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Home My WebLink About3129DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 63. -4 -17 BOX 25 ,iron I 11.11, E9 1% N96 L. k' :I �T I ,` poi L ikf J, ALL 03129 ev. 3y86 PUTNAM COUNTY DEPARTMENT OF HEALTH Dlvlaloaip[ Environmental Health Se vlccre,'Carmel, N.Y 10512, Engineer Maet Provide ~ P C H D Peimlt N 6 ;I "ted ad Owner /sppllcaut Name • Ma,Rtag- Address: ' 6- ( RUCTION ,COMP.LiAN.CE.I!OR- SIR.YtlG,E DISPOSAL AGO —'r-all Zlp�� ' _ Tai' Map Block ` Lot. S qc� . abdlvtsiosi Name Sgbdv. Lot*- Date Permit issued • Soparote Sewerage System built by � o'✓; /J' 1'i/^ , . ` . . ' Address' � ;'. .. Consisting of 'gym �U Gallon Septle'Tank aid L Water Supply: .: Public Supply yrbm Address I ort, Ptivate Supply Dialed by_/Jv1�So �9 . Addresses fildirl . ' G j ��/ .. Hes`Eroslon Control Been CompletW - BaUdlu' Type. - :. Number d' Bedrooms Hue Garb e'Grluder. Been InstalledY ;:. Other Requirements I eertity that tAe system(s)'as l sted'serving the_ above pr"m s,were'constructed- essentially as' o ails the completed work ( copies of wAieIt'are attached):,, and, in accordance with the atandarda, Hiles and iegul in, ac ord i lan and the'permit.issued by the hutnidi'County 'pepaitmenE Or 'Health... i Oita �� -' C Hied t►y V P.E. R.A. Address, la nn No. Any person.occupying pi4misesaerved by ,t above system($) shall.'prompfly take suchactbnas •sa►," he correction of any unsanitary condltioro from such . usage.. Approval •of the separate sewerage system shall become n n a. pubti: sanitary, sewer. becomes "Such, a►esulting a.V Is.ble and the approval .of the private water supply shall become null and,iold when a Dubtic w available. approvals are sutyect to iI" iutfon'or enange. when; in'the ludgri�en' t- oR •the''Commissl one cApf °Nealtli; sueh rwo 2 n; lion or change, Is necessary. T It lwc=:2� Cat B . m _' «'y'•$� Jkf., ��/ i. f x ' ..l5.ii�} f�`!G •f. =:i..l . _., b.:p h�..� ,Yn � � U f F 7 Ra LINTY DEPARTMENT OHF,ALTf3 ?x ur+ ' ; r 2a Q 9 f f3G l 7 u PTJTNAM CO. k5t�ia ""'i :-` ^. 55,E s F� WNI -mss. � r�'u�- (1'x 1 v r'}� "}�x'T/� Y�° .:w'."i, f' `h•' -`5 �C .�' .y ��-�>� �- Vn�O i1V�r18Ei�3fi ^�`��J :k"ia`'..•,r� `"+3 inn�d' V �... i r cff, d,%r!". �'i��i.':,,Pj' 'l 6�' -" a I t vt',t�'k y1'"`Y - 154=,, -.+' " "✓,', Uw _ 1�ELL OWNER .•t' Aoo ,la PBIVA ?E wsI■+. 3 `u+� d r r j L%; p �• 1 ..c✓ E. ,.n�r�`1:�YY t,�I �s�/� Y, /' �'E •Yt f� 1 C r� YrF fi. ❑ PUULIC x : �: , :., •.. . y USE F_ YJELL ,. u.:kr x A'�O a c.rM`�t-m` r Fr• i-!; r+. y, .t3 r F� y r r- 1 d4 v{ Q- ES(DENtlal� D PUBLIC SUPPLY ®AIRICONO (HEAT PUM D a6ANO0(VED� Yti� j1 i t O :BUStfVESS u5F' O FARM ®TESTlOBSERVATION O OTHER (specify) :_�.r ti =�r primary'f -2 'd ° w. � INOUSTAIAL 0 INSTITUTIONAL O STANO 8Y .r ,�.. :... x�c' 't•+}'R -JTrS .35+ Y'"" ;y .�-4 ;t Cc ,� r=. �• ' r,.s tag.s"�., ,+ s � Y FY �.xuv � `;� NfOUNT OF US ,¢ _ .�c . -. . C .�y a•L• -thew ? - t rt x YIELD SOUGHTy gpm !NO PEOPLE SERVED /EST OF OAILY USAGE gal t �. 4;AEASON�FUR y�REPLACE ERISTING SUPPLY it ®TEST /OBSERVATIONV h r[� ADDITIONAL SUPPLE 1 c�� e ; Y ®KILLING f k; ti r r EE - 5 f I?w s1JPPLX DWELLING) D PEN ERISTING tNEW �RL« F4 - _ DEPTH DATA ' �. -Y 7' L= tl c4 v5 yyy�ixY* '� � J -` ,�i' � Y:,- f� y �Y� 3{ %�a. Aa •; � � i YS:. .. r i /i� WELL DEPTH it STATIC WATER LEVEL �� 'ft DATE MEASURED'�r rT -; DRILLING« Cc�- R07ARY z �,0 COMPEESSEQ AIR PERCUSSION t ®DUG ;` EQUlPi1nENT D wELt POINT O 'CABLE PERCUSSION `< D:OTHER (specify). R.� . ti SWELL TYPE 'SCREENED z ®-OPEN END CASING D OPEAI HOLE IN BEDROCK O OTHER ' TOTAL LE MA TERIALS n Cd -STEEL r4D PLASTIC Cl OTHc'R �J � ; � � ti:�� ,.r , �, t�• :,. - - r LENGTH BELOW GRADE fi JOINTS ;0 WELDED [tZ)- THREADED D OTHER CASING 's'� — , DIAMETER SEAL'rCEMEN7 GROUT D BEN70NITE `❑07HER ;� QETAILS F WEIGHT ifi h� I- i DRIV SHOE D YES ® b UIVEA OYES �N0 . PER FOOT b f�. C , Y ;r =y ,� ,.V`}:a 1 +:. 01AMETER (in} LOT aN u LENGTH DEP7}i TO SCREEN (ft) " . :SCREEN °, .WE y'i kpEYELOPED7 z` FIRST .3. t y- .:7tuF iJ.( -'iT '+.� c"t4 u .. 4 �iC g x c a A '� 7 Mir;, M h 7. i ±. p YES ON0 t, nETAtLc r' s- r `_ o4 �k+n � -. iz } h ; EOS � . •fit Y.3..t�fi �n�. , t e 3 M 'r� � t p -.. t, '=� xP� 4 n} J t as t `:*rti�y, GRAVE � ,, GRAVEL DIAMETER TOP BOTiO h t :, r f + " ` O❑r}YN., S,, I.Z5 E a >;s O�F ACK i n, DEPTH At DEPTH h .r a K L f K i L. k-.Nr.3v_.1 c ? r a8.s� ii � �3 ,!K t - m" y . s , w ' k:: ,- r <,fF: 1�ELL YIELD�TEST d if detailed pumping' + mbre deta►led formation desert bons or sieve anal ses s p �I�LL -LOG =� Yy METH00 O PUMPED 1 tests were done is are•available'ptease ttkh DEPTH FROM ry sUAFACE eea�`, Well oia eft. _ .. r nr •....�• to ®.COMPRESSED AIR ;formation attached a1 BAILED 0 OTHER YES C] NO �n9 :; meter yf� f a; .;.FOartanoN,oESCAtPTwN ': sw, i 4 33 :s S :.:. -. .a O „� n, r. <.� d .... <..... ...:. .. .. .. W::..:..� .. �:.� • ... ... >.}'S Y,.y..v%t~'c..v mil 5 , rk -�.. .. riffs In:c tiy� ?t nt mayt pug •? r: t a• st tv rr... v- .went., f fC,si`t -....T .. �': o-l^F•J... _•A�,.. .'�t:.. ?` •L't WEII oEPTH ' oURATION ORANlOOWN > ti ' •: dYIELD �. Land Surface - t'J.- 7>p �, .A' a� r t.� u.. 4 }. s� C y 3 NJR1M�>:i•a .r t1 - _3'.y -•�' It t Ar Tim is is Iv r A n f v i, I ,f WATER ....0 CLEAR ° T MP. QUALITY '0 CLOUDY HARDNESS O COLORED ANALYZED? O YES O NO STORAGE 'TANSR : TYPE ire I I ! �� /� 0 ANALYSIS ATTACHED ?OYES O NO PULP INFORMATION CAPACITY GATO. TYPE � "^t t : h CAPACITY / r E IL r WELL DRILLER NAME OATS nc I lr, 7 MAKER �'1' f! l DEPTH AD ttTU r '- MODEL VOLTAGE HP P� A�',�<<z y . A /a,, <<, Apt ! OTII► YML ENVIRONMENTAL SERVICES 321 Kear gtreet Yorktown Hei -qhts, N.Y. 10598 (9 14) 245 -2800 Albert H. P3dovani, Director (/ .w•v .,..•�*- w...uaa.....4......, w- .n.'Ya:..w.'•-�st•u+c7 s•••o•.�ss saam.r -een- rz ..... ..- ...- ,...« Sq+•.�sv <►.�sc.+m.r�iis+. u. iir ...- ::.�::.:`a.:�:p+"e�I-w�Rj 4+:o:- .renisi+u o.m..iv:r. oai�:•.+.••w :.. LAB #: 32. 04006 CLIENT #: 1409 CAMI OF WESTCHESTER 631 HOLLYWOOD AVE 'PEEKSK I LL , NY `105/-.6 :SAMPLING ITE: RICHARD DR PUTNAM VALLEY,. NY COLD BY: L. BALIWOR NOTES. DATE AND TIME TAKEN NOT GIVEN DATE FLAG PROCEDURE 06/14/93 MF T. COLIFORM NON STAT PROC PAGE 1 DATE /TIME TAKEN: DATE /TIME RECD: 06 /07/93 15:15 REPORT DATE:• 06/23/93 PHONE: (914)- 739 -877 RESULT ABSENT /100 ML SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF NORMAL — RANGE ABSENT COMMENTS:. BACT THEE RESULTS INDICATE THAT THE WATER (WAS (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING O THE NEW YORr; STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. SUBMITTED BY :---- - - - - -- ------------------ Albert H. Pa.dovani, M.T.(ASCP) Director• ELAP# 10323 PUIMM COiAJl Y DEPAR'IIMW OF HEALTH DIVISION OF ENtT1R0I ]dt!AL HEALTH SERVICES .csao.:reen.,..e aem. an.:..�- .. �- KF.. .- ..:...cso.�.+m -..:.. _ . =- 1a..•.'..l:JcSv:.a.,' ' .... O6iR3er or Purchaser of . Wilding Section Block Lot r, .ding Constructed 'by %tion - Street _ciaality. Subdivision Name Subdivision Lot # GUARANTEE OF SUBSURFACE SHOM 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 "Certificate of Construction Compliance" for the sewage disposal system, or any !e 1 sk�th:.pyste-' :excgnt why . _ e_ � ire tc� .ape Vie: n oPe - caused by the. willful or negligent act of the occupant of the building utilizing to . 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 thi,s ys . Dated this of�® 19 ° Signature General Contractor (owner) ® Signature Corporation Nam (if Corp.) revm 9/�5 Mk Title Corporation Name (if rp.) Address /l PVll WCOUIfffNWAlifBtlflOFRBAIM gkmm d avkollmsom Bwm Swdesd. ON" N.T. ton � r PweW lbsll / \� w CiiQiCA73 OF CONNUANCE Paper PO�:DIYA� OIRO/aL >iY [ - puma I R y 2 4 yaw 9"dd. N..e ba�r/�ej� C�c��j SWIM JW / `�-/� Tax M" d 3 . y Efth OwwedAP�eswt l6sens c�ieg/ iii re�I� Utz: �lij � 4 C� r,� • R�.eai_ o Z.rw.� j j j Dale d Pttivlaws Affeeval r+ps Adios 6 % i' G� <ay s� Town i'�li/fs �' . ZIP Date Subdivision/ AnRroved Fee Enclosed ❑ Amn,tnr Yft lat Am ` / F® Sud w 0* Depth v.l... wombw Dealp Flow G P D 6 I PCHD NWBradm Is Res iwl Wiese M Is esw~ :..saw sowmy b em" of 1M"/9 f• -- sqaTwd, er To b' easbwebd by OW., 07 �/' Addlou wow llarb: w+aw gib F�rssu Addreah an i to a..a. SwmPb OgL%d h, AV on Adaow e- O�ss Rd�dentaM 1 no►seent that 1 am wholly and completely responsible for the design and location of the proposed system(pi 1) that the w else ww d1 wl s * n above described will be constructed as ~non the approved amendment there to and in accordance with the standseft ruNS a regu ns or COWKY Dessommelt of "nab. and that on completion.thereef a "Certificeb of Construction Compliance" satisfactory to the Commissioner of Maalthwlll M wbma" to the Osportownt. and a written paantee win be furnished the owner his sucassors. hairs or assigns by the builder. tent am bup er well place in pod .dpwating ooddRlon .any port of SM sewage sn is , —I system durkg the period of two jaujours Immediately following the date of the how sap of ten fee it M the Cortifteato of Construction Compliance of the Original system or an 12) that ten drilled well doucrNed allone even be MoatM as dneens on Ma approved pan and that said well will be Installed wit and regrTi oli s s of ten Putnam County OMortmMtt at "URIL Oste /// / Signed F.E._�f PA. / Lim Gl Lkeme NI_�7 �T S APPROVED FOR CONSTRUCTIONt N approval expires two Well the date Issued u IF t ildlq has born undertaken and is resoeMN for cause a. y be amen a medHlod when cen ne t�4 by ten Comm} Shan" or alteration of construction row1►M anew pen ill. Appvetted for disposal of domeAk tar artd/er Rev.. Gl j pate oy at •' TRta .T, DEPARTMENT OF.HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 a�d-a+G c;.w a:; rvji.. �,..= ..ra.:: _. _... _ .- ._._.. �._��:ws+r.`"..a- ++c•. .aoa. � ' vc :;:_..- .�- .-= c-..s..':.as7- ®+O ¢wo.:rzs+cz ^e.�. ".'""...._... : -�.e7 c APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT 0 �v Z 1441 %,%, LOCATION Street Address Town Village City . Tax Grid Number WELL OWNER Name leol--e Mailing Address ;,1e4 z2'92- rivate � fi�� ar4A��i1l% OPublic USE OF WELL 1 - primary 2 - secondary (RESIDENTIAL 0 BUSINESS ® INDUSTRIAL 0 PUBLIC SUPPLY 0 FARM []INSTITUTIONAL ® AIR /COND /HEAT PUMP 0 ABANDONED 0 TEST /OBSERVATION ® OTHER (specify 0 STAND -BY 0 AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE d.- Sal 0 REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION 12- ADDITIONAL SUPPLY 2NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE 13DRILLED DRIVEN ®DUG ® GRAVEL. O OTHER IS TELL SITE SUBJECT�TO FLOODING? YES 0," NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: .(Jd w GB Lot No. WATER WELL CONTRACTOR: Name IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: Address: YES do° NO 0 NAHE OF PUBLIC WATER SUPPLY: ~-° TOWN /VIL /CITY _T._ *9..q mom.. -•wT -}-!J _ 'Pir ^1]' ��L' "`Ti C'n 'I.iyP 7!Q' ism a�i : ^�..eca,- �,- .e...- .._- eo.►.�. :`. =.�-y �o..e.e., -- .� .. �... - ..:._ ._ ""- 9a�s;�le�atvi�, iC r3i'GRTY 'Flwr,•..,J�::,.J LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE ®ON SEPARATE SHEET �//-/ (da e) (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 thirt�� (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 drillin operations be contained on this property and in such a manner as not to degrade or othe wi a contaminate surface or groundwater. Date of Issue: L 19 q_ Date of Expiration 5 Z Z_. 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller LIN A1,1 Owner l-,401e.; rvj ffe,;'12,4Vy o' Address e, Aoeo-�,411;11 Located at (Street) Ifl ao�a,-- Sec. Block* Lot 17 (indicate nearest cross street) Municipality d11& �MIMVDIVGS VORMOZ009-1110,16ziA Watershed PO BE SUBMITTED WITH -APPLICATIONS Date of Pre-Soaking Date of Percolation Test HOLE NUCER C= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches 1,/-vam 117 2/ /7 /1-11'? 3 . Za2! 4 5 Ij 2)jV 12-9 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to* be submitUd for review. 2. Depth measurements to be made fran top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED, WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES 3' 4' 5' 6° 7' 8° 9' 10° 11° 12° 13° 4. HOVE ENO,' ,:�ejws /--dam 4,f Ole 14° INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED -- ��i%e- INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �J� /�� DATE: �i 3 DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided Wc,& 6 No. of Bedrooms �3 Septic Tank Capacity UGU gals. 1ype6!Lo � Absorption Area Provided By %j L.F. x 24" width trench Other Name j � Signature Address 2?Y7x THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sgeft /gala Checked by Date G.L. a� . 1' 2' Jl� 3' 4' 5' 6° 7' 8° 9' 10° 11° 12° 13° 4. HOVE ENO,' ,:�ejws /--dam 4,f Ole 14° INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED -- ��i%e- INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �J� /�� DATE: �i 3 DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided Wc,& 6 No. of Bedrooms �3 Septic Tank Capacity UGU gals. 1ype6!Lo � Absorption Area Provided By %j L.F. x 24" width trench Other Name j � Signature Address 2?Y7x THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sgeft /gala Checked by Date •• PUTNAM COUNTY DEPARTMENT OF HEALTH - — - �, _ �.:T�Yv� :;fie' x..r1r�Tne�� .c�y�n�� ^�t�►!_�`�,;.oc�..l�,..nA ..o...... .» .......�..:�= :,.:..:_�,' Date Re: Property of /� -'�o� �Gi,-�� g r"�� Located at Section Block Lot '70' Subdivision of �a S W" G'T� Subdv. Lot # Filed Map Date Geatlemeaf �, This letter is to authorize V a� ct�� `a ✓i 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 sozu?ect;on- :w -ith thi mc-:«er- and tc supervise -the construction- -c. system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health L,aw, and the Putnam County Sani- tary Code. Very truly yours, Signed v Owner of Pro arty ountersi' t� NOr 110, P.E. , R .s� �`�. — Address Address Town i .9 Tel.— ephone . 7:-1c L�7% Telephone 6UL"Arl %0VUnLL UQrA&%LrAr,na WE 6:DAL6la • Division of Environmentzl Health Services APPENDIX L AFFIDAVIT — CORPORATE OWNER APPLICATION FOR PEIL41T APPLICATION SUBMITTED TO I I C_QUO�1T•� 1!d , i.T61 P1 .PAA TO: Commissioner of Health In the matter of application 90f: a ff represent that % am an officer or employee of the corporation and am authorized to act for /.J� GI/'® yy;e' ,02 (Name of Co.rporatio having offices at Whose officers are: President: (Name and Add.sess) Vice — President: (Name and Address) Secretary: (Pane and Address) Treasurer: 1, 3 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 of 19 Notary Public THOMAS R. LAN(;AN Rlotery Public, State of Nwo,)(Ok loo. Q1 LA4B17952 qualified in Westchester Coin - Commission Expires April 6/84 oo f Signed: — &-2a 46 � Title: Egxporajs, ;ea 1 87 PDTNAM:CODNTY DEPARTMENT OF HEALTH ��\ Division of Stgteoomeetal Hes>lfh Sei vlcm. Caemel: N:Y lOSl? . Ptovlde Psiimlt Y .` on CEHfiPICATE OF Cis CONSTl:UC1i0N FOis SEWAGE DISPOSAL SYSTLM. Subdvlsion Nlume GO gg sa/a;;1 SON. Lot Y Tu Map S Block Lot y� 13. ` f'j / ' /d ' CEO Benewal p' Revision p Owner /Applleant Name d G > /orJ u i .Cl Date of imvions Approval M•�s 6 3 J L Address I�Cj // /Gy%I%� ti° To"— Ji 1Yl GAP: Lot . Area. Baildiog Type .. ; _ $. Fip- Section only De th •� volume . ' , P . N= *w of Bedrooms Dear Flow G P. D PCHDNotltk alien is Required When FM V completed Sepsntte Sewee V System to oon.it of Gallon Sepik Tank and 4 . O.O • To be oonstrdeted by d, t /7 A &*a Water SPIT: Pdbllc SuPPIY From Address ors_ Prlwte Supply Di"i by —A Otber Reriairemenb /� �� r I represent that I am wholly.and completely responsible for }the deugn,antl location of .fna proposed systems) 1), that the separate ,sewage', "s' sal system above described will be constructed �as shown onahespproved• amendment there to and in aCtOrdarlce with the stanCards ules7q regu a ions o . u nom County Do'piriment a .;Certificate' 01 Cons1ructfon;Complianee" satisfactory'to• the Commissioner of Hea%Ithwil) be submitted to the 'Department ' and 'a written yuararltee will be` furnishetl.the' owner bii'wctesso�t; `heNS ok assigns by the builder; that said builder will place in good operating condition, any part of-said •sewage disposal system; tlurinq t w0,'(2) years immediately following ihedate of the situ• once of the approvalof the Certificate of Construction .Compliance of the:orym 4ftb'_8F irs thereto; 2j that the drilled well described above will be located as shorvn'on the approved. plan and;that said well will,be:'instelled. m o ►` alndardf rules and regu a one of ' the 'Putnam 1. County Oepaitment'of' Health':. Oats �� //� �y Sig net! l P.E._ A.A. Address a `� Lieenss No zy �Q3" APPROVED FOR CONSTRUCTION T approval expires two years from the - 1`f1� sa + nst`r &ti n 'of the building has been uedertaken and Is revo' bla for cause or may be amended or modifieG whertconsidered necessary •D Qt " :a Ith. Any change Or alteration Of construction requires a new permit. Approved for 4 Date�� i DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER- `CARMEL, N.Y. 10512 (914) 225 -3641 `�,PP"�li✓a�I�N "1'U c:Ci1�S'C'F�` �iAT�� W'��'�°"� PCHD PERMIT _. e - - --I Z0001 WELL LOCATION Stregt Ad re wn Vilgl age/ 'ty Tax Grid Number WELL OWNER Name M ill .Q�r� 17 a�p Address / `_eof X ;l rivate cl, , �/ L/C OPublic USE OF WELL 1 - primary 2 - secondary SIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED ®.BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify ® INDUSTRIAL O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED d, /EST. OF DAILY USAGE 7a57 gal REASON FOR DRILLING SUPPLY OREPLACE EXISTING SUPPLY []PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ®DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE RILLED ODRIVEN ®DUG OGRAVEL ®OTHER IS WELL SITE SUBJECT 70 FLOODING? YES °'� NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: /✓ o g Lot No. WATER WELL CONTRACTOR: Name A �v'/l Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES d' NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER 'MAIN. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION ON SEPARATE SHEET 'r date) dAd„ ( to 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 s.hall: 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. Date of Issue: 19 Permit Issuing ffi is Date of Expiration: 19� Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Ins'pec�r Pink Copy: Owner 2/87 Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services APPENDIX L AFFIDAVIT - CORPORATE OWNER APPLICATION '' _ i .-TO: �Z. 7.- T __ Z 7 1. : Z; P U T q &M COUNTY - HEALTH ' bi P F. T M E N T TO: Commissioner of Health In the matter of application for: e- S .41ze- A., jG," represent that I am an officer or employee of the corporation and'am authorized to act for 1-3p lev /-e -,7 (Name of Corporatiorl having offices at Whose officers are: President: (Name and Address) Vice-President: (Name and Address) Secretary:_ (Name and Address) (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 S 0 day Signed: of P&*%V&4ne 19 almm",,-a LkMejL__ Notary Public THOMAS R. LANGAN Notary Public, State of New York No.OILA4517952 Qualified in Westchester Coun%4 6inmission Expires April 30,194 0 8/84 Title: Gbx�ora'te� Scat VZSMM SYSM ME NO. meted at (Stxeet) e- See. Block 4 rot (indicate nearest crws street) amicipalky Watershed AM - MAVISS Depth to Water Fr CM Water level moo u am Ground surface 7a Inches Soil Rate Start-Stop Wn start Stop Drop In KiWIn Drop Lxtwi Inches Inches 7 7 LL 34r S .zz3cx ..... I 3 N•!ES: Tests to be repeated' at same depth until aWaximately equal 501.1 rafwm-, are obtainedat each per test holso All data to'be submitted for review. 2. Depth U to be asde fraA tag of hole. PIT VT:71 HOLE NO. am NO. , HOLE NO. G.L. 21 V 41 So 60 71 Be go 10, 111 12' 131 14, RIO. m DESIGN soil Pate Used MiDA a Drop: S.D. Usable Area Provided J6-0ePe., No. of Bedrooms Septic Tank Capacity /?isZ? gals. Type Absorption Area Provided By Other L.P. x 240 width ..tiench OF NFL Y Nam Si i V Address .Y ❑ & A111-- Soil Pate Awrond sq.wgia. 0mclwd by Date 11 0 PUTNAM COUNTY DEPARTMENT OF HEALTH �,.:� -�., ,. >.,;..^ �.,... ....�.. - „�R :v�'a �' a.�`�'ai�i "' a��'° i�' �i�� 'ri,`1�';• "�'�A�;�°�f" °��JC��, "' ` Subdvo Lot # ---W Filed Asap.# Date Gentlemen: _ f This ]letter is to authorize 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 standarda9 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 J.�..- �_._.s -3 Pit^ -'hri - cl -•.: ]L 8�.. �e � .. -Gagr�:. a.�_.ta'avf ."'.v4^eS'a36 system or systems in conformity with the provisions of Article 145 or 1479 Education Lauv9 the Public Health 14aw9 and the Putnam County Sani- tary Codeo �)Ountersi p►NFfy to ��P � ,gC�I•g R4 P.E.9 R o�e `. Address O �/l 8 9� ti Telephone Very truly you ro 9 Signed L.J Owner ®f Pro arty Address Town 73 IQ 2zs-77 Telephone LZ • - - T e Y' CS '- i R j l06 J2_' t 10 /0/ J v{ = !ate fi(r a k RT�. cr 1 /�'.iT._�• .' fin ,':� /IR':� .�� . /��'S. � ! � jS r� - -_ \SV - tom: s -e x �. 1171 J . s 3