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BOX 15
01716
IN
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IN
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01716
.?,•�4 �,.._..��- }'�-�;
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TY DEPAflTMffi�PP OF HEALTH
PUTNAM COUN G
/c/'
DlvlaionotFhtvhonmeatilHedlti N.Y. 10512
Must
�� /
Ee�Eaeer Provide
CEHTIPiCATE OF CONSTRUMON COAIPLIANCE -FOR. SEWAGE. DISPOSAL SYSTEM
1 ��
4>
0`
Located at
J
` .Tax Map,
_Bloc&�
Nae
7-7 m
0 A
o m
Sgdlvson Nme�
51 f D Zp
dv. Lot
� ' .,
M01.11611 Aaaa.
Fee Enclosed •
Amount
Date, Permit
Issued 47
Soptgate Sewerage System bat, by n L
Canekft of —Galloa Septic Tank and
Water Supply: Public Supply From Addn=
on L/ Pdvate Supply D.M d by P4 F1 45 rif-0!34 Address ` b= /u
Lot Size L;�� G Has. Erosion rontr.nl RPPn CmmplPt-PA ?*
BaUding Type -- ' f
Number of Bed ems Has Garbage Grinder -Been InstillledY
Other $egdbemgnb
I Certify that'the system(s) as listed serving the above premises were Octed essentially ere alwvn the plans of the completed cork.(eoples
of which are attached), and in accordance with the standards, rules and r' ations, in ocordance with e f led lan, and the permit - issued by the
Putnam county beparrtmment OOf( Health.
Date D - / � "Ill' CMtifked by ,� P.E. ZRA..
Address �° � NO.
Any person occupying premises served by the above syltemis) 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 saweraga fystem shall become null and void4s soon as a pubtlo sanitary ee,1Fw becomes
avallabla and the approval of the private water supply'shall becom**.nu lt and vokl when .i, public Water supply III Ch N evallsble. Such approvals we
wb)ad to lficstbn or Mange when, in the Judgmint of LM Coninilstibrier "ot Nplth; such revoeatbn;':nodNkatbn or change 1 ►y.
Chafe B, TItN
3/89
1
WELL COMPLETION REPORT Office Use
DEPARTMENT OF HEALTH
Division Of Environmental Health1 Services r
PUTNAM COUNTY DEPARTMENT OF HEALTH
a
MOUNT OF USE YIELD SOUGHT gpm. /N0. 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 165 ft. I STATIC WATER LEVEL 40 ft. DATE MEASURED 4/18/94
DRILLING ® ROTARY 1E] COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
STREET ADDRESS.
WN /VILLAGILICHY
TAX GRID NUMBER:
WELL LOCATION
Lot #18,
Steinbeck Hill,
Brewster, NY
3 _ ,_,
WEIGHT PER FOOT 19 lb./ft.
NAME:
SCREEN
DETAILS
:..
ADDRESS: BOX 4.51
DIAMETER (in)
O PBIVATE
WELL OWNER
Crompond
Contracting Cor
> Crompond,
NY 10517
O PUBLIC
USE OF WELL
0 RESIDENTIAL ❑ PUBLIC SUPPLY
❑ AIR /COND. /HEAT PUMP O ABANDONED
1 - primary
❑ BUSINESS
O FARM
O TEST /OBSERVATION
O OTHER (specify)
2 - secondary
O INDUSTRIAL
❑ INSTITUTIONAL
❑ STAND -BY .
❑
MOUNT OF USE YIELD SOUGHT gpm. /N0. 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 165 ft. I STATIC WATER LEVEL 40 ft. DATE MEASURED 4/18/94
DRILLING ® ROTARY 1E] COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING 13 OPEN HOLE IN BEDROCK ❑ OTHER _
CASING
DETAILS
TOTAL LENGTH 31 ft-
MATERIALS: E7 STEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE 30 ft.
JOINTS: O WELDED ID THREADED O OTHER
DIAMETER 6 in.
SEAL: ® CEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT 19 lb./ft.
I DRIVE SHOE-:0 YES ONO I LINEA:OYES ®NO
SCREEN
DETAILS
:..
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
FIRST
❑ YES ONO _
houriS
SECOND'—
:.......�. _... ....
...... -
_...._.: ... -
_ T _
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK In-
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST 'If detailed pumping
METHOD: ❑ PUMPED i tests were done is in-
0 COMPRESSED AIR , ! ormation attached?
O BAILED ❑ OTHER O YES O NO
WELL LOG II more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
it. it
Water
8ear-
ing
Well
Oia-
nefer
FORMATION DESCRIPTION
coot
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
(t,
YIELD
9f:�
Land
Surface
overburden clay & boulder
13
H
t
ock at 13'
165
6
120
7%
13
3
D
it
ing in rock, set casing, gro
tec
31
16
D
it
ing in rock granite
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES ❑ NO
PUMP IMFORMATION
TypE submersibleCAPACITY =_g
MAKE. Gould DEPTH 140
MODEL7GS05412 VOLTAGE23OHP '-2
V_ ( r
I
STORAGE TANK: TYPE
CAPACITY GAI..
WELL DRILLER NAME P.F. Bea 1 & Sons, Inc DATE 8/17 / 9
ADDRESS 4 Putnam Avenue StGtdA
Brewster, NY 1050.
V_ ( r
I
O'r
PUMAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner o "r 'Purchaser of Building' J
,4-
Building C /onstru t by
Nv-
G
Location r /Street
3
Section Al�k Lot
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
UX represent that* 4C 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 bW 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 system, or any
repairs made 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 o to was
caused by the willful or n n ligent ct of the occupant of the )
the system. q S71 A, V
Dated this day of 9 l Signat
�i n A Title P4 0-4-
rev. 9/85
mk
Corporation Na
.(7�.0" 0
Ldina..utVliz4q
SoC/o c t\S�
BREWSTER LABORATORIES
Box
(914) 855-1930
SAMPLE NO. 8512
SOURCE: Crompond Contracting Corp.
Steinbeck Corners
Lot #18
Brewster, N.Y.
COLLECTED: 8 11 / 9 4
BY: P.F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
TEST WELL
I
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
8/15/94
THOWas -Meyer
Director
71
0 per 100 ml.
("!! 'M m M` 016KP
;09 e
Seedad ch*
1�-PC'H'DN IS Iiiiiiitl���Wbm FM IS CON~
HUMV61.41 Bad Dofti Flow G P-11
V 0
swraft q fil comm — . -, .. .
—5 I*ikaad--- 7yle'C' 9Q12A;Q1 P ;2
8 r4 Addrelos
WII Sy s` NO* FIro• Address
----- 7M�
en—&Lp�- Si" bl1 by ... .W o ll
f
so
the propand,sistimm 1) that the perate.
above doscribod . will be constructed as shown 96 1" ip - Or" amendmiant,ther'i'to and 1,nampordance With the StAridards. rules and regulations IT
County ;001*1`Tdnt, 10:- kiikh, --And that on Completion thereof a.--,CiiWIcit9 of Construction Compliance"' Satisfactory to the Commis"ner of Health will
d• aaabwatttee to too will 'be ' ed-,the oOnar; his' W'Sialipis by the bulkl0r. that Said 64106i Will
-0 r the PI
place in hood_ opprating� cdaiditlon. any'. part of nld�.'ivwigid Wi0d,of tW0!(2),-YQWs Immediately following the d1litill'o'll, the. lau-
M
once of,t".'000*81 0-the certificate 'of Conilthxti6n,c MOO is ',oft, inat. System or, any iipilri tliverato; 2) that the drilled . welt'doW.1110010 fi-
1;0 w co end rew-u%=—sof the Putnam
catnty Olin and that '"'Id Wall, it I In 4 k"" WI do 16 rules,
!h t
Date Sign, P.E. RA.
A or"
i L ic hSo IVO
APPROVED FOR CONSTRUCTION- This apprpv al expires two Years qom the.dato I" unless construction of the building Jus been undertaken and is
ri"le for cause or or, modified When coniidMW Aecesjjiy by:. the -Commissioner of.Hailth.. Any change'or alteration of construction
"alluirei a rArit permit.. Approved for disposal of dornealk: Sanitary, lor private water supply only.
Rev.
10/88 Data Title ow�
CE
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 105.09
(914) 278 -6130
rt �..-._ APPI;% ��T�TOAT°. dTpz �CC�T° B�RUCT-= �A��InT.�'i1ERw•6uE1;L4:_,,.�_ .�. __._ ..,- �.:�:- .�.-.:._..'w.�F...�.,wa,.
PCHD PERMIT #
WELL LOCATION
.—Street Ad ress Town
..t-- e1 d •Cz Z i L igoctd
Tax Grid Number
WELL OWNER
Name
Mailin Address
'I" 9
OPrivste
C � ava_�c �, ('�
2 .� -' Public
USE OF WELL
1 - primary
- secondary
RESIDENTIAL
BUSINESS
INDUSTRIAL
® PUBLIC SUPPLY
0 FARM
U INSTITUTIONAL
® AIR /COND /HEAT PUMP ® ABANDONED
p TEST /OBSERVATION 0 OTHER (specify
0 STAND -BY
AMOUNT OF USE
YIELD SOUGHT fpm /# PEOPLE SERVED /EST. OF DAILY USAGE YS014
® REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION 12. ADDITIONAL SUPPLY
9NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
i 9,eiCe
WELL TYPE
row
WDRILLED
DRIVEN
®DUG
®GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name: Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 3C NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ly-A
.,_m __DISTANCE . TO.'ZW1!ERTY- _-FROM NEAREST °WATER -MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(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: A jam_
199
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
• � �.��'N.A.L�C ..COiC7"N'�CX D)��.A,�TMEr7'r Off" ><X�_A,Z..'x`7E3
ty
;' == ::•- --'-;-'APP.LICATIO !FOR APPROVAL' OF PLANS: FOR A' NASTEWATER DISPOSAL' SYSTEH
Name .and�Address' or'Appli�cant. ` -
pM r,�r-> •'Y Ia���1
2. Nzine:of Project: �rOGJ�t� ��bw 3. _.Location:. T /V /C:; D
4. Project Engineer: SOP W- J- U -[ S. Address::.,
Ma
License Number:.��`"
6. T e oi= ' Pro• ect -
Private /Resident'ial Food '.Service. - Co,. �ercial
,,
-Apartments Institutional Mobile Home Park
Of ildin
rice Bu g Rea.lty•Subdivision Other,. (specify);
7. Is this project subject` to• State Environmental Quality: Review: (SEQR)?
T. oe.Status (Check One)'. Type I.': Exempt'
Type II.
Unlisted
8. Is;. a .Draft .Env.i ro' mental Impact Statement (DEIS): requi red? .....:.....: IJU
9 Has DEIS been completed and found acceptable by;Cead Agency�ty_ : ra /� :.4'..•
10. Nalpe -of-. Lead .'Agenc
t i . Is this project' in•. an area under. the, control .of: -local planning, zon•ing,;., "
, "o'r other_ offic1a1s :rirdin?nc.es ?'. :..:.. -... ,..- .'.......... •. ...... �l l:._.
t2. If so have plans been'- s ub,,n Itted.'to' such ,author.i ties? ..................... WA
13. Has prel iminary, approval been 'granted by .*such authorities? N A Date Granted:
14. Type of. Sewage Disposal:`Syste.i Di scharge ...... <: Surf ace, water: ✓ Ground' Waters
15. If surface water discharge, what is the stream class designation ?... ...... /A
:6. Waters index number (surface).... ...
. ... ..........
project`aocated' near a public Water-.. suppl y system, .... ..... . , , rO D
_ _ ....,.
3. If yes, nary of water supply. W/A Distance• to` -water supply
:9. Is- pro JeCt ' site - near'a- publ is sewage_ co_1•lecti'on .or..:: disposal system ?..:.. IJo
AMe., sewa*ge- system'" " - - '� //� ' _ :. Di stance to` sewage. system
:i Date obs served
- - '':ti` s ,•:'= ''„ _ ' _� _ ��� :';:: �`.. .7.
e -'23. Name..of Health .Inspector:
4. Project. `deli n: flow al o
g . (g 1 ns er_ day) Y) •.... ...
. 7,1i , t r♦a,, a o'
. }.fir: >� ^.;•:': S•:l• ' i.:• . ,—�.,_
2
25. Is State, Discharge Elimination SystemI.(SPDES)t Permit, required ?:
- 26. Has SPDES.•Appl ication been.. submitted to ;local DEC' Office ? -
27. Is.any portion of: this. project• located... within =:a designated Town or State
xetland?
28. '4�etland'' ID Number. ,:• ......................................... — IJhI
29�': Is; {Wetland Permit required? °....... ::. o ° ° ... �l
. . .... .
ti a—
Has. appl i*cation• been' -made to Town or DEC' Office? tJlr�,
30.,.'boes.-'project- :ce.Quire-- a. DEC Stream Disturbance Permit? .... _ °
31. Is or was project site used.for agricultural activity involving: appl.i,cation.,.. :....
.of pesticide$ toy- orchards or other crops, solid 'or., hazardous waste ' di- sposal;
landfilling' sludge application or industrial activity? YES.':or:.NO *)y
32....Xs project' located within 1;000- feet'of.existence of abandoned' landfill,
hazardous waste, site, salt stockpile, landfill;; s fudge - disposal -site ;.or,,:,...,.
any other potential known: source or contamination? ;'. ° YES or: NO._-
DESCRIBE:
33..,:, Xs tfie're ,a local master..plan'or fi`ie xith the'Toun or`Vi11 age.
� °.
34. :Are: co nnunity_.water, - sewer facil.ities- planned to`' be: developed within i5 years ?' VWKK)0100
35. Are an sexy a 'dis :areas in • excess of :_15,%"-s O e?
36 • Tax Hap ID Numbers
37. Approved Plans are'.to "be; returned. to: ................• • App�lfcant _�; Engineer
rr the application is signed by a person other than the appl icant .shown- Jh.._Ifen .1, . the.
=Pp1 ication:.must be.- accompanied' by •a Letter of Authorization Failure to' comply with this
Provision may .be grounds. for the rejection of any sub,•nission.
I _hereby_ affirm,:
under - penalty of perjury; 'that. information -provided'on this
true to
the best of my know7edge and bet ief.. state:rents. made_.
herein: are punishable
;False
as a e7ass X! His 6e,, h pursuant : to Sect io "n '21' '. 5 of
the Penal Law.
31GNMV
-
ES. & OFFICIAL
TITLES: e
AZLING ADDRESS:*,
'
} .•, , 1.. .v.
a.
y. S
4 p 4 -
s F
i r
J.
putnam - e-unty Department of Health
` . Divisior::: °• f Environmental. Sanitation
AFFIDAVIT - CORPORATE OWNER APPLICATION
;L
n.P?:ICA?'ION
• .PUTNAM COUNTY. HEALThf DEPARTMENT
;.F
N
TO: Commissioner of Health --In the matter of application for -
ire present .
'that .1 am an officer or employee of the corporation and am authorized'
to act for _ (.,�iJl'q _O/'I�CZ C/
Qltion)i � _(name
of corp-�i
Navin offices at - % ,P( G _ o tv v��
..
Ar.
Whose officers -are
—r
President4SE� Ill2 /%%4-r�L�_w_�,QUrrJ�oti,9
-' —�
-` -' _ — � (tame and- Tddress�— � .
•%
Vice - President
— (Name_ . and Address) ; ^ ~
Secrez_tary ~- _ ....
r
_ _
— ...
(Name. and Address) ...'
•
�•:
Treasurer'
. (tame and Address)_' _..._.._:.r -_ s
.
and tiat I= am-and w� ll be individually responsible fon any' or all aptp� ..
=1
of the- corporation with respect to the approval requested and -all .sub-
'
eeque *t aets relating -thereto.
Sworn: to •iiejfore this
me day Signed
of 19 Title
' i
�
Notary Puli ��-
-
Bo RE J. D r-S
t
i'ra�cirr�iaclQ,SPiii'sG� •..�'_! . �_i
i�(dTK_r_t1 i
. a.
1'1REG.
QUAL1FEDi:�UJ1Li1�e4'Lt..;:.:'% �
1AY COMIkI ION r'XF'Ma RUC. 12. ?
-
• •
i
.'.
-
......_ , ..: _. ..: ... .. -.- .. - Corparcite •Seal ..._.__
•
: • . '
,
QUA COinV YSf DEPAR�A�NI OP �ALTD `
``� , Dlvlebs
Oka Health Services. Csemel. N:Y Y051 ?: mtt CER1>Q+ICATI: FPsovWe Peimit //
ip
(O t�1S0Pi P®NDT FOR:SEWAGE "D>SPOSAL SYSTi
Loested s:t 1'� V. �i.7`� tl l �a << ®° . fLr�l ; wvarvLtu£ -T y. ewm a r9i e
Sudwhlelen Aiame �Z fz�l N:{ S �r�t.4t• d-a (� Stlbd. Lot k Blecll i %�
pli(L 1'z`lap }�7S B®ne..al O l;eyielon
o /fie i�ae ..1DEtL�xi�y`P+lT
Date of Pre
.. , ; .. vioptt A�trovel
Toren.:. Gr .2-M. , T d o f l 2
gasblo8 Type, i 0, SO kLm • --5 03 :1 - • Sul secdoo
Y. � D® tb - Volume
Nimber d Bed[obme Design. Flow G P ,D '� 0 ® PCHD i4 to Regal ed Wheel ft le completed
Sopseate. Sewerage System to eosielet d� �, D Galion' Septic STank' eat 57
To Poe coneoteacted by1"'dGlo d 5 NYAjg Addeese E°:1�• ga1G %�% h/1Mb�(.. . L ���[ .
(�
Water SUPpb': ' Ptmlk Soppb From Addres®
on ✓ Priyite Sappy: eNo� b
y /I!° d lrt �11�1 i.
D U N �l'�A/ 4JT�4s1dJS irk
Other ReQttuementa
1 represent that 1 am wholly and completely ►espohsrbla for the design and location of the proposed systems) ly. lost the;; separate "sewage „disposal systom
above described w�11 De „GOnstiucted as shown on thd.approyed- amendment thereto and in accordance with the sts�dardi, ruler an repu a ions o e u nam
County, Department 'of Neeltli; and that onacomplotion thereof a Cort�fioate; of Construct �on{ComO,lianca gtiifactory.to the Commissioner -of Nealtheyill
be fubmittod•lo tM Oepartn eht sand r. written ,iivarantee will be furnished the owner hrs wcoes;ors,,heirs or a qns by the tiup” that,iaid builder will
place i, good operetinq�eondition any,;part o1 said sewage disDOSet syriem,during` the period o4 two i2) years immediately "folbwkq the,rlets of=ths rasa-
anCa`of tlie'approval;of tM:Certifidteaof ,COnstrucLOn Compliance of the o►Igm51 system orany.rspeirs thereto 2) that the druiod wie0 "described above
will be looted as sl►own on tM approveA plan and -that nerd well will be installed i accordance with the,- standard ubs d r s1i%ni ot_ the'
County Deportment
ry�A
Date P E R.A.
g
7'
Address '
[/34Nicense No
APPROVED FOR CONSTRUCTION Thrf;app►ovel.expkes two years,.,from the. date,issued unlei C-, rucNOA of'th building has "been undertaken and is
revocable for cause oi, :ay. smanded or modified when considered oeceftecy, ,by the Comriri er- o9 `Flealtfi. y charpd'or "alteration -bf co' itruction
repuires a na e► ' Dr r dii — iii:�ot, domeriic sandary sewage,- n pr,vat t `pl o y
Re *,. 7P/
1/87 Date
BV Title
PUINAM COUNTY MEPARTMENT -.OF HEALTH r
DIVISION ':OF iLTH SERVICES.
_ AESICN :DATA : SHEEI<- IBSUFACE. SEWAGE
-DISPOSAL `SYSTEM FILE NO.
fd1ONe(z :Hr C�N7S
Owne_.
r �t�nnn� t0Z �• �. -C�v. �c3dress _: � t9: (� � . � Z. � . , .. C{�►'LM�d. �� �� .. L� �r 2
'l-v MA►2Kt�
Located -at (Street).::.: r_0&GrN QcN to .: Seca..:. kb .,Block---- Lot
(indicate nearest cross street)
,.y..vw ...::.:.... . ..w
r (Lo
.._
Municipality (`T EAMCM -L Q Watershed C 2,,D Zv ,
SOIL PERODIATION TEST DATA REQiJ= TO HE SUBNSI=D .WI'T'H APPLICATIONS
..Date of Pre- Soaking 10 3 S% Date of Peroolation Test Y hb 3 0
HOLE
PJE=, TION
Run (Elapse Depth to Water..From. Water Level
'No: Time lGroundZurface .In -Inc hes :Soil Rate : T
Star Stop Min. Start
t Stop Drop In Min/In Drop
(Lo Inches - Inches --,,-:Inches,i
As-
�4 L,�_
A H.
20A,'- -11;/4 3..;
1
2
3
NOTES: 1. Tests to be repeated' at same depth until approximately equal soil rates
are cbtained.at each percolation test hole. All data to'be sutmi.ttcd
for review.
2. Depth measurements to be made fron top of hole.
rev. 9/85
NOTES: 1. Tests to be repeated' at same depth until approximately equal soil rates
are cbtained.at each percolation test hole. All data to'be sutmi.ttcd
for review.
2. Depth measurements to be made fron top of hole.
rev. 9/85
RESCRIPTIONOF SOILS ENCOUNTERED IN = •
10°
�o
12° `
13°
14°
-
M01 a-VEL -AT' WHICH "MC11,I1kaTER f IS ENOOUNTER ° - < � -
INDICATE LEVEL TO WHICH. WATER LEVEL RISES AFTER BEING ENOOUN'i�RID lU��''
DEEP EOLE.OBSEMMONS MADE BY; bATEe
DESIGN
Soil hate Used 16 Min/1" Drop: 6,o o S.D. Usable -Area Provided
No. of Bedrooms Septic -Tank Capacity i 2S'7? - gals m Type G6.N C
Absorption Area Provided By ? L.P. x 24" width trend
Other Viz- ' � ��� . 12-x ? U j t2A_V PO-YL (.j�,U Svc. 0,) VL- W POS K e,&JL .
Name. ( T fLGt n? t2 �c�, hoc 9G Signature
Address 3
� ��1-t t2(�t �b �ni v {� SEAL � f
THIS SPACE
DEPARTMENT ONLY:
oC
w
No. 56124
Soil Mate Approved sg.ft,/galo Checked by Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
10 COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
� P L I A`1` b0_ N-'T_U" LONS'I'RIJC T" " '_WA' _TER' W2LA, :-
PCHD PERMIT
WELL LOCATION
Street Address Town Tax Grid Number
w o," l4�- � ' k7 . �4U-0 N - 71- 261 I
WELL OWNER
Name
a YU t,
Mailing Address
�rvPr.(erm"7 �+.
f--b. 60,t -770 Private
Lz' 7J W�i2 OPublic
USE OF WELL
�] - .primary .
2- secondary
XRESIDENTIAL
13 BUSINESS
O INDUSTRIAL
❑PUBLIC SUPPLY.
O FARM
b INSTITUTIONAL
OAIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
0ABANDONED
0 OTHER (specify
p
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE
SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
RNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
�iL
S DZNI:t
WELL TYPE
DRILLED
DRIVEN
DDUG
11
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: e-MAJ6 6 411
Lot No.
WATER WELL CONTRACTOR: Name M ILk- IDWILL'NeA ( e- Address: Pv 7N� � �
(3 2<.ws'-t��c.. �,u H 10 S'b
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: !u /A- TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAkEST WATER MAIN: N
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION OON S PARATE SHE
r �
(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 he Putnam Count
Health Depart /nit.
Date of Issue:: 19
Date of Expiration: ZzZC _19_... Peprit IssuiFg lc a
Permit is Non - Transferrable copy: H.D. File
Yellow Copy. Building InspM'V.L
Pink Copy: Owner
2 87 Oranae cor)v: Well nri11Pr
LAURENT ENGINEERING
ASSOCIATES, PC.
-D
-7-3�TAIRFIELD-!- fVE7;�
PATTERSON, NEW YORK 12563
914.278-6108
RANDOLPH W. LAURENT, P.E.
HARRY W. NICHOLS JR., PE. CONSULTING SITE ENGINEERS
November 30, 1968
Putnam County Department of Health
110 Old Route 6 Center
Carmel, NY 10512
Att.- John Karel!, Jr., P.E.
��;
RE: Steinbeck Hill
Lot # IS
Farm To Market Road
Patterson, NY
Dear John:
Enclosed are the following:
1. Four -4) prints of Drawing SS-18 "Proposed SSDS-
1-30-08;
Lot 1 revised 1 I
We would appreciate your continued review, approval and issuance
of the Construction Perm i't at your earliest convenience.
... ear.
Si ncerel y,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nichols, Jr., P.E.
HWN/rrtt
Encl.
cc.- Mr. David, Cioccolant-i W/I
J, t
AVV��
COPY
ev
A
==F�-MEC B
e � s :a �s CE2FM-W CF GF Uvar-
TUr k'-7 SUL--�,
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RE -H CC-,q=L=lC.Nl PE?V-TT
c T." If =EZ- m LICC-21NEMS
Per-mi t
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(ACS)
7 Cr
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3. F
Perc ass
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CcrLstzLz&t-4C--,- Notes
-'---lcces Cat
]Dr----;tls (,—:--zzChErcE C-Q
Perc & ceem Eales Lccat=,�
-Remrasa7 tiive c pr= man7 anz e:c-=anS-c,!
7
P i t & D Bcx SR---own
Ecusce - ITO. cf Ee-L-,--cvs
We? l—l- w /--;n 200 ft- c-= P--O-=csaE-
prccert---7
(T lc I t 1c t)
Ecuse -Se, 4"0;
No Be=:Lc; *M-=c. Ear-as 45' W/Claancut-
=r-j D-.1ZT3�M= CYJ P-r-N-
Fiel rc C-
I 1� T
10 L:O P.L.
20' to Fc=cia- L.;Cl Walls
100' to wen; 2001 i. D.•.C.Dr
100' tc S*---aam, Wa-=-rzcu-r, aka
131 to F--Ct; ric
35'tz
10, t.:) Wat-sr Line (pit-=-20')
50'
stintic
lo, f= 50' to all
�ial i t:: _r
I
Putnam County Department of Health
Division of Environmental.Sanitation
� CORD P,AT-E .Y:E � � &PF as Fr 1•rA JI 10
T TI N=
a CA 0 ...._. .............s ..,t . " _ .. ....v c ..z_:....
FOR PERMIT. APPLICATION SUBMITTED TO - -
PUTNAM COUNTY HEALTH DEPARTMENT ! :
The Commissioner of Health In the matter of application for .
lt E!/EWI)46 &%1J'if}-,�II L .�, L 7b
(�0 6,,,NT _ .� — .. _ ..., ._ 9 represent
that I am an officer or employee of,the corporation and arty authorized;
Id $® act for ; OA_ Ro e � �'1 i L! � ���!�i GU„��%��%i! / ° ,1.��_� [� 7.— -. -. — d
(name -
of corporation)
having offices at
L"_ j 0 �1Z _ e; _ _ Whose- officers -are
President�r�E4�STE� ��_._
'tame ana•Xddress)
Vice-President
(Name andAddre.ssT _
Secretary 1 _ CL0 GGO L- !iv_t7/ G4Y2 °?i 5e_ _ X)��
(Name and Address) °
(Name• and Address)^ --- _ _ _ ® —
and that I am and will be individually responsible for any or all, acts
of the corporation with•respect to the approval r quested and all'sub-
sequent acts relating- thereto,
Sworn to before me this �/ day Signed
.a
of 198' Title f
otgry Public
v
ANNE B. CORRIOAN
muma.,s,� *W York
�Y��411ifelvn ��r rWt
bko 23
Ae.1 04 aa74
E0�
w
o
Corporate Seal
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
Well Location:
Street Address: Town/Village &x Grid #
-�
r Map ;'x5—Block L/ Lot(s) 3
Well Owner:
Name:
Address:
Use of Well:
_Residential Public Supply Air /Cond/Heat Pump' Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People Served J Est. of Daily Usage gal.
Reason for
Drilling
Replace Existing Supply Test/Observation Additional Supply
New Supply (new dwelling) ✓Deepen Existing Well
Detailed Reason
,�� pV r C
for Drilling
Well Type
Drilled Driven Gravel
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision Lot No.
Water Well Contractor: V`M, �� l'J- Address: 29 �M My\n Q,D ,.fit//
Is Public Water Supply available to site? .................................. ............................... Yes No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date : - Applicant Signature:.. _ �. . � ....._ .. . _ __._._ ..:. _._ __'_._ "v ........... -
PERMIT TO CONSTRUCT A WATER WE
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and 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 or their designated
representative 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. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and 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.
APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well -has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water 11 driller certified by Putnam
County.
Date of Issue 11 02-- Permit Issuin al: Mft
Date of Expiration at Title:
Permit is Non -Trans errable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
'9
! 31 1
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well-Ldeatr6'
`Street Acl'dr"ess° $_.�,_��s.. as_,�- _
��rd s cry
owNil'Iage
h
__.
Tx Grid
Map,?, BJ. l oc_k : l_. L. o_ t (s.�)`
Well Owner:
Name: Address:
Use of Well:
I- primary
2-secondary
Residential Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion __x Compressed air percussion Other (specify)
Well Type
Screened Open end casi & Open hole in bedrock Other
Casing etails
TA 6tt,1( J
�0'C<
Total length ft.
Length below grade ft.
Diameter ( in.
Weight per foot Alb /ft.
Materials: Steel Plastic Other
Joints: _ Welded _ Threaded _ Other
Seal: _ Cement grout _ Bentonite Other
Drive shoe: Yes No
Liner _ Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Field Test
_ Bailed _ Pumped j Compressed Air
Hours
Yield gpm
Depth Data
Measure from land surface - static (specify ft)
i✓
During yield test(ft)
L>
Depth of completed well in feet
or r
Well Log
If more detailed
information
descriptions or
sieve analyses.._.
are available,
please attach.
Depth Fro an
Surface
Water
Bearing
Well
Diameter(in)
)Formation
)[Description �=
ft.
ft.
Land Surface
��
V
!
-mil. ......
_..:.
9
C0
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type �f,b CapacityPi�
Depth 459D Model 766f6'
Voltage =' HP
Tank Type Volume &/10
Date Well Co m leted
Putnam County Certification No.
m2r:::
Well Driller (signature)
Y,
NOr: Etact location of well with distances to atAe4st.tw peftnan t tan lmarks to be provided on a separ eet/plan.
:.:g � _:f
Well Driller's Name Address: ,
Signature: �„ Date: �'19 ci
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
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