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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -38 BOX 15 01717 Q, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES t WELL COMPLETION REPORT. Well Location Street Address: & TownNillage: Tax Grid ## Map 35. Block Lot(s) 3T' Well Owner: Ni- , e: W Address: Use of Well: 1- primary 2-secondary Residential Business Industrial Public Supply Air con /heat pump Irrigation Farm . Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion _A/ Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Casing Details Total length eft. Length below grade ft. Diameter in. Weight per foot lb /ft. Materials: Steel Plastic _ Other Joints: _ Welded )-e Threaded _ Other Seal: Cement grout _ Bentonite _ Other Drive shoe: Oyes No Liner:_ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First — Yes No Hours Second Well Yield Test _ Bailed Pumped , Compressed Air Hours Yield a gpm Depth Data re from land surface- static (specify R) Measure During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or - sieace a- nalyses.-..�.:.- . are available, please attach. ' Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface Alw _. - - M Y' _ ` _M +. ..a.. '�.. If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Informati§)n Pump Type. Capacity jz- Depth Zoo Model WeJ01.11 Z Voltage 2-3 6) HP -3 Tank Typel,,),>t 302- Volume _ ( Date /IC plet Putnam County Certification No. Date of Report Well Driller (si nature) NOTE: Exact location of we 1 with distances to at least two perman nt landmarks to be provided sepaz e s et/plan. Well Drillees Name t ` Address: 1Vy1h 6Z Signature: AA Date: White copy: HD File; Yellow copy - Building Inspector; Pin copy - Owner; Orange copy - Well driller Form WC -97 - s - - shat of - ' * PUTNAM COUNTY ,DEPARTMENT OF HEALTH DIVISION Or ENVIi2C�NTENTAx. HF.ATI.He;SF�It�IIr;ES , ..W FIELD:ACTIVITY.REPORT .YO NAM R: / Tet;. Street - Town . State Zip PERSON'IN CHARGE = /w v s Date, { Name an Title TYPE OF FACILITY. ` d(1 ✓ + -�% FINDINGS. �';d V�w Ee (/Ltl EJ� v� (�� 1�� �-� GP ;: Gtr _ - `.P•±'tQ .C�, ^' S a-z ``..y ^ tr `,V.� IL - d — • • Y TRI :.. 'Signafure and Title - - .RFPORT RRC;RTVRT) RY: �I acknowledge =receipt o --this report SIGNATURE; - n 02/.96 Title' - Mar 12 08 01:31 p Tyndall (845) 279 -5989 p.1 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES - •' 1 e i . aFA PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM (FAILURE AIB information below must be fiyll I completed prior to any scheduling SITE LOCATION p LVA L�d 13 TOWN c,44ers on TM # OWNER'S NAME � i` (1 i��� r,� rrrrti PHONE # MAILING ADDRESS PROPOSED CONTRACTORIINSTALLER v ADDRESS oQ r�W WREGISTRATION !LICENSE # Reason 4Qr exp1001111on: ❑ failure to surface D back-up In house Q find limits of system for repair ❑ other (explain below) FOR COUNTY USE ONLY ignature & Tide Date Date: Time: kiy:excetseptic e FOR ASSESSMENT PURPOSES ONLY NOT TO BE USED FOR CONVEYANCES PREPARED ar JAMES W. SEWALL COMPANY 147 CENTER STREET OLD TOWN. MAINE 1'V 0 4.89 AC.� SPECIAL DISTRICT INFORMATION i STATE LINE DI`7UTED AREAS COMP LINE -- CC ITINA7U5 OW1EA' TO" LINE -- - ROAD RQW.. VILLAGE LINE - -" M, �M/WATEialNE aLOCK LIMIT - - - SEECIAL DISTRICT ERDPERTY LINE Sl.'JDL DISTRICT L ORIG ' lOT LIIE - - - rV K PARCEL RO 1 P-n AC 7 ��, SCR001. -SCN• BREWSIER CENTRAL SCIOM DISTRICT . -• 3T3001 : {LS_T,».0 .s •.n 1{•n TM" DIM, • 1 1LA•10ACRIIA91! {/1 /u am Z431.. `11.35 AC. �• J al..- ,e.00.sA WYNEAO, a/•/" AMD a 1 FIRE •f• FIRE PROTECTION DISTRICT NO. I - G<` 1.68 ac "' "e''• -Q LmAa s a '°' s 11..a- / -1,•aa a- ala =••a /r w/ 11 {L. {•f {. {107 -1 -A fQN U11t ADI {AIV {i Yf/ 1Ls -e0 AaeA{e snnl An 18 {L{- 1{.111 + /{l {nn{ aw • - 9 ELM 1 j6co3 1 ±• 1.74 1 356.5Y 5.91 AC. CAL 105.7 AC. '� \ 1 5 I go5.1 67.2 �rlasl IAR ° /" L7B AG - 9 110.96 AC. CAL. 10&10 ' : 6i. I.54 At a 6 AG 10 Z2 1 .� P ° 1 1.37 Ar- 1 2 7ss.as O V ! .44.00 94 _ 66 89 2 90 a _/ • f..\ 4.95 AC. 66 ,111 ocis ± '�Bf pq'1b 8 19 9 17 +1, I 91 '350.29 AL LT AG ° 85 > 87 86 T 5 .. •• S.; ,1 s3 amx 1 84 C .•�./ 92 '7/Q = s m 90 vs 4 , , e^ I �` 63 ° 44.52 AC. CAL. �•�.7•�,, fe - 20 B3 a 93 24.58 AC. a' 19.69 AC. CAL. ,I 1 a 16 AC. Al 3a 8 Iz 1 "580,05 n'.2 " ,°ca a .v c 29 3�f :�3 N a 33 ' ••�••/ 55 'y -u' /9.33 AC. CAL. v 737.76 219.82 9{zsR - �,oT. •,� I• 9• / 5B 1 1' ; AC. S P32 m • ,2g n a p . m • 5 HILL 9 0 10 5 jI28.92 • 1 i . • , \ S's-D' u ~j 1.732 Aa G •� ¢4 r ! '� l Io 3 AC!, ; %; $ I _ 1 22.37 AC. CAL. s l 1.07 . 26 10 1 c 36 Ar s > Ac 17.66 AC. 53 1 �10 - . • I 31.7OAG 358.58 ��''•. I .,� J 49 /, �t n �»N.93 • / 54 �. 29 ' 1 i2 f q° LSB 1.09 1s, I -•+ ��2.5 AC. y • f X90 .y 1.19 /iG N 178.44 f 23 • 4 3.ILAG 215.T! X21 X22 q •1.24 At 50 1 Iva 2.21 A a .. ao ce 6n y� 4.72 AC. CAL. s i SI ° •. �I N 952000 i FOR ASSESSMENT PURPOSES ONLY NOT TO BE USED FOR CONVEYANCES PREPARED ar JAMES W. SEWALL COMPANY 147 CENTER STREET OLD TOWN. MAINE REVISIONS SPECIAL DISTRICT INFORMATION i STATE LINE DI`7UTED AREAS COMP LINE -- CC ITINA7U5 OW1EA' TO" LINE -- - ROAD RQW.. VILLAGE LINE - -" M, �M/WATEialNE aLOCK LIMIT - - - SEECIAL DISTRICT ERDPERTY LINE Sl.'JDL DISTRICT L ORIG ' lOT LIIE - - - rV K PARCEL RO 1 l!- .{.AalAAl1 ry1101A UrAI •r{ 7 {L4•17.53- 1e , t /b //1 W! SCR001. -SCN• BREWSIER CENTRAL SCIOM DISTRICT . -• 3T3001 : {LS_T,».0 .s •.n 1{•n TM" DIM, • 1 1LA•10ACRIIA91! {/1 /u am , al..- ,e.00.sA WYNEAO, a/•/" AMD a {L. -1 ACaAO[ { /u.{ 0W FIRE •f• FIRE PROTECTION DISTRICT NO. I - "' "e''• -Q LmAa s '°' s 11..a- / -1,•aa a- ala =••a /r w/ 11 {L. {•f {. {107 -1 -A fQN U11t ADI {AIV {i Yf/ 1Ls -e0 AaeA{e snnl An 18 {L{- 1{.111 + /{l {nn{ aw • - 0u..1..11•.r.: '% •r111{ .aW& , . /10/W7 . IM - '• �w.��*�� .6v=mom 19 'Sy effi,evany,r a 1- 2 the, or woe doecong6i Liconse P46 Rev Tit °' q DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 YAP.PLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # 12 -4 ?- WELL LOCATION Street Address iut:)J" t- (LL (v$ Town V111•eg Tax =r-mrzs61) - o - Grid Number z— 7_G+ 1 WELL OWNER Name Mailing Orvtwrr, S Dow. Co. L;r Address 'Ro �. 2oorrz, ZZ 6YL"5-tLn_ j io5-o2 I A'Private 13 Public USE OF WELL © - primary 2- secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP BUSINESS O FARM O TEST. /OBSERVATION 0 INDUSTRIAL b INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm/ PEOPLE SERVED 4 "(� /EST. OF DAILY USAGE 4Sb gal REASON FOR DRILLING 0 REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLING) O TEST /OBSERVATION L3 ADDITIONAL SUPPLY 13 DEEPEN ' E ISTING WELL DETAILED REASON FOR DRILLING WELL TYPE I L111. DRILLED DRIVEN ODUG OGRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES. NO IF WELL IS LOCATED IN A REALTY -SUBDIVISION, NAME OF SUBDIVISION: S76In113kZu_ . . Lot No. 1- WATER WELL CONTRACTOR: Name °@ B&, Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ NO- NAME OF PUBLIC WATER SUPPLY: IV +A TOWN /VIL /CITY R- D13TfSICE =- TES np.^P'EP.TY -FROM is .►Ti ST._' ;?ATER XA ►N? : - A-1 LOCATION SKETCH SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET f (date) 0(sign-at-ure) 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 manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: Date of Expiration Permit is Non - Transferrable 3/89 19 19 Permit Issuing Official White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COU91Y DEPARTMENT OF HEALTH TCTMI nO LTftrrr)n %TMLKTSAT. UVATMO C' mr / tl 01 too ou 0 Inacr."'r-C. Owner or Purchaser of Building BU i ding -/' I Location - Street 3� Section Block Lot Subdivision Lot GUARA= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM represent that kR afC 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 Mi6 which fails to operate for a period of two years immediately following the date of approval of the „ "Certificate -of-CConstruction_- Compl e ance" for the sewage dis ppsAl ;__sy�tatir�:or,anv��,:�._; 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 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 utilizi the system< -� - I Dated this � day of 1 � 9 Signatur rev. 9/85 mk Title %, -f I ..-- S7& ,'c. /ls Corporation Name (if Corp.) +L�'-e E-4 F" Lo ess ` oNYt.ok_ .•H r, i HZS M. -Owner _ � n .... Cry t;°f Address _ tv�, � ,,, � �; _ ; .. , r Sec. , ..; ,. .. �.�.: .. Block ` .'2 . rAt Z�, .(indicate nearest cross street)' i Municipality ��� 1'' 7Z iK So N watershed C,1 U Z nl SOIL PERCMMON MST DATA RBOUIRED TO BE SURC= V= APPLICATIONS _ Date of Pre- Soaking ; D 3 . Date of Percolation Test HOLE• - ::PEROOLATIUN ...:...._ .:::::: �:. _:::, :::._:::..P.E=LA M Run (Elapse Depth to Water Frcm Water Level No: . ....,.,_... ........ ..........:. i Time Ground Surface. In •Inches .�.........::_t .::...Soil Rate.*' Start-Stop !Min. Start Stop Drop In Drop • ,Inches- ..'.:.Inches Inches 2 Ca Sal It `SJ. 1 . 2 3 NOTES: 1. Tests to be repeated: at same depth until apprcximately equal soil rates are obtained at each percolation test hole. All data to' be submittbd for review. . 2. Depth measurements to be made from top of hole. rev. 9/85 PLTINAM CaRM %DEPARTME P. OF HEALTH;:.. °DIVISION :OF:- ' NTH ' 'SFKVICE'S T T --- _:= DESIrN; SI�A. SUT- S U MC E °^ -- 34*F. DTH. ?L, 1 . 2 3 NOTES: 1. Tests to be repeated: at same depth until apprcximately equal soil rates are obtained at each percolation test hole. All data to' be submittbd for review. . 2. Depth measurements to be made from top of hole. rev. 9/85 NOTES: 1. Tests to be repeated: at same depth until apprcximately equal soil rates are obtained at each percolation test hole. All data to' be submittbd for review. . 2. Depth measurements to be made from top of hole. rev. 9/85 % l TEST PIT DATA REQUIR °lb • ;ME SUBMITTED' Tdt APPLICATION \DEPTfi DPSQtZPTION OF SOM M=UMWM IN, TFST -IRMES HOLE NO.. . BOLE ,lam .: SOLE �a ... s ..w� . _.. .. _ -:, ,tom :.� .�.-�: _.��.•�,:., F .�;,.l�k � -,.�_: G.L. 2° r a 3° r 10° 3.1.° 12° No. of Bedroans Septic Tank Capacity gals. Type ' Gd Ai G absorption Area Provided By ry L.F. x -24".., width" trench Other TO Name LA U i-N 7 JN Cr.t k)" t tj� t'vC Signature N Ad 7 i Yz �l r up MI SEAL, No. 56124 O THIS SPACE FOR USE BY HEALTH DEPARTMENr ONLY: QFESSIQ �.�' Soil Mate Approved sq.ftt/galo Checked by Date WELL COMYL611UN Krruni office Use Only DEPARTMENT .OF,....H.EALTH YO��,, PUTNAM COUNTY DEPARTMENT OF HEALTH "STREET ADUR ESS:' TowilivitLAGLIcily TAi GRID NUMBER: WELL �LOCATIIJN Lot #17,, SiteinbeCk Hill, Brewster NAME: AGOREss: Box 451 0 PRIVATE WELL OWNER :,6rompond Contracting Corp., Crompond, NY 10517 0 PUBLIC USE`Of WELL �5 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED 1 - primary 0 BUSINESS ❑ FARM. 0 ❑TESTIOBSERVATION ❑ OTHER (specify) 2 - secondary '0 INDUSTRIAL 0 INSTITUTIONAL 0 STAND -BY ❑ AMOUNT OF USE YIELD SOUGHT m.1NO. PEOPLE SERVED 9p EST. OF DAILY USAGE gal. REASON FOR .[]REPLACE EXISTING, SUPPLY ❑TEST/OBSERVATION ❑ADDITIONAL SU'PPLY' DRILLJNG [ONEW SUPPLY (NEW DWELLING) ODEEPEN EXISTING.WELL DEPTH DATA WELL DEPTH 125 'ft. STATIC WATER LEVEL 0 ' ft. DATE, MEASURED 4/1-5/94 DRILLING [� ROTARY E]'COMPRESSED AIR PERCUSSION 0 DUG EQUIPMENT 0 WELL POINT. ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED ❑ OPEN END CASING 0: OPEN HOLE IN BEDROCK. 0 OTHER TOTAL LENGTH 23 tL MATERIALS: M STEEL 0 PLASTIC 0 OTHER LENGTH BELOW GRADE ft. JOINTS: 1 ❑ WELDED . 0 THREADED 0 OTHER CASING DIAMETER in. SEAL: (2 CEMENT GROUT 0 BENTONITE 0 OTHER DETAILS WEIGHT PER FOOT 19 lb./ft. I DRIVE SHOF-10YES ONO LINER: EYES ISNO, DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN CREEN (it) DEVELOPED? SCREEN I DETAILS FIRS! OYES O NO SECOND HOURS,. GRAVEL PACK 0 YES GRAVEL DIAMETER TOP BOTTOM 0 NO SIZE: OF PACK In. DEPTH 'ft. DEPTH K. WELL YIELD TEST If detailed pumping if more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. METHOD: 0 PUMPED �ff COMPRESSED AIR i tests were done is in- formation attached? DEPTH FROM SURFACE Water Well Oia- X_ 0 BAILED 0 OTHER ❑ YES 0 NO Bear- ig meter In FORMATION DESCRIFTION. coat it. WELL.DEPTH DURATION DRAWOOWN YIELD Land sur lace 8 Drilling in overburden clay & boul erq ItV hr.. Min. 912M. 8 Hit rcck at 81 125 6 60, 30 8 23-wDrillAnq in rock, set casing, grouted 23 125 Drilling in rock granite WATER. i 3 CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS COLORED ANALYZED? 0 YES ONO ANALYSIS ATTACHED? 0 YES 0 NO STORAGE TANK: -TYPE CAPACITY GAT,. F U M P,_,'-)NFGRMATI ' ON TYPE 'submersible CAPACITY 1 OCI WtLL DFULLER NAME P . F . Beal. & Sohs Inca 8/17 °/94 MAKER Gould E. DEPTH 80' - A*00REss 4 Putnam. AveneTasiqU ,miRE MODEL 10EJ05412 VOLTAGE230 HP Brewster, NY 10 56§ p J/6!1 DINIMMIAM OF I end- be APPROVED FOR CONSTRUCTION-This,ok mou'r Rev.� | lO/80��* 64ownw; his luic4� I a imor I heirs of,assipme by the builder. that said . buildei will 14iiiiiiw 860" will in accoi rice with the' it' .'-fia' 1 0 Putnam RZ4 Lice rove oigpires twoyagra from the, dato issu unimlss construction of the building hes been undertaken and is ,nsid4id-n oicessmi!_Y'by the Commissio'ne'r. of Hwttk Any change or. alteration of construction T1290 L: = LAURENT ENGINEERING �j ASSOCIATES, P.C. / MILLBROOKE OFFICE CENTRE Route 22 3. IL11own Road ....�....� - �, ....,_ ..� .,,.._., _,..,._.. .:.....::" B' Pe".ws'E'e�•RSG�'YdP'ic'1J`a09' " -. .__ ,..._ ..T .., .._, _.�....�............,...� °:...: RANDOLPH W. LAURENT, P.E. (914)278.6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR.. P.E. \ CONSULTING SITE ENGINEERS Dater 1 -21 -94 +: To: Putnam County. Health Department Job No.: 94004 4 Geneva Road Project: SSDS Renewal. Brewster, NY 10509 Attention: Lot #17 - Stenbeck Hill Mr. William Hedges Patterson, N-.Y.. Gentlemen: We enclose( 4 ) copies of: B/W Prints O Reproducibles O Reports O Tracings O Specifications Description: SS -17 "Pr Sent Via: O Our Messenger O Your Messenger Copy to: O Memorandum O Copy of Letter O 1 osed SSDS" Rev.-., 1719-94 :h•� Revised per your comments O Blueprinler O First Class Mail O Special Delivery ' J. ®. Hand Delivery O Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Per:(�"t? &? Randolph W. Laurent, P.E. PUTNAM COUNTY. DEPARTMENT_ -- .OF_HE.ALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date ,A!Q Re: Property of ,!5 1-1,E1 r 1117--S R4 5V�e4 O GTD_ Located at /a X2/`'7 To /ti/i/zri 4r Rv (T) 1-_�47'7_A512-SA1 Section SO Block Z Subdivision of Lot ZG. / Subdvo Lot # /.7 Filed Map # Z7_5_7 Date 8 31 S Gentlemen: This letter is to authorize /-/A /Z2Y w. a duly licensed professional engineer or 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. - -D_epartment of. Health -,, - -and -to sign -a1 -1 necessary papers on my: behal -fain q� connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, cis M on R of 11�E l &.0 t5 Dey'61410m�4 r co, L'vo N N Signed v Owner of Property Countersigne IT a 4i P.E. , ReA. , # I , ,� ip- ?J a a x 97 Address J'FO No. 56124 3 Aii2 �i,�G D 9 �,`'.' C I9 S/ z Address Town elephone Telephone .. -- t .Y , 1 — c-••.. - -. _•n. d PDTNAM COUNTY DEPARTMENT OF HEALTH i. Division of Environments! Health Servloes:' i el: N.Y l0S12 n CERTIFICATE 60 Proo de Permit M o .. � -. CONSTR ON PERMIT FOR SEWAGE DISPOSAL SYSTEM _ Q V Located at /V , y X11 �1�7% Town _pn.34{lago, ".. ..Xt.• } -� _ _ � � � � SgbdivWonName, � AAJlei qr�- _Sabd.LotN Tax Map Bloch r. _ .. - A" N t2d k K KA & Wr E Renewal_ O Revision ❑ "Owner /Applicant Name VrzA11%[ Q0M" _( C)D , LIP , Date of Previous Approval Mailing Address �• 8 • ��� Town G.ri zip. 2 Building Type j4ez 12 N -(IArL Lot Area FN Section Only Depth Volume Numbor of Bedrooms Design Fiow G P D D-f' PCHAD�Notification is Required When FIJI Ie completed Separate, Sewerage System to conslst of I29— Ga im Septic Task snd / lO To be constructed: by_M aAlrlft. jjja &Wff V' Vi 00 (_I kidress 10A &)' j Z- -7D Waiter SuPP1T: Public Supply. From Address or: - � Prlvate Supply Drilled by'� u-- `15YLt l.lii Nt�pd d" eQ y fL ��I'tM15 Yll t2.T�_ Other Reouli ithents' �( To , 2!. 'P�la -(.. Y.irr,Q.� -Ott Gff.V�LCaA%C� PUIZP051cr at&: 1 _.. v_ 1 leDresent thatf am wholly and_ comDietely responsible' for the design.antl loca above described will be constructed as shown'on trie.approved amendment -there County Department, of- Health ,.and thet,on completion tliereoi.a .Certificate be wDmitted °fo to e Department and 'a written, guarantee`:wili :De furnished place in g00%,, operating condition any part of "'3eid sewage disposal system ance of the approval of the Certificate ,of -Construction Compllance of t will be located as shown on the approved plan and that said well wall be Instal County De aitmen of Health, Date Signad Addresses � LP{ �2 ' APPROVED FOR CONSTRUCTION: This approval expires two years from the revocable for cause or may be amended or modified when considered necessar requires i new permit. Approved, for 'oral of domestic sanitary' ws 1. Date By _i lion of tne.prOPdsed {ystem(s); 1) that the separate sewage disposal system to'and in accordance with the standards, rules and regulations of 8 FU tnam of Construction Compliance" setisfactoryto the Commissioner of Healthwill the owner, his successors, heirs or_ assigns by the builder,�that •said, builder 4111 during'ahe period of two (2) years immedfately following the Cate of the Isau- iori9inal system or any repairs thereto; 2) t at the drilled well described above in aCOordanie "with.-the standaf6� IUleI nd/egu aTiTons of the Putnam P. E. R.A. No 5.4,114- unless construction of the building has been undertaken and is missioner of Health, jkny change or alfarafion of construction I •water sup �Knl - i i DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL ?4 T 9 PCHD PERMIT # WELL LOCATION .: Street Address Town Tax Grid Number Za kl"-T MSD tJ P H -- - ZCp WELL OWNER Name OA7tiog, Wcwg. Mailing Address p,D, Sac 1 -70 mew {O t2 Wrivate O Public USE OF WELL �- primary 2 - secondary RESIDENTIAL ® BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION CIINSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT 5,0 gpm /# PEOPLE SERVED-]� /EST. OF DAILY USAGE 106© gal REASON FOR DRILLING NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION OREPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING of WELL TYPE DRILLED ODRIVEN ®DUG ®GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES )C NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. 3 �- WATER WELL CONTRACTOR: Name jIl I U, ` rz il..i_j 6_9 Address: », 6* 4, � H IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ NO NAME OF PUBLIC WATER SUPPLY: �J�„� -- TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: PIA LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION ON SEP T HEET -7 / 151 eff _tj j date sign 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 W 11 Completion Report on a form provi d b the Putnam Co my Health Dep rtment. l� 0 Date of Issue: 19 Date of Expiration. 19_ er it ssuing ficial '1 Permit is Non - Transferrable WhI.te copy: H. W. Fi e Yellow copy: Building Inspector Pink Copy: Owner Gentlemen: This letter is to authorize- �ArL�j� W• ►G� -k7l,S -,�. a duly licensed professional engineer ✓ or 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"'df Article 145 or 147, Educatibri Law, the Public Health Law, and the Putnam County Sani- tary Code. Counters P.E., R. Address (RId >'7-:38 tee, Telephone Very truly yours, Mon A 0 1h51617S NV6ZoPlt 64r Co) L7 Signed C �/ Owner of Property o .60 x Address V Town qd -9)f- q4I Telephone P i 1 Putnam County. Department of Health Division of Environmental. Sanitation. G^P.- P:'�TE(�5'd�I�ER :�i�°�'TrI,.A mZQ%,= FOR .PERMIT..APPLICATION SUBMITTED TO - ', PUTNAM COUNTY }[EALTH DEPARTMENT a a T0: Commissioner of health In the .matter of application for o�I�Qo E n l �� s E vEGo° �1%l 6 .uT . /y> %%tl c� ��7-b represent , that I am an officer or employee of the corporation and arh authorized: to act for 40 Ai�e4c: Lr .f �.l'6 9 -L 2!%Gd—iv %�_� (name.of corporation) It o P�v97� • }saving offices at Whose. officers *are �—" PresidentQs?¢f C1OG�-- ��! and ���—STE_,� 74ame •Address) _ Vice- Presiden _ ' dd7/ s Gv1/J� .tJ _ (Name and Are Secretary 1� _ GLo GGO Z- 4vt -7'/ _ G `1 �- ,� XJ me (Na and Address) Treasurer (Name. and Address)^ - and that I am anti will he individually responsible for any or all, acts ok the corporation with respect to the approval r quested and all: sub- - sequent acts relating _ theretoo Sworn to before me this � /£ day Signed of 198 Title ,� q(.._(— otary Public • �v ANNE B. COWDAN S S � �C"A way PW* , sms of Play yet B y Cortmfa�Nn „ „" Red 41074 1488 -74 APDEMEC B PrMiAm CCLNI'v DEP -nano= OF HEALTH - DIVISIC'N QF ENviRCmwm?AL HEAL H SERVICES DDIV-DCn.L MATER SUPPLY & SJLsMFPC✓ M&_=— - DISPOSAL SYSTEMS / REJIE4 Sri-r CONS*= -=ICN P'RMTT s. (�me of C me_r) (Street licc..ticn) b ?u� Pe -mit Application Corporate Re_oluticn Plans - Three s`ts Enaine°_rs A.uthorizati cn Design Pat:--- Sheet- MM) SUEDrTrSIC'y Deep Hol= Lcc pe±-c �J j COnS7.S'e'lt Perc Res-,f_1-_S (3) F-11 Per-C Role Dept-1 C HCUSe Ply - Two se _= Well .� Fe-riu Variance Rezuest _ =t.. -rtA� Legal- Sab&viSicn Subdivision A -cDroval C:eck d Fa -a=rcval SSDS Ate- Lot= Wet'-and (Tcwi?/DE_" Ps=i = R & D) Da`a Cn DCS Plans & Permit SEma REQliUM D=;-=.,c- CN PIANS &°.vage System Plan SF' ace Svstan Hvd_aul i c P=QL'_l °_ Fill Profile & Di_�'.e .^signs D or J Bex;T_= nc-1 /Ca_" lerv; .P_ pi t det i1 Septic Tank - Size, DeT=.,1 We-11 1 Detail, Service L:L e if c,;=-_ Ccnst:'u &.icn Motes (grinder rte) Design_ Data: �erc bold cep L.. _. ._- . ._ ... Drive,wav & Sloces Cat FcoLil /C Drains (isc:iarge C{) Perc & Deep Holes Lcc_t Repres=entative or prL7ary and e.ensign flm..nsion A.re ;shcw�l ;gravity f-ICW,ssf=..size If P'mped Pit & D Box Shcwn & Detailed House - No. of Bedrears Wells & SSOS's w /in 200 ft. of Proposed SYSt, Property rtes & Ecurds House Sztbac:t Necessa +v (Tic;1t lot) House Save: - 1 /4 " /ft. 4"0; Zv�ce pike No Bemis; Max. Bends 45° w /cleancut SEP�RATILTI DISV�ti S SPECT�T� CN PLAN Fields 10' to.P.L., Drivevav, ie—r J e T_Ees,ToD of fili 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Str .=cn, Fiate_COurse, la:tca (inc. 151 to Drains - Curtain, Doer, Footing 35'to mtch b.sin,stc�iCi ']rci_r1,DiPE{1 w-te -rc.:�u 10' to Water Line (pits -20') 50' intermittent drairaae course Septic T.nks 10' f_on Founaati cn; 50' to well 15' Gve? i to PL 9 YES X l I i 11 41- I I I YJ i i I I I I I I I L provided re-ui r ='63 t 60 ft. ma:-C'. ParelIs_ .. C^ tours 100 i ( I I I I 1 i �1 I I F YsTEYM cla t^_ rr? r I 10 fiI? I not 4s ne v - I dsoth uces 100 vr. f ccd elev. I I I 200 ft_ res rvoir, etc_ Li 150 ft. tri _ 1 /9-a11. I II I I ( I Pe -mit Application Corporate Re_oluticn Plans - Three s`ts Enaine°_rs A.uthorizati cn Design Pat:--- Sheet- MM) SUEDrTrSIC'y Deep Hol= Lcc pe±-c �J j COnS7.S'e'lt Perc Res-,f_1-_S (3) F-11 Per-C Role Dept-1 C HCUSe Ply - Two se _= Well .� Fe-riu Variance Rezuest _ =t.. -rtA� Legal- Sab&viSicn Subdivision A -cDroval C:eck d Fa -a=rcval SSDS Ate- Lot= Wet'-and (Tcwi?/DE_" Ps=i = R & D) Da`a Cn DCS Plans & Permit SEma REQliUM D=;-=.,c- CN PIANS &°.vage System Plan SF' ace Svstan Hvd_aul i c P=QL'_l °_ Fill Profile & Di_�'.e .^signs D or J Bex;T_= nc-1 /Ca_" lerv; .P_ pi t det i1 Septic Tank - Size, DeT=.,1 We-11 1 Detail, Service L:L e if c,;=-_ Ccnst:'u &.icn Motes (grinder rte) Design_ Data: �erc bold cep L.. _. ._- . ._ ... Drive,wav & Sloces Cat FcoLil /C Drains (isc:iarge C{) Perc & Deep Holes Lcc_t Repres=entative or prL7ary and e.ensign flm..nsion A.re ;shcw�l ;gravity f-ICW,ssf=..size If P'mped Pit & D Box Shcwn & Detailed House - No. of Bedrears Wells & SSOS's w /in 200 ft. of Proposed SYSt, Property rtes & Ecurds House Sztbac:t Necessa +v (Tic;1t lot) House Save: - 1 /4 " /ft. 4"0; Zv�ce pike No Bemis; Max. Bends 45° w /cleancut SEP�RATILTI DISV�ti S SPECT�T� CN PLAN Fields 10' to.P.L., Drivevav, ie—r J e T_Ees,ToD of fili 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Str .=cn, Fiate_COurse, la:tca (inc. 151 to Drains - Curtain, Doer, Footing 35'to mtch b.sin,stc�iCi ']rci_r1,DiPE{1 w-te -rc.:�u 10' to Water Line (pits -20') 50' intermittent drairaae course Septic T.nks 10' f_on Founaati cn; 50' to well 15' Gve? i to PL 9 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 PCHD PERMIT #� WELL LOCATION Street Address own Village City Tax Grid Number ,_-> 1A ak9 Ta . - 1 WELL OWNER Name G Imailing Address W .0 ' dX � ' � o �IPrivate 3 Public SE OF bAELL l - primary 2 - secondary Me RESIDENTIAL ® BUSINESS ® INDUSTRIAL ® PUB IC SUPPLY ❑ AIR /COND /HEAT PUMP ® FARM ❑ TEST /OBSERVATION O INSTITUTIONAL O STAND -BY ® ABANDONED ® OTHER (specify AMOUNT OF USE YIELD SOUGHT_ f% gpm /# PEOPLE SERVED -& /EST. OF DAILY USAGE - *,19 al ® REPLACE EXISTING SUPPLY ® TEST /OBSERVATION CIADDITIONAL SUPPLY 19 NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED ®DRIVEN ®DUG ® GRAVED ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES &I NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: G' 1� Lot No. PATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM - NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROV (DON SEPARATE SHEET 1�r? --ell 4 r (date) (sign 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 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 PiU'TN',A.M CO'CJ�T'Z'�" 17EP,P�k�x'M)�N.T Off' '�3C>EAIC�'I'�3C AP -FGR -; �4 PROVA�L OF --P L- N&i;F -.OR ==A- -NhS ;E.WA -TER-= Q�St�QSkL: , YSTE:}_{ ,. - o ... _ i. Name and Address or Applicant: 2. Name of Project: 1� PD��t� ��I75 3.._. Location T /V /C: CM l:� 4. Project Engineer: �t�t�a� -I W. J.�Ut T 5. Address: t�( OD aWI6�r_ a. i O.Y. 10S al . License Number: ����,� Phone:_ 6. Type_ of Pro ect: ✓ Private /Residential Food.Service ....Corlmercial'',' 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? 9.. Has DEIS.been completed and :found. acceptable'by Lead Agency? 'l /A " 10. N,ame of Lead Agency 1. -Is -this -projectF in, an area under the control of - 1ocal.plarini_ng,,, zoning+,, ., - _._.___.. or other officials, ordinances ?. ..... .. . .............................. ...old . _._..._... S2. If so, have plans been_su ,pitted to such, author .sties ...................... r� /Q 13. Has preliminary approval•been granted by such authorities? tSA Date Granted: 14. Type of Sewage Disposa-l_'System• Discharge...... • Surface Water ✓ Ground Waters 15. If surface water discharge, what is the stream class designation ?........ O //A :6. Waters index number (surface) ........................................... . N) 4A :7. Is project located near a public water supply system? .................. N G S. If yes, name of water supply _ 4�l /A Distance. & water supply , 9. .Is project site near a public sewage., collection or disposal system ?..... I.io 0, Name of sewage system Q/A Distance to sewage system i. Date observed: 23. Name of.Health Inspector: 4'. Project design flow (gallons per day) ..................................... 6DD 25r. -_Is. -S tat e .Ro_l.l.ux.an.t .DjscharQe. -El if ination Sys:Per�. 26. Has SPDES Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State wetland ?.......... ....................................................... r\lrl 28. Wetland ID Number .....................:... .............................. 014 29. GIs Wetland Perm it. • required? .................................. ............ Has application been made to Town or Local DEC Office? :.....:........... 30. Does project require a DEC Stream Disturbance Permit? ..................... 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 tJo 32. Is project located-within 1;000•feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill,: sludge .disposal site or any other potential known•source of contamination? ..............YES or NO DESCRIBE: 33: 'Is there .a local master plan or file.Nith the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? UN KN01a1J 3.5:,_ Are, - any -- sewage- d- i-spes-a-1 areas n excess ni� i5� sT.ope ..:................. .:':. 36. Tax Hap ID Number ...................................................... � b 37. Approved Plans are'to••ba returned to: ................ Applicant _� Engineer If the application is signed 'by a person other than the applicant shown in Item.1, the. = pp.lication must be- accompanied'by -a Letter of Authorization.- Failure to, comply with this provision may be grounds for the rejection of any submission. .T hereby affirm, under penalty of perjury; that information provided on this form is true to the best of wry knowledge and belief. False statements made herein are pun ishab Ie as !a Class A Hisdeweanor pursuant . to Section 210.45 of the Pena 1 Lary. SIGNATURES & OFFICIAL I IAL TITLES: � .,AILING ADDRESS: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Data Re: Property of- Located at (T)T Section -Block G_ Lot Subdivision of tj -iG�- LL Subdv. •Lot Filed I1aP # ate .. Ilk Gentlemen: This letter is to authorize ���-'�t a duly licensed professional engineer or registered architect (Indicate to. apply for a Construction Permit for a separate-sewage system; to r. serve. the above noted property in accordance with the standards,. rules. or.regulations as promulagated by the Commissioner of the Putnam County .Y :De'. "artment of: Health'' and to.' si n. ah]'necessary papers; on my behalf.. xn:..;'.:::;�, P 3 . g :. s; a connection with this matter and to supervise the construction of said R1. system, -or ° sy_st.ems.. in conformity with thee prov.i:- s- io:ns.a -o.f- Article 1.4.$ or _..._ . -.... _.v .. _ _ .._ _.�.... .... . .... _... _ .. ..... 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code.. OF NFL wig '•u,. A- 0 Very truly yours', CIO z� Signed saner of Property Coun r A9p�.r...., r •S ?�' P.E. emk:, - Address a m P v A) D yv U5/ Address Town Bra -91� 5�P 690 Telephone Telephone i , Putnam County Department of }•Health Division of Environmental. Sanitation AFFIDAVIT - CORPORATE a4NER APPLICATION . ......... . . ......._ , ' F0 - R- _PERK1T•_X P'i' rCA ION 5UBMTTTED• TO u .PUTNAM COUNTY HEALTn DEPARTMENT TO: Commissioner of Health - In the matter of application for I, `- siQS��' /,/— Ni —•— — -- _ _ _ _ _ _ ''.. 9 represent. that .I am an officer or employee of the corporation and am: authorized ' to act for l.,�C11?� ,�'on/.�� Z — _ _ _ ' — — -- — '(name of corpo`p-dtzon)� — 1 having offices at 17)19_1�_ �� _C=' bM P0tvp _.�- -C -�v,5 _. _ _ _• _ _ �. ,: _ _ Whose officers are President G'-5 "Eon/ _m /l29-4 .3! i! w_�,QcirJPoti� ✓U.v% -' tame and Kddress)_ Vice - President -' (Name and Address), Secr4tary - (Name and Address)— r Treasurer' a;;d and fiat I- amend will be individually responsible fon any* or all aptp. of. the-corporation with respect to the approval requested and -all .sub- seque*'t acts relating -thereto*. Sworr to iiefore me this day Signed 19 '2 Title 1 Notary Pull ie" NOTM PUWIc,GTATT OT.' ,_� REG. f4ac'zi-' 5 QUAURED N DUTCHfHS C, My OOfe MISS.lN L-010 AUG. -1, � • Corporc to Seal • t . ERVAISTE!' ABORATORRES.ua. _ x_aaz wa Box 224 - BREWSTER, N.Y. (914) 855 -1930 - WATER ANALYSIS REPORT SAMPLE NO. 8513 TEST WELL Crompond Contracting Corp. SOURCE: Steinbeck Corners �— 52 g� Lot #1,7 Brewster, N.Y. COLLECTED: 8/11/94 BY: P.F. Beal & Sons BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method Q per 100 ml. 8/15/94 This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. DEPARTMENT OF HEALTH jWX0 WELL l:VrirLL_11L)P4 tcr, UAI Office Use Only Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH 2- STREET ADDRESS: WN /VI TAX GRID NUMBER: WELL LOCATION Lot #17, Steinbeck Hill, Brewster _4:3 5— -" C1- 3 WELL OWNER NAME: ADDRESS: Box 451 Crompond Contracting Corp., Crom ond, NY 10517 ❑ PBIVATE O PUBLIC USE OF WELL 1- primary 2 - secondary L21 RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND.IHEAT PUMP O ABANDONED O BUSINESS ❑ FARM O TEST / OBSERVATION ❑ OTHER (specify) O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ®ADDITIONAL SUPPLY NEW SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 125' ft. STATIC WATER LEVEL 40 ft. DATE MEASURED 4/15/94 DRILLING EQUIPMENT 13 ROTARY El COMPRESSED AIR PERCUSSION O DUG O WELL POINT O CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE O SCREENED ❑ OPEN END CASING (3: OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH 2 3 tL MATERIALS: ZI STEEL O PLASTIC O OTHER LENGTH BELOW GRADE 22 ft. JOINTS: O WELDED ® THREADED 0 OTHER DIAMETER 6 in. SEAL: 13 CEMENT GROUT O BENTONITE OOTHER WEIGHT PER FOOT 19 Ib. /ft. I DRIVE SHOE 0 YES ONO LINER: OYES 13 NO SCREEN ,. DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (It) DEVELOPED? FIRST S OYES ONO Not ptr GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER OF PACK in. 70P DEPTH tL BOTTOM OEM If. WELL YIELD TEST If detailed pumping 9 P P METH00: O PUMPED tests were done is in- C COMPRESSED AIR ,formation attached? O BAILED ❑ OTHER ; 0 YES 0 NO �IELL LOG If more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE water Bear- ing Well Dia meter In FORMATION DESCRIPTION poE ft. I IL WELL DEPTH It. DURATION hr. min. DRAWOOWN It. YIELD gpm. Sorrtace 8 Dr ll n in overburden clay & boul er 8 Hi r ck at 8' 125 6 60 30 8 23 Drill:ncr in rock, set casing, grouted 23 125 Dr ll n in rock granite WATER O CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? ❑ YES ❑ NO STORAGE TANK: TYPE CAPACITY GAT,. WELLORILLERNAME P.F. Beal & Sons, Inc. 8 1 /9 ADDRESS 4 Putnam AvenueSIGHATURE Brewster, NY 10509 PUMP INFORMATION TYPE submersible CAPACITY 10CI MAKER Gould DEPTH 80 MODEL 10EJ05412 VOLTAGE 230HP_i 3 /by V j ��r►w< - � 4` It !r .,� 11 S1. eet of . .. PUTNAM COUNTY{DEPARTMENT OF HIEt1'LTH i 1; �r. : �.',�' IVIST NLOI E1�1 +IitO�iMENT'AL 7iEATI H SER'�ICES & A,- . `f FLFi,`� uTvfV1.TY sP'ORT .,,�%•�yt 11t ', : (t \+ 'v -en t �r'i r �r a. ✓r .:J y, i .. ,� .rt N1' , " r. P ,tir :. _ TPl v5gp{il i 4sv{.H a .M4��''r"87t`1•�h�d --..�(� nSy } ` r li ._ ft t s '�; 4 ;� J,,, feet' .Town State` Zip ✓�,: i'S Y ry'?... S 4F 7 :t ,, f� i - ! f. r f 3 EiRiR�h..'.'T: -ain ` T�Ta r FI-- R a.5 Vr tC�aT5 � �HeS�x��h';cA7' L 7�R�y,tl 7 G1 E l.. f ",s N , k 17ate: -j /% G �'x l f s + R r i 1 ' r7�7arne and Title 1. LL7i_ '��� u i'- 3 t�c r, , t `�'C._ l f /'✓` t ,'. 1 1 r ' �' , l;r� { 1.4 LLu le ;. ...?L� l..iiU:e n.S...... .,,3 ..r l j.- .. \ F .:.t 8t . K 1 �1 \ 1 �y i. : 7, 1. l 1,A �� 1 \ t 1. F F'��i�DItGS ' a S� d 1 N r"..,"", lj ! ti 4 K. +.5" ff i ear 4,,. U �.. { ;h , ,. Y, . „ .t ,. i, .: �.k. • f� _, .� l , , % � :. . 1 0 . y F S j '. j . . n - 1 it 4 K�. bi May-05 -06 12:04pm From- T -344 P.001 /001 F -T47 • � t . o- .... o..o v V V l V 0 . � �� —I"11� � 1• � 6�6��'if3 ! we�.r�! B ° ® SION OF-ENVIRONMENTAL HEALTH SERVICES I' -� _ �.c....�.- .,��c't.,»%..: r _ ,/ � ....... .. -- _. ..... T,a:n ia%,- . .c ,... �.. .. ...u_� .» :,.. •a� .. r,�.�, ->.:n. . °.'' "� \�. ... /'1r' Il ❑ ❑�/ Rep�rP�ltw"Idiftimorm ® �{sftInWwashed .. , 13 1�`. ftepgrvaft mbvft Cam% W em* of Awn Fdo PA& ❑ nti�elrl®111 SM LOCATION j(o y TOWNS TM #' OWNER'S NAME 14 PHONE O R3fj',c,2 2 j_= t,( MMUNG ADDRESS -° eo m -Ir It hh ne Re *rrsbip rta., 66mar. lemnk aonbaftO DATE S 1 d $� FACJt.I1Y TYPE �r:.s. • _ PCHD COMPLAINT # PROPOSED INSTALLER n � ; `il � fr �� S ��_ PHONE # �'�7.d. A®DRESS S• V r FMGISTPAi ®N XJCENBE 0 L� e progglM pncitwe a separate sketch locating the hotme, property firms, all edjaewd wells witinn 200 test of repo and the location of existing and praposad Walem) NOTE: The Dq=imetrt may require s0mitts! of proposal ffnt licensed pralmlonal depending an the nwUre and oWnt of ttte ntpalr. ° �., , A o-as avvnermaree m C W 1, the septlo InstaWr, agree ID = - SIGNATURE ' TITLE •GATE the conditions d1his,peffriftilDr do septic sysui[n repair DATE I - rernent of any Town Perrot Vapp mole. mft of as hulit repair sketch by the sepal system brsteiler aril n 3D dap afthe repair, in dupfiame shomft: a owners name, Sloe Street Newv6 Two and Tax Map rnrmtmr Ix Loudon of ineWled coWnenm fled to ttw foxed points c. &jam descdoon 164;.. 12M GaL Concrrda septic tank, a m) d, inWeis° name and pharm number a system mpg& tD lee performed in =mdanw Wib the dxnm pmposai and aondkimss 4 the pmpasedSETS repairI9 considered a bed1t design and (here is no gumanms ID the derfatlon altvvhM the complreed =5 repo vrZ tuition. pll dwnoik fs tb b ''bmdctillediur8 mrUmi®tiorr >r, da So Iran bean ot5minad frre the Deparbvwnt; ° vingh"L USE MLY _ All � �s Sigrrat ne & TGe: COPIES. PCHD; Owner. Inateller Proposal Denied rpieK m (,,213 c e-'6 - aor► Dais No 0 F° ti • F r 1 ewle 9 .r i o. N c. ss{' �►1c e S Tt';i�t�i`f�5`a1VitGE'It;'ii liY; ;P AA Commissioner of Health LORETTA MOLINARI, RN, IVMSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 FACSIMILE TRANSMITTAL To: _ IA4 AlA-,c$,o gzjc -P Fax: Date: to bWp i From: —toe R' C9II3i' iR11 .'..U::7NUI- �._- .- ....,,..,,. County Executive 1-6ifq- 773 -03g3 Re: Pages: CC: ❑ Urgent AA For Review ❑ Please Comment ❑ Please Reply CONFIDENTIALITY STATEMENT: The information contained in this facsimile may contain CONFIDENTIAL and legally protected information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that.any dissension, distribution, or copying of this telecopy is strictly prohibited. If you have received this telecopy in error, please immediately notify us by telephone (845- 278 -6130) and destroy all documents associated with this facsimile. Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 arlvIntervention /Preschool(845)278 -6014 Fax(845)278 -6648 May -05 -08 12:04pm From- T-344 P-001/001 F-747 %two A OFENVIRONMENTAL WALTH SERVICES 'Pit 7'P0$S'ft01.1F-QR-§W-AGE -T-Rg&_TMENT S MEN REPAIR vft"WUWQ*r paw -13 hfai in WiGW.I 13 Watershed 13/ 13 EA • ftx*voft ftft Camera W. Bm* or cmawn ftft PAM 143 Wegftd Re hln W01LaFs-e eofose arD Ivrtdo U-"Jdtt Flavfim SITE LOCATION 160 y TOWN ers TIVI # IT-- -V OWNERS NAME PHONE4 kKr,,2 2q-60 §(p"' IVWUNQ ADDRESS -Sepine- APPLJCANT K-j Name 8L Reftmldp riA., 6mar. lanot wAftbo DATE 51, Io FACILITY TYPE PGHD COMPLAINT # PROPOSED INSTALLER ttSevl-na Z-&,c--.--PHC)NE# ADDRESS _[REGISTRATION /LICENSE* q3 Pro sal (IncWde a operate slefth lowUng the house, property Ums, all adjacent wells wRtdn 200 fed of mepk end the Wotan of existing sad proposed wimem) NOTE The DeparWeit may require subminel of proposal from Acensed proiesslanal depending an the nattim anti mannt of the ma Mr- 1*,"a& OWTIXSoree WWROX.9 N*ftp = ted.oatht pmt - SIGNATME TITLE -DATE -5 0(g (awned I,th8G8*h1StBWr,89(601DCQMp Moon4ftionsOfthi-S.PeffntUtosopUcvpWfnmpair "0 BIWATUR& TrrLE4 PmacW=Prawdmdh1ha 13 MEN i. Procurement ent o f any TWm Pam it It aWicable. z "mbWonafasbufltrapirsketchbylbosepboyrtaminsWlwvMnSDdepoftherepw, 1ndupIWaWs1hcWkW Owners name, 8ft Street Mvra% Town and Tax Aftp number tr- tacdon of inoWled ccn$onwo Und to tw bled pairft r- %am decer"on (eg., 12M g& Ca, c E h a seoct=K eta) d. kwWoIW name and phone number a System sepirtp be performed to amodaim wftft don pwposef and condWm 4 Us propmdSSTS remkis emsidered a be0tV design and Owe is no gammas ID the dumpon alwhich1he =AMbagan to do so has been oblOfned ftn the IN"ftellL 89TERUN.V38 ONLY Pmp=l AppMved PMPWW Denied Inspector's Signabue & T111• Date on 5ale� proposai is in wnplimce vMh Wlmbb codes yes '0 NO ❑ GOPM PCM Owner. Ins-faller PC-RP. 09ML Rev. ZW f. k I to Op" i PUTNAM COUNTY DEPARTMENT OF HEALTH -DIVISION -OF ENVIRONMENTAL HEALTH,SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 4_j A � , . . Address _/6 /Vik�, ROO Located at (Street) / r 7�4 f,1 -; /!�� t Tax Map Block y Lot "? IP �q, -7CnTa,Q ndicate nearest cross street) Municipality Watershed �1_91,,— SOIL PERCOLATION TEST DATA Date of Pre-soaking 0 Date of Percolation Test y/� °�' Form DD-97 ............ .... . ................. . ...... ....... 'Depth t er*.::.. . ..... ...... 'F roun From X-X "-:":'L "eve .Z01 e N``... ..... .... .... . . . . Time t e . Ela se Time Surface (Inches) Start a prop In Inches Rate .... ....... . . . . 2 3 /z, g C; Z C) 4 9 5 , r L/0 2 12:y 30 ela 3 o y, 4 04) C) Z c> 5 3, 17; 2 Z, 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equalpercolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s;2 mirl-f6q 1 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: ?E (6VL/414 t-> Address: AA tt— A7 c7 Located at (street):n / p ..�i J�i s / TM # Section:'�J— Block !;"Lot /. Municipality: 4- o Watershed: 6 J, ^ N }arc SOIL PERCOLATION TEST DATA Witnessed by: L4-.) 1 -)4'- ti .4 �- Date of Pre - soaking: L1 ;- o Date of Percolation Test: U Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop water level drop in inches Percolation Rate min /inch - iVC3 ZO a� a •r .. 2 '2- o - t Z: zj, 16 �. �- a 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Notes: 1 2. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min /inch, < 2 min for 31 -60 min /inch). All data to be submitted for review. Depth measurements to be made from top of hole. Indicate level at which groundwater is encountered /U Indicate level at which mottling is observed Indicate level to which water level rises after being encountered 914 Deep hole observations made by: Z w i",�� /y" A aU a �, Date r Design Professional Name: Address: Signature: Design Professional = Seal TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # 0 HOLE # HOLE # HOLE # HOLE # G.L. 0.5' 1.0' 1.5' 2.0' ✓�`St �_ VtA7 2.5' _ A74,0 3.0'i 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' y 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered /U Indicate level at which mottling is observed Indicate level to which water level rises after being encountered 914 Deep hole observations made by: Z w i",�� /y" A aU a �, Date r Design Professional Name: Address: Signature: Design Professional = Seal TEST PIT DATA -._. . -. ter.. � pL ... .trr .a e�wa::...r.s.>.R.:a DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES - ....._P....F...._ .. nn...•��w.svte..a. .w�e......�. DEPTH HOLE # w. � .a� .. ...r -.-�. --. r -Fy. vss an...a.;�vaA:.N +... ..n- �.,�.'.iP ��,W .4'w•�:. - .awr.. �.� ..w .. . HOLE # Z HOLE # HOLE # HOLE # G.L. 1.0' 1.5' 2.0' i/ & LX V6RX 2.5'$'� 3.0' 3.5' 4.0' 4.5' 5.0' i 5.5' 6.0' 1/ V 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' _... .. - _ ..... _. .... ... 10.0' Indicate level at which groundwater is encountered ti Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Af Deep hole observations made by: e,w 1,A, ��� ��,, 2 Date b ' Design Professional Name: Address: Signature: Design Professional = Seal SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 To: DAN Fax: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health From: P14 19A TW VA Pages: V (including cover) Phone: Date: 51 / q10, ? Re: cc: ❑ Urgent /For Review ❑ Please Comment lease Reply ❑ Please Recycle In the event of transmission/reception difficulties, please contact the Environmental Health (EHS) office at (845) 278 -6130. Thank you. The information contained in this facsimile is confidential and is intended only for the use of the named addressee. If the reader of this message is not the named addressee or the person responsible to deliver it to the named addressee, you are hereby notified that any use of this facsimile or its contents, including dissemination or copying is strictly prohibited. If you have received this.facsimile in error, please immediately notify the Putnam County Department of Health by telephone at (845) 278 -6130 and mail the original facsimile to us at the above address. We ivill reimburse your telephone and postage expense for doing so. Thank you. w w w.putnamcountyny. com Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 i MEMORY TRANSMISSION REPORT ..._ ... ,.... ,,.,...- ._,...�.....�a. -:�, a,... �.._ x,. __...,.,...�._,.�...:-�: -..�.� - ...o...�T!. `...�._.. �.MAa� }9- 7_QOB- 9Z:1�.8PM.,• TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 925 DATE MAY -19 02:16PM TO 919147730343 DOCUMENT PAGES 006 START TIME MAY -19 02:16PM END TIME MAY -19 02:IBPM SENT PA�ES 006 STATUS OK FILE NUMBER 925 ** SUCCESSFUL TX NOT ICE * ** SHERLITA IAM LER. MI?, MS, PAAP y ROBERT J. BONDI Cammiss /oncr of Hep /fh V- Cor.nry Exacutl,.s LORETTA MOILINARI, RN, MSN �6r`w ROBERT MORRIS, IP6 ASFOCJQIB Commiss /over pfNeo /fh Otracfor prE »v[ronme »ta/ Haa /th DEPARTMENT OF HEALTH 1 Genova Road, S=wste:r, Tlew York 10509 mlpml Tos DA" ff- - (� �.. �Jop Ron cr_:a O Urgant Por itevimw Plans® Cemmotst ®'Fla=w Roply C3 Plcmma itacyold In flit cyartt of tralssmission /raceptioa diffievaties, pieava contact tiro Eaviroamaa:._y Ja.estlth (1i73S) oflca at (845)Z78-63L30. Thstnlc you. Tha !iT/or)italto» contained l» this faCCimtLa is — zr,4Lentlal and is lnte»ded o »[y for tha srsa ofthe »ant.a adctrassaa. 41.11,0 rmud¢r gj•[hie• frsaau•Qam L, nu1 thm nan,ad adt4ms s0e or tha perso,, r—jp ibl. io delver a to 0— na d uciarwss . yotr oleo• h--&by that 4, v z se of* this faestmila or ifs contents, i »e /.ding cussami »at[nn or copying is .srrtctLy prphlbllOCL J1',vo,r hov¢ 1 --toad rhis fi- CSlmf /a in error, p1a 0 a-p»se for - m »rb• th e mnaport»nf q1 HOa/th by to /aphon¢ at a84a S25 -6Zo p i _ fl rha a tp c pl the pbOv W. w /l/ byour pcord pcctcae [»a -c o. Thg1f[c you_ 1v1 v w.pttYnt+f+troun=1rny.COf,t GnvlrOn men tae ■Aealth (8455) 278 -6130 rW (8 -9) 378 -7931 W.tar Supply S—U. (845) 225 -51 86 F— (845) 225-541 It Nurcln¢ Sary lcac (845) 278 -6558 Fax (845) 278 -6026 WIC (849) 278 -6678 Nursing *tome Cora Par (845) 378 -6085 Early t_ta ention/Preschool (845) 278 -6014 Pex (845) 278 -6648 Fax:914- 773 -0343 Aug 14 2008 17:43 P.01 �actiry .EPA 117 �1 New York C[ty 7N epaftment-of E ron.men'tal Protect"O" �" . 1p�k�► •PIS 'i � !i : +. U i - R .A E SEWAGE TREAt4k T SYSTEM, REPAIR , DETER IWON' Pursuant td the at t ority ganted under: Article 11 the, :, ew York State Public Health Law; Rules and Re ations Far Tbe. ,. Proteciio rom: Cc Degradation and Pollution Of The New York City hater Supply Its }So ' es, 15 RCNY Section. 18 -38 (or Chapter 18);., and 10 NYCRR Ap &llpi 5- h astewater Treatment . Standards - Individual Ho Sehold Systems; . ]Puiaaana 1, Septic Repair Program Plan' — lY>larclB �Q9Q�. 1- O YV- L • •IlDEF Froject# � �' PC� k$epair# La Site Location. b��o �. 1- '�( C - 'A' 1 # J I v v Reason fdt i .1,t evie r Drainage Baste C 200' of WC/Wetland Repeat Repair inn S Ym.�. i• •� 1 Name of Owner: � 1, V410 Owner's Acres : I, . Drainage Jas�n f 'r+m'ec., Safe• _ .___. Installer: G`'� General Desc I i ' ii ® S� a e System Repair: �P g Y p r .. bates of Site ! s itio s ti and Soils Tests; Approved Complete Delegated Denied r . *Required: Sol s ests Repair Sketch WC/Wetlands Wells Other Reason Ili T1 Pete 7Wp ma it I6 a FIngmeerin Div1s ate :. I �x, tr..I4I I n J1 •. b ' .: t•, i � ��. ..0 ��' .. a�{ �j�•J�wt.QCi .. +7J'i� Efr'��i.�Y:& E 1 ..:•.: . ' " •. 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