7v XPrivate �3 Gl44v►Q4- ica3iz OPublic USE OF WELL ®`.primary 2.- secondary 0,RESIDENTIAL O BUSINESS O INDUSTRIAL O PUBLIC SUPPLY O FARM []INSTITUTIONAL O AIR /COND /HEAT PUMP .0 TEST /OBSERVATION O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT <pn gpm /# PEOPLE. SERVED /EST. OF DAILY USAGE > Ogal REASON FOR DRILLING NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL O TEST OBSERVATION DETAILED REASON FOR DRILLING r9 Pm, I Paw Grp WELL TYPE ®DRILLED DRIVEN DDUG GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES )< NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. 'Z-b WATER WELL CONTRACTOR: Name AAjLJ_ t7r7ALAA M(4 (2.a Address: 9,jqV&%, IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: w / A- TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION JgON SE ARA� SHE z -)A g (date) signature) 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 p provided that within thirty (30) days of the completion of water well construction, r 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 t Putnam County Health- -Depar ment. 7 Date of Issue: 19 -� / Date of Expiration: Z i 19 G� Wermi;:tssuing Official Permit is Non - Transferrable copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller T% n �� �... t� • • • a r • to v t M- DESIGN DATA SHEET- SUBSUFACE S&gAGE DISPOSAL SYSTEM FILE NJ. Owner VaV1o,LorMrzm4 CO..tt_,Z19. Address Fo, r3o?c 6t?o GtMr.L NL� l05 2 F�2 M Ta M Aiuc-(j.�-t rt r> $ Located at (Street) Sec. P-V Block 2- Lot Z-G. (indicate nearest cross street) CSueSDIV L o-T Zeal Municipality Z F,K B o ,,J Watershed C gu -ro IJ SOIL PERCLLATION TEST DATA RBQUIRED TO BE SUBMIMED WITH APPLICATIONS Date of Pre- Soaking UD 13 1 'S Date of Percolation Test HOLE NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Tim Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min/in Drop Inches Inches Inches 1 2;02- 2:ss :53 24 2 2'-59 - 3:53 54 24- 25� /Z (��Z 36 3 3.55 - 4.52 ; 5I 24- 25 Y2 l 2 35 5 1 47 3 3; 4S - 4; 38 150 4 �.. 5 1 2 3 4' 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 C(-0-( a a°) � 91' G.L. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. I HOLE NO. HOLE NO. 2' 3' 0 4' (,o 5' -61& I2oC1,. e 5(0" 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNUATER IS ENCOUNTERED N /A - - INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE HOLE OBSERVATIONS MADE BY: DATE: - DESIGN - -- - Soil Rate Used I° �'S� Min /1" Drop: D,SD S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity 125 gals • Type GoAN C Absorption Area Provided By 00 L.F. x 24" width trench Other Name (. mj ►'L -�N-r . km & f wtut 1G A'oc , pC Signature VVL W", , - 2 I a1, LL Address '13 FAi n-r-1 a w7 Dm i v f SEAL No. 56124 � AR0 1:-,V O��� THIS SPACE FOR USE BY HEALTH DEPARDM r ONLY: Soil Rate Approved sq.ft /gal. Checked by Date . 4ExlsrINCi WELL OS 4? b .. I FARM N TAX MAP. j division of &pproved as. applicable Putnam C un D /MENS 4s -BU14T /ON CHART OAt FT.) N° A B 35.5 20.5 / 2 50.5 90.0 3 50.5 330 4 S 54 35 5B. S 39.0 43,0 6 63.5 51.0 7 69.0 5 7. 5 8 74.0 E4.0 9 800 70. S 10 54.0 -33.3- // 573- 41.5 12 elf 46.0 13 66.0 52. o 14 7/.5 58.5 15 770 65:0 4 82.5 7/0 /7 270 45.0 l6 -340 5/. 0 19 410 56 S 20 46.0 63 0 21 56.0 70.0 22 62 5 77.0 Z3 69.0 82.5 24 .6/0 46.0 25 935 90.0 26 970 66.0 Z7 /00.0 70.5 28 103.0 75.5 Z9 10-90 62.5 30 113.5 89.0 TH15 IS, TO CE2TIFY THAT THE SEWAGE PlSPOSAL SYSTEM WA-5 WNSTKUGTED AS INDICATED ON THIS