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BOX 22
02599
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R @U. :/86 ` Division of Environmental Health Services Caemel, N Y.1051? Engineer to Pmvide permit N ;'.
on CERTIFICATE OF COMPLIANCE '
g
Permit I —
CONSTRUCTION PERMIT FO SEWAGE DISPOSAL'SY S TEM
Located at"4�j Town or aVillage
_ --
Subdlvision Name � 1��+� � t' tiabd.' N ,t k Tai Map
Renewal_ C3' Revision ID
��cx�l)
Owner /Applicant Name ( 1 J� S. '
Date of Previous Ap royal
Mailing Addreee�i►�vti. r ��' . Town �vfJ� 7,ip
Building- Type Lot Area f Fill Section Only Depth ' Volume
Number of Bedrooms Design Flow G /P /D PCHD Notification Is Required When FIR is completed
Separate Sewerage System to comist of _ - liWGallon Septic Tea and �� ®® �^' l� � � z
To tie constructed byCi�°�°� `t�"ddress
Water Supply : Pdbllc;Supply From . Address
onPrlvate Sup, piy;Drllled by l l� i�.� e
Other Requirements
I represent that-r'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 , thave to and in accordance with the standards, rules and regulations of e Putnam
County Department of Health, and that on completion thereof a 11,6ertif icate 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 the date of the issu-
once of the approval of the Certificate of Construction, Compliance of the original system or any repairs t hereto- .2) that the drilled well described above
will be'located'as.3h'own`on the approved plan and that said well will be installed in accordance with the j ndards les and regu a wns of the . Putnam
County e�srtm t of H alth. u
Date '' \\ Signed P.E._>L RR.A. _—
Address �Y�.J �.F ��' License No _ - ;I 1.
APPROVED FO NSTRU_ 1 N: This approval expires one year f_r m t ate issue as constructs' n, f the building has been undertaken and is
revocable for taus or may ed or modified when considered n` ces r by the - 'ss o ' r f It Any change or .alt n of co ruction
requires a w for disposal of domestic sanitar .s e, and /or IV er� % //� /►
Date - BY Title _
V
5'�
'I.
J.
C.
APPENDIX C
FP.LAb SITE INSPECTION
Date
I-
& I
Ic 1 10
;;CATION I CFi i cb 'S.
TM # OR SUBDIVISION PT XPT 0
EFWAGE DISPOSAL AREA
a- SDS area located as per approved plans
b.
Fill section - Date of placement
2:1 barrier. I - W1= AVG. DPTH
c.
Natural soil not stringed
d.
Stone, brush, etc., creater than 15' from SDS area.
e.
100 ft. frcin water course/wetlands.
SEW-AGE DISPOSAL SYSTEMI -7
a. Septic tank size - 1,000 1,250
b.
Septic tar-k instal—led level
c.
l0' mininu =. fran foundation
d.
No 90'3 bends, clew out within 10 ft. of 45' bend
TZrT
e.
DISTRIBUTION BOX
T All outlets at sarrn- elevation - water tested
2. Protected below frcst
3. Minimum 2 ft. original soil between box and tren-&-es
f.
JUNCTION BOX --proper-ly set
g.
TRENCHES
1. Length recnlired Length installed4jo
2. Distance to watercourse measured ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 "/foot.
UU
6. 10 feet from propex-ty line - 20 feet - foundations
7. Depth of trench < 30 inches frcm surface
I v, Nei C24
8. Roan a]-lcwea for expansion, 50%
9. Size of gravel 3/4 - 11" diameter
10. Depth of vell in trench 12" minimum
11. Pipe ends canoed
h.
PUMP OR DOSE. SYSTEMS
1. Size of perm chamber
Overflew
3. Alarm, visual/audic,
4. PLunp easily accessible manhole to grade
lx Ji Irr\
5. First box baffled
6. Cycle witnessed by Health Dep=artament
estimated flow pe-r cycle
HOUSE
a. House located per avoroved plans.
e- I (CA
b.
Nurnber of bedrocms
WELL
a.
Well located as per a-ooroved plans
(
$�
b.
Distance from SDS area measured ft.
c.
Casing 18" above grade.
d.
Surface d-ranage around well acceptable.
IA
OVERALL WORKM-ASHIP
a. Boxes prope--Iv grouted
GS -Ij
b.
All pipes partically backfilled
c.
All pipes flush with inside of box
d.
L
Backf ill material contains stones < 4" in diameter
e.
'Curtain drain installed according to plan
f.
Curtain drain outfall rotected & dir.to exist.watercours
g.
Footing drains disc±3,arge away from SDS area
h.
Surface water prote-c-tion adecuate
e kl�
i.
Errosion control provided on slopes reater than 15%.
--K
& I
Ic 1 10
Putnam County Department of Health
Division of Environmental Sanitation
' - AFFIDAVIT'- CORPORATE a,NER APPLICATION
z r7
FOR PERrJTT..APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT .
TO: Commissioner of Health - In the matter of application
'for
-- - - -,., ... ----- -
- - -.� represent
that I.am an officer or employee of the corporation
and am.authorized
to act for _ _ �� i c 0 e c_C_ T�3— _s iii . .
--
(name of corporation)
_ - - — — — — —
having
having offices at _ — _ C G kJ T Z-A _� u — _
_ — — — l _
— __- -_____ L{M5 v�zv)__ tU _ Ilos't-)__Whose
officers-are
President _ _'��� i I `� l�y_�C2,�� ��J 4vhu �� _�i 1,
Name and ddress)
-'
Vice - President �
/L
_
Name and Address
_
Secretary
_— _____ --- _ _
(Name and Address)— _ —
Treasurer Er F ! ti =�
(Name and Address) — — _ — — —
- - --
and that I am and will be i.ndivi'dually' responsible for any or all acts
of the corporation with respect; ito- 4theE:a`pp_rgval requested and all sub-
sequent acts relat'ng thereto. r x.. Y a 'a .
Sworn to. fore this day Signed <::::::_ -
R.IAN A. K NO
of ' tic, Sta Po l
Qualified in We m- r C6umv _
otary PablidF / I
Title
. Corporate Seal
PUTNAM COUNTY DEPARTMERr OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
(Name of Owner)
VIE ;� SHEET. CONSTRUCTION- ..PERMIT•
DATE
BY: �.
( Street Loca ion )
DOCLNENiS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
If PWS - Letter
Variance Request
REQUIRED DETAILS ON PLANS
Sewage System Plan
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions.- Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
;E}cpans -i-or*-- ?rear shown - ;.gravity•- €low;,sutf: -iz� �--
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, large Trees
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains- Curtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' fran Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
Putnam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE CJPIEk.PPLICATION:. _
FOR PERMIT APPLICATION SUBMITTED . TO
PUTNAM COUNTY HEALTH DEPARTMENT
10: Commissioner of` °Health = In the matter of application for
l '..
I,d....— ... ___ —_____ ____ represent
that I.am an officer or employee of the corporation and am authorized'. :
to act for
'(name of corporation— )—
having offices at
-- - —1J o t' �r�` ►'cC _�'�, _ _ _ —
-- -- — - — -t - - —
-- -L_— -- — — — — — — Whose officers are
President _�_�,.� �i fz ��_ �, L'
_ — (Name and Addres
Vice- President _ �_ 32t Sa-_ — _ — f -4 - _ _
9..
f.
�. Secretary % %(_4 +t }
(Name and Address)
Treasurer :.
(Name and Address)
and that I.am and will be individually responsible for any or all acts
of the corporation with respect to the approval requested and all sub-
acts relating thereto. _
Sworn;q is day Signe ... _ _ ..
C. State y
of Yl�estcf 19 Title _ _ _ _ _ _ _ _ _
Dre
. Notary Public
Corporate Seal
Re: Property of
Located at t -0 (
(T)
Subdivision of
DIVISION OF
Section
Date —e !j e)�
Block, lot 7:>
Subdv. Ibt # Field Map # Date i%_tA90 (3)198�
Gentlemen':'
This 'letter is to-authorize
a duly licensed Professional.Engineer or.Registered Architect to
IC :[E)
apply for a Construction Permit for a separate semge system, to serve the above noted
pr6perty in accordance with the standards, rules or regulations as preuLdgated by the
Commissioner of the Putnam County .Department of Helath, and to sign all - necessary papers
an my behalf in cormection with this matter and to supervise the - construction of said
system or. systems in..conformity with the provisi - , – ii '
.qf . , Ca
ons; �rlwli an - Uw-,-
the Public Health Law, and the Putnam County Sanitary Code.
Countersigned
ID., I I I RAO' 1 4
F
�ZEess
Telepbor-we
Very truly. yours,
b -)
SIMD
Nner of Property
w I" ZA
re 416
ne epbone
UtFAK I MtN I ur MAL I r1
Division Of Environmental H�.�yh Services
°
TWO COUNTY CENTER — CARMEL, N.Y. • 10512 (914) 225-3641
r _ pPCATION"TO 'CONSTR'UCT A WATER WELL'_ _
J _
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL .IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: \jjj' ;� TAT a�
LOT NO_:
WATER WELL CONTRACTOR: Name- �C `??CST- "(t_lt - Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: — YES NO
NAME: OF.PUBLIC•WATE'R SUPPLY: - TOWI /V /C
a`3S\U In ryU
.DISTANCE T0. PROPERTY FROM NEAREST WATER .MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION.
Pr
! T yam'
PERMIT
O
r 4
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
bf-the Putnam County Health Department attached to this
permit.
3. Submit a W ll ompletion Report on a fo pro r-d e d b'
the Putnam rCou ty Healt Department. !.
Date of Issue: ` 1
Permi Issuing 'Official
Permit is Non - Transferrable
STREEi A00RESS.
WWN)VILLAG CITY fax UAW NU ER.
WELL LOCATION
W ( -..
Cam,T "ccl.►At -�l �/ ta,E Z_,S
NAntE. •
ADDRESS:
PRIVAT[
WELL OWNER
07,
❑ PUBLIC
USE OF WELL ,
XRESID NTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS
❑ FARM • • ❑ TEST /OBSERVATION 0, OTHER (specify)
2 -secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY ❑
AMOUNT OF USE
YIELD SOUGHT
MI�. SI�a•�� I- +
_ - gpm. /N0. PEOPLE SERVED `r / EST. OF DAILY USAGE �' gal.
REASON FOR
.NEW SUPPLY.,.
❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/ OBSERVATION
DRILLING
❑ gEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE
DRILLED
F_� DRIVEN DUG GRAVEL E] OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL .IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: \jjj' ;� TAT a�
LOT NO_:
WATER WELL CONTRACTOR: Name- �C `??CST- "(t_lt - Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: — YES NO
NAME: OF.PUBLIC•WATE'R SUPPLY: - TOWI /V /C
a`3S\U In ryU
.DISTANCE T0. PROPERTY FROM NEAREST WATER .MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION.
Pr
! T yam'
PERMIT
O
r 4
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
bf-the Putnam County Health Department attached to this
permit.
3. Submit a W ll ompletion Report on a fo pro r-d e d b'
the Putnam rCou ty Healt Department. !.
Date of Issue: ` 1
Permi Issuing 'Official
Permit is Non - Transferrable
y u%
Notes: l) . Tegts to be repeated at same dept
rates are obtained at each percolation. teal
for rev ew.
21 Depth measurements to be made
)NS,
CT�ON ,
(Rate
h :1
�ri:'•;r3'i
r. �`
PUTNAM UNTY DEPARTMENT OF
DIVISION OF-EMRONMENTAB
�,;
COUNTY1. QVFICE 'BUILDING CARbE1
DESIGN DATEi `$HEET- SEPARATE
SEWAGE DISPO�A '
Own r
Ai67S Address 4
wic � r c E D. d-
Lor;ated at (Street) Sec "' -.. .
(( n ica e nearest cross s,
i
Municipality _1 uT—Mn n'l
Wat9ri
SOIL PERCOLATION TEST
DATA REQUIRED TO
B:. y -jII
Hole
Number CLOCK TIME
pEOpil�" .0
Ru. apse
P o. a .,e a�'
No. Time
From Ground
Start =Stop Min.
Start
, a'
Inches e
• � -yon 3
�s-- � ; • r�:�
2 X10 (,, _ 41! S �l
443 7 12
3
;r.
v��•t .�• 1k
-yy '
.
2 .
_ . .
y u%
Notes: l) . Tegts to be repeated at same dept
rates are obtained at each percolation. teal
for rev ew.
21 Depth measurements to be made
)NS,
CT�ON ,
(Rate
h :1
�ri:'•;r3'i
r. �`
TEST PIT DATA REQUIRED TO BE SUBMIT
DESCRIPTION OF SOILS ENCOUNTERSM
DEPTH HOLE' NO.. HOLE NO.
U.L.
Ar
6
pit
1811
2411
3011
36 It
4210
IN
4811
It
54
60
6611
7211
78
8411
INDICATE LtM AT WHICH GROUND .WATER IS ]EMN
INDICATE-'L=�TTUMCH WATER't= RISETT d
TIZISTS ivADL 6
DESIGN
Soil Rate MirVl"Drop.- S.
No. of Bedro,-pn1s------3 Septid-.^Tb:nk Ca
Ab s orpt;,on,/,Krea7F-r—ovi (led By
L.F.x2411
N
Address
CA71km OL- -(\J-Y
THIS SPACE PM' USE" BY HEALTH DEPARTMENT ONIV-
Soil Rat6 'Approv6d Sq. Ft/Cal.
4,
a
t. I
ie ,
._ --.a. ._ max. --',_ -^5'n ,•+Y'^'AmaQ+e'x? ?!o� ^'e �-,+. -�^.. R. _ 'X+„- '�"• -T-t _
P.UTNAM COUNTY DEPARTMENT OF. HEALTH ENGINEER . MU ST
0 PROVIDE
Division of Environmental Heaslth.:SaiWgn, Carne/ N. Y 1051? PV 62-86
PERMIT #; .
CERTIFICAT OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM P u t n a rn V a I 16 y
or .Village
Town
�•y�..i is ..M_ :.,.. -� --. x: eas ' o• :w. a m .. .. �o , ._._.. r. • ..:.m> t .i�' _- .am ...� . _... . r- .:�,..r> �.� y+r -. > -x.�_ ..�... +1 ._ s.�s , :,... .. ..:.w s .. =...x .
Located at W i- c c o p e e r Court Tax Map Block J
W i c c m p e e Estates 1 0 Cormerly Tax Map Lot a 3 7 subd. Lot g 7
Owner '
Separate Sewerage System built by M e c a m Development Go r p, Address 4 4 N o r t fi C e'n t r a I A y e n u'e E I m s f or
Consisting of 11250 Gal. Septic Tank and 400 L F A b so r p't i o n T r e n c fl
Other requirements
Water Supply: Public Supply From
X Private Supply Drilled By To r 1 i s f) & So n s
Address Box 271 , Armon_k New York 110504
Building Type I F a m i I y Residence No. of Bedroom$ 4 oats. Permit Issued 8/19/86
Has Erosion Control Been Completed? Has garbage grinder been installed? no
I certify that the system(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 standards, rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health. _
Date T� Certified by P.E. X R.A.
Address C a a h ' n A c cn G r a t e S- P f* License No.
Any person occupying premises served by the above system(s) shall promptly take such'actlon as may be necessary to secure the correction of any unsanitary
conditions resulting from such ysage. Approval of the separate sewerage, system shall become' pull and void as soon as a public sanitary sewer becomes
available and the approval of thaPprivate water supply shall become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Co o fr%of Health, such revocation, modification or change is necessary.
_ U By . 4e "% V r TttN T I ►
Rev. 6/85
__..._-._....... �--...__. �...__ .._..._.._._...�..__...._.....- ... .. ... .....x .. .;;._. -_.. a _.. __.. ._....__�_._..-- ...__...�:.__.: .._.,_....�..__ _............ ....r ...
A CCU
WELL COMPLETION REPORT
!y .e
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Office Use Only
WELL LOCATION
STREET ADDRESS: WN /VIL 1TY TAX GRID NUMBER:
WELL OWNER''
N ,�� ADDRESS:
A //® /
11'r /�°% ( i "�• 4 lylr /�✓� /✓
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/ COND. /HEAT;PUMP D ABA "ONED
❑ BUSINESS ❑ FARM ❑ TEST / OBSE.RVATION ❑ OTHER
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY O
MOUNT OF USE
YIELD SOUGHT gpm.INO. PEOPLE SERVED - / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
'JZ NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/ OBSERVATION
D REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
DEPTH ft.
STATIC WATER LEVEL ft.
46L ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING WOPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH ft.
MATERIALS: ASTEEL O PLASTIC ❑ OTHER
LENGTH.BELOW GRADE ft.
JOINTS: ❑ WELDED ,THREADED ❑ OTHER
DETAILS
DIAMETER —in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE;KOTHER
WEIGHT
PER FOOT — lb./ft
DRIVE SHOE O YES jNO
LINER: ❑ YES ❑ NO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
DETAILS
FIRST
O YES ONO
HOURS_
SECON(I
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE.
DIAMETER T
OF PACK in.
TOP '^
DEPTH fL
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED tests were done is in-
O COMPRESSED AIR ,formation attached?
O BAILED ❑ OTHER ❑YES ONO
WELL LOG it more detailed formation descriptions or sieve analyses
are available. please attach..
DEPTH FROM
SURFACE
Water
Bear-
ing
Wall
Dia-
peter
FORMATION DESCRIPTION
CODE.
ft.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAV'IOOWN
It.
YIELD
gFm.
Surface
A
:!
OVATE$ )kCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ❑ NO
ANALYSIS ATTACHED? O YES ❑ NO
STORAGE TANK:
CAPACITY ilt ae> -o GAL.
PUM(P�HF RMATION ; , f
TYPE✓ +✓ Z1141^94 '� CAPACITY /
MAKER S -�"��� DEPTH
MODEL �Sf VOLTAW�� HPI
WELL DRILLER1i1I,, /Lr J j -j fj ` DgiE ,1
ADDRESS /' SIG RE ll , �
— ��, t "—"�/ i
WELL UUMYLLTLUIN rcLrUAI
Office Use Only
.e
DEPARTMENT OF HEALTH
D4v-i,r on - -Of- Enuir:ox7_Qntia.1
PUTNAM COUNTY DEPARTMENT OF HEALTH
STREET AOURESS: wN1r1L ! I Y TAX GRIO NUMBER:
"'
WELL LOCATION
�/ ���(
WELL OWNER
NA E ADDRESS:
� � � , � c l ��►, J
❑ PBIVATE
❑ PUBLIC
USE OF WELL
;,KRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABA ONED
1 - primary
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
2 - secondary
❑ .INOUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED /EST. OF DAILY USAGE gal.
REASON FOR
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
'
STATIC WATER LEVEL ft.
[DATE MEASURED /i7
DRILLING
O ROTARY ;4 COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH ____ ft.
MATERIALS: ASTEEL ❑ PLASTIC O OTHER
LENGTH.BELOW GRADE ft.
JOINTS: ❑ WELDED JkTHREADED ❑ OTHER
CASING
DIAMETER — in.
SEAL: ❑ CEMENT GROUT O BENTONITE AOTHER-
DETAILS
WEIGHT PER FOOT - lb./ft
I DRIVE SHOE: ❑ YES i�NO
LINER: ❑ YES ❑ NO
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (f t)
DEVELOPED?
SCREEN
_..- TAJLSl -
FIRST
-
:.. -... _
- -O.YES :QNO
SECOND
HOURS
GRAVEL PACK
❑ YES
GRAVEL
DIAMETER .
TOP
BOTTOM
❑ NO
SIZE
OF PACK in.
OEM ft:
DEPTH It.
WELL YIELD TEST If detailed pumping
WELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.,
METHOD: O PUMPED tests were done is in-
t
DEPTH FROM
water
Well
O COMPRESSED AIR , formation attached?
❑ YES ❑ NO
SURFACE
Bear-
ing
Orat
meter
FORMATION DESCRIPTION
CODE.
O BAILED O OTHER
ft.
ft
WELL DE PTH
DURATION
DRAWDOWN
YIELD
Land
Surface
ft.
hr. min.
ft.
gpm
o
WATER J. kCLEAR
TEMP.
QUALITY ❑ CLOUDY
HARDNESS
O COLORED
ANALYZED? ❑ YES ONO
0
ANALYSIS ATTACHED? ❑ YES O NO
STORAGE TANK: TYPE C-C.;)t re67 Z,
�/JJC 'a� GAL.
PUMpMF RMATlON
:. y t� e
�
CAPACITY
CAPACITY /
nfl,
WELL 0RIL -- AN, f /tl � o,w f
'' j
MAKER _,ri/�ar7 1J - -- DEPTH
ADDRESS 5 SIG' RE
;';
MODEL
VOLTAGNt HPL—
, -- //
i Mk;. 003301
Medical Laboratory, Infdrkt
_ 321 Kear Street
-- ti • - _ �CArmelonr S aP:eslski�h;.,.a:.._..w
C t
J / `SCork�iown Heights, N:`Y. 1'0598: Mt..., Kisco New City _
(914) 245 -3203
Director: Albert.H. Padovani.M.. T. (ASCP)' Date Taken : is ' 5' 8--'q H
T-` Date Received: - A
T.orlish & Sons , Date °Reported:tl- _
.PO Box 2T1 Collected By.D` Torl'ish
Armonk, NY 10504 R.ePer.red By:
Sampl e . Sou'rc e :'7fll -- K T-T
L J e� Rip v
LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER
GENERAL" BA.CT,ERIA
_ Standard Plate Count per 1.0 ml
(Agar plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE 0-IFT)
Total Colifo.rm Der 100 ml Q
Fecal Coliform ner 100 ml
Fecal Streptococcus per 100 ml
MOST PROBABLE NUM_! FR T.£CHNTOU
Total _..Coi.i:fo,rm:_ Index -per 100 ml- --
Fecal ,Coliform: NPN Index per 100 ml
OTHE? ANALYSES
THESE -FESULTS INDICATE THAT THE' WATER SAMPLE (WAS). (WAS NOT) .(NOT APPLICABLE)
OF A SATISFACTORY SANITARY QUALITY ACCORDING T NEW YORK-STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT.THE TIME OF COLLECTION:'
Albert H. Padovani; 14.T.. (ASCP), Director
LEGEND
.RDS Recommend-Disinfect-
ing Water Source
TNTC = ,Too Numerous To Count
CONF = Conflu -ent
< = Less Than
> = Greater Than
PUTNAM _COUNTY DEPTA- .R..�D=- . OF. HEALZIJ.-
DIVISION _ OF *ENVIROMA HEALTH SERVIC ff
Owner or Purchaser of Building
CC"
Building Constructed by
Location - Street
Municipality
� �N1 � L.Y �cS1 C7Er:JL,E
Building Type
'0� I 3, 7
Section Block Lot
�ItLc��"�EC �.S►�TC.S ,� ,
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that.I am wholly.arid'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
- = -o ate for; -a - iod of two years immediateL followin .a the date of roval .of. the
"Certificate of Construction pliance" 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 determination 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 operate was
caused by.the willful or negligent act of the occupant of the building utilizing
the system.
Dated,this S day of 19
General Contractor (Owner) - Signature
Corporation Name (if-Corp.)
Address
rev. 9/85
mk
Signature
Title
IvtCC�►�- 7C✓CLoto"ACO-7 Copley
Corporation Name (if Corp.)
`�q No C.. ti -, L.4-( 1't�X'
ess
kG_ w/
z- - - -^a. T 111-rnWl D"nr%n1V
Office Use Only
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY .-DE;fKRtMffl4t-'br" HEALTH' _
STREET ADDRESS: TOWN/ VIEEXCLICI I Y TAx GRID NUMBER.
WELL LOCATION &IICCopo�e .11 -7
WELL OWNER
1 ADDRESS:
A E:
N7
'/
❑ PBIVATE
0 PUBLIC
USE OF WELL
1 - primary
2 - secondary
A
X-RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND.IHEAT * �P-UMP ❑ AB E
ON D
❑ BUSINESS ❑ FARM ❑ TEST/OBSERVATION 0 OTHER (specify)
C3 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE — gal.
REASON FOR
DRILLING
0 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION
0 REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING, WOPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH
MATERIALS: ASTEEL 0 PLASTIC 0 OTHER
CASING
DETAILS
LENGTH.BELOW GRADE 16 —ft.
JOINTS: ❑ WELDED ,THREADED 0 OTHER
DIAMETER — in.
SEAL: 0 CEMENT GROUT 0 BENTONITE AOTHER
WEIGHT
PER FOOT lb./ft.
DRIVE SHOE: ❑ YES �NO
I UNER:OYES ONO
SCRE EN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
0 YES ONO
SECOND.
GRAVEL PACK
1
0 YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in. I
TOP
DEPTH ft.
BOTTOM
DEPTH — It.
WELL YIELD TEST If detailed pumping
METHOD: 0 PUMPED i tests were done is in-
• COMPRESSED AIR formation attached?
• 8AILIfD 0 OTHER 0 YES 0 NO
if more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
I
SURFACE
r
Waller
Bear.
ing
?�efl
Dia-
meter
In
FORMATION DESCRIFTION
COGE.
ft.
WELL DEPTH
It.
DURATION
hr, min.
DRAWOOWN
ft.
YIELD
gFm.
Land
Surt2ce
7
GrA)
,3qo
WATER )kCLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES ❑ NO
STORAGE TANK TYP E&Je (ty-ry'a 1,
CAPACITY JAJ"_-� GAL.__i�y
WELL DRILL A I D&4-11M
ADDRESS Wo VaA 511019!
150�J�21) 1 �R)rmO. lud /asod
PUMaP414/F 13MATION
CAPACITY
MAKER DEPTH
MODEL VOLTAGN�� Hpi—
WELL UUMrLhilun r%.Mruml
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT 6 HEALTH 7
Office Use Only
STREET ADDRESS: TRNIVIELACILIGIly W GRID NUMOM
� X
WELL LOCATION
WELL OWNER.
NA ADDRESS:
7A .4 by.
P81VATE
0 PUBLIC
USE OF WELL
1 - primary
2 - secondary
ORESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT.-PUMP ❑ ABA ONED
❑ BUSINESS ❑ FARM ❑ TEST/OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED /EST. OF DAILY USAGE— gal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPT H Ul ;Ko— ft]
—
STATIC WATER LEVEL -4-1-Sr—ft.1
DATE MEASUREDZL
DRILLING
EQUIPMENT
0 ROTARY 13 DUG
)< COMPRESSED AIR PERCUSSION
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING, 5(OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH I I — ft.
MATERIALS: )kSTEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE -7,0 — ft
JOIN TS: ❑ WELDED ATHREADED ❑ OTHER
DIAMETER — in.
-
SEAL: ❑ CEMENT GROUT ❑ BENTONITE AOTHER
WEIGHT PER FOOT 1b./ft
DRIVE SHOE. ❑ YES kNOLJNER:
❑ YES ONO
DIAMETER (in)
LOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
SCREEN
DETAILS
FIRST
0 YES ONO
GRAVEL PACK
0 YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in. I
TOP
DEPTH _fL
BOTTOM
DEPTH - It.
WELL YIELD TEST If detailed pumping
METHOD: 0 PUMPED 1 tests were done is in-
0 COMPRESSED AIR ' formation attached?
0 OTHER 0 YES
0 BAILED 0 NO
it more detailed formation descriptions or sieve analyses
IWELL LOG are available. please attach.
DEPTH FROM
SURFACE
Water
Bear.
ing
Well
Oia-
meter
In
FORMATION DESCRIPTION
CDOE
it
it.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
lt.
YIELD
9prn .
Land
Surface
7
tvi co- C.- 7 e,4
390
00
WATER )kCLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES ONO
STORAGE TANK: TYPA1,11hyreal,
CAPACITY tAj"-)( GAL. Lly
dip
PUMTPH , F RMATION : , 4_1�
'41
ujzmlc�j .0— CAPACITY
L10
MAKER DEPTH
MODEL VOLTAGN�� HP
. t_1
WELL DRILL AME
ADDRESS
A:�s
O)v
4rm A
"Go