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BOX 22
11 INNS AN 1 11
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02617
PUTNAM COUNTY DEPARTMENT OF HEALTH
..':_D_IVIS_IaNT- -OF- 1--EINVIRONMENTAL HEALTH
Date
Re: Property of
Located at
(T) Section Block Lot
Subdivision of hJILCOPEE C51 A UT
Subdv.-Lot # Filed Map # .2111% E Date
T PP ' i
Gentlemen:
This letter is to authorize FCZAM�— 5_IL_LIjAtJ
a duly licensed professional engineer — or registered architect
(IndicateT
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 bi) al 4 A-'n
-0o* Oct :and to. supervi.se -t1he -'c_onS'tr-uct'I-bn ---,t, f-- 'a-=.o
system or systems in conformity with the provisions of Artic.IeE'2145---6k_-
CZ fl-I
NJ
147, Education Law, the Public Health Law, and the Putnam Cou* 'A
y SLI
C.)
tary Code.
Countersig4ed:
OF NE-ij,
F
Telephone
Very truly yours,
Signed
C5rkner of Property
Address
I A
Town
,7,3q-
Telephone
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVIS ON -OF ENVIROirAL HEALTH SERVICES
Owner or Purchaser of Building
09
Building Constructed by
Location - Stre9t
Municipality
Building Type
Section
Subdivision Named
Subdivision Lot #
GUARAN17EE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
V
Block Lot
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
o rate ._for a, period two years immediately following tthe date of approval of the
_ �- .
"Certificate of Construction Compliance" for the sewage disposal' systan,` 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 :2 G day of 19 q ( Signature
Title��C
Gen Contractor (Owner) - Signature
Corporation Wame
/ (if Corp.)
Corporation Name (if Corp.)�a G.GzucGi
Addr s '161 y /4 S �/
Address
rev. 9/85
mk
ti
YML Environmental
Services
�Yorktdwn:.Heights,, NY, 1059.8..
ELAP #10323 (914) 245 -2800
d'2—
COL'D BY
NOTES _
X
RESULTS OF
ANALYTE RESULT UNITS
/potable
ALKALINITY
pH LT 2
rrg/L
Nonpotable
,
_ NaOH _
AMMONIA
�
V <20 >4C
mg/L
HCl _
Na2SO3
CALCIUM
STAT!
mg/L
Z Ac
CHLORIDE
6
rrg/L
COLOR
Units
CONDUCTIVITY
umhos /cm
COPPER
mg/L
CORROSIVITY
LSI.
DETERGENTS y
mg/L.
FLUORIDE
rrg/L
HARDNESS
mg/L
1IRON
mg/L
LEAD
rrg/L
MANGANESE
rrg/L
MERCURY
rrg%L.
per'100 mL
NITRATE
FECAL COLIFORM
rrg/L
per 100 mL
NITRITE
E. COLI
mg/L
per 100 mL
ODOR
FECAL STREP.
TON
per 100 mL
SAMPLING
SITE �9 plrAl, 'j d�G �� /✓ y �b���
X
For Lab Use Only
/potable
HNO3 _
pH LT 2
<4C
Nonpotable
,
_ NaOH _
pH GT 9
�
V <20 >4C
mg/L
HCl _
Na2SO3
>20C
STAT!
_
H2SO4
Z Ac
KNOW
6
MF MPN P/A
X
RESULTS OF
ANALYTE RESULT UNITS
pH
S.U.
PHOSPHOROUS
mg/L
SILVER
mg/L
SODIUM
mg/L
SULFATE
mg/L
SULFIDE
mg/L
SULFITE
mg/L
TURBIDITY
NTU
ZINC
SPC
per 1.O mL
TOTAL COLIFORM
per'100 mL
FECAL COLIFORM
per 100 mL
E. COLI
per 100 mL
FECAL STREP.
per 100 mL
These results indicate that the water sample tram AS] [WAS NOT] [NA] of a satisfactory sanitary quality according to
the New York State Sanitary Code, for the ers tested, at the time of sample collection.
These results 'indicate that th wa er sa le [WAS] [WAS NOT] oe�ti f a satisfactory chemical quality according to
the New York State Sanitar Code, for tl parameters tested, at of sample c ollection.
SUBMITTED BY:
Albert . Padovani, M.T. (ASCP)
Director
NA = Not Applicable N = Not Present (Negative)
P = Present (Positive) SA = See Attachment(s)
Also done because Total Coliform was present
TNTC = Too Numerous To Count
> = CT = Greater Than < = LT = Less Than
ELc= =L =_:i Cc_c
Ev
� fir, -� i _ .
zt Cg �-L �
D - 5r.:Z. r Ate_,
=
b_ fill Dam at placE•�rit
2.1 b�Tri =Y . LG— w " =-' ?tiG_LPT_
c_ ra Jr i sci_ r_c s t�,
I-^-
C_ .C•`..._.r°, br s E =C_ , C=_% =T- t�tII 1.51 f_an EDE LE=_
E_ 100 ft- f =c.., Hc=_ cC gL�= i Lrrs -
a_ Ee-:-t.,Lc tank =_Z-2(- 1,000 I. 50
G_ !'7 ` Si'L• Z�Tit -it —__1 - C.L'T —= �Cr
go' C_♦_ CLi_ W- =^ t n 10 - _ C_
E� : E E! .Tc _C:7 - kc =_ j�- - - -�_--
p -cam =� �Cw f =-sue
I I I
j42- -i- L =- Cr-C--ELI
elm Sh
Fcct
C. i0 y___ -_ L- --c Lr 1 -- - 20 T=�
E Fcci a! ir-we -Cr er. - -s -Cr, 50S-
see C. C= :aL 3/4 _
C— i c- ]--i tzEmc h 12"
!I pi?
2- �' _! C-w sir
le Lr
F� T5 b =,C
E. Orcl w_- -___ -= bti E =i :-
ES I— TTc L =- , cw car cY C! e
r. . Ft Lam=
Es
C- Cs- r"c 13"
4
C= 'z:u.t:
L, _ 1_? 'Tc�
C_ A_i vices flush wi t� 1^.5_Ge Cf h
< 4" III G? =TCT_
e_ C�� La-4 n ��; _ ��?? � acCCrcl ^c to Cl
a-11 I
to E'i5t_CrcL:az- l'=
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CCl S! CtcS C =_�='" t- -^ i -� _ ( I I , _--------
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 # �V- 9 -40
WELL LOCATION
Street Address
LJ�
Town/Village/Cit y Tax Grid Number
Q "tk-M
WELL OWNER
Name
"
Mailing Address )21Private
&?_ co i t-A Ave. PtEK6 LL i . IcbG(oCo13 Public
USE OF WELL
1 - primary
2- secondary
V RESIDENTIAL
D BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM Q TEST /OBSERVATION O OTHER (specify,
O INSTITUTIONAL O STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED 1 Mm, /EST. OF DAILY USAGEl�j 0al
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION GlADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING L] DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED _
DRIVEN
E]DUG
GRAVEL O
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 1/ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Wjz4oPM
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _�NO
NAME OF PUBLIC WATER SUPPLY: �•l�A TOWN /VIL /CITY t-11A
o �DTST -TO- PROPERTY' FRM4 NEAREST WATER MAIN r s..
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
-6�
(date) '
7
PERMIT TO CONSTRUCT A WA
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
any and all water or waste products from such well
property and in such a manner as not to degrade or
Date of Issue: ` 19�
Date of Expiration 19
shall take appropriate action to assure that
drilling operations be contained on this
otherwise contaminate surface or groundwater.
?ermit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
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
Prue PRRMTM
WELL LOCATION
Street Address
Town/Village/City Tax Gri Number
WELL OWNER
Name Mailing Address rivate
1, .-e-C P_ 4Dl \ /^L_ AL_per I`1Y. OPublic
USE OF WELL
1 - primary
2 - secondary
KRESIDENTIAL
b BUSINESS
® INDUSTRIAL
®PUBLIC SUPPLY QAIR /COND /HEAT PUMP ®ABANDONED
O FARM. O.TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT S gpm /# PEOPLE SERVED I R' M./EST. OF DAILY USAGE5f gal
E3 REPLACE EXISTING SUPPLY O TEST /OBSERVATION CS ADDITIONAL SUPPLY
ZfNEW SUPPLY NEW DWELLING M DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DEN
®DUG
O.GRAVEL
OTHER,
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF' WELL IS LOCATED IN A REALTY. SUBDIVISION, NAME OF SUBDIVISION: 7Ir
Lot No.
WATER WELL CONTRACTOR: Name 'ro e'E 'ETC— _fZr*ll tE.G> Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: t /A TOWN /VIL /CITY I-JZA
DISTiANNa- TO i'ROP8RTY'_ P909 NEARE9T_F1AT9R "H IAT
LOCATION SKETC SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
ao,
(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 such a manner as not to degrade or otheKwise contaminate surface or groundwater.
Date of Issue:
Date of Expiration 19���-- Permit Issuing Official -
Permit is Non - Transferrable White copy: HD File Pink cd y Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
_0�57n�
PUIMM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEPI GE DISPOSAL SYSTEMS
REVIEW SHEET - CONSTRUCTION PERMIT
(Name of Owner)
DATE
G C�'Ao ,� BY:
(S treet i )
DOCCMS CLJ GG
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc
(3) Fill ,f
cd
HQu� Plans - Two sets
permit; PWS letter
Variance Request
024 -ERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland ( Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Swage System Plan - ( north arrow)
Swage System Hydraulic Profile - Gravity Flcw
Fill Profile & Dimensions - Volwme
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction - Nlot-s ` f gr te
-inr -rate)
Design Data: Perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
DgDansion Area;shown;gravity flow,suff. size
If Puq:)ed Pit & D Box Shaun & Detailed
House - No. of Bedrooms
wells & SSDS's w /in 200 ft. of Proposed Systens
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
3EPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
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, Leader, - Footing
35'to catch basin,stormdrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
3eotic Tanks
10' fran Foundation; 50' to well
.5' Well to PL 9
'P=M COUNTY DEPAF64W OF aM19
DIVISION OF ENVIRCNMENIAL HEALTH SERVICES
DESIGN DATA SHEET'- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
4D Gou�M �.
Owner 1�/G- ScoKK� _ - -� i _ ., Address
Located at (Street) Vjie_c.r>FC---E `Zp Sec. 19 Block I Lot I4P.1422
(indicate nearest cross street) E5C?� .. s,e�p.A Le-,-r- i
Municipality �i_rF ti 1,4 t� �/�L�E `( Watershed N v r
SOIL PERCOLATION •= DATA REQunup TO BE SUB IITrED WITH APPLICATIONS
Date of Pre- Soaking 5 2? � _ Date of Percolation Test
Sf211g -1
HOLE
NUA BER CI= TIME PERCOLATION
PERWLATION
.. Run Elapse Depth to Water From Water'Level
No. Time Ground Surface In Inches
Soil Rate
Start -Stop Min. Start Stop Drop In
Min,/In Drop
Inches Inches Inches
lEA(�) _Nq 24
3 GCS7 -y5I 'Z� 2 24
drf3► -Qt�-� . '2.4 24
5
2 9 r 7
39� -R-3(, 21 2cv 2 7
4 G-56,- 1C.) 1 21. 2v 2 3
7
3.
4
.5 -
i
NOTES: 1. Tests to be repeated* at same depth until approximately equal soil rates
are obtained.at each percolation test hale. All data to*be subnitted
for review.
2. Depth measurements to be made from top of hale.
DESIGN
Soil Rate Used P-5 - i C Min/1" Drop: S.D. Usable Area Provided SCE c:-
No. of Bedrooms Septic Tank Capacity /moo gals. Typel'"
Absorption Area Provided By 33 L.F. x 24" width trench
�sroN
Other
IM
Name ���I� r. lSd L�.��"�S tom- L , Signature
Address izT. SEAL,
yr. - 40
. �OF Ncv�'
THIS SPACE FOR USE BY HEALTH DEPARDMW ONLY:
Soil Rate AnnrmmA /--'1 1.4- _ 9 1
TEST PIT DATA REQUIRED
-
TO BE SUBMITTED WITH APPLICATION
DESCRIPTION RIPTION OF SOILS . ENCOUNTWM_ :IN _TEST ;HOLES, :
, •_ ..: ,_ . .
DEPTH. HOLE -NO. I
HOLE NO. Z
HOLE NO.
-G.L.
2'
3'
C,;Iy
a�
4' Lcy�
► �,s�h�
m
,61
_.
W
r� p m
c�
rm
71
.
C- m
81
C/)
9' .
.10'
_ 11'
12'
13'
14'
INDICATE LEVEL' AT WHICH GROUNMATER
IS ENC7JURMW r .
INDICATE LEVEE, TO WHICH WATER LEVEL RISES AFTER BE G IIJOOUNTE
M %2,
DEEP HOLE -OBSERVATIONS MADE BY:
SzJZ
DATE:"
DESIGN
Soil Rate Used P-5 - i C Min/1" Drop: S.D. Usable Area Provided SCE c:-
No. of Bedrooms Septic Tank Capacity /moo gals. Typel'"
Absorption Area Provided By 33 L.F. x 24" width trench
�sroN
Other
IM
Name ���I� r. lSd L�.��"�S tom- L , Signature
Address izT. SEAL,
yr. - 40
. �OF Ncv�'
THIS SPACE FOR USE BY HEALTH DEPARDMW ONLY:
Soil Rate AnnrmmA /--'1 1.4- _ 9 1
!'" )74017_ 3 /RA PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512®
Engineer Must Provide
P.C.H.D. Permit k - --
yy %cG' . e e- 05-1 Subdivision N c Subdv. Lot #
Separate Sewerage System built by 441IU490ef
Consisting of Jae O Gallon
n 3 i zP:�
Water Supply: Public Supply From Address
or: Private Supply Drilled by ��� �
Building Typo ✓ � -� � Hue Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?
Other Reuulrements
I certify that the system(s) as listed serving the above premises
of which are attached), and in accordance with the standards, rul
Putnam County Depar en Of Health.
Date ec ati
Address
as shown on the plans of the completed work ( copies
nce frith the fjled plan, and the permit issued by the
P.E. R.A.
License No.�����
Any person occupying premises served by the ova systems) shall promptly _ta,s Erich action as y be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Ap oval of the separate sewerage-System� shall- become hull and void as soon as a pub V: sanitary sewer becomes
available and the approval of the private water supply shall become null and void' whein a public water supply becomes available. Such approvals are
subject to m9dification or change when, in the judgment of the Commissioner of Health, su ovation, modification or change Is necesse�ry.
Date B �~ Tits
o r lQ�fgAll COMlf!! D>@A i1rt�'QIP OV EMU 8
V BkOndVadimmanniallWhOwde &CWMILX-T.10 0 wYe..lialeealtl
n
� M Swats DERGI , s>tMI111
.� V.IiccoPF� RoPto .
otllaad�p�Ikd.elfao. �Nll G�oTO
2
as OF D
Find # FV _ 9 -Cf Q
Tama w VWhW
Tu Ift 19 wil t
):mwwd if flaialt p
Dab d Previews Approval 1q0
limltK i l l zip o
Fee Enclosed [3 Amnnn,t
N.Nft TA I MMILY cei Mau 4, 231 Ad- p® S"W O* LJ Dptp vabm
14 1 d Mioama 3 .DWV now G P D Pct Modenthe `Remind wb. Fa b a mpisbd
tpmw $* NW Is aamUt er.�OG�O loots, Sarnia YMk ••w �j L,F o r 2 � b•c I I� P�SoPPJ'It71� '��rlC�t -1
U b:easiwMabd ip�c� AS r-IE C) MRJ6—
WOO SEPNIP FaMa Sop* Adieux
ere Mow Stippb Ot�ad IV ) 0EQ Adiasao
Ohm gogtiammn
1 rap►essnt "that 1 am wholly and Compeeteq rsfponsbe for the design and location of the proposed systemts): 1) that the septraft for dI sal system
above deseriN will be Wnstrueted as shown on the approved amendment than to and In accordance with the standadf, fUlai-8511 rues -8511 reed
t, wA*y Department of Health, and that on eompNfkM.thereof a "Certificate of Construction Compliance" mtistedory to the Commesioer of Haelthwill
be Sd m%RM to ten OMartnewd. and a written %wroatse will be furnished this owner. his successors, heirs of assigns by the builder. that mid buNder will
pteoa is qsW .dparatbr/ coal in. any W1 of mw owns dkpdsal system durl" the pwiod of two (2) yaws bmedi My fobwklp the date of the her
anoa of the aPill l of the CdrtNkate of Constweion Compliance of the origkel system or any rgwlrs tltehttoi ll) that the drNktO well descrIM a6—
tam be IeCatwl as O Mrs on the appreved plan MIA that mid WON will be Installed In a cored" with the standard rules and ree—M rs--of of the Putnam
CMarlty /
at IUaltli
Signed P.E. k' R.A.
A S=i &-- =A ,f� (-�. License No 5036
APPROV[D FOR CONSTRUCTION, The appoval expires two yews from the date Issued unless Construction of the building has been undertaken and if
sovocfbe for gym or may be WAWAed or modified when Considered neeesmry by the Commissioner of Health. Any Menge or alteration of construction
lw1uNN�a now permit. A rroved for ddkypoml of doneAk Unitary "MOM • private water Supply only.
Title-
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