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01750
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16,
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01750
• � PDTNAM COQNf7 DEPABTMENT OF HEALTH -
�. Divided Oft freetnentel HeaHb Servloer,:Caemel, N.Y 10512
Eogmoff sultPeoyldo
H.D: Pefmit
CATS; OF CONSTRucnoN COMPIdANCE FOB SEWAGE DISPOSAL; SYSTEM
ao rY a ��
Locaied at`t Ta: MAP?_ Black Lot —�—'
.,�
Owner /apppca it Name " v z ,, "13 Formed y Subdivision Name
Melling Addeesa i yea �, G% d GzYJ 6 . St Mv. " Lot, # • .
Fee Enclosed Amount 200 Date :Permit Issued
�. on tr_ h A� rl
Separate Sewerage System balk by. S /} S i r • • -- 1 %'
Conaletiag of �'�. Gallon Septic' Taal: and
Water Supply: PmblIc Supply From Address .
on / Private Supply Drilled by A� ' Address w "� ►-u..r sr /�
BaudiogTypel�cF%�e�, 114' Lot Size,` ; /`tC; Has Erosion Cnnt /rn�fl RP rnmi PtPfi% - L
Number of Bedrooms___ Has Garbage Grinder Been insisinea
Otlier Regalrementa
I certify that the syetsm(s) as.- listed serving the above premises were constructed essentially as shown on the plans of the completed work:( copies
of which are attached), and in accordance with the 'standarde ruled and r ations, in accordance with th fil' p ,.and the permit•issued by the
Putnam county Department of Health.
bate Certified by P.E./ P.A. 'AIX `L yJG Z License No. Z
Ada'ress
Any person occupying premises saved by the above system(:) shall promptly take Such action as may be necoMrY to secure the con salon of any unasnnary
conditions resulting from such ufaye. - Approval of the sopirato..sawaiape ,system shall become null and void as all as a pubv-i unitary sings becomes
m,
available and the approval of tiro pririte; water supply shall become null and void Wh" .a public water supply bflcomes availsbN Such approvals are
sublact Co modification or change when,'in the Iudgmant of the Comm)ssloner of •Health, such• is400stlon,'mod"lcMloe or change is necatsary.
Title 3/89 o.t.
4.A__ C%G
WILL !;UMYLh'1'1UN Kt.YUKi
Office Use Only
DEPARTMEN'C OF HEALTH
....- .Division Of .Environmental ilealth Services
UW, PUTNAM COUNTY, DEPARTMENT OF HEALTH
STREET AOURESS: JDWN/VlLLALjt1U1Y TAX GRID NUMBER:
WELL LOCATION
Steinbeck Cor-riers_ T3retas ter, NY _ Lot #7
NAME: AOORESs: PgIVATE
Banker &. Banker Realty, . 77'7 Kest Ptttiiaiu AVe. ,Greenwich O PUBLIC
WELL OWNER
USE OF WELL
): RESIDENTIAL U PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
2 - secondary
❑ BUSINESS. O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL Q INSTITUTIONAL_ O STAND -BY ❑
MOUNT OF -USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
[-]REPLACE EXISTI'IG SUPPLY ❑'LEST /OBSERVATION p ADDITIONAL SUPPLY
DRILLING
[ANEW SUPPLY (NEW DWELLING) ❑ DEEPEN_EXIST'ING WEL1,
DEPTH DATA
WELL DEPTH ;�I� ft. STATIC WATER LEVEL _lUU ft. DATE MEASURED 3/21/94
i9W nATAnY ra r..0MPnFSftFIi Aln PrnmIq. -.tnw n DIX
❑ WELL POINT ❑ CABLE PERCUSSION U OTHER (specify):
DRII.1.INn
EQUIPMENT
WELL TYPE
❑ SCREENED 0 OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH 100 ft MATERIALS:. 99 STEEL O PLASTIC O OTHER
CASING
LENGTH BELOW GRADE ft.
JOINTS: O, WELDED ® THREADED ❑ OTHER
DIAMETER 6 in_ _
SEAL: ® CEMENT GROUT O BENTONITE ❑OTHER
DETAILS
WEIGHT
PER FOOT ' `:J-�: Ib. /ft.
DRIVESHOE:.O YES ONO ;.
LINER: CJ YES ONO
SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (it) DEVELOPED?
DETAILS FIRST -- — _— OYES ONO
SECOND HOURS
- OYES _...... _ ...
GRA.UEL PAC.( -. 0 NO . GRAVEL........... -_. _ _.Dt/IMETIR_..._ .. top,: E;OTTt;at -
SIZE: OF PACK In. DEPTH ft. DEPTH ft.
WELL YIELD TEST I If detailed pumping WELL LOG II more detailed formation descriptions or :Sieve analyses
METHOD: O PUMPED 1 tests were done is in- are available, please attach.
� DEPTH fR0h1 Water Well
XXCOMPRESSED AIR ,formation attached? SURFACE. Bear- oia- FORMATION DESCRIPTION p0E
O BAILED O OTHER ❑ YES O NO. It It inv never
WELL DEPTH
It.
DURATION
h.r, min.
DRAWOOWN
It.
YIELD
9FR
—
surI;:r
11
—
n in overburden clay & bowl
er
Hi
l; r
ck at 70'
545,
6
48o
5
70
100
Dr'
1.1_
iig in rock, set casing groutit
100
5115
Dr
T.J.J.
aig in rock granite .
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE WellXtrol #251
62 (;AI,.
PUMP INFORMATION 11CAPACITY
TYPE submersible CAPACITY 5 g
MAKER Gould DEPTH 500'
MODEL5ES0741z VOITAG�30 HP3J.�I
WELL DRILLER NAME i' . F . Beal & Sons , Inc. DAT
ADDRESS 11' Putnam Ave. StGNAT1JBE 1 4
Brewsl,:rt,, NY 10509
3/89 - — -
PUIT'AM COUNTY DEPARTtMENr OF HEALTH
DIVISION OF ENViR0NLMERTAL HEALTH SERVICES
Owner or Purchaser of Bui din
Building Constructed by
Location - Street
Municipality
�zd l ��+, �� w f • .
Building Type
Section Block Lot
,G le- / ci (/ I V." rf 12a� f �
Subdivision Name-
Subdivision Lot 7
GUARANTEE OF SUBSURFACE SFAAKA-GE DISPOSAL SYSTEM
.I represent that I am wholly and completely responsible for the location,
workmanship, material, construction and drainage of the sewage. disposal system
serving the above described property, and. that it has -been - constructed as. shcwn_on
file :approved plan or: approved `amendment .thereto, ;;acid n .accordance . �iitii the -
stancrds rules' and regulations of the Putnam County Dent of Health, aiid
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years iumediately following the date of approval of the
"Certificate of Construction Compliance's for the sewage disposal system, or any
.rera.iss .made..by me -to .such system, except . where the failure-to.. operate properly_ is--,_ _ _
caused by the willful or negligent act of the occupant.of the building utilizing
the system.
The . undersigned further agrees to accept as conclusive the detemnination of
the Director of the Division of Environmental Health Services of the Putnam County
Department of Health as to whether or not - the failure of the system to o was
CLcaused by the willful or negligent act of ,the occupant of the a. ng i z ng
the system. Z-Z(.
Dated this /`r day of � , , 19 � Si K t ' N,
Title
Gene Contractor d 0,t E - Signature
Corporation Name (if Corp.)
• .r. -
rev. 9/85
nnk
14 ,car ' 11
Corporation Name (if Corp.)
Mdress
- MhiAM COUM'Y DIIIrAJIMM ' OF HDALTH
C Ywr to PeevWe IratalE
/ DWY� d HaYIA S�lo�s. amel. N.Y.1�SU
M CM= OF CO
1
C MUMnll: Pll� FOR SeWAM Mwosg SYS18A[
Lde ed at
`J�IiIWvsMSR tsslllee � i v v r r r . ri ✓ l��d- "�!ff i" � '^y = =� _� `3. y�- . �<
Reeewal ❑ ❑
OwMdAppilIcout Ili Dade of Peevlops.Approvd '
16iiF Adiue 1- aJ-'M i . Towe, ` IN jG G �_ ZIP (%,6'�j O
-Datg_,Subdivision Approved �'L � D - �� Fee Enclosed 07)
T,p Sr.r � ksf._. I.T ��%rol .Aa. 2 ` tt-; AG Ism seta odr Vab O
Ntt obw d Betbeeuse 4 ' DeI W Fbir G P D - PCHD NotlOntloa le Required Wbeh Fm Is to soleted
SeNede Seweee0e syeteg, to secret d 1 2�2Q_GWIM SepUe Teek.and ��� �/: Oa &cL?
Ti bw ee�et:.al.d 4s Tt�? P Addleas
Waller Seaadrs Pile Super Ft». Ad&m
an _Pdlrtate Supply DrMW by Addrou;
OIMir
1 represent' :that 1 am wholly and completely responsible for the design, and location of the proposed systein(s)1 11 that the saparate saw di sal stem
above described. will be constructed as shown on the approved amanAmeni thereto ono in accordance with the standards, rules a Maws o ham
County D"Wt ant Of ""Ith, and that On completion thereof i "Certificate of Construction Compliance" satisfactory to the Commissioner of, 14"Ith will
be submitted to the Department. and a written guarantee will be furnished the, owner. his successors. heirs Or assigns by the builder, that, said builder will
ga.ee in 'geed .OpMating i0ildition any' part of, said fawa� disposal system during the, — iob of two (2) years ImmadiatelYfol"ing thedate'of the isev-
anp. of the approval of tMCertNk:ateof`Conatruction Connpllenu of a original system or any ragir hereto:2)that the o►Illed wNl'despibed allow
woo located ea shorw'oe tM approved-plan and that seed well will M Inst in accordance tM st ►d rule and rpu aliions of the Putnam
County Department of Health...
Date signed P.E. R.A._
Address.l�'A' I�y'� ,v "�'' License No
APPROVED FOR CONSTRUCTION: Thi approval aspires two years from the data issued unless construction of the building .Ms been undertaken and is
MvocatiN for cause or may be amwldaA or modified whin considered necessary by tM Commissioner of Health. Any change or alteration of construction
requires a permit. Approved for disposal of domestic sanitary sewape_&nnd /O�r- -Nate water supply only.
088 Date '4;L'44—
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLiI L° TION TO l';l1TSS'1'RUCT A WATER WELL
PCHD PERMIT #��
G
WELL LOCATION
Street Address
own Village City Tax Grid Number
J S
WELL OWNER
Name
Mailing Ad reds
OP ivate
O Public
USE OF WELL
1.- primary
- secondary
® RESIDENTIAL
® BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
0 OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT r> gpm /#
❑ REPLACE EXISTING SUPPLY
® NEW SUPPLY NEW DWELLING
PEOPLE SERVED ±_� /EST. OF DAILY USAGE ±O gal
O TEST /OBSERVATION D. ADDITIONAL SUPPLY
® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
CIL
WELL TYPE
DRILLED
®DRIVEN
®DUG
®GRAVEL.
O
OTHER
IS WELL SITE SUBJECT TO FLOODING?
YES
NO
LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:/
Lot No.
WATER WELL CONTRACTOR: N Q Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES r/ NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
- --r
DICTARYCE TO_FROPERZ .. FROM NFA —REST WATFR MATN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ''
ON SEPARATE SHEET
(date) ( signature
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in su _ch a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: G 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
PiJ'TNAM CO�CJN'rY i'jEPARTMENT OF HEAl'�TZi
APPLICA_T -ION_ FOP, APPROVAL OF PLANS .FOR A., HASTE}! ! /Al ER,_DISP,.DSACr _SYSTE!,: ,_�: -., _ >•.., .:,
1 . Name and Address of Applicant: � 4v. { o � ��, l3�.k� v y. A
/ GS 2�G
77l LilrS"�li�iz4... � rycahk-, 4 C% QCiR30
� r
2. Name of Project: Mle-a, 1.a%•X� 3.•_• Location�/V /C: =Y f
4. Project Engineer: z✓Y• Li/, Wtd,,Jr - /T> 5: Address: '73
License Number: Phone: P-? 1 G
6. Type of Pro ect:
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)?
!yP& Status (Check One) Type I.. Exempt
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? ............. /V 2
9. Has DEIS been completed and found acceptable by Lead Agency? ........... / f
10. Name of Lead Agency / ✓/ /�
11. Is this project in an area under the control.,.of-Jocal planning, zoning,
o.r: ntl er off icials,�.crdin nce3? .......::. :.. : .. .:.....::....:.::......
12. If so, have plans been submitted to such. authorities?.: ...................
13. Has preliminary approval' been' 'granted by such authorities? Date Granted:
14. Type of Sewage Disposal, System Discharge...... ^I Surface Water Ground Waters
15. If surface water discharge, what is the stream class designation ?........ ✓�-
'6. Waters index number (surface) ........... ............................... /U
:7. Is project located near a public water supply system?
S. If yes, name of water supply / ✓�� Distance to water supply
9. Is project site near a public sewage collection or 'disposal system ?..... / " Y
0. Name of sewage system / ✓/ /`�- - Distance to sewage system
1. Date observed: S-Z- 23. Name of Health Inspector: IMA4•J 8(/CJz1J4
4. Project design flow (gallons per day) ...... ............................... 00
_ Fa
r•. s .2.
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?..
26. Has.SPDES Application been submitted to local DEC Office? A-
27.'Is any portion of this project located within a designated Town or State
wetland ?. .... ....... .... ........... ...............................
28. Wetland ID Number ........................................................ /✓
29. -Is Wetland Permit• required?.... ............ ............................... ,
Has application been made to Town or Local DEC Office? ILI
30. Does project require a DEC Stream Disturbance Permit? l;
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
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 N'
DESCRIBE:
` J
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? /v d
3.5.- Are-any-sewage disposal. areas in excess of 15X slope?,-._,. .e..;o-....- ...:...,_.,.'.._....
/mod
36. Tax Map ID Number'+ ........... ..............9....L........... .......... . 5,
37. Approved Plans are to"be: returned to: ................ . Applicant Cam" Engineer
If 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
Drovision 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 Penal Law.
SIGNATURES & OFFICIAL TITLES:
AILING ADDRESS:
PUIMM CCUNIY DEPARnvEn OF
DIVISICN OF •• •' 1f Y• REALTH SDWICES'
DESIGN DATA SH=- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Located at (Street) 116032tz fl,41,0t_ Sec. '-jt . Block Lot
(indicate nearest cross street)
tniczpality Watershed
SOIL PE'RCOLATIGN 'TEST DATA RB: U(M D TO BE SUB,4I = WITfi APPLICrATICNS
Date of Pre - Soaking Date of Percolation Test__
HOLE
NRx_BER C= TIME PERC7D=CN PERCOLATICN
Run Elapse Depth to Water From hater Level
No. Tim Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop Drop.In Min /In Drop
Inches Inches Inches
1 _2 II
2 :�O
T3
4'
3 2 -2
4
5
1
2
3
4
5
NOTES: 1.* Tests to be repeated•at same depth until approximately equal -soil rates
are' obtained at each percolation test hole. All data to' be submittbd
for review.... •.
2. Depth meassirenents 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
DEPTH HOLE NO. HOLE NO. 'HOLE NO.
2'
31
41
5'
6'
71
81
91
10,
'11,
'12'
'13'
"14'
INDICATE LEVEL, AfT waTcH.,G--RC.)C7N9A.TER.. IS ENCOUNTERED
INDICATE LEVEL TO WHICH SEATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP BOLE OBSERVATIONS M, -DE BY:— DATE:. y, 2
DESIQ4
Soil Rate Used 2,0 Ydn11" Drop: Usable Area Provided
No. of Bedrooms Septic Tank Capacity _ 1�7)�50 gals.' Type
Absorption Area Provided By
?0 L.F. x 24" width trench
Other -1 1 to i K\
Naze Signature—
IQ
Address SEAL
AU
2
THIS SPACE FOR USE BY-HEALTH DEPA ONLY:
Soil Rate Approved sq.ft/gal. Checked by Date
Putnam ..County Department of Health
° Divisic :)f Environmental Sanitation
AFFIDAVIT - CORPORATE aJNER APPLICATION
FOR PERMIT.APPLICAT•ION .S_UBM.7
:. - _ :t unrJ�COUNTY'fEAt,TNy DEPARTMENT ;
TO: Commissioner of Health - In the matter of application for
X INK represent•
that .1 am an officer or employee of the corporation and am; authorized'
• ' �c, � • ....�
to act for, �� �_ i ti� > _
-- --
— — —
— r- --
'(name of corporation)
having offices at — -77 ) — — °`'""', - — — cr
•� Y, �
Whose officers -are
President -- -- �,.�,�v� --- - - - - --
Yame— and Address)—.7
Vice- Presic en t -
'•.� ~ —�- -(Name and Address) ------ ^ —��_ -- '=
Secretary _ — — — •-
_ — -- - — — — — (Dame and Address) — — — — — —
Treasurer'
(Na— — _ ) _ .
me and Address_
and that I --am-and will be individually responsible fon any•or all aptp
of. the- corporation with respect to the approval requested and•all .sub -
sequei
Swor t acts relating thereto. _
n' t t
o afore me this . .. "'� day .Signed
of ��U 11P� 193 Title
N
BONMEJ.DAM
NOTARY PUBLIC. MATE OF hTW 7
REG.149MV5
QUALIFIED IN DU T CHESS COUNTY• .
MY COMMISS'ON EXPIRES AM 1$ 3-
Corporate Seal
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