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BOX 23
02776
LA
1
y
02776
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-- iF�n -T ^n,,. � :x� a l' •Canes � . ��.•� � � ,. � .� � I
���,P�S�'�. a � �a 5,.. � Jn:t.EyD �i� � u '4'I �I-' .�� ; . •�.•: _ .- ..::�.. _ � , , ..... _ �. _ :.
-FI USE ONLY
'--,51 <W. d _el-e
SITE LOCATION.23 54( l•' / d TM #.
, 0 WNER' S NAME PHONE
MAILING ADDRESS z ::� .53 fT . /f.' 4
PERSQ,N INTERVIEWED PCHD -a�� si^�
�� PCHD Complaint #
Name Relationship (i.e., owner, tenant, etc.
DATE /0�%4lid' TYPE FACILITY
ADDRESS
INSTALLER 7- 1-3,47" PHONE_
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.
I, as owner, o)orted a nyof owner aeree to the conditions stated on this form.
SIGNATURE TITLE DATE
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 S n treet Name, Tow and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 12-50 gal. Concrete septic tank; three precast 6 diam. X6` deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved.
Inspector's Signature & Title /DAYE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
PUTNAM COUNTY DEPARTMENT OF HEALTH
ON. OYENVIRONK".
CERTI FffCATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # A 317 - ea R Z 4'7- 6 d
Located at 23 -� #-
Town or Village
Owner /Applicant Name ��c.✓�G�°` . / %`� °�'/
Tax Map G 2
Block /
Lot `Y- 3
Formerly Subdivision Name
Subd. Lot #
Mailing Address -3
Date Construction Permit Issued by PCHD A�//Y / ®a
Segairate Sewerage System built by
® 6✓° h G/'
Address
Consisting of 11„/1°10 Gallon Septic Tank and
Other Requirements:
WateK Su Ry: Public Supply From Address
01r: k,' Private Supply Drilled by �'X �� %� Address
Building. y e r %.. d K%A', ��` _ uas cres:3n vCx'2�. "mil t�ZeI'i Corii ie tcuf
_.. _.� r
Number of Bedrooms -3 Has garbage grinder been installed? �d
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: // a/ Certified by
Address 5�
� 9
Any pers occupying premises served yv the above
to secure the correction of any unsanitary conditions re' R
treatment system shall become null and void as soon as a
P.E. V4 R.A.
License #
4ptly take such action as may be necessary
i usage. Approval of the separate sewage
sewer becomes available and the approval
of the private 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 Public Health Director, such
revocation, modifi tier e a is necessary.
B.. Title: 3 Date: 4
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
PUTNAM COUNTY ]DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner or Purchaser of Building
�f
Building Constructed by
1- � 7 A4 I r�
Location - Street
% ,5�; d �
Building Type
2 / 4j'
Tax Map Block Lot
TownNillage
Subdivision Name
Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above- described property, and
that is 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 whi,;h fails to operate for a period of two - years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment 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 Public Health
Director of the Putnam County Department of Heath 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: Month 11 Day C> Year d 1
General Contractor (Owner) - Signature
Corporation Name (if corporation)
Address:
State
Zip
Title: aj_1_XA_49
Corporation Name (if corporation)
Address:
State Zip
Form OS -97
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PIt ®P® �I' F ®I�ySEWAG DISPOSAL SYS'Y'gM ][EW� s
SE ONLY
7� U60
SITE LOCATION.23 5A y* /I d TM# f -z-
OWNER'S NAME Gv�'/ i_ ;Z," .arc, /-PAC PHONE
MAILING ADDRESS Z _:;� .S &
PERSON INTERVIEWED PCHD SU `�^-+
�� PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
DATE la zeoe_02�pTYPE FACILITY
ADDRESS
INSTALLER PHONE
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.
I; as owner, or 5ported,4Xn ,of ovyTxpr agrple to thc cc.iditionz- elated on this f3tri.
SIGNA TITLE DATE
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 comers).
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.
Proposal approved
Inspector's Signature & Title
COPIES: white (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99M L
D
RM 'td. -. t
-i� T-
Iv
L, 9
`2
1
. . . . . . . . . .
A P
fum CQUMTT
orvislcm IF
MflITAL HtWM SERVTrW
ir
A P
fum CQUMTT
orvislcm IF
MflITAL HtWM SERVTrW
ir
UTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
. � , _ +_.•� x fY r..uv -r � •r..r. r.T. .e.•.-r� �. .�.N.n �. w.lin �
w•ns '�•.'�:' ;T U.u.r .....:r'r'...yr ...n,. r -. n.rM.•.:i.r _ ... �vFA.v . . -• .. w. ..
...fit'- .r. r . c:.t- K.,...w.. ._.. ..... _ .. ._.. .... _ .._
0
LETTER OF AUTHORIZATION
RE: Property of
Located at -51�fd #i
er try -r G
T/V�a 14 Tax Map # d2—
Subdivision of
Subdivision Lot # Filed Map #
Gentlemen:
This letter is to authorize
Block j Lot �9 3'
Date Filed
a duly•licensed Professional Engineer ,,,"' or Registered Architect to apply for the required
wastewater treatinent and/or water supply pelmit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater tretment and /or water supply systems in
conformity with the provisions of Article 145 and /or 147 of the Education Law the Public Health
--- _ .. . - a�cc�v;-•ci�'1u I.��
Putnam ' vui.tty SaFlaaiy L.Udc. _ ......... ,__ _. _ ,.... _.._
Very truly yours,
Countersigned: Signed:
. � NEB, .
P.E.,l ,� , # Z L/ y (owner of Property)
Mailing Address �rMailing Address: 3 aL4 'e
State Zip State Zip %
"telephone: <I,- Telephone: (0
Fonn LA -97
-;LQcat d v
a,.
Owner-
rat r
st. Ing
Other ,rd q ui
FV
B6ilclirfq�
Has Ero"sip'n Co t9l -Be - (
ceriify e s"em
attached) and in -:a66oi
,Date
n Y'�peVs6f occupy
in
conditions
resujting frprr
..available and the apprpvi
'subJeci to':,modification �
Z.-_
PEEKSKILL MEDICAL LABORATORY
.1879 Crompond Rd. Barclay Plaza Bldg. A, Apt. 1
RESULTS OF EXAMINATION OF WATER
,:2q� 75
OWNER DATE RECEIVED
CITY, VILLAGE, TOWN &/OR NAME OF SUPPLY DATE REPORTED
)�f -ae_ set -7-31- 75-
SAMPLING POINT
BACTERIA PER ML. (Agar plate count at 350C).
coLIFORM GROUP (Moat probable N6./100ml.—)
–RAI L -ppm
DETERGENTS - Ppm
NITRATES (as N) ppm
IRON# TOTAL - ppm,
FLOURIUE (F) - Mg./I.
These results indicate that the water was yell of a satisfactory sanitary quality when the sample was - collected. .
A. H. T)ADOVANI, M. T. (ASCP)
el
TOU'r OF PUTNAM VALLEY
uV ALL I;+3ILLERS LOG AND REPORT
669
WELL DOCATION mss?
street section block lot
V,1EL:L OWNER -W-
me_. address city or town
/�e- 71 ',.,/
name address city or towfL
YIELD TEST WATER 'I EVE -fir
Bailed Measure J rom 1 c
or
i rPump ec[Y-Hr s. Statin ft
L� j.`.,L, e.te. L: _leaches Yield.: 3 GPM or
L DE,11TH OF JELL - Feet
surrace
Make:
Length
Diameter
Plot
ize
`Give description of forma1-ion penetrated, such as; peat,�w
Groul urface `silt, sand, gravel, clay, hardpan, shale, sandstone;
grenite, etc. Include siza of gravel(diameter and sand
(finer medium, course), color of material, structure
(Loose, packed, cemented, soft, hard).(Ex. Oft.to 27 ft.,
f- ne,_ acked, ,yellow sai dl 27 ft to 134 ft_ gr�aY��r•anztei�
A�- ,'A.._ ��' , i:�t,; r rti,4_scr�_L,:.,tyo� - S�c:t�h e apt •-moo, a��or of
at least two permenant Landmar?pa
:uate ,- Jel.1. C;)mrl.eted. � � Date of Report
We 1 '. Driller
;,a signature
�.1
' L
Owner. or. Purchaser of building
Municipality.
e>• .r.. ....�:- .c,a_.. . .•ire • 7r �� r .- -. � :,,. a a .. `- ar. w .a. _ .. a na...., as. c_c......:. a a .errM . a ....�.., > a:.�.. �...e. .s. ..,.. .n. w. •:.•e
.Building. Constructed by Sep =t ax jA- ,LrjAp
Location"- Street Block
Building Type Lot
GUARANTY OF SEPARATE SEWAGE 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 guaranty
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 initial use of the sewage disposal system, or
any repairs made by me to such system, except where the failure to operate properly
iC C�pitCr?rl by thin toi1.1 fill, nr nacrl_i_rrrnnt mr+i- of the nnniin _nn •ft of tl-,o 'hi vi.I rlinrr 11 ti 1 4 .-7inrr
L_'C
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 wheth::r. nr -not the- •fai- ilure. of the system to _operate_.- as- -.
caused- by the willful' or negligent act 'of "the "'occupant ot. tfie-builci'ing uti1 "zing -the
s stem_
Dated this day of G 19�.j--Signature
Title _
(if corporation, give name and address
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL 'PLANS BEFORE CERTIFICATE
OF COMPLETION WILL BE ISSUED.
GUARANTOR IS.REOUIRED TO FILE NOTICE OF DATE Or-FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
Z, ,5
r 'r
'Numberr -,of Bedrooms
,?Separate. Sewerage Syste[
Y To be. ;constructed by
;Water solii y:+
Other Requirements _
7 represent that J;am whol
'above 'described will be co
County `Departrient of `:,
be submitted °to, the DeF
`},place m� good operating;
ante o f. the appioval ?of;
will.be =located`a ,,, awn of
County ,Department of H
KI
.Putnarn;
n ,and' is.
�i newnn hny cna nyv, vr auerauvn vT; consuucuon
{ Title
PUTNAM COUNTY DEPARTMENT. OF FEA_L,TTi
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO._
r I-VI-A4,11-1 d4eZ,4' Owner � ��,��� rf6' ����i�'�j�� -.i.�' Address �i`o 4�� '/r,�:.��,� �'i�,� A/- y.
...
Located at (Street c�l� y°' /�/ �7 i� . JL Block o / Lot /a�� 2.3
�indYcate nearer- cross street)
Municipalityv,J
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
apse Depth to Water a er ve
No. Time From'Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
4
4
5
1
3
5
Notes: 1) TeAts to be repeated at�same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
T _M3
_DT�I'CPIP TO1,4 OF LSOILS EYCC73T,77
;3 �L - T_� ERED TEST- HOT
DEPTH HOLE NO.
G.L.
L
61t
1211
18" A t .
2411
3011 'N P47VO'f4Wj�
3611
4211
481.1
5411
60"
EMS
7211
7811
HOLE NO. 10Y
HOLE NO.
4(
cte AVIV-0
8411
INDI WAr.r:ER TS..FNn,01Pj'mL 7.,RFD
TCATE.*jE-\7�,]T -
INDICATE LEVEL•TO WHICH WYAER LEVEL RISES AFTER BEING ENCOUNTERED
- -, T_� - 1051woe -- 7
':TESTS MADE BY 12— Date
Soil Rate Used DESIGN
JO Min/1"Drop: S.D. Usable Area Provided-
No. of Bedrooms Septic -Tank Capacity VA e3 Gals Type
x).. �,w . VLZCY��Z
Absorption Area Provided By 17 ZL F.x2411 idth trenc
LOIDE77-r- Other
S I A N1 L rE "1 3o (I
gna
Address _q
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved
ked by L Dat
1974
PUTNA11, COUNYy
0E HEALTH
ru 4
PUTNAM COUNTY DEPARTMFNT Or HEALTH
L SERVICES
DIVISION- OF ENVIRONNTFNTA I {EALTH
Date
Re :.. Property of ���.. s`�'' �= /� ,�✓ .
Located at'l5iVi /o y.: %r'
r Block Lot
.Gentlemen: .
This letter is to authorize TANLV 1. ®E
a duly licensed professional engineer or registered architect
(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
UU1111C1:L.LU11 W-LLli uil, iitdL�tel. dlu 10. SU[JLi'V.L8e Ule_ CUntilrucr:_lon OI Sala
system or .systems in conformity with -the provisions of Article 145 or
_Education Law,,.-.the Public Law an _the. ,Putnam County: San * -
. _. . , ., .. :.:. -.• • :-.
terry Code.
�ountersig d.
Very truly yours,
Signed �.2cn �z_ �_�%v-•m��- --��R_ �.
Owner of Property ;•
11144
Address
P.E., Vic:, # 5�
Address Ui J. LANUtK
BOX t`
245 -2645
Telephone
Telephone
i
y
>77m-77-�n-a.v;•=.7,7 —^,nr�c.7mrarse�a- °.r..c s�- �.^.�.%'.""'.r+xyn w^°,..••..^- ,;-ri-^c ''. ti�,.".",�'",'.i�;r Syr:..- -3,•tt .• .°-mac- - a3z�'• --s - ':�
i
soTN DT ® HEAH P[
3/86 Cdiaiie N.Y105�1a2 glneea s
.21
-1 m
s X ADIFP ®cAl c�� TEM
_.
PUTNAM COLMTY DEPARD ENT OF. HEALTH
DIVISION OF ENVIRONIMENUM _ RFAUR. SFRVI S... _..:...._._...._ .. .......... ., .. -
�l
Building Constructed by
,�'�'r✓C� %�`✓ �jo��,��ii i�� �ri cam'
Location - %%Street
Municipality
Building Type
Z2,0 4-5--
Section Block Lot
/°c/ g a
Subdivision Name
Subdivision Lot #
GUARANM 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
, `Yr� f =catE� ) ',ai.-tructior C n o "�:� ��� �- `:..._.�.. �, . .
�s to z !��B tail F?.. _.:P;a 7r�.:r%.l .+,i. 7 - systr'm-,. or-arly' ..�.
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 / % day of
General Contract Owner) - Signature
Owner or Purchaser
Building
�l
Building Constructed by
,�'�'r✓C� %�`✓ �jo��,��ii i�� �ri cam'
Location - %%Street
Municipality
Building Type
Z2,0 4-5--
Section Block Lot
/°c/ g a
Subdivision Name
Subdivision Lot #
GUARANM 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
, `Yr� f =catE� ) ',ai.-tructior C n o "�:� ��� �- `:..._.�.. �, . .
�s to z !��B tail F?.. _.:P;a 7r�.:r%.l .+,i. 7 - systr'm-,. or-arly' ..�.
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 / % day of
Address
rev. 9/85
mk
Signature .e CAW., w%,c►4-,A-
Title (��' ey-
a
Corporation Name (if Corp.)
Address
General Contract Owner) - Signature
Corporation Nam6
(if Corp.)
Address
rev. 9/85
mk
Signature .e CAW., w%,c►4-,A-
Title (��' ey-
a
Corporation Name (if Corp.)
Address
YML Environmental
Services
321 Kear Street, Yorktown Heights, NY-10598
-Z-r-d '73 inn-i
DATE REPORTED
V i4rjL&1A
SA SITENG 9 h uA,, wN. \1W � y
&A-VUL � \)aj(Q.4_j /AJY I U ��q
/Rc;,' z � a-
LAB NUMBER 32-004944
DATE/TMETAKEN
For Lab Use Only
_V15otable — HNO3 _pHLT2 _A,44�
Nonpotable — NaOH — pH GT 9 <20>4C
COLD BY STAT! HCl Na2SO3 >20C
H2SO4 ZnOAc
I
NOTESJ I ",01M':91'1Ml2jtMV) MPN P/A
X ANALYTE
RESULT UNITS
ALKALINITY
/L
VAMMONIA
n-g/L
CALCIUM
wg/l,
CHLORIDE
nng/L
COLOR
Units
CONDUCTIVITY
umhos/cm
COPPER
rr9/L
CORROSIVITY
LSI
--PBTE, T'NG--ENx-'
FLUORIDE
mg/l,
HARDNESS
mg/L
IRO
n*g/L
LEAD
n g/L
MANGANESE.
rrgx
MERCURY
rrg/L
NITRATE
n-ig/L
NITRITE
n-g/L
ODOR
TON---
X ANALYTE
pH.
PHOSPHOROUS
SILVER.
SODIUM
SULFATE
SULFIDE
SULFITE
TURBIDITY
SPC
TOTAL COLIFORM
FECAL COLIFORM
E. COLI
FECAL STREP.
RESULT UNITS
S.U.
mg/L
NTU
mg/L
per 1.0 mL
per 100 mL
per 100 mL
per 100 ml,
per 100 ML
These results indicate that the water sample [WAS] [WAS NOT] [NA] of satisfactory sanitary quality according to
znAS1
the New York State Sanitary Code, for the ararn rs tested, at the time of sample collection.
These results indicate ,that the w .. r s p! [WAS] [WAS. NOT] NA] ,f a satisfactory chemical quality according to
t
the New York State Sanitary Co re, for parameters tested, at t e bti of sample collection.
p
NA =Not Applicable N = Not Present (Negative)
SUBMITTED BY: P Present (Positive) SA = See Attachment(s)
Also done because Total Coliform was present
Albert H. Padovani, M.T. (ASCP) . TNTC = Too Numerous To Count
Director > = CT = Greater Than < = LT = Less Than
WELL COMPLETION REPORT Office Use Only
DEPARTMENT OF HEALTH
" ` °'Jjivison` iif'Giivioiiinzn� dlr TealrLc� scivYC�s • ^�
PUTNAM COUNTY DEPARTMENT OF HEALTH
BEET ADDRESS: 75WNIVILLAGLICHY TAX GRIO NUMBER:
WELL LOCATION
Q
p,
WELL OWNER�a
NAME:
RESS:
��
IVATE
li l IBLIC
o
USE OF WELL
1 - primary
2 - secondary
O RESIDENTIAL
❑ BUSINESS
❑ INDUSTRIAL
D PUBLIC SUPPLY ❑ Al /COND. /HEAT PUMP ❑ ABANDONED
❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT
i
-S gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
bN SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH a ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY
❑ WELL POINT
❑ COMPRESSED AIR PERCUSSION O DUG
❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED
❑ OPEN END CASING ❑ OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH._ ft-
MATERIALS: STEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE / X1.5 ft.
JOINTS: ❑ WELDED VHREADED O OTHER
DIAMETER in.
SEAL: O CEMENT GROUT ❑ BENTONITE THER
WEIGHT PER FOOT Ib. /it.
I DRIVE SHOE O YES QWO I LINER:OYES 0
DIAMETER (in)
'SLOT SIZE
LENGTH (11)
1 DEPTH TO SCREEN (11)
DEVELOPED?
SCREEN FIRST
_
LI ET I I ' .. - ❑ YES O NO... _.
SECONO�
GRAVEL PACK ❑ YES GRAVEL
❑ NO SIZE:
WELL YIELD TEST
I If detailed pumping
METHOD: O PUMPED
t tests were done is in-
0,1(OMPRESSED AIR
; formation attached?
O BAILED ❑ OTHER
:OYES ❑ NO
WELL DEPTH
DURATION
DRAWOOWN
YIELD
It.
hr, min.
It,
gpm.
a�
4�-
6_
WATER ❑ CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
I OF PACKR in- I
TOP
DEPTH tt- I OEPTHOM
WELL�L� LOG 11 more detailed formation descriptions or sieve analyses
are available. Dlease attach.
DEPTH FROM
SURFACE
Water
?ear-
ing
well
Oia-
meter
FORMATION DESCRIPTION
cage
it.
ft.
Land
Surface
STORAGE TANK: TYPE
CAPACITY GAI..
WELL DRILLER NAME NAME z; G OAT 3d
AOORESS ' " u 0 "% � - SltGiff=RE
P•oed„ 6 sY r��l�
1PU ll 1a AM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y. 90592
SEWAGE DOSPOSAL SYSTEM
Permit a ��/JO�
: �= Lo' ca' Ye77 'a�°'`>� {•�.'w�"- �"f���'�;�"f ..F -y�,- - ..�.... ;,�,;e,u- p,y�rro- �,tF���Hio€.a. = -.r :.-. w,.Qe " »..�.?5�.+�.'��'�
a-^
Subdivision Subd. Lot A Renewal [3 Revision _[3
Owner /Address' °� ^Al iaterOf Previous Approval
Building Type Lot Area J1, 7`3 Fill Section Only 13
Number of Bedrooms 3 Design Flow G /P /D �-` P.C. H. D. Notification Required
Separate Sewerage System to consist of /V, 8Cy Gal. Septic Tank and s t „ o de-
To be constructed by Address
Water Supply: Public Supply From
Private Supply to be drilled by
Address
Other Requirements 1'
1 represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, ru ft!
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactic
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or a
place in good operating condition any part of said sewage disposal system during the period of two (2) years nNd
ance of the approval of the Certificate of Construction Compliance of the original system or any repairs the to; it
will be located as shown on the approved plan and that said well will be installed in accordance with the stands® %k o ar
County Department of He Ith. .°
r m
Date' S' netl !_ f'J
Address ✓� ��� r'/�t -%i ` I
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued un less ..nstruction i e but
revocable for cause or may be amended or modified when c idered necessary y the ioner of Healt h. yb
requires a new permit. Approved for disposal of dome i ,y s ge, d star supply only, w�a�
Date -�T By Title
Rev. 9 -91 NJ
�e fpi{sioner of Healthwill
!d®b4�E Ider,ytfF;4 said builder will
I I)o °.dYin9.6i gate of the issu-
.he dfjll- _- __ej,;te1l described above
I regu a o ;°o Of '.� the . Putnam
, n
tl?has' 4e®n�u(idertaken and Is
,Qra &14efjYlo1h of construction
- ....... -.- -o - ...._.. -. .. ... -.. -.... .a. -. _... _. -.�_.. _.., .... .: -.a .¢. ... r._-- •-- a'°.- .- o- .v.w +�.. - ..�. -.- a -. .�.- ... .P.- ..a...., .... ---�. __w..�... �.. ..�...9. ..- ...e..�+...»
ea
J 1%
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-OLrn r^�r Qr T t T
1,� 1.--F�E E�;I�ING;:z:rARu��;.:,��.
DESIGN DATA SIFT- SEPARATE �SEWAGE DISPOSAL SYSTEM FILE NO.
Owner s ��-" /)�a // Address / ,00 �P
Located at (Street �� %s ' Sec. 3 e Block Lot
�Indicate neares- . cross .'s ree
Municipality ";P, ya t �l e Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
oe
Number CLOCK
TIME
PERCOLATION
PERCOLATION
Ran
Elapse
Depth to a
er
a er ve
No.
Time
From Ground
Surface
in Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
1 4� /e ivy � 2 .4 .2 ? -)
.4
5 - -
.1
F4
3
4 OCT 2 91,982
5 PUTNAM COUNTY
WT. OF HEALM
Notes: 31 Tests to be repeated at same depth until approximately equal soil
rates eL.e obtained at each percolation test hole. All data to be submitted
for
21 Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
E NOS i? OL1Z.-
G.L.
6
1211
18"
24"
3011
36"
4211
4811
5411
6011
6611
,721'
78"
8411
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVL RISES AFTER BEING ENCOUNTERED - .
-1; Jl*-Y-0�.,
DESIGN
Soil Rate Used ey-7-7i Min/l "Drop: S.D..Usable Area Provided e
No. of Bedrooms .."31--septic Tank Capacityl loe7 e7, Gals.. Type M4
Absorption Area Provided By =:.Y b width trench.'
Other
iName --jo,-5 h I �a V4, V tq
Addresst'72- P ae=74, i A If
zfw, K- F,16-3 -a NO t7 7",
THIS SPACE FOR USE BY HEALTH DEPMfTMEK 'ONLY:
Soil Rate Approved l-` 'Sq. Ft./Gal.i Checked by.
00
low-,
2j�
4
*'
O�*Date
i
i
l y A
- ,Q�. (ac-( n
you w
n� �r��
e�rDom r� nc� L h�us
e�foom ro nch 5 +1 U, MALLta�
I � -
I
' tt� be. US�n 4e grit.
j
�Ome� end W
CA well -
b
Etale.K
.
C � �k � Y.
c> C 105-7 5
y
{
4
i9 vat
y urn �� ✓rn.�.0 � w� eaa�
be � rr�r ALL ua�
4-01 0c)
ebeA IT)*
Ot..v- a-CAP
ffy
house- Ls t-iovae,
s�ri�L and OhZL Uje, - Vla ve- -jv
� `T1 husb�u,% �s �lorn� c
m� D) Uje cls
�SOaeN9II, -AL Ir-lel., Ux caf) (��CL Ohal-
y tel Slb
�`:ivt-4-dLi ris, go Ptexxe- S� vk
�06"tl &rkc ("✓
cg3- spy
� ���, cur
3 5
IOS9f
i
a
i
:a
70�� Of PliDg(faAf
TAX MAP NO: 0 62- 000°01 91- 045- OC C --000 :
VALLEY TAX LkTV
LOCATION: 23L30 SKYE GH RD
3RD Ph RTV
DIMENSIONS- ACRES- 1( of I
PlAYRIAS �E
: • pm 79 C= BS?
SCHOOL DiSTRICT. ��a�D� .'
IN j
0 ~
' 11117g5/95
PROPERTY CLASS: '2100
LEVY DESMPT$ON T.AXA.SLE:'JA_UE
TAX RATE
TAX A"OVNT
e
(;Uuw -MAN LOU itzozo:;lovu
0 !
TUN OF (PtflNAH VALLEY 22g00 � 71o5380'00
1581o1)t I
' 325-036
IPUT VAL FXRE PROT 22270
6004&1t ®L°
I331ob3 j
06 � ®O30�000�am�5�o� 0 o ��
� i I
TOTAL
°
OWNERS CltOAP94AN CHAS F.
RUTH
's! HALF TAX
2nd F3ALF TAX
NAME 1EIICt(LEFt ROBIN CHAPJAA94
8 TAX COLLECTOR
V:4 OF PUTNAM VI",IL:Y
�
$ 22 5t��7�1H 0 RD
� t,
ADDRESS PUN API VALLEY Rid!
105 79
,
i
KEEP TH9S STUB FOR:`YOUR RECORDS.
,I
i
ICJ X.L I.L uA -V A X—N. Ak
I GENEVA ROAD
BREWSTER, INTEW YORK 10509
Phone: 1-84:5-278-6130.
Fax: 1-845-278-7921
FAX COVER SHEET
ze FAX NUMBER TRANSMITTED TO: 2
To: /5'1'
Of.
From:
Date:
I DOCUMENTS I NUMBER OF PAGES* I
01
COMMENTS:
al4ec
7
w
2-00 Mr
* NOT COUNTING COVER SHEET. IF YOU DO NOT RECEIVE ALL PAGES, PLEASE TELEPHONE US
IMMEDIATELY AT 845-278-6130
IV
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