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BOX 23
'
02708
LIM
02708
Re_�" -31!�06
Located i ,41" 'Xs
O /
:'v�
wner /applicant Name 'J d
Mallng Address
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512 ��
Engineer Must Provide
I I -1 P.C.H.D. Permit N
N�COMPLIANC FOR S AGE DISPOSAL SYSTEM
� 'OWn OL e
r i r 7L' Tax Map 23 /At,'* Lot
��
J 4 He/�1 Formerly Subdivision Name � ` — Sabdv. Lot #
ZIp S �% Date Permit Issued
Separate Sewerage System built by 110 14104 elle- Address `+
Consisting of % C V O Gallon Septic Tank and S 6 y 4 o'-'- - Z-4 " W, � /'e, S
water Supply: Public Supply From Address C ,
or: A"" Private Supply Drilled by A/ Y7 Address 15- ra a`�' d '409,
Building Type Ali-5; dew d r Has Erosion Control Been Completed?
Number of Bedrooms -3 Has Garbage Grinder Been Installed?? A/O
I certify that the system(s) as listed serving the above premises were cons t me own on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and re stith the filed plan, and the permit issued by the
Putnam County Department Of Health. ^ /l
Oats Z� ?/ 'q/ 9 Certified by P.E. Y R.A.
i
Address License No.
Any person occupying premises served by the above system(s) shall promptly to sill i4QAal necesu►y to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage syste ti, po nd void as soon as a pubt,: unitary sewer becomes
available and the approval of the private water supply shall become null and void w ` ate► supply becomes available. Such approvals are
sub)ect to modification or change when, In the Judgment of the Commissioner of Men such revocation, modification or change Is necessary.
Date `iE' 6 G �C� . _ BY- _ Title
�C
-T• _. -..._<: wSo-
Wn" tJ.Vrlrj rz11Vn 1 rrVA1
DEPARTMENT OF HEALTH
:•......,.:e•.a- ..y. >._w.lis v..n Tir -�1 ..�S��- FC'S'.;F °. t. uy �...�T.; �Y �"'J':,�5'e�• -�
PUTNAM COUNTY DEPARTMENT OF HEALTH__'
,
WIVRILUMNICI
Office Use .Only
- `-,.. _.- _
-
WELL LOCATION
STREET ADDRESS: W—N I Y TAX GRIO NUMBER
/c/ e. S��
WELL OWNER
ADDRESS:
�3 ' g
P81VATE
❑ PUBLIC
USE OF WELLRE
1 - primary
2 - .secondary
ENTIAL ❑ PUBLIC SUPPLY AIR /COND. /HEAT PUMP D ARAN NED
❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHTS"' gpm. 1N0. PEOPLE SERVED ===: / EST. OF DAILY USAGE .1 v n gal.
REASON FOR
DRILLING
EW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TESTIOBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL eft.
DATE MEASURED
DRILLING
EQUIPMENT
ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
WELL POINT ❑ CABLE PERCUSSION ❑OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH ft.
MATERIALS: RSTEEL ❑ PLASTIC ❑ OTHER
LENGTH .BELOW GRADE _—AA-ft.
JOINTS: O WELDED i9THREADED ❑ OTHER
DIAMETER " in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE BOTHER
WEIGHT
PER FOOT 1b./ft.
DRIVE SHOE $DES ONO
LINER: OYES &NO
SCREEN
DIAMETER (in)
SL07 SIZE.
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
❑ YES
'HOURS�M'� - -
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH tL
BOTTOM
OEM ft.
WELL YIELD TES? It detailed pumping
METHOD: O PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER ❑ YES O NO
'WELL LOG 1f more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
suaFACE
Water
Bear-
ing
Well
Dia-
meter
FORMATION DESCRIPTION
CUE,
ft.
ft
WELL OEM
tt.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
3
7�
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? 0 YES O NO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY A GAL.
WELL DRILLER NAME OA
ACORES �J ``. Gr> rURE v
/U .1
PUMP INFORMATION
TYPE CAPACITY
MAKER Z DEPTH
MODEL VOLTAGE HP`
LAB
Yorktown Medical Laboratory, Inc.
A : A Date Taken • 1- A -49b Time
321 Kear Street
Date Rc , d: 11a7& Time:
Yorktown Heights, N. Y. 10598 Date Re
.r Porte 3 9990
.._:,w. ,..�..: - �.,.,. - ..(9�'� P�+� �e`s� ,f`�'`=•= ' -. �.-� - .q�.,.. _w... rF. --�� :.;._� ,........� -.� -..tin I - a`.�:::. - ,�•`%i �- ��- :,.�,....,.,..
�.� .
Director: Albert H. Padovani M. T. (ASCP) PO /Client #
r Ref erred By: eL
d o�� Sampling Site:
Phone (I/Z)
L
REPORT ON THE QUALITY OF WATER
INORGANICS mg L MICROBIOLOGICA 1 Om
_ Alkalinity
_ Chloride
_ Copper
Detergents, MBAS
Hardness, Calcium
Hardness, Total
Iron
_ Lead
—.Manganese
_ Mercury
_ Nitrogen, Ammonia
_ Nitrogen, Nitrate
— Nitrogen, Nitrite
_ Phosphate, Total
Silver
_ Standard Plate Count
(CFU /1 mL)
Membrane Filtration Method
Total Coliform
Fecal Coliform
_ Fecal Streptococcus
Most Probable Number Method
_ Total Coliform
Fecal Coliform
_ Sodium Fecal Streptococcus
Sulfate
Sulfite.
Zinc _ Total Coliform P A
PH SI AL M S ELIANEOUS KEY FOR TERMINOLOGY
_ Color�(Units)
Conductance (ohms /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 or ab se
(For Lab Use)
SAMPLE TYPE:
(Check One)
✓Potable
_ Non- potable
OUTGOING:
(Check Each)
HNO
HC 13
H2SO4
VN OH
ZnOAc
_ Na2S203
_ Other:
INCOMING:
(Check Each)
.....nom._ 4�C.::.... � .:..� . .
GT 4 /LE 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 IME OF SAMPLE COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOL4COLLECTION. MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA DRINK-
ING WATER CODES, FOR THE P ERS TESTED, AT THE TIME OF
X %yj." 7/87 (Rvsd1 /90)RWE
A e-r a ovani, Director
PUTNAM COUNTY DEPARTMENT
SIn�j CAF
�o
9.11 17"60, 4
Owner or Purchaser of Buildi g
Building Constructed by
Location Street
Municipality
Building Type
a3
Section Block Lot
1"061 - ;/ -'y g
Subdivision Name
2
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 iumediately following the date of approval of the
� ,- - •r�:.— 'e —•iur. e' * br Y:e •s��raye -di��- 1 systu„- or'a .
�f - c�ir_ ,r�.v 1„ • yL r ,
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 24 day of 19 Y-' Signature
�jV e') Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Corporation Name (if Corp.) f
Address r/
Q �G�Y 1�% ....wtluCw�__u wonOYVU U1,
'. 1
Otroei>Appliciist Nome, ` e h a ': E -' •
Date df Pievboa revel
Millbng. Addtreae ..Totvin of q� o Zip
t.iepiesent toaCl am wholly.and completely responsitrle for the design rn .a
above described will,be constructed as shown, !on the'approved amendment
County ,, Department :of' Health, and that on completion thereof a "6iki
be' submitted 4o the Department, and 'v: written guarantee will be fu_ir
place, in goodropeiatinq condition. any. part o1 said sewage . disposal s,
anCo. of ,the - approval, of'•tne Certificate, of, Construction. compliancai a
will OetouteA'as sAoswn.on the aDP ►owed plan and .f hat said well will be',Irif
County Depart ant of Health. T
oats �...�
Ik
APPROVED FOR CONSTRUCTION Th approval expires Ro years fro
revocable for cause or may be amend or modified•when c risldere nea
requires,a ne ermi.• roved for disposal of dome c sanit se
j Date By
the separate ,sewage disposals stem
,the
and regulations * of the Putnam
y`to the Corhmissioner of Healthwill
by the•builder, that said builder will
Stately, following the'aate, pCthe Hsu-
that the drilled well desc►iped' above'
I and, regu 00ns : of.' the • Putnam-
Syr ,.P E. R.A.
001st license No
tcir -Pif the' building. has been undertaken vnd Is
'.Any change or alteration of construction
IW only. 1n1
Title � / #f/
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
WELL LOCATION
Street Address Town Village ity, Tax Grid Number
✓ls; .- ; ee- � � /� :23--r--e
WELL OWNER
Name `
dry
Mailin Add res / ivate
�3Sr�o s�/� asa/ %��/�r %�1�. O Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
® BUSINESS
® INDUSTRIAL
Ir
® PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION 0 OTHER (specify,
0 INSTITUTIONAL ❑ STAND -BY
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED __ /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
UNEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY ®TEST OBSERVATION
®REPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
RILLED
®DRIVEN
®DUG
El GRAVEL
®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES A"'- NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Gn c 1/7c° Gv
Lot No. Z
WATER WELL CONTRACTOR: Name o frr! !4a• i Address: 3o iye,- %�9�•
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A"�'.NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:/t/-,,�c,3
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON REAR OF THIS APPLICATION P<N SEPARATE SHEET
(date) ig t.ure s
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 ed by the Rutnam bounty
Health Depart ent.
Date of Issue: 19
Date of Expiration: 19 � ermit. ssuin f i,ial
Permit is Non - Transferrable �� copy: H.D. Fil
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
___ Orange copy: Well Driller
\ib w
PU'1147M COUNT`_' DEPARTMENT OF HEALTH - DrTISICN OF ENVIRCNMENAL HEALTH SERVICES
MIVIDUAL WATER SUPPLY & SUBSURFACE My�... -- DISPOSAL SYSTEMS
... . ... .. .r.P'•r�...C. ... .. .. a .l• r... yr pa.. .rw.ra ... --.. n .. .. .. eR!- i.:... t... x ♦..._-.. n —.. .... rr .v,y.. ��..r.r
REVIEW SHEET - CCNSTRUCTICN PE —%14IT
00.1vo-
of Cwner) (Street Lccaticn )
CCi'vTS
YES
I NO
x
x
Ix
I
I
I�
t
A.111
A
I
I
I
LF trendy provided op
reuirad 100,1
kj C S 60 ft. Max.
Parel.lei to M=ntOurs 100% e:%m- — 0�
I
I
-Tel
11
x.
u
A-p AbobO sac.
-X�N AEI ,e S
FIA SYSTEM
c k ba. rez
10 fV
fi , tes
as
e -th gatlices
Zo
100 vr. flood elev.
200 ft. reservoir, etc. Li
150 ft- trigall /gall .
DATE REVIENED :
BY: Lt.j
DOCIRNE I'S
Perm. Application
Corporate Resoluticn
Plans - Three sets
Enginee_ -s Authorizaticn
Design Data Sheet (,DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Death
House Plans - Two sets
s/s
SIJEDFTISION
Perc
(3) Fill
ca
Well permit; P S letter
Varia ce Request
�AL
Legal Subdivision
Subdivision Acproval Checked
E;c- aoorcval SSDS Adj. Lots Checkad
Wetland (Tcwn /DEC Pernit R & D)
Data Cn DDS Plans & PeYnit Same
REQUIRED DETAILS ON PT A-NL S
SeWace Svsten Plan - (north arrow)
Sevage Syst'-n Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or ren /Gallery; Pump. pit details
Septic ank - ize, Detail
Well Detail, Sery qp- idne.. if over. ...
- c- onstj�uctior17Uctes --(;finder° "rate).
Design Data: perc and deep results
Two-Foot Contours Existing & Proposed
Drive-way & Slopes Cut
Footing Gat.; er.Curtain Drains (discharge OK)
Perc Deep Holes Locat 0+"%f ANE'
Represen runary and expansion
Expansion Area; shown; gravity flow, suff . size
If Pumved Pit & D Box Shown & Detailed
House S No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Server - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveday, Large Trees,Top of fil.
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake Unc. ern
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stornxirain,piped watercours:
10' to Water Line (pits -20')
50' inte- rmittent drainacte course
Seotic Tanks
10' from Foundation; 50' to well
I C 1 W-1 1 4- nr
UjIUu'1 UA11�1) I .1 i11111'[r . i
DIVISION OIL ENVIItCRHW- rAL REALM SUNICES
a' tE IGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
:e%.r .. '•� �Yt�.�' ii%' G'ij �'��' � �j-� — �:.j�'-�' f°'- • x'.,'1 "'`"" •...•� ,dl.'i7. _� r. !: _ -. a .:-.-
Located at . (Street) �// G Sec. Block 3 Lot
(indicate nearest cross street)
=icipaiity �y G.� �� Watershed
SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMI= WITH APPLICATIONS
Date of Pre - Soaking Date of Percolation Test
HOLE
NLZMM CLOCK
TIME ,
PERCOLATION
PERCOLATION
Run
Elapse
Depth to
Water Frcm
hater Level
No.
Time
Ground
Surface
In Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop In
Min /In Drop-
Inches
Inches
Inches
0
2-2-
7,
17
2 7' >v
3�y Y3
%/
4
5
4
5
1
2
3
4
5
NOM:
rev. 9/85
1. Tests to be. repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be submitted
for review.
2. Depth masurements to be made from top of hole.
TEST I'I'I' DNVA 'M SUIMITI'll) W1111 APPI,TCATION
DESCRIPTION OF S011Z ENODUWMED IN 'IEST HOLES
DEPTH HOLE NO. NO. HOLE NO.
21
31
41
51
71
81
.91
10,
12'
13'
14'
1NDICA-TE-*LEV'M'AT'-% k.RuuNC"A=j-- -1.13 utiii
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENIMUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used Min/1" Drop: S..D. Usable Area Provided
No. of Bedrocms Septic Tank Capacity gals.
Absorption Area Provided By L.F. x 24" width trench
Other
THIS SPACE MR USE BY HEALTH DEPAR24DN ONLY:, N W. 2489b . -`W
Soil Rate Approved
sq. ft/gal. Che&ftd-by Date
DIVISION OF' HEALTH SERVICES'
Owner -y r, A/ Ile -i Address 4.O 1,4/% acJ-.
Located at (Street) Sec Block :5 — Lot
(indicate nearest cross street)
Municipality 7 4/4' 4y' Watershed'
Date of Pre-Soaking
Date of Percolation Test
HOLE
NUMM C=
TIME
PERCOLATION
PEROOLATION,
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
75 V
2-
2 75W
4
5
2
4
5
1
2
3
5
NOTES: Te repeated at Same depth. until approximately equal so rates
e,0 percolation test hole. All data to' be submitted
..'at each
o
2. Deptimeasu "rements to be made from top of hole.
rev. 9/85
4
5
2
4
5
1
2
3
5
NOTES: Te repeated at Same depth. until approximately equal so rates
e,0 percolation test hole. All data to' be submitted
..'at each
o
2. Deptimeasu "rements to be made from top of hole.
rev. 9/85
T
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
r -per_ _sc _ -. - bJ�.ar �:cYt3Q1� • -i.rSo _x: -- fir•:`.- .:�Cxs -.. �r :�•ror -�.e s.�ll.'0I.:iG�.:lP�t1:V'-P,z� -� _ iav:�.:a ,..;s:z��tiu�- .zlllr�- •r'.,=.. ..._ . �<s.,.= ,.s-u:• r.e. aTb,..;••,+
G.L. ✓ ";< C� a / ✓%.' �' /
1' Jr
2'
3'
4°
5'
6°
71
8°
9'
10'
11°
12'
13'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED ---
DEEP HOLE OBSERVATIONS MADE BY: L // �'�` DATE: " ✓ ��
DESIGN -
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided'�"4 "'
No. of Bedrooms -3 Septic Tank Capacity / -', gals.
Absorption Area Provided By 3711c' L.F. x 24" width trench
1iC'M"m
Nam �� �/� r " Signatur
Address
on
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: �Fo
o 10 %�
Soil Rate Approved sq.ft /gal. Checked by
Type ✓ G 4 e rl'
Date