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631 - 589 -8100
63. -4 -16
BOX 25
03128 .
q`-j-
q
Rev.; 3/8
4
Located
Owner /applicant Name
Mailing Address
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y.40512
Engineer Mast Provide
P.C.H.D. Permit #
. 63,
1 CLZMTIJ!NCE:FOR SEa
�Jar /�
V h[ `� /�c/I • Former!;
i G.W at;,J 4r-e-
-
re _
4,— tc
kGR DISPOSAL SYSTEM
_71p
Separate Sewerage System built by �
4✓/7`'ll' �
Consisting of a s Gallon Septic Tank and
r.
+Ta: MapBlocke Lot'f
Snbdivf b iaton r✓Nnme Scabd,. Lot #
Date Permit Issued Fa
24 "w,Je
Water Supply: Public Supply From Address
or: -,"Private Supply Drilled by Al J2'4 2te" -S y9 Address _ "o
Banding Type d•Olide Has Erosion Control Been Completed?
Number of Bedrooms oi Has Garbage Grinder Been Installed? d
Other Requirements
I certify that the system(s) as listed serving the above premises were cone tp®ferb as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and raga a with the filed plan, and the permit issued by the
Putnam County Department of Health. Q r I
� P.** Oats artifled by P.E. R.A.
Address G� i✓lJ }- :a:�; °� License No.
L2
� .11.'i:a.;. '1 �•1
m
Any person occupying premises served by th above system(s) shall promptly t v_ necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage cyst ably@ find void as soon as a pub(;: sanitary sewer becomes
available and the approval of the private water supply shall become null and vo g� 4� '�l�I _watsr supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the Commissioner east ,3urth`revocation, modification or change Is necessary.
Date ,
WELL COMPLETION REPORT Office Use Only
i_)EF R1 ?WN 1 - l0' i Iix Fii�i;l
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH' �� 7
5 AO ESS: WNIVIL ily TAX GRID NUMBER:
WELL LOCATION )/-7r
ADORES
WELL OWNER S
PUBLIC
USE OF WELL
r�OESIDENTIAL
❑ PUBLIC SUPPLY O A COND. /HEAT PUMP
O ABANDONED
1- primary
❑ BUSINESS
❑ FARM ❑ TEST / OBSERVATION
❑ OTHER (specify)
2 - secondary
p INDUSTRIAL
O INSTITUTIONAL ❑ STAND -BY
p
MOUNT OF USE
YIELD SOUGHT
gp m. /N0. PEOPL'E SERVED / EST.
�
OF DAILY USAGE �% gal.
REASON FOR
X NEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O TEST /OBSERVATION
DRILLING
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH
as' ft.
STATIC WATER LEVEL
ATE MEASURED
DRILLING
g-BOTARY
O COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT
❑ WELL POINT
❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
CASING
DETAILS
SCREEN
❑ SCREENED O OPEN END CASING. XOPEN HOLE IN BEDROCK 'O OTHER
TOTAL LENGTH
LENGTH .BELOW GRADE
DIAMETER
,WEIGHT PER..FOOT_ ... -.
—� DIAMETER (i_ j I
DETAILS FIRST
SECOND
GRAVEL PACK O YES GRAVEL
O NO SIZE
WELL YIELD TEST
If detailed pumping
M HOD: O PUMPED
t tests were done is in-
COMPRESSED AIR
; formation attached?
BAILED O OTHER
; O YES O NO
WELL DEPTH
DURATION
DRAWOOWN
YIELD
It.
hr. min.
IL
gpm.
.2
Bear-
met er
FORMATION DESCRIPTION
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
PUMP WFORMATIGH
TYPE N aAPACITY
fL MATERIALS: ,STEEL 01 PLASTIC O OTHER
�9 tt. JOINTS: O WELDED .9THREADED O OTHER
in. SEAL: ❑ CEMENT GROUT O BENTONITE 90THER
DRIVE SHO' ES ONO I ' LINER:OYES UNO
'SLOT SIZE LENGTH (If) DEFT -H -I'0 SCREEN (It) t DEVELOPED?
O YES ONO
i HOURS
of I 91<
STORAGE TANK: TYPE
CAPACITY
WELL DRIljp NAME
G
co Z, > a
strfntnmc c
DIAMETER
TOP
BOTTOM
OF PACK in.
DEPTH tt
OEM It.
I
It more detailed formation descriptions or sieve analyses
WELL LOG
are available, please attach.
DEPTH FROh1
Water
well
SURFACE
Bear-
met er
FORMATION DESCRIPTION
CUE
ing
In
Land
Surface
of I 91<
STORAGE TANK: TYPE
CAPACITY
WELL DRIljp NAME
G
co Z, > a
strfntnmc c
LAB # 32..o`3205.3 1��7✓ Y
Yorktown Medical. Laboratory, Inc.
321 Kear Street Date Taken: 2 -14 -90 _ Time 11AM
Yorktown Heights, N. Y. 10598 Date Rc' d : 2-14-90 Time: 11 .20AV
Date' Rpp�rt_od lx94
_ .� -. ". _....; , •a: _--_ _ ° � ::;: ; "s�i _'� _= �� ir=_.. �.._ ..:........Y -F....- . w �-, �;- � -� _ e c t e d �y y - -, � -...,: .
iol 1. Balei.von
Director: Albert H. Padovani i"L T. (ASCP) PO /Client #
F_ , Referred By:. 3 s' - �'23•
Sampling Site: Ta • .3, Ric -ard
Florentino Baleivon Orivl, Putnam Vly, BY
631 Highland Ave
Peekskill, NY 10566 Phone ( )._739 -28'77
L J
REPORT ON THE QUALITY OF WATER
INORGANICS (mg/L MICROBIOLOGICAL 100mL
Alkalinity
Chloride
Copper
— Detergents, MBAS
_ Hardness, Calcium
Hardness, Total
_ Iron
Lead
Manganese
Mercury
_ Nitrogen, Ammonia
_ Nitrogen, Nitrate
_ Nitrogen, Nitrite
Phosphate, Total
Silver
�. Sodium
Sulfate -
Sulfide
— Sulfite
Zinc
PHYSICAL /MISCELLANEOUS
PH (S.U.)
_ Color.(Units)
Conductance (uhms /c)
_ Odor (TON)
Turbidity (NTU)
Standard Plate Count
(CFU /1 mL)
Membrane Filtration Method
Total Coliform 1
Fecal Coliform
Fecal Streptococcus
Most Probable Number Method
Total Coliform
Fecal Coliform
Fecal Streptococcus
Presence /Absense (PA
Total Coliform P A
i
KEY FOR TERMINOLOGY
CFt = Colony Forming Units
LTI = Less Than
GT = = Greater Than
NA = Not Applicable
SA = See Attached
TNTC = Too Numerous To Count
REMARKS COMMENTS For Lab Use
(For Lab Use).
SAMPLE TYPE:
(Check One)
Potable
_ Non- potable
OUTGOING:
(Check Each)
HNO
HC13
— H2SO4
NaOH
ZnOAc
_ Na2S203
Other:
INCOMING:
(Check Each)
40C
4 /LE 200C
GT 200C
_pHLE2
_ pH GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS) (WAS NOT) (NA) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THB,.MW YORK STATE PUBLIC.DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE.TIME OF SAMPLE COLLECTION.' -
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) (NA MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE C DRINK-
ING WATER CODES, FO)Z-�THWARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
7 /87(Rvsd1 /90)RWE
-P
PLT 14AM COUNTY DEPARTMENT OF HEALTH
DIVT.SICii OF SAL HEALTH- SERVJCF -q
Owner or Purchaser of Buildin Section Block Lot
Building Constructed by
Location - Street
Municipality
i
Building Type
°C9 V'-' ®O / ac raj
Subdivision Name
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
!'f i ; a i r�_rf (�n,,�ct i i i �ln C'C�Ttl1CS [.l nri� " -Thy' the. si - waT -r- •iis.nnSaI SvS`Ert :;r any
E'_t._ It >_ - - - - - - -
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 S
�X'Title
imr�alContractor (Owner) - Signature
" cvr
Corporation Name (if Corp.)
'/w •
Address
rev. 9/85
mk
Corporation Name (if Corp.)
Address
: ,PDTNAM COIINTY DEPARIMI NP OF HEALTH
<��� Dlylelon Pvhoomental Health Servlon Carmel. N:Y lOSl? ermtt M .
`Einglneei'to Pr"oyWo P'
. oa CEBI'IFICATE OF LIANCE
CONSTEIIC140N F0 SEWAGE DISPOSAL SYSTEM Peamlt :N S' g
b _ .,lX , .....t'V.�.r.Nif•! /�.-rl..f+.' Y...w .:��._.'.:._.Y. 4 .��St --J �' � �i� c'i�.ta - M'S�. s .
- Sawmdon N*li . cs% l%i�✓i" cubd. Lot Y - 3 s f ebac
Tar Map �` Lot
r, Owner /App"! 1 am _ /1��i aJ to J;�G �,h ��'J . aenewal ❑ Aevlslon s _
Date of Prevloae Approval
Mfg Address g Town tip
g TM :Lot Ares s� -/O p7C
Fi11.;Sectlon OdY Deptb: `Volume . ;
Number of Bedroom— Deslgn Flow G P D D d PCHDNotlBcatlorilsRegaleed,Wti" `Filhla,completed
Sewe S stem to cautilet of ?3 U Gaon Septk Tattil' °a
Sopantte . Y O �..
A. .
TO 66
oonateacted by ' '
r Addeeae
L Water Sappb:Ilc Sapply'Fmm Address
(` on Prlvafe Supply DMed by sddrese
•
Other ReQairementa
-.
I represent that !,a7! wholly :,arid completely responsible for,the design! -and location of the pro 1p tMt tha: separate sewage ,dis oral system j
Is above. described ,;411 be; "constructed as shown on, the approved amendment there :to and .in ac, a trt rtls rules an .regulation, o e u n m
..'
ok
County.,; .Department .oi NeNth: and that on_,complet�on tliereot a Certificate ° ° ?of Constr e:.' �tory,to tea Commissioner of Nealthwill
f� be submitted, to the Department; and: a written. guarantee .will D'e,`furnished the own hissyt W 0� p s tiy.the DuilAer, that said tiuilder`wlll
place in
good .operating condition any, part of faitl sewage disDOsal, system ;tlurrnq a -two (2) Im lately follovyinp.thedale of the isau
an be of the approval' of the ,Certificate of Construction,,.COmpliance of +the,or inal
t ._ Itst 'ariy s t o 2 hat' hs dr well desalbed above 4
will be located as rh'own on4ths s?pproved plan anp,that said well will be_;inst611ed, in c rda it st nd ijf rule t angt regu a IT o- ns {o the ;Putnam . 1
County` Oe rtman- ' f = Mealth t o
✓/ .�� ,�
Date
E Synetl v s'' P R A.
J—
'`t^"
t� AAdress License No y V
t pP builtlinq has b
S` APPROVED FOR CONSTRUCTION Th `. a royal expires two om the a issu vR#n ens cori3t� ;oxP b he een, undertaken and, ;is
jF t revocable for cause or may b!,I mentletl or moddied.whan`'co dared n essary ;by th o ` isf�`n8r [aPl�althr�mitny cherpe or- ,i'6wition`of construction
f requires a new lermit:RADProvsd for disPOSaI oiaome c fa a swage, and ' r ivat $teH
RiV �z�� i)�� /� Raaabnxcpar GO
P its
z gy
l4Y .
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
A�._;:�,.:._.... -= APPLICATION TO�CONSTRUCT A WATER WELL •' "• � -� ;,� �r. +,%'�/��
PCHD PERMIT
WELL LOCATION
Street Address Town /Village Cit Tax Grid Number
WELL OWNER
Name Mail ' ng Address r f/�1l� // �Wrivate
n� O Public
USE OY WELL
1 - primary
2- secondary
G ESIDENTIAL
0 BUSINESS
13 INDUSTRIAL
0 PUBLIC SUPPLY Q AIR /COND /HEAT PUMP 0 ABANDONED
0 FARM "0 TEST /OBSERVATION 0 OTHER (specify
0 INSTITUTIONAL O STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT
S-" gpm /# PEOPLE SERVED G /EST. OF DAILY USAGE ZrO gal
REASON FOR
DRILLING
M&W SUPPLY O PROVIDE ADDITIONAL SUPPLY ® TEST /OBSERVATION
OREPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
®DRIVEN ®DUG ®GRAVEL ®OTHER
IS WELL SITE SUBJECT;TO FLOODING? YES 1✓' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 0 v S 4,10,9c% 67,gler—i
Lot No. 7�
WATER WELL CONTRACTOR: Name Al. Address: off2
r
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES ,/ NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON REAR OF THIS APPLICATION O
/c N SEPARATE SHEET
��
( ate )(
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 pr d by the Putnam County
Health Department.
Date of Issue: 19' P�ai )29�e_lw
Date of Expiration: /_2-22-1 19 ermit s.suing Official
_
White copy: H.D. File
Permit is Non - Transferrable Yellow copy. Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
AFFIDAVIT - CORPORATE OWNER APPLICATION
...,^:,.,. �-::. �. y:. i:: pi..: c:: z::. �.. r.+'::�..�u:;.a`.`.n..:.,�...., :er,'s'"...:.:3- :.:.;:v.:. o:. - . a" e.s: i. -+ �n:.:. c',.;. �, r. ��o�-. n. �a:: c:: e: y_.. ow:. �s�a:: ,•...:;..�:,we- :n: ;.:.u.:•:n:: �....,:»:°.:...:Ca"i�;•
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
i
,1
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 /OG(�4Q i I c/i L010+/ C �OR"::�p
(Name of Corporation)
having offices at
Whose officers are:
President:
Vice - President:
Name and Address
P . /ao kfk"
/ID .4
t/
(Name and Address
Secretary:
:..._ : _.. • ::.. ..... (Name and Address.) _.
Treasurer:
(Name and Address
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts relating
thereto. -
Sworn to before me this day Signed:
of 19 7 Title: P,ipJd��XP..
Notary Publi
CATHY BALCH
Notary Public, State of New York
Qlfd. Orange County #4636912
Commission Expires 1- 31 _9.8
8/84
1
II.
IV.
V.
vi.
- .�: a - - - _ - ._:�.. =:�•a:.<.�.�: -.v =sue::: � -:- �- z��.,� -��.,_ �.�. =:..r�.,
a. SDS area located as r anorove3 Plans
FINAL SITE -12\ 'iCN
--z - --
b. Fill section - Date of placement�
2:1 barrier- I=- W-= r"I AVG.DPTH
Inspect_.
i�y
STF=- ICc�TION i L (
I
C�v -� <�"
o
rA
PITM-MST a N �`" ��'
TM a
OR. SuEDMSICN LOT
1. SEWAGE DISPOSAL ARFA
9
b. SA._.ntic tank insta_lSed level
I )
II.
IV.
V.
vi.
- .�: a - - - _ - ._:�.. =:�•a:.<.�.�: -.v =sue::: � -:- �- z��.,� -��.,_ �.�. =:..r�.,
a. SDS area located as r anorove3 Plans
:. ;�.:.;;� �_..._ -
--z - --
b. Fill section - Date of placement�
2:1 barrier- I=- W-= r"I AVG.DPTH
c. Natural soil not st-riv3
I
I
d. Stone, brush, etc-, greater than 151 fran SDS arm.
I
e. 100 ft. from water course/wetl
5�-Ma..GE DISPOSAL SYSTEM (-
a. Sentic tank size - 1,000 1,250
b. SA._.ntic tank insta_lSed level
I )
I
c. 10' mi _n in= fran four an
d. No 90° bends, cleenout within 10 ft. of 45° bend
I cl (
I
e. DIS=Tj-TION BOX
1. All outlets at salre e? eVati on - water tested
2. Protect--d below frost
3. bll nim= 2 ft cric?na_I soil. L- -_rie=-ri box and trsnches
( I
f. JUNCTION BOX - properly set
g- TRENCHES
S !,
1. Len remixed - y D(� Z 2*i `r1 ills to � ed 90 U
2. Distance to wate_rc�ur se RL�3S 'L'" =S : ft.
3. Instal -Ted ac —rd nq to plan -
I
4. Distance cen^� to ce_rit_r
5. Slorz of trench ac _stable 1/16 - 1/32 " /foot.
I I
6. 10 feet from -Drcoa ;v line - 20 feet - four.:aticns
ixcl
I 1
7. Demth of t_e-nch < 30 inches fran m=zace
8. Roan allowed for ex=a -s-ion, ,Of
9. Size of Q_ravel 3/4 - 1i" diameter
I
10. Depth of cm vel i*1 trench 12" minim=
L. • Pire ends cavoed
h PDT OR p2 E SY.S'L S LL . -. - - -
-. _` •1e .51LE'Ul L.7l:�iL:1 i=1c i�r- f"___•�,,,_ s. .- ..- ..�..� -_..q� __..__ �. _.
2. Oti Ter=1Gw tank
I
3. Alarm,
-
4 Pump easy i v accessible ranhole to =rde I
5. First box baffled
I I
6. Cyc1e witnessed by Health Dera_' uu --,lt
estimated flow per c c-1 e I
I
-2
a. Eduse located ver c.Dnrcved plans.
b. NLmL -.s of bearoars
PELT
a. Well lccate3 as re-- a-- mroved plans
b. Distance free SDS area sF--sured jLr,) T ft.
�
C. Casing 18" above grade.
r I
d. Surface d_ra i nace around we? 1 accen able.
0V-�.AIL W(DR�.c-IP
a. Boxes Droperly grouted
I
b. Ail pines martially hec f-Med
c. ALI pipes flush with inside of box
�
d. Backf ill, material contains stones < 4" in diameter
e. 0=tain drain install-3 according to plan
i I
f. Curtain drain cut`all protected t dir. to ex-,:st.water-= rs�
g. Footinq drains discharue au-ay Fran SDS area
I I
h. Surface water r)rot --ticn adequate
i. E_�osion ccn`o Drovida' on sloces areater than 15 %.
1,.
PUTNAM COUNTY DEPARTMENT OF
DIVISION OF ENVIPaZENTAL HEALTH SERVICES
ti"�- S i�rs L^.. E ''+D ^ �' , DIS n^ ;�,J%S'.�... __..... • .:'%'I�`J' i " "iw`!: • _ . . _.... .
^i.: ►� t� .F 3 �..^..r41 ^�4s ` � ....a•- ,- .r._... tip.. s ..R• ..r,,.,t,,. riw.a.a.u.v...:.. ..:r.rt.. :�•.w.�.: is
Owner 13a /c:- (j',^ C/ rr e� �/L % Address d >' , J / dc1 I'c'. �"� 1✓J�J�
Located at (Street) 1 G G,i� i d� Sec. 3-5�' Block 40-' Lot.; f)v • /
(indicate nearest cross street)
Municipality L�' Watershed
• • •2AWA• • • •• v
UIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking
Date of Percolation Test _ lS
HOLE
NUMBER CLOCK TIME
PERCOLATION
PERCOLATION
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
2,�Z:Z
3) 32-- /Y1
4
5
5
1
2
3
4
5
NOTES: 1.
2.
rev. 9/85
Tests to be repeated
are obtained at each
for review.
Depth measurements to
at same depth until approximately equal soil rates
percolation test hole. All data to'be submitted
be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
a KE
G. L.
lc
21
31
41
51
61
71
89
go
.10,
ill
12'
13'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED e
INDICATE LEVEL To WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: 2a,7-j- JJj-1W DATE:
DESIGN
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity gals. Type ��o
Absorption Area Provided By L.F. x 24" width trench
Other
Name
Address
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
01. -fit
Ft
Soil Rate Approved sq.ft/gal. Checked by Date
L� -Voz=