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Home My WebLink About1745DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -84 BOX 16 01745 y o■ OR OR ILA EL I r � L • ■ 1 NOR Or■ ' , L OR Or J6 I 01745 i " y .t ` 4 WEL_ LUMYLL" 1UN rzruml DEPARTMENT OF HEALTH Division Of Environmental Health Services pUTigAyl COUNTY DEPti:R",M NT OF HEALTH - Office Use Only j� / — WELL LOCATION STREET ADDRESS: WN111tt 1 Y TAX GRID NUMBER: Ice Pond View Estates Andrea Wa Patterson, NY WELL OWNER NAME ADDRESS: Eagle River Builders, PO Box 970, Carmel,. NX O PUBLICS USE OF WELL 1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /CONDJHEAT PUMP O ABANDONED O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY O MOUNT.-OF USE YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 3. to: _5 / EST. OF DAILY USAGE gal.. REASON FOR DRILLING ZK NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY .O DEEPEN EXISTING WELL DEPTH DATA ` WELL DEPTH 1,000 Jd STATIC WATER LEVEL 10 ft. DATE MEASURED 11/25/88 DRILLING EQUIPMENT O ROTARY fckCOMPSESSED AIR PERCUSSION ❑ DUIG _. O WELL POINT ❑ CABLE PERCUSSION" ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING, XRkOPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH 32 ft MATERIALS- JWTEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 30 ft. JOINTS: ❑'WELDED xtkTHREADEO ❑ OTHER DIAMETER 6 in. SEAL:X3 CEMENT GROUT OZENTONITE ❑OTHER WEIGHT PER FOOT 19. lb./ft- I DRIVE SHOE. MES O NO LINER: ❑ YES ❑ NO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (11) DEPTH TO SCREEN (f if DEVELOPED? FIAST ❑YES ❑ NO SECOND 7 HOURS GRAVEL PACK I ❑ YES ❑ NO GRAVEL = SIZE DIAMETER OF PACK in. TOP DEPTH ft., BOTTOM DE?TH It. WELL YIELD TEST ' If detailed um in P P 9 METHOD: ❑ PUMPED 1 tests Were done is in- r' COMPRESSED AIR , formation attached? iI BAILED ❑ OTHER ❑ YES O NO IPIELL LOG It more detailed formation descriptions:or sieve analyses are available, please attach. DEPTH FROM SURFACE - Water Bear- in9_ well Dia- Deter FORMATION DESCRIPTION CODE, it. ft_ WELL DEPTH ft. DURATION hr, min. DRAWOOWN It. YIELD 9Cnt• Sur 20 Hard & loose cobbles. 20 1000 Medium to hard grey & white & pink 1000 7 - 700 5 WATER XX CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? YES ❑ NO ANALYSIS ATTACHED ?= YES ❑ NO STORAGE TANK: TYPE - CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE NP WELL DRILLER NAME DATE ADDRESS M� DRILL C' Putnam Ave. Brewster, NY '11,'President te. f gal ANALYSIS DATA SHEET /J 2 G '51! TYPE: PW LOCATION: REPORT TO: ADDRESS: CITY, STATE, ZI DATE COLLECTED: TIME COLLECTED: COLLECTED BY: 2 Pheasent Crossing; Brewster, NY Bonavenia Construction Corn. 86 Harmony Hill Rd. P: Pawling, NY 12564 11 -08 -94 11:35 AM A. Bonavenia REPORT DATE: 11 -10 -94 LAB # 94 -7636 _.SAMPLE..SOURCE: Hose bib ANALYSIS RESULT Total Coliform Absent DATE UNITS METHOD ANALYZED COLILERT 11 -08 -94 THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REQUIREMENTS OF NEW YORK STATE DRINKING WATER STANDARDS. s �d Laboratory Director NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 Clock Tower Commons, Rte 22, Brewster, NY 10509 / 914- 278.7600 /Fax 914. 297.0536 2 LINTY DEPAIITMENT O- F HEALTH DhUm otEnwhonmentd Haltb Sarvkea,.Geme1, N.Y. 10512 qj - Mad Provide CER1IIlt OF CONSTBUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM�P/Y, {e t Locatsd.at L� G �. - Ta MAP Block IN, .. . ,. Owner /appllMnt Name Formerly Subdlvlsh Name ; o SSG °/. Subdv Lot �.. Momag Addtess Fee Enclosed Amount Cl Date Permit Issued' Separate - Sewerage System built by Address Consisting of L 6e') y . - Gallon Septic Tank end'D Waor SappLy: /Pubic Supply •Fnm jJ )) Address n on l Private Supply Drilled byt lecrisL!' -� r.i : Address ��'^,Aa», /S�v/> i.ry�• �l! Type Sifft LG .`Lot Size j� -1 Z.. Has Etr/osion Cnnt.rnl. RPan Cnmpl.- (1.9 BWldbM Number of Bedrooms Has Garbage Grinder Henn InsWled! ` J Other Requirements I certify that. the systam(a) as list" - serving the above premises were cons"ted essentially, as shown on the lans of pcepleted work,( copies of which.are attached), and in accordance with the standards, rules and regal Lions, in accordance with the f pl , the pirmit• issued by the putnaa Coun)ty / Department of Health. t)ab 1l -2 tm _ C) Catified,.by v Atld►ess •, ', Any parson occupying pnmkes swv.d bY. the above Wst.m(s) shall, promptlyteke such action as may be _ necessary to Mean the eon.dbn. of any unsanitary conditions resulting from such. usage. :A iPVOvil of the sopanto sawwags< system sna0 become null fnA, void aa.soon as a pubcto unitary now becomes Sw abia. and the approvai of the pi.Wste.(voter supply shall become _nuivind wold When a public wetar supply becomes avalloble. Such approvais we subject. to modifleation or dung. whin, 'in the judgment of the comemsfo t- eHleek s revocation. modification or change -is necesas►y. Taos 3/ 89 at. PUTNAM COUNTY DEPAFM,! qT OF BFALIH DIVISION OF ENVIRaNMENTA.L AFA.LTH SERVICES Orwner or Purchaser of Building Section Block Lot /'? Z G -g/ Build /using Constructed by - Location - _Street f / ��i cipallty Building Type Subdivision Nary Subdivision Lot IT C-URRANL E OF SUE—SURFACE SDL�-.GE DISPOSAL SYSTF•i I represent that I an wholly and completely responsible for the location, wor}Qnanship, material, construction and drainage of the: sewage disposal system, serving the above described property, and that it has -.been constructed as shokm 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 cFner, his successors, heir's or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a_period of two years i=ae3iately following the date of approval of the "Certificate of .Construction Canplience "..for the sewpp e da.spx_�-sal, system, or any repairs made by rye 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 detenmi- nation of the birector of the Division of Enviror_rental Health Services of the Putnam County Department of' Health as to whether or not. the failure of the system to operate was caused by the willful or negligent act of the occupant of the building -utilizing the syste-n. Dated this way of Gv; 19 C Contr ctor (Deemer) - Sig tore Corporation Name (if Corp.) j Address —7 S7'7 rev_ 9/85 Mill c Sionature , 4:0- Title x , Corporation t (if Corp.) J/r F ess APPENDIX C PERMIT # FINAL SITE INSPECTION TM # OR SUBDIVISION LOT # 1 . SENAGE DISPOSAL AREA a. SDS-area located as per approved b. Fill section - date of placement 2:1 barrier LGTH C. Natural soil not sv d. Stone.brush,etc.,gri e. 100 ft. from water 4 11 SEWAGE DISPOSAL SYSTEM a. Septic tank size -- b. Septic tank install c. 10' minimum from fot d. DISTRIBUTION BOX 1. All outlets at s< 2. Protected below 1 3. Minimum 2 ft. or, 0 e. .JLMUT I ON BOX - proper 1 y set f. "TRENCHES 1. Length required - Le 2. Distance to watercourse measured 3. Installed according to plan 4. Slope of trench acceptable 1/16 - 1/ 5. 10 feet from property line - 20 feet 6. Depth of trench < 30 inches from sur 7. Room allowed for expansion, 100% 8. Size of gravel 3/4 - W' diameter cl 9. Depth of gravel in trench 12" minim g. PUMP OR DOSE SYSTEMS 1. Size of pump chamber 2. Overflow tank 3. Alarm, visual /audio 4. Pump easily accessible manhole to.gr 5. First box baffled 6. Cycle witnessed by Health Department 111. HOUSE a. House located per b. Number of bedroon IV. WELL a. Well located as c b. Distance from SD: c. Casing 18" above d. Surface drainage V. OVERALL WRKM MH1P a. Boxes properly gr b. All pipes Dartial c. All pipes flush % d. Backfill material e. Curtain drain in f. Curtain drain out g. Footing drains di h. Surface water pro i. Erosion control o i 4" r :3• YES I NO I commENTS L� i rimer ■ iii 61iel�k UWAM FUUMUCOU"ff DZPAMIMT OF MALTS " &*a . woe MdAmcfandwMENOW MkM &avowa. ii. 1-r.16M PI-41510 Naft Ad*nn T%— 0 . ..1,A --r —4 �4 A- I AnirmtI e, I/)*— C 1 0 tU="W"jLjz'UjIF %"MWA4ALT%AM ez 4 raA ;kv— 7,7 MAM Deft of PirevIam Appmvd. A �12 013AL so I W . Boo o* LJ Dp& — 'VG . &me Nttabic e[ Bete alle D.1g. Flom G P D PCEM Negagetsm to Beelob" Wbm FM Is 6ammWed Saipasage SO@& Tatift sewe"M Sys$= to eatedst d C'i5o /' /" -r. �k7.'o - I To ba,, 1 by Addn.=— Waleir Sqpptn Fddb stq !Y Pftm an P --At*= --dwab S IW* DOW by Odor I repennt that l am wholly and completely responsible for the design and location of the PrOPOnd system($), 1) that the separate -dial stem above described will be constructed n . ucted as shown on the approved aandment th ' ova to and in accordance with the Itandards, rules anTrequMations 01, na County Deportment I of Health, and that. on ionipwion.thereof a '!Certlf icat6 of constructioriCaimplignce" stl5fktory to the Commissionwof Healthwill be sulbinitted to the Department, and a written guarantee will bo furnished the owh6r, his succosews, heirs or ,signs by the builder, that saii.bulkitir will pHca in good operating condition any .part of sold so 1092 disposal I systorn during I the POTM of two (2) Y*i Immediately following the delta O('11114 New an" of the approval at the Certificate of Construction Compliance of tho original system or any repairs thWato; 2) that the drilled well described above will be located g$ ahoism on the approved Alen Ian and th I at all well will I . �Inac"co n0a, A ►dI6 ruilLsprid regulations of the Putnam County Departuneest of Malth. Deft Sion j. P.E.1— 6A. Addrea L ones N r APPROVED FOR CONSTRUCTION- This approval xpiro's two YOOL the data 1"I unt.4 r. structlon Lf Jhe building Ass b. undertaken and is revocable for cauge or may be amended or modified wren considdi0d, mry, by the Co issionor of Health. Any chango or alteration of construction "awl'ai a new'Zmit.. Apor . for disposal of domestic sanita by of W taw 2uppiV only. Rev. 0110A /6 Dece 10t 150 My Title 1 APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM ..v.�.._..:�.:..;.. Name and Address or.lAPPlflca• can �� - v..� -. ., �•e�...�.u.....f� 1. -- v 1 2. Name of Project: 1�f?'IiPDGJ�t� ��DS 3..__ Locationcm /C: � 4. Project Engineer: L�br T 5 Address: MII UffLOD D 1G ��►.1' Li N b ��8� Phone• 2�1i? �1,pA Io 7. cense um e& . t Proect: of T!Private /Residential Food - Service •..Correnercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) , Is this project subject'to State Environmental - Quality Revi:ew.(SEQR)? Tie Status (Check One) Type" I.-. Exempt ✓ Type II. Unlisted, 8. Is a Draft Environmental Impact- Statement (DEIS) required? ............. N U 9. Has DEIS been completed and found acceptable by Lead Agency? ........... NJ /A 10• Name of Lead Agency- rJl� 11. Is this project in an area under the control of -local planning, zoning, .or other officials, ordinances? - 12. If so, have plans been _submit.ted to such, authorftiesi ... _ _............. . 01/A 13. Has preliminary approva11'been' granted by such authorities? 0A Date Granted: 14. Type of Sewage Disposal: .System Discharge ......• Surface water v Ground Waters 15.. If surface water discharge, what is the- stream class designation ?.. ....... O/A '6. Waters index number (surface) 0141N, 7. Is project located near a public water supply system? .................. rJ(/ 3. If yes, name of water supply Q/A Distance•tc - water supply , 4. Is project site near a public sewage collection or disposal system ?..... ►Jo ). Name of sewage system 0 /A Distance to sewage system f • Date observed: ;'— 2 23. Name of Health Inspector: Project design flow (gallons per day) ..................................... ono s 25. Is State Pollutant Discharge Elimination System (SPDES) Permit. required ?.. �p 26. Has SPDES Application been submitted to local DEC Office? .............. ,.� �►.11 27. Is any portion of this project located within a designated Town or State wetland? ................................... ..........................:.... r)Q 23. Wetland ID Number .......................... ..................•............ ►J /d 29. -Is Wetland Perm it. • required? .............. ............................... R1- Has application been made to Town or Local DEC Office? .................. tJ1.3. 30. Does project require a DEC Stream Disturbance Permit? ►.10 . 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal;'- landfilling, sludge application or industrial activity? .........YES or NO K)v 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-..wit h the Town or Village? ...:.....:: 34. Are community water, sewer facilities planned to be developed within 15 years? M L-Q 00 .. 35. Are any sewage disposal areas in excess of 1.5 %•slope? .. ......... . 1,0 36. Tax Flap ID dumber ......................................................... 37. Approved Plans are' to''ba. returned to: App-1 icant _Y/" Engineer I+ the application is signed by a person other than the applicant shown in Item.1, the. application must be-accompanied by•a Letter of Authorization: Failure to comply with this -provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury,• that information provided on this fbm, is true to the best of m.y knowledge and be 1 ief. False statements made herein are punishable as a Class A Hisde,,,eanor pursuant to Section 210.45 of the Pena 1 Lair. 3IG,NATURES & OFFICIAL.TITLES: 01"roo .,AILING ADDRESS: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New-York 10509 (914) 278 -6130 PCHD PERMIT��` WELL LOCATION Street Address To Village City r U/'� . o Tax Grid Number lad. WELL O ER Name Mailing Addr ss WriVate pro O Public E L OF WELL 1 - primary 2- secondary ® RESIDENTI O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP D ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT gpm/ # PEOPLE SERVED gjr�5_ /EST . O REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION Sf NEW SUPPLY NEW DWELLING ❑ DEEPEN EXISTING WELL OF DAILY USAGE-6.-,V Sal 13 ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING -?� 1 WELL TYPE DRILLED DRIVEN EIDUG GRAVEL. O OTHER IS WELL SITE SUBJECT TO FLOODING? YES i/ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:G1�I.1� Lot No. 2i TT- WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES V1 NO NAME OF PUBLIC WATER SUPPLY: A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: _ A LOCATION SKETCH 6 SOURCES OF CONTAMINATION PROVIDED DON SEPARATE SHEET (date) (s gnature) 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 -y (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 Department attached to this permit. 3. Submit a Well Completion Report on a form provided by of the Putnam County Health 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 anner as not to degrade or other a contaminate surface or groundwater. Date of Issue: Cn 19 Date of Expiration all , Permit Issuing Official Permit is Non - Transferra le White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller [� PQi?IAM COaNlY DFS'AMffidT of kBAI'!H �7� a DldAea dlOs SQV1oer. Cam. N.Y.1®�iH1 fs Fan lsio Rant i aal cisrur CATZ OF COIMP1JAri M Reatl�t i 20. L T� /CONSi�IICnOPO POMN 1ON SEWAGE D18lOiAL SgSt®I[ reatad.t fl � ✓ffa2r� 70119,(cYf�'. - � ��r�, - , ,. NO®e X11 �U Vi Sul ► F�7 Oar W /A kW Noiwe Deft of PseAM Approval . 2 per l .MWIA-0 - ao,= inlid( -i G"�`. z1v Date Subdivisidn''Ap_proved �L - �O - g� Fee Enclosed ❑ Amnrint- stdits Type —Let Aeeo.1 �'� v �G Flfll Seclian oaJy Naatibaa d Bsrdeeo�s G— DWv Flog c F D FCHD Nolildndest Is Rea dmA Whas FM ii; eospkted Sapitnla SewrnlSa S a e.saaot d c�8a. seP& T:mk: a D To ko, erat eirtl by dd eaa Wtilet1, St P*.- PdWIC Supply From Add rer OfMe Ytsq.4s..t. 1 rep►asent;ahat 1 am wholly,ai d completely nfponsiele.for the defien and location of the proposed system(s); 11 that the aparste savii disposal system above Osseriiiid will be constructed at shown on the approved amendment there to and_ in1.accordance with the standards, rules a rewu wns,o ham County l Wrtnant of /lMttty aridahat on complotiomttlNaof a,r'CortifiCete or Construe lon COreiOiiance" satisfactory to'tM Cominisabnar`of Nealthwill tie .mmitt'" to the Department. and a written guarantee will be furnished the owner, his sucoaaaoss, Heirs or assigns by ttie builder, that: laid builds► will gdaco in -pod operating condition any "part -of . , W swage disposai system Auriip the ptuio0 of two (t) ywrs Imrtwdlataly folbwieij ;tMdate oO;ttN iwu- anq of the aptooval of the. CertHk ate :of Conrtrudiob Complienu otth,191nal system or any rapatrs then o; 2) that the drilled well deaattiad atuoiw WIN be bested as Ill = on the approved plan and that aid well will be Ins accordaneo with the stance ru and a lu ns of the Putnam County Department of " anh. Date % "� J � SgOnsll P.E. _ R.A. Addrasst_`��r �� License No APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless Construction of the building has been undertaken and is revocable for cause or may be amended or modified when consiii"o necasca_ ry ey. the Commissioner of Ftealth. Any change or alteration of construction re,41r, s,a ppmit. ' Approved for dispoat of domestic sanitary der s, private tee supply only. Date a. DEPARTMENT OF HEALTH vision of Environmental Health Services Geneva Road, Brewster, New York 10509 (914) 278 -6130 PLI[CATION - TO,: 1^iJ�ii51 x:15 L'1' ^` "": -.�a`i '� r`� 5'eJ JL: iJ'.•�- es.,,`..nu.n r.��..... �a rw.... a.- ._...,.._.- - ..:.. . _..v_. PCHD PERMIT # 'p Ifi Al WELL LOCATION Street Address Nt2 DL To Village City Tax Grid Number WELL OWNER Name Mailing Address 0 AV V-- UIG GrPrivate O Public USE OF WELL 01 - primary 3- secondary RESIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION U INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT r7 gpm /# PEOPLE SERVED 15�.-� /EST. OF DAILY USAGE God gal 0 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY C(NEW SUPPLY NEW DWELLING Ll DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING ti ►?J WELL TYPE VgDRILLED DRIVEN []DUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES /// NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: V/0 Cdi�;7 Vlf -[J � Lot No. 2/ WATER WELL CONTRACTOR: Name HjW�1Li {N�, Address: M� ^►,1l IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES k/ NO NA10 OF PUBLIC WATER SUPPLY: A TOWN /VIL /CITY DISTANCE TO PROPERTY -FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED OON SEPARATE SHEET (date) (si ature 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 Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health 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 Exp ion 1 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 County Department of Health \ Division of Environmental Sanitation AFFIDAVIT - CORPORATE 94NER APPLICATION _.,��..:: -- -•.FOR � P:P�M�T:- APFI.Z'CArI T'i`I'�i�'`T` x.�,....�.,_..._LL . �..__. ....:..�.�..n_ �.,__.:.. .PUTNAM COUNTY }[EALTF{ DEPARTMENT TO: Commissioner of Health - In the matter of application for I �>—� �� — -- ._ - - - -- _ ...' - -- represent that .I am an officer or employee of the corporation and am authorized to act for.. (name of corporation) having offices at _ 7 7 i -------------------------- c oG�3o Whose officers -are President Vice - President -'(Name and Address) Secretary — _ _ _ _ — _ — — _ �' (Name and Address)— — ^ ` w' — Tremirer _ {tlame,and Address )...= .,..__.._w_:,_.:__�..___ - and that I --am-and will be individually responsible fon any,or all apt¢ of the-corporation with respect to the approval requested and•all .sub- sequent acts relating-thereto. Sworn' to before me this uh day Signed of U I'1��. 1913. Title 1%•%P ' c«¢�� Notary' PublW ®ONM E .D. DADS r;OTMpumar. UP= OF NWYM REG. #4985305, QUAUFlED IN DUTCHESS COUICY MY COMMISSION EXPUOAU6. 9Z Corpor4te Seal I PUTNAM C OUNTY D E PARTMENT O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Appl i cant: �� /`c5 o� �e c•h 4j et � �Gr+ -per 5�� C� Zve Cyr- a t -j c.4 0- 6F,-,9 70 1 y f 2. Name of Project: TC A"), F j i 4� -1, •�� 3.._, Locationo /V /C: 4. Project Engineer: 5. Address: License Number: SC. ( ? Phone: ? CO a l o 6. Type of Project: i1 .. : _.. l/ Private/Residential Food.Service ....Commercial , Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 1� /o 9. Has DEIS been completed and found acceptable by Lead Agency? ........... ✓ �-+ 10. Name of Lead Agency / ✓l�� II.- rs-thi -s .project in, an area under the - contra r of =local planning; coning, �U or other officials, ordinances? ........ ............................... 12. If so, have plans been..submii:ted to such :. author .sties .7.................... V114- 13. Has preliminary approval been granted by such authorities? Date Granted 14. Type of Sewage Disposal_ System Discharge ...... ~' Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ �- f6. Waters index number (surface) ........... ............................... /U 17. Is project located near a public water supply system? Y" 18. If yes, name of water supply /A/ //4- Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... WC) 10. Name of sewage system Distance to sewage system 11. Date observed: -2-- 23. Name of Health Inspector: Ik1tckti-e-1 .4. Project design flow (gallons per day) ...... ............................... CedO 2 .. 25'."`°"I�" Sta't "Po i i ut "D itiarye ETimi nati"6n_..System,:-(SPDES)" Pt`rm `requ'i famed ... ,"°'_..__ 26. Has SPDES Application been submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State f wetland? .................................. ............................... 28. Wetland ID Number ........................ ............................... 29. •Is Wetland Permit - required? ' •e ............. ............................. <. 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', f� landfilling,'sludge application or industrial activity? ........ YES or NO ' 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or r any other potential known source of contamination? ..............YES or NO DESCRIBE: 33. Is there a local master plan or file with the Town or Village? " 34. Are community water, sewer facilities planned to be developed within 15 years? 35. Are *any sewage disposal 'areas An" excess of 15% slope? . � 36. Tax Map ID Number ........................................................ 3S= 37. Approved Plans are to 'be returned to: ................ Applicant C/ Engineer If the application is signed by a person other than the applicant shown in Item.1, the application must be accompanied by y-a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Hisdemeanor pursuant to Section 210.45 of the Pena 1 Law. SIGNATURES & OFFICIAL TITLES: 4AILING ADDRESS: FCit1AM COD[fF! DElANUM OF BEAM a Fa..Ya Ftl.itlt / DNIi e/�tOe�a l Bo" 9�nleaa. CaavooL N.T.1�51? a• CWWWAIB OF gowuANCE Ftslt. FEvbt FOE M.MACE DEPOFAL SISTOW Towle Lwnarail ai. �� F' W Vie: Z..Idon 9 o..adA/*ro�tr� To MArz E-751 . Deft W! Fie�Mda A 2 37ASeer. Date Subdivision Aqnroved, S;/()- O!j Fee Enclosed Ammint . �� v�Tr� Lti< ,.. Soils ijM FE Seder old, Dap6 Vale Knobr 1 iitl� �P Flow G T D �oG FCBD NNbeatlarb Sated Was M b enmp eted =.p.+ ••m• sy.b. 6 a:.r.t or 1 GoU so. s.up r..k U be eti��eMi y T i7 Adlha+ee WNW SarbY FtYe saw* Firm Adhoes Deli b A I L - 11R l t.l. t f� Ad&... �l i'[►� /srl,/l iF . -� _i 5"� = Miller Rar2tike�wb 1 lope" t that 1 am wholly and completely responsible for the deN/n and location of. the p►opo'od systamhA: 1) that SIN: separate sawaee diva system stave described WNl W: Constructed as shown on the approved arinndment. there to and in accordance with the standards. rules an ►eju ns of T ariiii Collltty Dapaftment . tlMRhr and that on Completion,tnaraof a ""Cortifkate of Constructlen Compliance" Satisfactory to the Commiwbntir of Waalthwill to tuMwMad to t1N, t aper .M. and a written guarantee will Oo .furniep" the owner. his r/CCeNera,, heirs or' asstons by the builder, :that, aid builder will pig"-in 900 /..opawtine cowdNldn any part of loW. sawave disposal syftMl burble the period of two (2) yeYf Immediately` following tMdate of the NMr aaioe of the eo peeat. ef tai Certificate of Comtructbn "ellsnq oft .. orijieal System or any repairs o. 2) that the drilled well described above WIN be located at tta ' dh t fie appiovill "M and that old wall wi110e Insta in . accordance with the eta rA i u . - and rNuTai;;rS_Of the Putnam Dab Z� '1 9MM0 r P.E. V" R.A. 4. Address . - license No rF APPROVED FOR CONSTRU&SCN: Thai ,apprewl. expires two tM dab I unNSt 'confhuet'_n of the buildinj -has been undertaken and Is MVOCabla for Cau/a.er,may.00 amended F inedMleO when on' y -Oy the C Inmissloner of Health. Any chance or altwatlbn of construction rebuYas at pporrml Apbroved for dMoosel. of domestic nd/ ate water supply only. AL ReV . ' 11 fJV / EY Title I AWL Putn as hV ounty Department of Ilealt Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT. APPLICATION SUBMITTED- TO _ PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter. of apps ication for` I� _ 1-2 0ile.�LdAV EL — — — — — _ _ represent that.I am an officer or employee of the corporation and am•authorized• to act for —m. t - (name of corporation) r having offices at Whose officers -are President C�Q� %��r-- - - - - -- tiame an A�3dress) - Vice- President (Name and Ad a rrs) Seere Lary --- (Name and Address) Treasurer _ _. ..— ---- .(Name and Address) - -- -- - - - = -- and that I= am-and w�.11 be individually responsible for, any or all acts of. the- corporation with respect to the approval requested and•all.Bub- r sequent acts relating thereto. - Sworr to iie fore me this g' day :Signed of 19(' Title Notary FUbli �Er BONNIE J. DAVIS �. Notary Public, State of Now fort e 1 Dukn•es County 4y CoTmtesbn Expires April n 19M ! - Corporate Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA DISPOSAL SIS R - owner j62qzn -b RICK-tf EST. Address 1,7 0, bax ' ?? Located at (street) M JrO Sec. J.S. Block Lot (indicate nearest cross street) Municipality L , � &TTT e-s'G �tJ Watershed �' /P-l� V�j SOIL PERCOLATION TEST DATA RDQUMED TO BE SUBMI= WITH APPLICATIONS Date of Pre- Soaking J la - of Date of Percolation Test � HOLE NUMBER CZAR TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches t9-F ) 2 1'. �4 101.a4 X5'/8 1' �-3 1-0' 0-5• Jr�' ,5 50 1-94 'A )'/a C�-7 4 5 2 10 A4 04 1 3 101A IU'sLi `1:19 o�j 02s`1q 4 5 1 " E 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 from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES r._ DEPTH : HOLE NO. i' HOLE NO. HOLE NO. G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' ill 12' 13' WIT S INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: (-I ,1!`/ , 1`11 C �-I I)L Dom:' DESIGN Soil Rate Used 0 Min /1" Drop: S.D. Usable Area Provided No. of Bedrooms '?) Septic Tank Capacity 100 gals. Type Absorption Area Provided By L.F. x 24" width trench Other Name N.Al2fZ-S W, �.i itlV��s �3 f . , t om. Signature Address , -u F-cxi 4;e o SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address' of Applicant: -V5A1;?A A TO .�A�K T EV4S; 2. . Name of Project: 1L'E f6il1] VIEW _FEST ' ' ..3.. Locatior�T V /C: - �7^`fV'— -W 4. Project Engineer: }Vg V,7 '3f? -- .: S. Address:.1_�5 V�i1e'P t(-b Q2 -'y - 5 uyyr� t ;��, ITC 1 I �I�S�'Iti` 4; �� •� lr�l0 �' License Number • ' "1 Phone 6. , TyQe of P o ect N_ Private /Residential Food .Service , ,�,..- -. -- Commercial Apartments' Institutional Mobile Home Park Office Building,-,.,. Real ty,:Subdivision- Other: (specify) :z _ 7. Is this project subject io' State Environmenta du'al.ity Review (SEAR)? Tvoe Status (Check One)'" Exempt Type II. Unlisted X_ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 9. Has DEIS been completed and found acceptable by Lead Agency? ...... ...... N A.. 10. Name of Lead Agency - 9 --it. is this-project-An- asp area - undo r- the- contr- c4,a —✓ or other officials, ordinances? ......... ............................... 11 12. If so, have-•plans been submitted- to such authorities? ...........+....... RA 13. Has preliminary approval been' "granted by-such authori t i es? u A Date Granted: 14. Type of Sewage tDisposal•System Discharge.....;.. Surface Water. ✓ .Ground Waters 15. If surface water discharge, what is the streams class designation ?........ 'N,A- 16. Waters index number. ape).,. .............;..........:... , 17. Is project located` "near a..public water,, supply ,system? °:....... l�h` 18. If yes, name of water supply,, Distance to water supply 19. Is project site near a public sewage collection.or disposal system ?..... K 20. Name of'sewage system Distance to sewage system 21. Date observed: 23. Name of Health Inspector: OPT 24. Project design flow (gallons per day) ...... ............................... (Gc�� 27. Is any portion of this project located within a designated Town or State . wetland?..m o..... e .................ee ..............................e .e. 28. Wetland ID Number ...e..... em......oeeeemm. ......meem...mee ............... KA 29. Is_Wetland Permit ,required? e'eme:ee.me.mm.ee..eeeemmm . emeeem... :moeom. tN O Has application been made .to ..Town. or Local _.DEC Office? - e . e e e m e tit A . 30. Does project_„• require.; a_.DEC,Sstream Disturbance Permit? ........mee....e... 31. Is or was project site used.for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application' or_ industrial activity? em.. YES`or N0 �- 32e Is project .located within5,1;000.'feet.of axi'stence of='abandoned - landfill; hazardous waste site, salt stockpile, landfill, sludge disposal site or. any other potential knownlesource of contaminations o.. m ".o m.`.YES or N0. i d'` DESCRIBE: ;. 33. Is there a local master plan or file with the Town or Village? 34m Are community water, sewer facilities planned to be developed within 15 years? 1� 35m Are any sewage disposal;: areas in* _excess: of 15%' slope? 36. Tax Map ID Number ......e ................. ................. -r m o e o o s o e o s e o o m m o o e m o e e e s e m s a - 3T. Approved Plans are to -bey returned to: mmee`............' Applicant_ _.,Engineer.,. If the application is signed by a person other than the applicant shown in Item 1,.,the_ appl i cat ion • must= :be,:accompa hied. by-;a- ?'Letter of Authorization.' Failure to' comp ly with "this " provision may be grounds for the rejection of any submission. I hereby affirm, underpenalty.of perjury, that information provided on this'' form Is true to the best.of my.knowledge and belief. False statements made herein are punishable as , a : Class A tMisdemeanor, pursuant `to `Sect ton 210e 45'_of the.Pena 1 Law. P SIGNATURES &OFFICIAL TITLES. ` 5VM4 r�w[w ® Bulletin 1116 �oN t7 V I k,�d "T A_-7'1&5. Outstanding Features: 1. Oil- filled ball bearing motor provides life -long quiet operation. Motor is Y< HP single phase, 1750 fprr with b_uilt-iri protection. 2. Exclusive single rotor and shaft are'supported by one long bronze sleeve bearing, lubricated for life with oil in motor. 3. Non-clog cast iron impeller, threaded to steel shaft, allows all ordinary sump deposits, includ- ing washing machine lint, to be pumped without binding. No suction screens to clean. 4. Mechanical shaft seal, carbon and ceramic faced, super lapped for perfect sealing. Buna N rubber, brass and stainless steel used in seal parts. 5. Choice of cast iron or bronze construction. 6. Designed for field serviceability. Motor stator winding, mechanical seal, or level control switch can be replaced quickly without the use of spe- cial tools. 7. Each unit given a complete operating test before shipment to assure exacting specifications will be met. SP25 Submersible Pump. for Residential and Industrial Sump and Effluent Service HYDROMATIC I Lr90 PUMPS A Marley Pump Company Applications *Septic tank effluent *Flood control units *Air conditioning condensate •Industrial circulators -Transfer tanks •Basement sumps *Elevator pits -Water coolers q Specifications Capacities Heads Solids �..NPT Motor Teo... _.,..: _ _ _ ._ - To.....: - ».'1rtdlin e -:. .Disclhax - -i : - _.:�{P�:,._, - roGorrtroll - - _ - �.�_ .... C'6 nstr'u'ction 45 gpm 21 feet 5/8 -inch 1 -1/4 -inch 114 Auto or Man Cast iron or Bronze' 'Pump case, motor cap, support foot and baffle are cast bronze 85 -5 -5 -5 metal on bronze pumps. Shaft is stainless steel. Lifting handle and outside assembly screws 18 -8 stainless steel on both cast iron and bronze models. Trouble -free Diaphragm Switch Diaphragm type pressure op- erated level switch sealed into watertight housing. Switch diaphragm is isolated by oil retained by a second dia- phragm. Solids cannot affect switch operation, and switch will continue to operate even if exposed diaphragm is punc tured—an exclusive HYDROMATIC feature. Standard switch setting is 8 inches but can be furnished special for levels to 30 inches. Power Cord: Automatic model (SP25A) furnished with vented power cable with molded plug in 10 -foot length as standard. Other lengths available. Manual models furnished without plugs. Dimensions Performance SP 25 - MAX - 'SnLInS_5 /R" W W U. 2 O Q W S J Q 1-� O H U 1U 2U ju aU 50 60 U.S. GALLONS PER MINUTE Bulletin 110.2 New 4/84; Supersedes 210.1 LITHO IN U.S.A. 7 NOTE: CASTING DIM. MAY VARY ±1/8" Distributed by: MARLEY• THE MARLEY PUMP COMPANY HYDROMATIC PUMPS / Box 327, Ashland. ONO 44805 (419) M-3042 In Canada — V41ain Canada ltd ltee_ 126 East Or. Bramplm Ontario L6T 1C2 International Saks — Ashland. Ohio Tete■ 987432 ■ mnm. mmmmmm No 00m, a AMPS AT 115V.' 11 MEM ENOMMOMM .00000000 MEN U 1U 2U ju aU 50 60 U.S. GALLONS PER MINUTE Bulletin 110.2 New 4/84; Supersedes 210.1 LITHO IN U.S.A. 7 NOTE: CASTING DIM. MAY VARY ±1/8" Distributed by: MARLEY• THE MARLEY PUMP COMPANY HYDROMATIC PUMPS / Box 327, Ashland. ONO 44805 (419) M-3042 In Canada — V41ain Canada ltd ltee_ 126 East Or. Bramplm Ontario L6T 1C2 International Saks — Ashland. Ohio Tete■ 987432 HYDROMATIC SECTION loo PUMPS PERFORMANCE DATA & DIM.ENSIONAL_DpAWI,N,G •.z_; :.:..., MODEL: • • HP OTOR ■■■■■■■■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■■ ■ ■ ■■ ■■■■■■■■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■ ■ ■■ ■.■o;! ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ ■ ■■i / ■ ■.� ■ ■ ■. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■ ■1■ ►• ■ ■ ■ ■ ■ ■ ■ ■. ■ ■ ■ ■. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ ■■■■■■■Iq ►. ■.....�.� ...............■.■ ....... ■.■■■■■■■■..■■■■■■ ........ ..... .......................... ■■ q■■■ I ■■ ■q....■�......... ■ ■. ■ ■..q.... ME ■■■ 1■■ ■■■ ■. ■ ■�7 ■ ■ ■. ■ ■ ■ ■ ■ ■ ■. ■ ■. ■ ■. ■ ■ ■■ ■ ■qq ■I■qq ■ ■ ■ ■■►� .. ■■■■■■■■ ■q■■■■ ■ ■q ■ ■ ■I■=■ ■ ■ ■ ■ ■ ■ ■■ i■■■■■■■■■■■■■ q I■ ■■■M.■■■■■■■■■ ■■■■■■■.■■■■■■■■■■ ■■mmam■■■ ■ ■ ■ ■■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■.■■■■ ■■ MODEL:- SP25A 7' /s NOTE: CASTING DIMS. MAY VARY = Ve m /y, yo APPEMIX B PUMUI.M COUNTY DEPPRZAnT OF HEALTH - DIVISICN OF ENVIRONZEMAL HEALTH SERVICES f� INDIVIDUAL WATER SUPPLY & SUBSURFACE MiA-GE DISPOSAL SYSTEMS `i`4j) VSEW e-5 r,4resA,, I,w sHEEr - CONST rrVrTnN Pr'RMIT A-A �f `� ! -' BY: Ji�nlrl G.br.a of Owner) - (Street Location) CMMFN -Ts YES) NO I I I i I I I �I Y I Lam, r=anch provided k'!1 ra rui_a-2 60 ft. max. Pare 'lei to contours 100% e=. - —•�i• � I I I I I X I MY. 5LOPE SAS ' I IX FIX, SYSTE c vi -.rr' er I X I 10 It. F fill tes , new spaq. , ,. X deo as X 100 .flood elev. I x 200 ft. reservoir, etc. Li X 150 ft. trigall /gall. X DOCTj7AaIl'S Pe--.nit Application Coroorate Resolution Plans - Three sets Engine s Authori zaticn Design Data Sheet (DDS) Deep Hole Log Consistent PerC Results Perc Hole Dept's s/s S — D1 7ISION P =Y`' °_ (3) Fill cd Z House Plans - Two sets Weil pe_rini t; Pn7S letter Variance Reo-sest Cr'I. v� M + Legal Subdivision SucdiVi sion Aoorovai Checked P,c-a_ prcval SSDS Adj. Lots Checked Wee? and (Tc;, n /DEC Pl-__ni t R & D) Data On DDS Plans & Perni t SST? REQUIRED DETAILSS ON PLANS Sa7wage System Plan - (north arrow) Sewage System -Hydraulic Profile - Gravity Flow Fill Profile & Dtnensicns - Volure D or J Eox;Trench /Gallery; Ply pit details Septic Tank - Size., Detail Well Derail, Service Line if over Construction Notes (grinder rate) Design Data: perc and deep results Twa xt Contours Ex-1s ting & Proposzr - Driveway & Slopes Cut . Foctin /Gstte_r,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area; shown; gravity flow,ssff. size If Pumped Pit & D Box Shawn & Detailed House - No, of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems Prcper� Metes & Bounds House Setback Necessary (Tight lot) House Saver - 1/4"/-Lt. 4"0; Type pipe No Bends; Max. Bends 45" w /clesnout SEPARATION DISTANCES SPECIFIED ON P1 2N Fields 10' to P.L., Driveway, Large Trees,Top of fil 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Take (inc. e- Par - 15' to Drains- C'urt-ain, Leader, Foot .ng 351to match basin, stormdrain,pipe`i watercours 10' to Water Line (pits -201) 50' inte ittent drainage course Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL 9 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER,.CARMEL, N.Y. 10512 (914) 225 -0310 r Agel_I(ArlrT Tn r1�?Sra`rm .TER rE��P CHD PERMIT WELL LOCATION Street Address ,J,0 Town Vi age City Tax IZ67 if 0 Grid Number ' WELL OWNER Name Mailing Addr ss 1 17% 112 0 e J 0 0G= as �a5 0`� QfPrivate OPublic E OF WELL 1 primary 2 - secondary �/ ® RESIDENTIAL ® BUSINESS ® INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT 15 gpm /4i PEOPLE SERVED . _J5� /EST. OF DAILY USAGE 6,00 gal REASON FOR DRILLING 0 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Cl ADDITIONAL SUPPLY KNEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL DETAILED REASON FOR 'DRILLING (� WELL TYPE DRILLED DRIVEN ®DUG ®GRAVEL. 1.1 OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION,. NAME OF SUBDIVISION: 10E)'6AYT? VlG�J ES%j�T S Lot No. I*;, WATER WELL CONTRACTOR: Name MILL- 7/2ILU k) TiJ[_. Address: PI) rA6r, Al)e. -04 Gf)-S7�W— IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES No NAME OF PUBLIC WATER SUPPLY: �h TOWN /VIL /CITY DISTANCE TO -PROPERTY FROM. NEAREST . WATER MATN : LOCATION SKETCYON SOURCES OF CONTAMINATION P 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- Putnam Co my Health Departm nt. Date of Issue: 57 17 19 Date of Expiration: V/ 2 g PdOmit Isluing Officifl Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Rev. 10/88 Pink Copy: Owner Orange copy: -Well Driller Outstanding Features: 1. Oil-filled ball bearing motor provides life-long quiet operation. Motor is 1/4 HP single phase, 1750 rpm with built-in automatic reset overload 2. Exclusive single rotor and shaft an1eupporhedby one long bronze sleeve bearing, lubricated Tor xna with oil in motor. 3. Non-clog cast iron innpeUer, threaded to steel shaft, allows all ordinary sump deposits, includ- ing washing machine lint, to be pumped without binding. No suction screens toclean. 4. Mechanical shaft seal, carbon and ceramic faced, super lapped for perfect sealing. Buna N rubbar, brass and stainless steel used in seal parts. 5. Choice of cast iron or bronze construction. ' 8. Designed for field serviceability. Motor stator winding, mechanical seal, nrlevel control switch can be replaced quickly without the use ofspe- cial 7. Each unit given a complete operating test before shipment to assure exacting specifications will be met. A�U�U^4��0t^K�X0�� `,�_ — *Septic tank effluent °F|ood control units *Air conditioning condensate *Industrial circulators *Transfer tanks *Basement sumps *Elevator pits *Water coolers pany 1. Oil-filled ball bearing motor provides life-long quiet operation. Motor is 1/4 HP single phase, 1750 rpm with built-in automatic reset overload 2. Exclusive single rotor and shaft an1eupporhedby one long bronze sleeve bearing, lubricated Tor xna with oil in motor. 3. Non-clog cast iron innpeUer, threaded to steel shaft, allows all ordinary sump deposits, includ- ing washing machine lint, to be pumped without binding. No suction screens toclean. 4. Mechanical shaft seal, carbon and ceramic faced, super lapped for perfect sealing. Buna N rubbar, brass and stainless steel used in seal parts. 5. Choice of cast iron or bronze construction. ' 8. Designed for field serviceability. Motor stator winding, mechanical seal, nrlevel control switch can be replaced quickly without the use ofspe- cial 7. Each unit given a complete operating test before shipment to assure exacting specifications will be met. A�U�U^4��0t^K�X0�� `,�_ — *Septic tank effluent °F|ood control units *Air conditioning condensate *Industrial circulators *Transfer tanks *Basement sumps *Elevator pits *Water coolers Q �-0 Specifications Capacities Heads Solids NPT Motor 45 gpm 21 feet 5/8 -inch 1.1/4 -inch 1/4 Auto or Man Cast iron or Bronze* *Pump case, motor cap, support foot and baffle are cast bronze 85 -5 -5 -5 metal on bronze pumps. Shaft is stainless steel. Lifting handle and outside assembly screws 18 -8 stainless steel on both cast iron and, bronze models. Trouble -free Diaphragm Switch Diaphragm type pressure op- erated level switch sealed into watertight housing. Switch diaphragm is isolated by oil retained by a second dia- phragm. Solids cannot affect switch operation, and switch will continue to operate even if exposed diaphragm is punc- tured —an exclusive HYDROMATIC feature. Standard switch setting is 8 inches but can be furnished special for levels to 30 inches. Power Cord: Automatic model (SP25A) furnished with vented power cable with molded plug in 10 -foot length as standard. Other lengths available. Manual models furnished without plugs. Performance 24 SP25 — MAX. S( 20 W 16 W LL Z 0 Q 12 W X J _ Q H O 8 4 0` 0 518" SPHERE — 1750 RPM FULL LOAD ' AMPS AT 115V. 5.5 10 20 30 40 50 60 U.S. GALLONS PER MINUTE Bulletin 110.2 New 4184; Supersedes 210.1 LITHO IN U.S.A. Dimensions Distributed by: Mar+��v THE MARLEY PUMP COMPANY HYDROMATIC PUMPS (. Box 327, Ashland, Ohio 44805 (419) 2893D42 In Canada — Wylain Canada Ltd. Ltee., 126 East Dr. Brampton, Ontario L6T 1C2 nternational Sales — Ashland, Ohio Telex 987432 0- 101 M NOW 0503 Vija 14k W r r`n7i. r T'1T_ S c r.AGE- ;..st�7r�1;"D SPDS _ SYSZDi��.. � - . •. `. •• • .. • ' ifLJ1�71Y i.l'1�...J iiiiil 'aJLJ li•J �./AL � _ _��'t'T�-L�— •w'Y °�.• _ PD �Gx �70 11i LVJ Owner TO i 4 9Y—C7' �S77 F 5S Address C'/�/�/I� F7- N `/ aS/ Located at (Street) flq2M F!J n'IIVIZG %7- ,P4 fin sec_ eo Block 9_ 1t 2b ( indicate nearest cross street) (,401--.-( 2� Municipality TbLU� U� O/� r r� 50A) Watershed C" "/J SOIL PERCOLATION TE:SI' DAM RDQ[TIRED TO HE SUBNIITI'ED WITS APPLICATIONS Date of Pre- Soaking Date of Percolation Test - HOLE NUMBER CLOCK TIME P�f' tCO=C?4 PERCOLATION Run Elapse Depth to Water Fran Water Level No. Tine Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches .r4/-,,. �9va, 45 /A Poe 2 i ' 3 4 0 2 / C /' c 3 4 S 1 '/2;D PT a1 2 ' S - / , !� 3 4 5 &0 6 vq la 0 S U NOTES: 1. Tests to be repeated at same depth until approximately dual soil rates are obtained at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made from top of hole_ rev. 9/85 TEST PIT DATA RBQUIRED TO BE SUBMITTED WITH APPLICATION Calo SUBMITTED DESCRIPTION OF SOnS RXMNTERED IN TEST HOLES D= HOLE NO. "04MOYFn 02 HOLE NO. ENVIRONMENTA-L IHELa,LD4 G-L- 11 2' 3' 41 51 61 71 81 91 10, ill • 12' 131 141 INDICATE -LEVEL AT WHICH GROONDW&= IS-ENCOUNTERM INDICATE LEVEL TO WHICH WATER LEVEL RISES A= BEING ENCOUNTERED LA D= HOLE OBSERVATIONS MADE BY: 67PALE� (2, DATE: DESIGN Soil Rate Used#& -(PO Min/1" Drop: 0, 45 S.D. Usable Area Provided No. of Bedroans Septic. Tank Capacity /,,1 ei 0 gals. Type Cdl) (2i Absorption Area Provided By L.F. x 24" 4dth-tremh Other 77' DE-A-P t1,0RT)91A) Vi-9141A) Name /?S S-66 C" Signature Address 22P4-1 SEAL Z: w4- 0451 THIS SPACE FOR USE BY HEALTH DEPARDTM ONLY: Soil Rate Approved sq.ft/gal. Checked by Date. HYDROMATIC PUMPS SECTION 100 PERFORMANCE DATA & DIMENSIONAL DRAWING 377 MODEL: SP25A 43/4 .4 61/4 o. 45 /e O 11/4 STD. PIPE 0 53/8 fl 71/2 - 1.4 61/4 T -- - - --- - I r 2% p- NOTE: CASTING DIMS. MAY VARY ±'/8 Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE OWNER APPLICATION _4T__A_PPLICATION SUBMrTTED- TO PUTNAM COUNTY JIEAT.Tlj°,DEPARTMENT TO: Commissioner of Health In the matter of application 'for` L L9L' L represent that.I am an officer or employee of the corporation and am . authorized to act for 01 J-2 _24f (name of corporation) having offices a t X -7� Whose officers -are President L-- lame an res Vice - President — .-P_aL_rz (Name and Addrrss) Secretary' (Name and Address) Treas.urer, Address) and that I=awand w;Lll be individually responsible for, any or all acts of the- corporation with respect to the approval re U /qpested and-all.s b' equent acts 'ielating thereto. swom: to be fore 'me this 2Lg-- day iSigned rn of A rj 198 Title T Rotary' Publioj BONNIE j. UAVIS Notary Public, State of Now York' Dutch#ss County My Commli n Expires April A 19 1L V, . Corporate Seal a� R, h revision of E iror —mental Health =i- eem--'- 9.pproved for conformance with -ipplicable Rules 3.nd Hsyslations Of the Putnam County Health Department.; Z cv —. -- - S T.9 X • . 1 PROJECT F /G p,4TTERSO� CLIENT FRA BREWS: DRAWING .45— BU /L T D/MENS /ON CHART (/NFT) ab t /66.5 214 0 2. 194.5 215.0 3 192.0 2//.0 4 1870 207.0 5 /d/. 5 705.0 6 /770 20 /.0- 7 17 ?.0 B 166.0 9 170.5 /62.0 /0 1650 156.0 /60.0 149.5 /2 154.0 143 0 13 1475 /370 14 /42.0 132.5 15 /36.0 11?7 0 ab