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BOX 19
ul" IL p-
4 r
02219
I
'!'�ry�.,,� f*F'•m�mT'"cT'RNt:'T"*' t.. ,fi-('' "i t'' 3�-.+, t 'fsY ,,y�,yyM m '`" R t •,".k S'-f -, Vii' ,x:'w„R
Rev 3 8 PUTNAM COUNTY DEPARTMENT OF HEALTH
Y Dlvteton of Env�orimon4il Health Servtcee, Carmel, N Y 10512 r w 4°
Engineer Must Provide
CERT E OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM (� P, � ---------
Town or tijLage
•�� � r �ci' IQ11Qp�. �t^r vc� Ta: MaP � ocic Lot &�3
p bdlvt
_Owner/ ` yc- nt Name, Formerly ' Sna ,t ston Name v. Lot
MaWng Address �O d I B r_ 7�p I:OS'i Date•t?eno>tt leaned
Separate Sewerage System bath F7'1'►1 ey1 i�A �' i�S'D'
Consiettns of ° GaRoa SdpYr Tank ar I�
Water Sgpply: Pab1lc.'Sdppiy From �. Address': „ R
on k Private Snpply. Dr111ed by ��r° 4 i mt N fAiE: "� �d�re�e
M
Control Boen CompletedYE f /`�°
8'.TYPai�E°
1
IV or>e
Nnmber of Bedrooms �� `,Him
`Garbage Grinder Been Instaped?
`-' '
OtherR.gnlremente
" I certify that;the sysEeA(s)- as,liated serving the above 'premisei.mere construct" essentially as,ehovn on the plane of the completed 'work (copies
of rhich are attachedj-;;and in accordance with -the standards zules and zequla ns in accordance;with'the filed plan and the permit issued by the
4PUtnam ;County Depsit�cent;0f ,Health
Date �� o�ime Certified by P.E..�c_'R.A.
Address (� < L'IGna
Any person,occupytrp pramiseo se ved by the above system(o) shalt promptly eke ouch�actlon is may ba neptssry to acu►e the cor►ectlon of any. unsanitary
i
conditlons resulting from such usage Approve( of the .separate sewenye.'systsm shall become null and void a't soon as a pubt': MntUry pvw► becomes
availible: and the app oval. of;the private; water supply shah, become null and -void when a publk wets supOtY .becon►a available. Such. approvals are
:<..
subject _to "modification 'or change wAeri, in the: judgment of the Commiaslon of Health 8th r otatlon,'- mod lfleatIon or 'ehange;Is` nsicasary,
OatsC.;`
K,
P0
10
DEPARTMENT OF HEALTH
ipiental:,:Fey�lp �e:rn :L P
, Division _.gjay#,o_L c s
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ESS: TAX GRID NUMBER:
WELL OWNER
NAME: ADDRESS.
r. . I- is y
M -4,
PBIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
- 'RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIRIC OND.1 T PUMP ❑ . ABA DONED
❑ BUSINESS ❑ FARM 0 TEST/OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL 0 STAND -BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE 6_66)gal.
REASON FOR
DRILLING
.[:]REPLACE EXISTING SUPPLY []TEST /OBSERVATION ❑ADDITIONAL SUPPLY
EW SUPPLY (NEW DWELLING) EIDEEPENI' EXISTING WELL
DEPTH DATA
WELL DEPTH a ft.
STATIC WATER LEVEL ft. t
I DATE MEASURED 6-- -96
DRILLING
EQUIPMENT
C3 ROTARY XCOMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK 0 OTHER
CASING
DETAILS
TOTAL LENGTHGL ft
MATERIALS: •RSTEEL ❑ PLASTIC ❑ OTHER
LENGTH BELOW GRADE tt
'
JOINT—S: ❑ WELDED IRTHREADED ❑ OTHER
—DIAMETER 6 in..
SEAL: aCEMENT GROUT OBENTONITE OOTHER
WEIGHT
PER FOOT 1b./ft..
DRIVESHOE.)KYES D NO
LINER: ❑ YES WO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
io
FIRST
OYES ONO . I
HOURS-1—L—.—
S
. . ..
_. . — —
GRAVEL PACK
0 YES
0 NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH tL
BOTTOM
DEPTH — It.
WELL YIELD TEST If detailed pumping
I
METHOD: 0 PUMPED 1 tests were done is in-
�'COMPRESSED AIR formation attached?
0 BAILED 0 OTHER 0 YES ❑ NO
WELL LOG "more detailed formation descriptions or sieve analyses
are . available, please attach.
DEPTH F"ROMi
SURFA CZ
hFaler
Pear-
ing
!�ell,
ola-:
meter
In
FORMATION OESCRIPITION
COOE
—
ft.
ft.
T It.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWDOWN
ft.
YIELD
opm.
Land ce
surfa
1jyCh_
ZLj
5-
1
727,24, 1 A-
4 0) .
d A�
3262
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? 0 YES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK: TYPE
CAPACITY GAT,.
WELL DRILLER NAM' A3090D 4_)CLj_ DATE
AOORESS 0T6 .52 SIGilft V-0 —IP-510
1 /Q.5—/yL
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
Yorktown Medic, l 1. amatory Inc —
0
Date Taken: 10/15/90 Time: 3;3OPm
321 Kear Street Date Rc' d : Time : pm
Yorktown Heights, N. Y. 10598
-
.. . __. . ...., : -_:_. ... ,....., Date_ Reported: OCT. e logo
Collected Sy . :
-
Director.
. .,
Albert H. PadovaniM. T. (ASCP) PO /Client #
T- Referred By:
well S ag:
JOHN H. PRENTISSP.E.
, k rd V1 Pei
RD 9, FAIR STREET Putflam ey_,
CARMEL,NY< 10512
Phone ( ) 832 -9191 6� q,
L ..J
REPORT ON THE QUALITY OF WATER
INORGANICS (mg /L3 MICROBIOLOGICAL 13OmL '
o 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
Fecal Coliform
_ Fecal Streptococcus
Most Probable Number Method
_ Total Coliform
Fecal Coliform
Fecal Streptococcus
Sulfide.- _. Y..... -..._ ... _ Pre sence /Ab.sense..(.pg)o
_ Sulfite
Zinc Total Coliform P A
PHYSI AL MISCELLANEOUS 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 /COMMENTS For Eab se
(For Lab Use)
SAMPLE TYPE:
-.(Check One) .
Potable
Non- potable
OUTGOING:
(Check Each)
HN
O
_ HoSO4.'
NaOH
ZnOAc
Na2S203
Other:
INCOMING:
(Check Each)
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 COILECTION.
THESE RESULTS INDICATE T THE WATER SAMPLE (DID) (DID NOT) (NA MEET THE
SATISFACTORY CHEMI QU TY STANDARDS OF THE NEW YORK STATE C DRINK-
ING WATER CODES, F ' TESTED, AT THE TIME OF SAMPLE COLLECTIONo
0
&A0 L 0
9'
ctor
7 /87(Rvsd1 /90)RWE
GT
4/18 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 COILECTION.
THESE RESULTS INDICATE T THE WATER SAMPLE (DID) (DID NOT) (NA MEET THE
SATISFACTORY CHEMI QU TY STANDARDS OF THE NEW YORK STATE C DRINK-
ING WATER CODES, F ' TESTED, AT THE TIME OF SAMPLE COLLECTIONo
0
&A0 L 0
9'
ctor
7 /87(Rvsd1 /90)RWE
i
PU1 NAM COUN-i'Y DEPARTMa4T OF I1EAU11I
DIVISION OF ENVIRONMMrAL HEALTH SERVICES
Peter FaubelF 9 1 12 -13
Owner or Purchaser of Building. Section Block Lot
Dye Bros., Inc., Rt 22, Wingdale, NY 12594
Building Constructal by
Oak Ridge Drive
Location - Street
Putnam Valley
Municipality
1 Family residential
Building Type
Roaring Brook Estates
Subdivision Name
Lot 501 -502
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE'DISPOSAL SYSTEM
I represent that I am wholly and. completely responsible for the location,
workmanship, material, construction and diainage'of the sewage disposal sy §tem
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
_._...._�.__. iepa rs made by.n�e ,to such• Systc -gym•,. exxcept- wh6Lre:.tbe_._Eai. Mize .:ko..:opeirate,propez�y...is. _.., .._
caused by the willful or negligent act of the occupant of the building utilizing y
the system.
Ye
The undersigned further agrees to accept as conclusive ,tl e.deternunation of
the Director' of the Division of Environmental Ilealth Se. vices o,f `.ttie Putnam` County
Department of Bealth as to whet}�er or not the failure of th :esy`s °temto operate was
caused by the willful or negligent- act of the occupant of3 •the' building' u,tilizing
the system.
Dated this day of &Gf1i 19 Signature
Title Azat, �
��. (Owner) - Signature
Peter Faubel
60 Marvin Ave., Brewster, NY 10509
Address
Walter Bates & Son Excavating, Inc.
Corporation Name (if Corp.) ;
RR 1, Box 333, Broadway .
caress
Amenia, NY 12501
** Call John Prentiss, P.E. at 914 - 878 -6170 when work completed but uncovered.
rev. 9/85
FMIAL SITE ZEcrc� rV Cat=
I
CN
o
CR sUTE-Dr I slur Lam'
......... .... : .
Si r' DISPCSAL PSr?
sic are= l�r-` =^ as per a =rovrzd Dlans
cn - Date oz placerazt
2.I bar1; LG�' W iL �i'G_ ip
C_ rat='Ll Sci r_Ct =- -irr d
c_ Sire. )='r'y E =C_ , Cr t`T t�sn 15' f -cm SLS ar�-
e_ 100 f -cc Lr = =�:Y�t a_rd<_
I_ _ c^ ' D SPCEAL S can
c_, SS7tiC t��; — 1 ,00 -.?�0
C,-_. • i t_r it i - c- _. _ ='7E!
c.
C_
DO r. mini :Ti - _=---.1 fC.LT: t=Cli -
RE 90 a �cr�c, C_e c t wi thin 1a f =. GL 4';0 1✓C:C
C.:_ =_-= at �a�= e?=_�, -a CZ - wan�r t=St�
Prot = == ti fres
i I
r
� 'TCN rK v- cYC=e_rly s__
- --
or
_
C.
/rte ,, ' ^cam'
Lai
�
L ,`, �-
6. 10 cam,__ 1_ _ - 20 T -_ - zC�r�= :_C:'s
I
- ---
i . rem-" C- _ --
I I
E. Rccn a?lc: _cr E_r.=n_icr_, 50 -`_
I
4 S_ZE Ci C
I
_=7: '' in t= `nG'2
C= C -
1 � . Pine E^• .= crL =-=
.......
2. Guar! -- t_D- .
I I
= P 1 aTnnr
4. g'St'1D E =5 - -'T 1 °- ILS�'� ^CZ° t0 CicCe
I I
F- Tst hc� c_ =1�
I b
I I ef
^- t:,-
es t at ON
`
ITi . ECUSE
a_
F-U.== 1CG_= Lam'" c L•:4ad, I71c ==
V. I
re 1a - ^ -G
D
b.
Di S anc_ z- S are= Ine- =S':? _= .
I
c _
C_=inc 13 It Z � cr ace
i -
V Cv R!_L ,- kCRR -L c -=
I
Yes orccer_'r crc���
I
b.
P-' ices ca= __2:,_1-r taco i�
I
I
c_
Ali pi=es f =�•�=� wi `Z ins-ide or hCx
I
c_
Fr = 'cfi11 ira` = -_GL ccr_ --is stC•r_E_ < a,� in c� a-rer-
1 I
E_
C�T� =iz c-�;n ; ,51 accordi_nc
f _
`r.: y'. Fc C Ev�S�.Wcle_TCr/Li
C:._r ain cry__ cwt= =? 1 erct :. to
=�
I
C.
scCt? nc cra' -_ c ._c ^.=rce ai4-- fz: SD5 area
I
I ( I
h_
S - - =ce wat-- crcta = =c:" adE-702-tE
i_
L =CS_Ci Cc. `�! C== �%'' -C =-� CP_ SI CCES C' -=t
PUTMAM COUNTY DEPARTMENT OF HEALTH NO. 803-90-19
COMPLAINT OR SERVICE REQUEST RECORD
TOWN.__..., -11,99
90 . ..... :REFERREDwTO`-
TAKEN BY Bill Hedges TELEPHONE CALL IN PERSON LETTER
CONFIDENTIAL
REQUEST FROM A- morplij TELEPHONE 528-2235,
ADDRESS Oak Ridge Drive, -Roaring Brook, Putnam Valley, NY
ENVIRONMENTAL HEALTH: Home Sewage '. Rodents* Refuse Public Water Food Service
Camp I —
Migrant Camp Other
COMPLAINT OR REQUEST N,jaht,,r installing 8DS less than 100 to well- new house -
FOBEL Oak Ridge Drive. DIRECTIONS: Roaring Brook - 6N to o Oakridge Drive - new modular.
ACTION TAKEN BY /9ZVII
FINDINGS
_AI
11-2 4�
FOLLOW UP INSPECTION (s)
DATE _FINDINGS.
?ROBLEM ABATED
)ATE PERSON NC%TPM-D�,
a� "0I /X/
ESTIMATED TOTAL MAN HOURS SPENT
(A
i
C•�- •�'�_. .ki�'j,.7" Y`-^^.'+'^.' �-•— q•.'++°" G._n'r,•5-- •�T'�'���- °7'�"`rrri "'T' F ! 1 y. .'T'�'1 "F 't .'rte .. ^:
�, t i:xt *�
(Sb� • PUTNAM COUNTY DEPARTMENT OF HEALTH , 4v
1 DIA" of Environmental Healtb Servke9 Cal mel, N Y 10512 ' t EnQlneec to Provide Permit. M '
i ' t u , on CERTH7CATE,OF C /MP t
TRUCTION PERMIT FOR'SEWAGE DISPOSAL SYSTEM p �iG/
1
Oak Ri =die Drive Town or .�
Pu
. - e
..��nv; •,Rives h}a w. . �"�h ,n " •.r .. ... w.',i s.!t. ..� .• ..eiN . T. - T..iJ'v
tnam V
,..• ,
an,e Roaring'. =Brook, 50� " 1
Sabel. Lot Y
`Block ,
r �P
Tea: 9 Lot . 13
r
Renewal ❑ Revleion ❑
Otr dAi pplkantNnne FMr & Mrs Peter. Fauber,
Date of: Previoue Approvah r
Addreoe 60 Marvin Ave _ Br e
MaWng To,,n ewst r, .NY 7j 10509.
e ..;
P.
Date Subdivision A roved Fee Enclosed Q- r.Atnount. :'$15,0 00
PP
Hullding Type' Frame i Lot Area 22,274 sq; ft
FIR Section Only , Depth Yolttme
is
Nolnber of Bedrooms Three ,Design Picric C P D 6OO PCHD Notlficatlodia Regdred When`hlll b completed
Sep.rae Sewerage System to coniat ot` 1000 G„pgn Septic Taakad , 375 l f: 2 foot wide trench
f
To`bs oomtiicted by OWlle r L Addreae r
Water SuPPh 1 Pab1M•Sapply From Addreea' `
ori' xr Prlvafe3sspplyDf�lled'by Anderson .'well' Aga! Putnam `Valley'
ptbe;Reoalrementa 1z to 2' }select':fill 'for Q•radi '> Purpose remove..;a`ll..boulders
1 repro, senf that I am wholly and completely responsible foCthe tlesgn.and location of 'the proposed systems) 1)'that'the separate sewage disposil system
aDOVe.desec+betl will be'eonstructed as shown on tAe approvetl =amenOment there :to antl iri aceortlanee with the stsntlerds ^luleaan "u la ohf•o• , e u ham
County Department oh
Health;, and that on comptet�on thereo/ a `Certificate-: of Constructor Compliance 'iatisfictoiy to the Commissioner of'Heelth will
bs:submitted <to the`Doper ment and '-& written guarantee; will De: /urnishetl the ownei his sueeeuors, heirs or assigns by:the builder that sold builder Will
Pleats .• m
g000 :openUn conbitioe an Yp. ., _ ! y y n.9 date of the iss6-
9 y pert of wid sews tlifDOfal system "during the penod.of two. 2 ears Immetliatel � follow{ the
ance:•ol. the _approval .,of the CertGfiatej;of; Const(uction. Complknce or the °original•system orany repairs thereto 2),that.,the drilled.well' described above
will ba located as shawn,on the approved plan an0 tMt pid well will Deinstalletl' .� accorGance with t an ;r - :rules antl ►egu aoni of .,the :Putnam
County Oepartmsnt of ,Health _ AA""._
wce:` 15 -MaY :1989 :,, i signed: �i: / P:E._)L F.A.
+•Add ►OSir�'�9.: °Fair 8t, , Carme NY 1051'2 29206
p license NO
APPROVED FOR CONSTRUCTION This a proveGexpires two years Irom the ;pate issued unless construction of ";the buitging,h'as been :undertaken and If
revocable for'cause or may be amendetl,oi:rh CHdi d wMn:eonfidWed neeeffary.;by the 6ommisiioner' of. yealth. Any change'or alteration of construction
requi4s a new permit. APDroved ftlrt difpofal of• tlomeitic nits► .amfage o iivata water, w ply only.
Rev: : • ' �!
l/87 Oate- �' • - g9' ^�` Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
WO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT `A WATk'RIWELL
PCHD PERMIT # &W
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
Oak Ridge Drive Putnam Valle 9. -1-13
WELL OWNER
Name
Mr. & Mrs. Peter
Mailing Address QPrivate
Faubel 60 Marvin Ave. Brewster NY 10509 O Public
USE OF, WELL
1 - primary
2 - secondary
(3 RESIDENTIAL
® BUSINESS
® INDUSTRIAL
® PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
Five gpm /# PEOPLE SERVED Six /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
ONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ® TEST /OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
New Residence
WELL TYPE
19DRILLED
®DRIVEN
®DUG ®GRAVEL C] OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL .IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Roaring Brook Subd. Lot No. 502
WATER WELL CONTRACTOR:
Name Anderson Well, Inc.
Address:
Putnam Valley
.IS PUBLIC WATER SUPPLY
AVAILABLE TO SITE:
YES X
NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY�FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED (See Job# s.o. 2508, By John H. Prentiss,
®ON REAR OF THIS APPLICATION ON SEP TE SHEET� P.E.)
(date) ignature)
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.
Date of Issue: ��19�G�T�f
Date of Expiration:
Permit is Non - Transferrable
2/87
ermit Issuing ici
White copy:
Yellow copy:
Pink Copy:
Orange copy:
H. D. File
Building Inspector
Owner
Well Driller
PUMAM COUNTY DEPARDUaU OF HEALTH
DIVISION OF ENVIRORMCAL HEALTH SERVICES
:-.7-- DESIGN MT-Aa SHEEZ.-SUBSUgACIESSIAGE -DISPOSAL SYSTEM FILE NO. : ..' r Owner Address Ct'm � C-
Re: Stze Pla
Located at A\k (0 6 L) !;-r- Sec. Block Lot
.:,s(indica-tainearest, cross street)
0
Municipality C4 III q'L le L-4 Watershed Grc =1
1!!-or 01,0
SOM PEKO=CR -/TEST DATA REQU= TO BE SUBMITTED WITH APPLICATIONS
Date of Pre-Soaking!- ..:,Date of Percolation Test
!1 o r
HOLE
NL14BER i= T11;0.0 hw:cl PERCOLATION PERCOLATION
� 1-6
Ruth' Le.-.tse do no(:FA( to
to C(Depth:- to .dater Fran
Water Level
No.
TL-ne
Ground Surface
In Inches
Soil Rate
Start-Stop
Min.
Start stop
Drop In
Min/in Drop
Inches Inches
Inches
_29
3 joj>_- 1o74
2 7S3-)0C)1
3
5
S
4 1609,-K'30F ; 'i 1>1_� >_e_1
5 101 b- 10-9
11
1 low - 100
21 loa
_29
3 joj>_- 1o74
4 12:->4
5
S
2
3
4
5
N=: 1. Tests to be repeated.at same depth until approximately equal soil rates
•.are obtained at each percolation test hole.. All data to'be submittba
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST P,�Tj L)A ; MUIRED TO : BE SUBMITTED _ WITH APPLICATION
DESCRIPTION OF SOILS ENOOUNTERED'IN'TEST'HOLES
e NO'
HOLE
„ . , c a HOLE Noe. HOLE 1sOe
r�i7e Lo
)cqti
a°
3 ° .� ►c� 4r Pti
40 5j&,uk3 t-1
9°
10°
11°
12'
13°
C' ✓ � ►-S
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: am.' DATE:
_ DESIGN
Soil Rate Used 11- t S Min /1'° Drop: S.D. Usable Area Provided �n`J
Noe of Bedrooms - _ Septic Tank Capacity 1600 gals. Type ►" 1 r-, soPj A-j
f Absorption Area Provided By 7 S L eFe x trench
Other
Name
JOHN N. PRENTISS, P.E. Gy
Address RD9 FAIR ST 914-878-6170
CXRMtL. NEW YORK 10512 NO. 29206
OFTHE ST01''L
SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved
sgeft /gale Checked by
Date
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/ A JOHN H PR ENTISS' ~ /PE wp: .
.' . .. . I.. *.. I I . — � I . .1 I
CONSULTING ENGINEER
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. '10512 (914) 225 -3641
r APPLICATION TO CONSTRUCT'A WATERIWELL �/�// O n
PCHD PERMIT # 4�
WELL LOCATION
Street Address Town Village City Tax Grid Number
Oak Ridge Drive Putnam Valle 9 -1 -13
WELL OWNER
Name
Mr. & Mrs. Peter
Mailing Address, QPrivate
Faubel 60 Marvin Ave. Brewster NY 10509 O Public
USE OF :WELL
1 - primary
2- secondary
® RESIDENTIAL
0 BUSINESS
0 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
Five gpm /# PEOPLE'SERVED Six /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
ONEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST OBSERVATION
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING .
New Residence
WELL TYPE
ODRILLED
DDRIVEN
[]DUG
[]GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES' X NO
IF WELL IS LOCATED IN A,REALTY SUBDIVISION, NAME OF SUBDIVISION:
Roaring Brook Subd. Lot No. 502
WATER WELL CONTRACTOR: Name Anderson Well, Inc. Address: Putnam Valley
.IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION . PROVIDED (See Job# s. o.' 2508, By John H. Prentiss,
ON REAR OF THIS,APPLICATION [11ON SEP TE SHEET P.E.)
(date) ignature)
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; i
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. .1%
9
Date of Issue: /vf% vim 19 5' /
Date of Expiration: 19
Permit is Non - Transferrable
2/87
Permit Issuing ici
White copy: H. D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller