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BOX 17
01902
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01902
Rev, 3/ 86 rf PUTNAM COUNTY DEPARTMENT OF HEALTH t
Division of Envirodin Health Serviees, Caemel, N Y 10512
� eer Mast Provide
.H D Permit# _
CA OF COIVSTRIICTION COMPLIANCE. FOR SKWAGF DIS�O$AL
Town or Village
Locsted at Tax MeP Bloch -�3 Lot _
L� //g%i? 1% K 03986
Owner /applicant Name —� 7/ Formerly _ Subdivision Name Sabdv. Lot #/,j2 g.3
Metling-AddressTz7i'11yoB� E 9
�P
Date Permit leaned
Separate.Sewerage System bWlt by �� �� Address
.1
Consisting of j Galton.:SepN Tank and
. y
Water Supply: Public Supply From Address.
on Prlvate Su 1 Drllled.b 6� Address �l �i, �'Zi. t_
PP Y: Y
Balldhtg.Type ` �S a'�� Has Eeoslon Control Been ComplgtedY
Number of Bedtooms• Has Garbage
Grinder Been ListaRedY
Other Regnlrements
-I ceztify' that' -the syetem(s) as listed "serving the above premises pre construeted,eeeentially as ,e ;the lane of -the completed woPk.( cop es'
of which are attached) ar�d in accordance with the etandads rules and re at acco an'e'w a fi ed p and the peimit issued by the
Putnam Count Depa tment bf Health
Oats Csrtifietl by G�li , P E V R q w
y
Address Llcenw No *;
;G
Any parson occupying premises served by `t fie above`aystem(sj shall promptly take wch action of may be negssary to secure the corredlon of any unsanitary
conditions resulting from "such usage ,Ap6roval %oi the separate sewerage ``stam'shall become null and void ee noon as: a puti(I- santtry iawi►sbacortiec
available and ths`approvel of the'private.'wpter supply shalt become'tiu ntt i ir! Yr an '8,'publtc watav wpp1Y: becomes avaiNt►Is. Such app►o Isis are
sub)eet"to modifi'223 onor 'hinge', when, °in the Juegment of the m, 7 o r of M It ch'revotation; niodiflcation -or`chanys/Isn�eeesw�y.
Oats�� 010 BY Title
4
:.,.., DIVISION OF ENVIROI -TR SERVICES
Owner or Purchaser of Building Section Block Lot
Building nstructed by
Location - Street
Municipality
Building Type
Subdivision Name
Subdivision Lot
GUARANTEE OF SUBSURFACE SEWAGE 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 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 me which fails to
operate-for. -a period, of. two years immediately following the -date of_approval of the
._ "Certificate of Construction Compliance" for 'the sewage' disposal system; or- any -
repairs made by 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 detPn+ination 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 utilizing
the system.
Dated this t` day of Q 19 a Signature r
Title
Gen n for (Owner) - Signature
Corporation Name (if Corp.)
Corporation Name (if Corp.)
Address
Address
rev. 9/85
mk
A/ P� ol.
y .e
W `
WELL GUMYLL'11UN x..nrUAI
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPART1kENT..OF_HEALTH„
Office Use Only
r—, —
STREET ADDRESS: TOWNIVILEXUA31Y TAX GRIO NUMBER:
aoT * V ��- AA ��oQSon% -
11WELL LOCATION
WELL OWNER
NAME: ADDRESS:
A/, 41 /(/.
PRIVATE
❑PUBLIC
USE OF WELL
1 - primary
2 - secondary
WRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED •S / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
)dNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION
❑ REPLACE EXISTING SUPPLY. ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL ft.
DATE MEASURED 9-43_::q
DRILLING
EQUIPMENT
❑ ROTARY 19 COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. NrOPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH J O ft-
MATERIALS: OSTEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE ft.
JOINTS: ❑ WELDED . 19THREADED ❑ OTHER
DIAMETER 6 .1 in.
SEAL: 9CEMENT GROUT ❑ BENTONITE ❑ OTHER
WEIGHT PER FOOT lb./ft.
DRIVE SHOEgYES ONO
I LINER: O YES li[NO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED 1 tests were done is in -.
'COMPRESSED AIR ,formation attached?
0 BAILED O OTHER :OYES O 'NO
It more detailed formation descriptions or sieve analyses
WELL LOG are available, lease attach.
DEPTH FROM
SURFACE
water
8ear-
in y
Well
met
meter
FORMATION DESCRIPTION
caoE.
ft.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
. ft.
YIELD
90m_
Lane
Surface
Sf�NL)
a p
aS0 FT iPd GK
�i2AGTIJ�� -- � /5 —all(o
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? O YES O NO
ANALYSIS ATTACHED? OYES ONO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
CAPACITY
DEPTH DEPTH
VOLTAGE HP
WELL DRILLER NAME B0gz) OAS /_ C
ATURE
e ��� J Aj /D O
AoORESS� !, Gl TES G .a SIG/ O
/
!/ v
Yorktown Medical Laboratory, Inc. - --
321 Kear Street Date' Taken: 9/25/90 Time • 2pm
Date Rc d: Time:
Yorktown Heights, N. Y. 10598 Date. Reported • -
. Zn-
Director: Albert H. Padovani M T. (ASCP) PO /Client #
r
Referred By:
Sampling Site:. Well
TOWN OF PATTERSON Batavia Rd.
JOHN N. CALBO B.INSP. Pat erson,
ROUTES 164 & 311 Phone ( 914) 279 -9208
' PATTERSON,NY. 12563
REPORT ON THE QUALITY OF WATER
INORGANICS mg L MICROBIOLOGICAL 100mL
_ Alkalinity
_ Chloride
_ Copper
_ Detergents, MBAS
_ Hardness, Calcium
_ Hardness, Total
_ Iron
_ Lead
_ Manganese
_ Mercury
Nitrogen, Ammonia
Nitrogen, Nitrate
_ Nitrogen, Nitrite
_ Phosphate, Total
_ Silver
_ Sodium'
Sulfate
_ Standard Plate Count
(CFU /1 mL)
Membrane Filtration Method
Total Coliform 1
Fecal Coliform
_ Fecal Streptococcus
Most Probable Number Method
_ Total Coliform
Fecal Coliform
Fecal Streptococcus
Sulfide - .Pre sence /Absense-- ( -PA) - t
_ Sulfite -
Zinc Total Coliform P A
PHYSI AL M SCELLANEOUS KEY FOR TERMINOLOGY
— pH (S.U.)
_ Color (Units)
Conductance (uhms /c)
_ Odor (TON)
_ Turbidity (NTU)
CFU = Colony. Forming Units
IT =
<
= Less Than
GT =
>
= Greater Than
NA =
Not
Applicable
SA =
See
Attached
TNTC
= Too Numerous To Count
REMARKS 0MMENT For ab se
(For Lab Use)
SAMPLE TYPE:
(Check One)
Potable
_ Non - potable
OUTGOING:
(Check Each)
HNO
HC13
_ H2SO4
_ NaOH
ZnOAc
— Na2S203
_ Other:
INCOMING:
(Check Each)
LE 40C
_ GT 4 /ICE 200C
GT 200C
PH LE 2
_ pH GE 12
Other:
NYS ELAP #10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS)) (WAS NOT) (NA) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO YORK STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE OF SAMPLE COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) MEET THE
SATISFACTORY CHEMIC QU ITY STANDARDS OF THE NEW YORK STATC DRINK-
ING WATER CODES, F "E ARAMETERS TESTED, AT THE TIME OF
7 /87(Rvsd1 /90)RWE
a ovani, .'I: (AS P),. Director
John M. Simmons, M.D.
PUTNAM COUNTY HEALTH DEPARTMENT .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
INSPECTION
NAME �'a'°"�'- ..'_. �~' .�.' :_ -%.% �, Orig. Routine
Orig. Complain
ADDRESS °°'^ .�` e7 Orig. Request
No. Street Town — � IM No.
MAILING ADDRESS --:� -"7
P.O. Box Post Office Zip Code
0 N 04 11 DI • 15767A
Name and Title
DATE ,' TYPE FACILITY
TIME �'✓ -tea °� TIME LEFT
FINDINGS: ;
V / ►T
Canpl iance
Canplaint Camp
Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
I _ � '"° /� ✓, �J` / /ate ----
INSPECTOR:' °�
,-'S' e and Title
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE:
:}
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OF
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alloviia
1Jarooir� p�� y
KNEW
�o cn� �i �1 � Totem �
Subdivision Aboroed Fee Enclosed ® a,nrif;�t
- -
'����i t-tAt. >rot Am l vases
- Pitl�as a[ o�taa�a_ • . Deai�t Flow G P d �-�� :PCHD 1t1 Whsm P� E$
I—t L(
P
Ts be aaea4�aQatl f 1�
Wage Sfappb:: �e'tZe>� Fao® '.'
1 rop�oeont that 1 fam who11Y ond''eomplet�ly ►oeponsibN fa tM dssignand bcation o1 tM proposed systom(� 1p 4ha4 tM aspa►a4a sowaSO ditposel ,tystam
aboip dosuibb will bi;oonfdructid as stawn"`on tna'approwd anNOdmint thMS ao and In accordanp with tAa at�ndards, ►ulelt:en7a ioOuroTion� •nam
CouMtr Oip6rtMant,' %ot Iloettli,' and that on eompNtlon tnsroot a 'CartNkBts' of Conot►uction'`Compllaeieo' flotisfOCtory, to.4M Commistiork:;of PlonOtioexill
.�'...u� •u'..:..��.waw ewiI s:�wwm .wla .s r'maa�vi;.hslsa er •affiNns'�1i. tA6.®YIIdp. 411at -imid b1110dio vill
a"...�,v o...... tom... .. --
i411eeef tAO app►arat'of QAe CMtWkste:ot }Conftiuetlo� ComplNnp of tM orlbfnalsystom os sng npsNS QAa®BoiZ) JI!e .t dell wNl ®esealBoa:.
tYNI mo IOrltad sAOU+w'.On tM approrod plan and tllot void wall willlba'InstalNd''. M ida w' tM a; Ms. r eau s of tM Qautnerte
Y S1/no0 . e' p E R.A.
3
AOPROVEO.FOR'CONSTRUCTION: Thk approwl•axptns iwo your =;hum tA0' date 9stuad unless eonstruetio o4 buio8oq is 666 i uD0®rtaheh and is
ra110Ca0N for t.eYfa or;.moY M;.elllMldad or modNNd wMn eonsidand Aocvssory - y.' he Commission ot. �Flastib. ny .cte®hSo or .olgsratlae "oF eonstructian
1
faqubos permit. Approvod for dHlP0Wl of dommtk sanita►Y and Water Su only.
Re
i4
lU /88_°it° s* - �-
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION .TO: CONSTRUCT �A-,WATER- . WELL-.-= -- - --
PCHD PERMIT # /'
WELL LOCATION
St eet Address.
Town/Village/City
Tax Grid Number
WELL OWNER
a
J I,"�;�
Mailing
Address
OPrivate
O Public
USE OF WELL
1 - primary
2- .secondary
CTRESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT S gpm /#
O REP CE EXISTING SUPPLY
�W S LY NEW WELLING
PEOPLE SERVED 4- /EST.
0 TEST/ OBSERVATION
O DEEPEN EXISTING WELL
OF DAILY USAGE 900 Sal
L1 ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
'DRILLING
3 `'
WELL TYPE
DRILLED
QDRIVEN
[]DUG
OGRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES Cf NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: __RXpy PA L,AVe?
Lot No. (f' _3 7
WATER WELL CONTRACTOR: Name; Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCHH y& SOURCES OF CONTAMINATION PROVIDED
� (aPN SEPARATE SHEET ze
(date) (( 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
thirt7 (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��T Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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-- DESIGR':DATk SHEfi- SUBSUFACE SFWAGE:,DISPOS'L- SYSTEM
Omer Address
Located at (Street) ] -rA J ► �. , � ,� TSee. Block Z- Lot
(indicate nearest cross street)
Municipality Watershed,,.
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking 12r l� 3_ Date of Percolation Test -7
HOLE
NUMBER CLOCK TIME 46 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
L 1
l 2 0- / S 1& �7 `�O
3 0
4
5
1 _t7 = fo
c7 —
z 30- J C7 36 a� zG?� 14-f
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated at'same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be submitted
for review.
2. Depth n-easure ants to be made from top of hole.
rev. 9/85
Y �
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. i HOLE NO. HOLE NO.
G.L. "7-7
2'
3' ' ►
4'
1�
5'
6'
of
7'
8'
9'
10'
11'
12'
13'
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: j , '7,0„x,.► DATE: a, lei
DESIGN
Soil Rate Used _ Min /1" Drop: S.D. Usable Area Provided`Z9
No. of Bedrooms Septic Tank Capacity gals. Type AS2"
Absorption Area Provided By L.F. x 24" width trench
Other
Name i I I t < <�1,�.�.- ��u..� ►?
Address K 7A3
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved
0°
SEAL r
ems.
,*O_ � p�.gQ,6k''
Ec510N�t'�
sq.ft /gal. checked by
14 1
44,
4c-
41
-T �o � vow rtc.Tk►
-T-Owki ov-
0
MA,
SY�IUM V!A'z NO-, IW:wl,
Villf
01, FCU', fUl"NA,"!
Putnam County Department of ReRIth
division of Environmental gealth Services
Approved as noted for oonformanOO 91th
appli 8
Rules d Regulations Of the,
ai�
- 3u es nuntyaRealth Department.
8�fgnature & Title Date
M