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Home My WebLink About2321DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.10 -2 -38 BOX 20 02321 ' �'16 6 4 r 1, �' - :r r k�. 02321 OWNER'S NAME $ ,4 SITE LOCATION 4 MAILING ADDRESS `'I PERSON INTERVIEWED DATE -A1 PROPOSED INSTALLER PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPO6AL SYSTEM REPAIR '- Na AtZ6uT P PHONE N ) q J 34 _7"- A. b JJ ne, g. PCHD Camplaint #33e 17_19 Name & Relationship onship (i.e, owner,tenant, etc.) TYPE FACILITY S� cue e PHONE 0 REGISTRATION # K "— `) lg V Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered ++architect. c� _ (__�J }�7 1 ]�' /(� V- _ 1 a 1 -- ate _. - � r.--. ,/1 t c P 1LrD � J i�C7t-1 cd � ` Z ,>,-(- (1 -� , v. I °t7 9 . 1_ _ Llti 1 `7 k u Y L/ ; uA n3 r AA n _�h1-9 .P- A ( e �1C� ,4�- c5 1-n Ems- (G , r-, A - Proposal approved Inspector's S ture & Title Proposal Disapproved roposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE Q W Y) 2 DATE itlf�/fl nW: %hite (PaD); Yellow (fin ED; Pink (40-icwt) Rey: Owner /appliceat Name MatHng Address 4 5; Separate Sewerage System Con ®isting of bav sot N .- 65 Y water Snpply Pnbllc Supply From Address Private. Sapply-DrIDed by MILL Y- -.DRILL Addree®" REWSTER.. N . Y Building Type QNE FAM RES gas Erosion Coutrol Been Completed? .YES • No Number. of, Bedrooms 3 Has Garbage Grinder Been Installed? , Other Re4nirements : , I certify that ;the systi*(s) as. listed serving the above premises ;we conatruc d. essentially as ho the pla's f [he completed,work,( copies of which are attached)_; and'in,accordande 'with the standa=da rul'e's an `egulati,'s ,a rdan Jwi led: an the °permit issued by the Putnam county Department of Health 9./14 % 8 9 Date Ce►tdied by Pk R.A. Address TWO MUSCOOT RTH PAC NY 10, 41L1/� wo .1 1056 A'ny 'person 6ccupyin9 p, ►emises served by the above'systaini s shall prom ly,aaik s ch a n as may_b®'necespry to racuro then raction of any unsanitary condltlons, resulting from such usage Approval =of the s®parats sewers ^systo Sh become null and void os soon as a pub,': sanitary sewer becomes available and the approval of the privite, water, supply ;hall beeome.null,a. d wan a public viatbr supply: beeoii►®a avalklblo Such opD /OVele are subject' to modit cation' or chaQnge when, h ,the )udgmgnt of the Commission Health, such revocation, modification or,ehango Is noeesseryy.1 Title ;Date BY Yorktown Medical Laboratory, Inc. LAB # " t - - =j 321 Kear Street Date Taken: 8/29/89 Time: 11:30 AM Yorktown ..rn ��i..... .. ,�.... ..,.. o, .. s.r He s &.,,.. ,,. _N . Y 10593 Date Rc ' - d ..8r/- .u2w9a/. 89 � Tia7 i vm7 e : . .. v2._:v 3-. 0 PM , e' (914) 245 -2800 s ' "e'poPted : AUG. 1 Director: Albert H. Padovani A.F. T. (ASCP) Collected By : MR. DUNHAM Referred By: j- Sample Location: OUTSIDE TAP: DUNHAM, MARLOW 45 ARBUTUS ROAD PUTNAM VALLEY, NY 10579 L J LABORATORY REPORT ON THE QUALITY OF WATER Phone # 225 5535 Phone # Sample Type: Repeat Test? _ ( check each) INORGANIC NON-METALS mg/L) MICROBIOLOGICAL (CFU /100mL) Acidity Alkalinity _ Chloride Detergents, MBAS Hardness, Total Nitrogen, Ammonia Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite METALS (mg /L) GENERAL BACTERIA _ Standard Plate Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE Total Coliform ` Fecal Coliform Fecal Streptococcus MOST PROBABLE NUMBER TECHNIQUE_ _ Copper. 40c Iron _ Total Coliform Index Lead = - Manganese. Fecal Coliform Index- ____ _ Mercury GE 12 _ Sodium KEY FOR TERMINOLOGY _ Zinc CFU = Colony Forming Units MISCELLANEOUS PH (units) Color (units) Odor (TON) Turbidity (NTU) CON = Confluent (q.v. TNTC) LT = C = Less Than GT = > = Greater Than N/A = Not Applicable S/A = See Attached TNTC= Too Numerous To Count REMARICS /COMMENTS (For Lab Use) ✓ Potable _ Non - potable STP INF _ STP EFF Other: Sample Status: (check each) Outsoin HNO3 -HC1 - H2S.O�±...::;.... _.._ Na0H',r, Zn0Ac r. Na2S203 Other: Incoming'._ , ALE 40c GT 4 °C _ — PH LE 2 PH GE 9 PH GE 12 Other: ELAP No. 10323 THESE RESULTS INDICATE THAT THE WATER SAMPLE. (Was (Wasn't) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH NEW ORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME.OF SAMPLE C CTION. THESE RESULTS INDICATE THAT THE WATER SAMPLE (Did) (Didn't) (N /A) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK PUBLIC RIN NG WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTI . Lx / /c'c ��'yt��2c ia'I / 2 /86(Rvsd7 /87)RWE Albert H. Padovani, M.T. (ASCP), Director PUTNAM COUNTY DEPARTMENr OF HEALTH DIVISIOki OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building WILLIAM DRIVE Building Constructed by ARBUTUS STREET Location - Street TOWN OF PUTNAM VALLEY Municipality ONE FAMILY RESIDENCE Building Type 15 2 4 Section Block Lot ROARING BROOK Subdivision Name 65 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" -tor—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 determination of the Director of the Division of Environinental Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this day of 19� Signature 11 �(_ � Title General Contractor (Owner) - Signature Corporation Name (if Corp.) V� v ,Y� Address 0575 rev. 9/85 mk Corporation Name tif- Corp.1 -- Address -'--i,--PUTNIAM- COUNTY- -HEALTH-b&PARTNENT'—:... DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Camnissioner of Health - FIELD ACTIVITY REPORT - Sheet l of L'L," ADDRESS 13 iQ MAILING ADDRESS I P.O. Box Post Office Zip Code -1 IR-DW at me PERSON IN CHARGE I OR INTERVIEWED (il-SIU-11 I Name and Title DATE lei 7_- TYPE FACILITY TIME P o TIME LEFT FINDINGS: Orig. Routine Orig. Cmplain Orig. Request Campliance Cmplaint Comp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other - xPita-wr Lltlz- �) 1!�- Tr'w%� A-AAm 9 -- k4'%fl* 100 -A I st INSPECTOR: TELEPHONE: Signature and Title PERSON IN CHARGE OR I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: Explain �� W 04 WP,LL UUr1rL i z11Vn Azrvn DEPARTMENT OF HEALTH _ - - =,3 vision= "8 €- EnviraiamA at al Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only - WELL LOCATION STREET ADDRESS: TAX GRIO NUMBER: Arbutus Road Putnam Valley, New York WELL OWNER AM ADDRESS: &� O� - G. Dunham 43 Arbutus Rd. , Putnam Valley, New York PBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary CR RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 3 . to 5 j EST. OF DAILY USAGE gal. REASON FOR DRILLING �12 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION R❑ REPLACE EXISTING SUPPLY ❑, DEEPEN EXISTING WELL DEPTH DATA ` WELL DEPTH 525 ft. STATIC WATER LEVEL ft. DATE MEASURED 3/10/89 DRILLING EQUIPMENT ❑ ROTARY >J COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. 49 OPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH .41 ft_ MATERIALS: 3,0 STEEL ❑ PLASTIC ❑ OTHER CASING DETAILS •LENGTH:BELOW GRADE 40 ft.. JOINTS: ❑WELDED- THREADED ❑ OTHER DIAMETER 6 in. SEAL: IZI CEMENT GROUT ❑ BENTONITE ❑ OTHER WEIGHT PER FOOT 19 Ib. /ft. DRIVE SHOE EYES ❑ NO LINER: ❑ YES ❑ NO DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? ....SCREEN FIRST - - - OYES ❑ NO HOURS SECOND GRAVEL PACK O YES ❑ NO GRAVEL SIZE DIAMETER OF PACK in. I TOP DEPTH ft- BOTTOM DEPTH It: WELL YIELD TEST If detailed pumping r METHOD: O PUMPED tests were done is in- O COMPRESSED AIR , formation attached? ❑ BAILED ❑ OTHER i ❑ YES ❑ NO WELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. FROM URFACE Water sear- ing Wetl Dia- meter FORMATION DESCRIPTION CODE. fL WELL DEPTH ft. DURATION hr. min. DRAWOOWN ft. YIELD 9Fm. Land Surface 5 Clay & silt 5 20 Soft fractured bedrock 245 1 30 245 i 20 5251 lHard grey granite. 500 2 - 500 7 525 6 - 500 10 WATER )M CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? IWES O No ANALYSIS ATTACHED?)& YES O NO STORAGE TANK: TYPE CAPACITY GAL. WELL DRILLER NAME DgTT,T,ING AT .20 89 ADDRESS Putnam Avenue SIG T E Brewster, NY Cal Ro es t PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP Pl90 (sel �/i PETER C. ALEXANDERSON County Executive ENID L CARRUTH. M.P.H. Public Health Director . I JOHN SIMMONS. M.D. Deputy Commissioner JOHN KARELL Jr.. P.E. DEPARTMENT OF HEALTH 01 recto'r DivNion Of Environmental Health Services 110 Old Route :Six Center, Carmel, New--York .10512 (914) 225-0310 September. 15, 1989 Mr. Joel Greenberg, R.A. RFD #2, Two Muscoot.North Mahopac, New York 10541 Re: Application for Dunham Street: Arbutus Street Town: Putnam Valley. Dear Mr. Greenberg:. This department is in receipt of the above referenc6d project. —A-7fzv*:Lew --of,-your�.-appl.icat-ion—will—,-ngt-.Ike .--made, until. this office - S receives the required fee. (See attached -f(i c , r6l ery ru yours, John Karell jr.r P..E. Director, Environmental Health Services JK:cj PETER C. ALEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 . September 15, 1989 Mr. Joel Greenberg, R.A. RFD #2, Two Muscoot North Mahopac, New York 10541 Re: Application for Dunham Street: Arbutus Street Town: Putnam Valley ENID L. CARRUTH, M.P.H. Public Health Director JOHN SIMMONS. M.D. Deputy Commissioner JOHN KARELL Jr., P.E. Director Dear - Mr. Greenberg: This department is in receipt of the above referenced project. A review of your application will not be made until this office _.. -._.._ receives the required fee. (See attached -fee. schedulel . ery ru yours, John Karell Jr., P.E. Director, Environmental Health Services JK:cj Ayf OJ-V-J- .--��,47-1 PUTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER TO PROVIDE PERMIT # ON CERT FI E OF COMPLCE. ff Division of Environmental Health Services, Carmel, N. Y. 10512 PERMIT CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM Putnam Valley Town or village 15-.--B lock .- -Lot 4 'Located .Arbutus_.= S.treet�- .— _..—�. - _- .._......rax map . _ Located "X Subdivision Rnari nQ Rri�nk T.AkP subd. rot k 65 Renewal _❑ Revision -[I-- Owner /Address M. Dunham, Arbutus St, Put. Val , NY 1057,% of Previous Approval Building Type One Fam. Res. Lot Area 23, 229SF Fill section only 13 Number of Bedrooms 3 Design Flow G /P /D 600 P.C. H. D. Notification Required Separate Sewerage System to consist of 1000 dROT.F of F i P1 r9 G 2 ° -n tl n _ C NOT SELECTED To be constructed by Water Supply: Public Supply From XXX Private Supply to be drilled by Address Other Requirements Gal. Septic Tank and NOT SELECTED Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regulations of e Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill 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 place in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately following thedate of the issu- ance of the approval of the Certificate of Construction Compliance of the original system q:�the epairs thereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be Insr� -site-,�� in accordance standards, ru�1�Is and r�$u a ions of the Putnam County Department of Health. \ \ _ n ¢ J „ _ / j Date 9/23/85 Signed APPROVED FOR CONSTRUCTION: This approval expires one year fr the ate issued revocable for cause or may be amended or modified when considered nec nary y the Cot requires a ew permit. Approveq for disposal of domesti a or pr' Date 1 t/i By Rev. 6/85 P.E. R.A. XX .0 - NY 10541 Li arise No. 110 5 6 construction of the buildi has been undertaken and is ier of Health. Any change or alteration of construction Title - V ^ F�iT2'TM�?; ^'y"�"' ,-- '�:. { a.•y' t'S '�.' ^' vi�!'•"a ^�'.npy+: l F . �vY '.. Sr t F "'.'t f 't' •ri 9 a`t "t '4" °?.,.' A '°i k' �Vht. - PUTNAM CO UNTYDEPARTMENT OF .HEALTH i ft?V.. ^3 Division of Environmental Health SerYlces Cerroel. N Y,1051? EtigBoeei to provide Permit q ', " J .8,6 on CERTIFICATE OF COMPLLINCE ONSTRUCTION PERMIT FOR SEWAGE DISPOSAL` SYSTE)YY PUTNAM "N, 'I Y Town tea ARBUTUS . STREET or Vluage_ < ROARING` BR LAKE 65 15 2 4 bd)vielon Name - Snbd. Lot q Tai Map Block Lot ewal vision R en � � Re p , Owner /Applicant Name: M DUNHAM .. , Date of Previous A p v ro al ARBUTUS-. - STREET PUT U�Lo 10579 Mailing Addrelia Te ,`NY ONE FAM. RES -2: 3 2.29 SF F. Balldbg Type: Lot Area ` ' Fi11 Section Only Y. ' . Depth Vohtme Number of Bedrooms 3 Design FIow;G /P /D: 6'00. PCHD Nrtlticstlon Is Rettnlred When FIII )s completed 1000' 480LF OF,..FIELDS 2' Ors. o c.. Separate Sewerage System to conelet of Gallon Septic Tank, aad To; be oonstrac by ted NOT :, SFT F T n Addresti ` Water SuPPIJ Pdbllc!Snpply From °° Address`. or: XXXXX Private Sapply: Drllled by1�OT 'SELECTED - Addvewa j Other Requirements represent thatCam wholly.antl completely .responsibleforthetlesignarid ,location ofthe. proposed systems) 1) that the-separate "sewagedisposalsystem above Gescnb'etl, will be constructed,as shown on the approved amendment there to and maceoraance the standpitls rules -and. regu a ions o e u nam:. County Department of :_Health, :antl that on completion theioof a .Certificate of constr•ucGOn. Co Pil rice'- satisfactory'to the Commissioner - :of Hei46will be submitted to ;the ' Deppartment, antl a written :guarantee will be :furnished the owner, his succ r hoirs or assigns Dy he bwlde ►, that said builder :wilt Dlace in good operoting'conoition an`y "pail o /'said sewage tlisposairsy" during'Uie.: —iod, tw (2)`years,lmmedia ly followiig "thadate of the ` issu - ante of the epProval of the Certificate =oi Coristiuction Compliance' , f: the o insl system or.a y r pa' thereto; 2) t the drilled.well.tlescribed above will'be located ^as showwon the'approvetl plan and -that saidwelPwill.be, stalied. -in a rch ce ;with - to r rules d regu a ions of. -, the 'Putnam County Department of: Health. Date MARCH :-'-3 i !. ,198 Z Signed US COOT NO ._RFD# B 48$ OPA NY10 4 11056 •tense Addre No a _ APPROVED FOR CONSTRUCTION This'.appioval' expires'" ► fro the` to issued less construction oT the DuilCirig has been undertaken and is revocable for cause or may Bq,amendedor;modified` when conditleretl net nary y the Co missioner of .Health. -Any Change or alteration of construction requires a -new permit ' " for /,`� /0isposal 91, domestic rani y`fewantl /or private water supply only. /A"pproved Q{/�� ,�/ ' Date— .7� Title'". iy�U In DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE N0. Owner 'Mario �Dunham: Address Sprout Brook Rd Putnam Val NY 10979 Located at (street' Sec. -15 Block 2 Lot a , ( ca a .nearer cross. s. ree ... , ...:,..,..,., . P,utKa4 Valle Hudson• Ri. Municipality:..:.' Watershed .:..SOIL PERCOLATION •TEST DATA REgRMM.TO BE 'SUBMITTED WITH -APPLICATIONS Hole. Number CLOCK. TIME PERCOLATION PERCOLATION RUM— luapse Depth to Water Water 78701 . No.....:.....: .,.:..:... Time From. Ground Surface in Inches Soil Rate Start -Stop ..Min. Start `.Stop Drop:in Min. /in drop Inches. Inches Inches PTH #1 .1...9:45' :10:15 30 15 17.75 2.75 30/2.75 =11 10:49 . 30 •15 17.75 .2.75 30/2.75,11. 3 10 -:53 . .30. 1.5. .:. 7 -.7 _ 2, 75 .301-2.75 =11 .. Notes: 1) TeAts to. be repeated: at same rates are obtained-at each percglation for review. Depth measurements to be'made depth until approximatelyy equal soil test hole. All data to be submitted from top of hole. 6011 66 V1 78".. 8411 INDICATE -LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED D NONE INDICATE- IEVEL-10 WkCITWATER LEVEL RISES AFTER BEING ENCOUNTERED NONE TESTS,MA.DE BY Joel L. Greenberg Date March 25, 1985 MSIGN 'Boil Rate Used_j_L- Lyi.rVl "Drop: S.D. Usable Area Provided q, niinsE No. of Bedrooms 3 Septic Tank. Capacity 1000 Gals.: Tvjnp_ Concrete Absorption Area Provided By Qft(zh 180 L. F. x24 xxxx 36" fd—i - -'- 0 r v Fes. A --flume. Gj:panhfera algf Address Muscoot No:tth,,RFD#2,Bx 488 Mahopac,"NY 1 1 MM�Ijw THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:, Soil Rate Approved _Sq. Ft/Coilo' Checked by k, �°_N E w -t O _ Date V. Un F�PL SIME Ii%'SPECI'_TCN Date Sn=- LOCATION AkQ v -'-V"\ PERMST DI Q OR SUBDIVISION IDT a / Inspected by Cy-NFR 1 � U N /t,R.1 -1 I a. SDS area located as pe; a=roved plans %ZI b_ Fill ser-t_on - Date of placement 2.1 barrier- WZD'I'H AVG _ DPTH -7-A c. Natural soil not strimed d_ Stone, brtia, etc., cr=ate_- than 15' fran SDS area_ I I I e. 100 ft_ fran water course/wetlands. U. SZ G'.DISPOSAL SYS " a. Seot-i c tank size 1, 00 1,250 I b. Septic tank installed level ( I I c. 10' minimu-n fron foundation d_ No 900 barnds, cleanout witRin 10 ft_ of 45° bend I I I e. DIS=Tj -TICN BOX 1. All outlets at same ellevation - water- tared f 2. Protect_-_-i belcw frest I I I 3. Minim= 2 f t. or_c? rig soi? bet-weezn box and tr_n(:hes I I I f. JUNCTION BOX - vronerly s =t I I C.F�Tf'�'F 4 1_ Lerngth ra i_-_ad. - W !! Ie_ng-tth insta11 ed. �tO I 1 I 2. Distance to water- ccurse = u'e f :_ I I I 3. Irls_=> i ed according to Dian ( I 4. Distance cent- to c entar ( I I 5. Slors of t e-nc-1 acc =Jule 1116 - 1/32 " /icot_ I SCI 1 6. 10 fart from me ty line - 20 feat - foundatiors I S I I 7. Denth of t_ ==lLn < 30 inches from surface i 8. Rccm a-1 c-.ved for ex-- an5ion, 50% I I 9. Size or arr'vel 3/4 - li" Cicmemar I I I 10. Dect_rl of gravel in t_e*lCrl 12" miniu= 111. • Piro ears M. —,_ad h. F-W-P OR DOSE SYSTEMS 2..Ove_11cw tank 3. Alan, y s-m /aiad o 4 Pum easLV accessible w nilole to aide ( I 5. First bcx baf fled I ( I 6. Cvcle witnessed by Eez-11 tit DEmFir utlent estin a.D— r! CW Per cvcle I I I a. Rouse looted Derr approved plans. b. Number of bedroars �r a_ Well lcc--t -- as pp_- a*.:-i+roved plans b. Distance from SDS area m= sared /o 6 ft. I I c. Casing 18" above grade_ I I I d_ Surface d_r=inace around well- acceot.ble_ I I . O4E-R11L WORKI.9 -I IP ' ' - arcut .6 a_ Boxes .oroc�l ed I I b. ALL 1 p roes r.ar- -aa_1 -1 v ba6cfi11ed c. AL1 pioes flush with inside of box d. Backfill material contains stones < 4" in diameter 1 e_ Cxrtain drain installed according to plan f. Crtain drain cut=all protected & dir.to e- cist.wata- _=Ursd I I g. Footing drains discharce awav fran SDS area I h_ Surface water Drot_- r-t-icn adecuate i. Ez osion crn`o nrovid- cn slopes greater than 15 %. I -_J I DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #�5 "(!/ WELL LOCATION S e =Add T lage Cat Ta G .Num er WELL OWNER Name Mail' 1. d rivate O P , , 1 ► ublic USE OF WELL )9/RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED primary ® BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify :2 - secondary ® INDUSTRIAL 0 INSTITUTIONAL O STAND -BY k AMOUNT OF USE y YIELD SOUGHT PEOPLE SERVED /EST. OF DAILY USAGE gal `'`REASON FOR PEW SUPPLY OPROVIDE ADDITIONAL SUPPLY ®TEST /OBSERVATION DRILLING ORE LACE EXISTING S PLY jWEEPEN EXISTING WELL ` s DETAILED -.REASON FOR DRILLING WELL TYPE RILLED DRIVEN []DUG OGRAVEL ® OTHER >3. IS WELL SITE SUBJECT TO FLOODING? YES _ NO . IF'WELL I LOCATFiD IN REAL Y SUB IVI I N, NAME OF SUBDIVISION:. Lot No. WELL CONTRACTOR: _'Name '�,W *kiF_. .. Address: —' -,;IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO �It X-11. '.NAME OF PUBLIC WATER SUPPLY: —� TOWN. /VIL /CITY ,*;DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: h,.x,LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION ON SEPA E SH ET (. ate), (s nat 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 provi d by the Putnam County Health Department. Date of Issue: 19 t Date of Expiration: 19 e mi ssuing Official Permit is Non- Transferra le copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner Z�87 Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH 1 DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date 9/23/85 Re: Property of Marlo Dunham Located at Arbutus Street (T) 15 Section - - -- Block 2 Lot 4 Subdivision of Roaring Brook Lake Subdv. Lot # Gentlemen: Filed Map # This letter is to authorize Joel L. Greenberg Date a duly licensed professional engineer or registered architect xx (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said 147, Education Law, lic Health Law, and the Putnam County Sani- tary Code. Very truly yours, Signed aa Countersi d: F o 0110,6 -{off wner of Property NEw P.E., R.A., # 11056 Arbutus Street Address Muscoot North,RFD #2,Bx 488 Putnam Valley.NY 10579 Address Town Mahopac,NY 10541 528 -5571 Telephone 628 -6613 Telephone SITE LOCATION OWNER'S NAME_ MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES I PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY ?d 0 l TM# V/ /0 a- 3 F PHONE PERSON INTERVIEWED 11�17r/17e PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE lO %y�o/ - TYPE FACILITY PROPOSED INSTALLER /�? � � S 61 � w pm � �S PHONE ° �.� � 3 V TIP ADDRESS �✓� Gip d '.� �', �?o�io,�oc� REGISTRATION# Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. �c — A d o/" x, , A �w - ,-as•oi;mer; e d ent of owner agree to the condition stated on * rri ,his foi: - ��' �� T SIGNA TITLE DATE _ GL�' Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99M L & e ATE �9L7*09*10. 0.00 iJ I A5 DuIL-r Lo �ATIOI��41, ul _j WCL 3-31 Well Z 5 451 &5' 51' 71 ' 65 57' 7W W ix .66 JU, P 10 AREA s 213j 9 214.2 34t.f 'S. -75, 64- or .811 164' )_3 k6 40.72• .'.14 4-0', - is 43' to q-: NJ 1& 47' S1' 24.30" 1112 '12-21 55, ., - - Is 5 7' &4 r 10) 62' 70' 20 6, E31 7GI lZI 73- Set D 601 iZ4 23 UA U 9+1 47.09' 64r of Ove _1001 40' 14. 4. Ll A5 DuIL-r Lo �ATIOI��41, ul _j WCL 3-31 5.51 Z 5 451 &5' 51' 71 ' 57' 7W W ix JU, P 10 75' -75, 12 .811 164' )_3 a a 10, .'.14 4-0', - is 43' 45'. 1& 47' S1' 17 '12-21 55, ., - - Is 5 7' &4 r 10) 62' 70' 20 6, E31 7GI lZI 73- Set IM 601 ..0151 23 55, 9+1 9 1 '-- _1001 c!) tv CCW io 9 Yd a of fist 60 fi 12 I ITInstdi 1 j z U. I L.T. L 1-\-e o -u -r 5,VtF_D .4- d, V3 Is IS TOCERTIFY THAT THE SEWAGE DISPOSAL - "!6 THIS 0 16 SYSTEM WAS CONSTRUCTED AS -INDICATED ON THIS ¢ 1 :,D PLAN AND THAT THE.SYSTEM WAS INSPECTED BY HE -OVEI�. THE. SYSTEM WAS BEFORE IT WAS COVERED 1 .4 CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES. -AND REGULATIONS OF THE PUTNAM COUNTY Otto R 8- U T Ll S S T R t-& T DEPARTMENT OF'HEALTH AND THE NEW YORK STATE A DEPARTMENT OF HEALTH. ul _j WCL Z ul >, 00 z W ix JU, P JR W(.) uo 0m Putnam County Department Division of Environmental Health Services a a wth, Lpproved as dt".d for conformanoe Of itb� a applicable_ Hules and Regulations Putnam County Health - Department. Aim UIL IjAmm t.rg pito a 4,C J 0 Ile C, 4. Ll io 9 Yd a of fist 60 fi 12 I ITInstdi 1 j z U. I L.T. L 1-\-e o -u -r 5,VtF_D .4- d, V3 Is IS TOCERTIFY THAT THE SEWAGE DISPOSAL - "!6 THIS 0 16 SYSTEM WAS CONSTRUCTED AS -INDICATED ON THIS ¢ 1 :,D PLAN AND THAT THE.SYSTEM WAS INSPECTED BY HE -OVEI�. THE. SYSTEM WAS BEFORE IT WAS COVERED 1 .4 CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES. -AND REGULATIONS OF THE PUTNAM COUNTY Otto R 8- U T Ll S S T R t-& T DEPARTMENT OF'HEALTH AND THE NEW YORK STATE A DEPARTMENT OF HEALTH.