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BOX 25
03132
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03132
PUTNAM COUNTY DEPARTMENT OF HEALTH ENGINEER MUST
F Division of Environmental Haulth Services, Carmel, N. Y. 10512 PROVIDE
/ PERMIT #
CERTIFICATE OF CON UCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Z7N a r" ��,, /�� i9
,�J Town or Village
- LOCateC :5t ,. li "• f 'F Fes' �j 9'�i " _ 7 - i" �i ,.. ,t . ' Tax Map µ.... ,. .. : Block'
Owner
Formerly Tax Map Lot # �'�� Subd. Lot s
Separate Sewerage System built by R- 4 on e-va Address rive) ~
Consisting of /X�47 Gal. Septic Tank and d e r _IeAe--s
Other requirements
Water Supply: Public Supply From
if" Private Supply Drilled By
Address
Building Type
e ®v
Has Erosion Control Been Completed?
Has garbage grinder been installed?
i certify that the system(s) as listed serving the above premises were constructed esse
of which are attached), and in accordance with the standards, rules and regulations,
Putnam County Department Of Health. �(4'
Date Certified by
Address
Any person occupying premises served by the above system(s) shall promptly take sd
conditions resulting from -such usage. . Approval of the separate sewerage system s
available and the approval of the' private water supply shall become null and void w
subject to mods ifi�catioonn or�c/hange when, in the judgment of the Com miisssioneeNof
Date �!�/ yli"�
Rev. 6/85
h1449
on the plans of the completed work ( copies
d,R a filed plan, and the permit issued by the
P. E. R.A.
License No.
2-7
is cure the correction of any unsanitary
i n as a public sanitary sewer becomes
comes available. Such approvals are
isy Iflcation or change Is necessary.
rule
PUTNAi`1 COUN T'Y' DFI)ARTM.E.NT OF FTEAME r
owner or Purchaser of Building
13 ur &>G 5 x2tlC
Building Constructed by
l:� i Ckhg2D Dr.
Location - Street
Municipality
__2 5709Y 0040x�i4C
Building Type
Section Block Lot
b 0 4 VV000
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEXAGE 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
�ratF, Ti?r a rr x or, twc:
.lLertificate of Construction Compliance" for the sewage disposal 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 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
caased by the willful or negligent act of the occupant of the building utilizing
the system. ,:JC; y,��/;ni� C?4>tib f epl, All,
n
Dated this -day of 19 Signature
Title
di�,�.V�: '�u,��r o=rs .ANC• s �,
General Contractor (Owner) - Signature .4..A v',,i.��vt %cq_�
corporation Name (if Corp.)
Corporation NaName f Corp.)
Address'
Ca A -9 TAMAIZACK A,
Address . e -C .
rev. 9/85
mk
.,..: CA..006,455 j
Yorktown Medical Laboratory, Inc. LAB # �
321 Kear Street 3/2/88 2pm
Date Taken. Time:
.�....x.•......... -.�o. rkt_owc:n •Z•u ., .-r- _--- •.... -... _ . -.�- = .o- :'..^r:.: , ..�'G•w.:..at_ .�.. P�
C-
(914) 245.3203 Date -
AR,__QQ�e�,___
Director: Albert H. Padovani M. T. (ASCP) Collected By :
T-DOUG HAIR 1 Referred By:
RD#2, PEEKSKILL HOLLOW RD. S 'c aras iron
CARMEL, NY. 10512 , Nt.
Phone N
Phone N Sample Type:
L '� Repeat Test? _ 1(check one)
LABORATORY REPb T Oil -_.THE''B'ACTER=1`0`L0G•T'GAL .Q'UALITf-, OF
GENERAL BACTERIA
Standard Plate Count:.(CFU /1.OmL)
(Agar Plate @ 35 00
MEMBRANE FILTRATION TECHNIQUE (MFT)
Total Coliform (CFU /100mL)
Fecal Coliform (CFU /100mL)
Fecal Streptococcus (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
20
Total
Coliform:
MPN
Index
(per
100mL)
Fecal
Coliform:
MPN
Index
(per
100mL)
OTHER ANALYSES
REMARKS (For Laboratory Use)
Potable
_ N.o.n. --.p o.t a b I.e..,
STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
Na2S203
Incoming
LE 4 °C
GT 4 °C
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tion of Source
TNTC = Too'humerous To Count
CON = Confluent ( =TNTC)
LE = Less Than or Equal to
GT = Greater Than.
N/A = Not Applicable
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THE YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
t
/x/ IV -'j y
Albert H. Padovani, M.T. ASCP), Director
For Lab Use Only:
_ H/C to
" WLLL UU1'1rLL11U1N r -MrUAl
DEPARTMENT OF HEALTH
_ Divisi_on .Of .Envirc(fivental Health Services
.. s. \•j.'al�O� � �- ti 3. V-. �..^�r � ". t¢r-:••¢- :..c�:..;�s.. c.'. .r:r £>..n . .RSia.+e4 -: ae•.x�; .• a�% -i.i
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
LV _/0
_
-..�r_.�'.T�9.: �. �... v.^aer. :.n �:. -:�i. . �..� r
WELL LOCATION
BEET AOURESS: I I L QU I ./ TAX GRIO NUMBER:
WELL OWNER
ME: ' ADDRESS.
®. PRIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDEN AL ❑ PUBLIC SUPPLY. ❑. AIR /COND.IHEAT PUMP O'. ABANDONED
BUSINESS ❑ FARM . O TEST /OBSERVATION O OTHER (specify).
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT J 3 s{c�g
gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
]a NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /08SERVATION
❑ REPLACE EXISTING SUPPLY D DEEPEN EXISTING WELL
zOEPTH DATA
WELL DEPTH ��� r ft.
STATIC WATER LEVEL 3O , ft.
DATE MEASURED
DRILLING
EQUIPMENT .
6-ROTARY Q COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING. ED OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH a I ft
MATERIALS: STEEL ❑ PLASTIC D OTHER
LENGTH.BELOW GRADE ft.
JOINTS: ❑ WELDED aTHREADED ❑ OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT O. BENTONITE BOTHER
WEIGHT
PER FOOT ZJ'. 1b./ft.
DRIVE SHOE &YES ❑ NO
LINER: DYES IRNO
SCREEN
DIAMETER (in)
SL07 SIZE
LENGTH
(it)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
❑ YES ❑ NO
I .. o....�. -« ._
- Y
SECOND'
_ _
.- _. ..-. ..-- -
... .�.`yT.. _
a...�. ._ . ,.w. ..a ... a�,.l.,.
�.pr r... ... -_w ... A -C '°•en.
I1N411J �:1- .
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST Ii detailed pumping
METHOD: ❑ PUMPED ; tests were done is in-
COMPRESSED AIR , formation attached?
O 8AILED ❑ OTHER ❑ YES O NO
LOG If more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
Water
Bear-
Well
Ola-
peter
FORMATION DESCRIPTION
CODE.
ft
it ling
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft,
YIELD
gpm.
Surface
a
7
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE _, HP
WEL WR NAME / J �� OaiJ`
ADD ��i. d�fGrrkiURE �7
0
FL' L S= RiSPF=ION Date -7 Z2
j� In=: �- _b'y�
ICN � I �, -�i�-� !J, � Ci�vT]�2 E>- � C - � • /t'�� �>
`LEI OR SUDIVSI0 LOT A r
v c n -�
SEWAGE DISe CEAL AREk -
a. SDS area lccated as per aooroved nians + ` wt•�
b.
Fill cacti cn - Date of placanent
2 -1 bar-_er LGTH W=Ei P_VG.DPTH
J
C..
Natur,_l soil not strioced
I
d:
Stcr_e, brish, etc., ureate_r th- ,--a 15' from SUS area_
I I
e_
100 ft. f-on water course /We}? a.*:�__-_ _
IX I I
II. Sr�T.,9G:. DISrC'E L S'ISTFM
a. S`n is tz-x:< size - 1,000 1125
I I I
b.
S=•cti c t`*L< i,-ista-11led level
-
c.
10' mini_nim from foundation
I I
a.
No GO r.
0° bC ^as, c1a=CUt Witnzn lO fr. O- 450 �.rsi
( I
e.
DISTR!~L1ICti BOX
1. P11 cL't! eT..s at saIiie ele<rat? cr - draterr t=—c",w•
+
I
B-ees prcce._ grouted
2. Prcte`t belch frost
I I I
All pipes partially backfillEr+
3. 2 ft. cricinal soil c= Nacn ccx and trenches
c.
f.
JLICTICN BOX - orocerly set
I 1
g.
TP.F._L C-=-
1 La ct _, r=.-u; red - d v Lan=h installed � � L
( I
cur-ta- i n drain installed accord
2. Distr_ce to waterccurse rneas* ,_ ft.
I I I
Cures i n dr i n cutfall protect=
3. Ln_ a lea ac=.,rdinc to plan
I
4.' Dis _a:nce cent °7' to center
I I I
_
5 n
.. Slcce of trench acc°_ota.ble 1/1- 6 - 1/32 -/z-cot.
I I
6. 10 r == f=3tt orccerty lir e - 20 fe✓t - fmmdati CP.s
Y. D✓:, : cf t=--r-ca < 30 inches f_an surface
I A I I
8. Roca:: a=? c.;ad for e_xransicr, 50%
I ( I
9. Size cf travel 3/4 - 1t"
10. Ee -n"- ci travel in trench 12° min;mimai
ll. P, Le ends c oCC^
I Al I
h
RY. -V CR MEE SYSTEMS
1. -Siz�" cf•' -.��w G:,G:;n.:.r -• ..._..
III
� ; ;
2. Cve_Tlcw tank
3. Pla=n, visual /audio
4. Pmm easily accessible mar:ncie to trade
5. First bex haf=ted
6. Circle witnessed by Health Decrtne_nt
estirated flcw per cycle
� ► ,
ns
ft_
eptable.
s < 4" in diameter
g to plan
& dir.to exist_watercour
g. Fcot� na trains cascharce away tree SDS a*E=
h. Surface water rotection ade:te
i. Err =s? cn controE provides on slot
Ub
IV. HOUSE
'
a.
Hcuse lccated per aperoved pla
b.
NLncer of bedreans
V. WELL
_
a.
We1— lccated. as per aooroved p
b.
Distaste fran SDS area measure
-
c.
Casinc 18" above grade.
d.
Surface drainage around well a
r_
Vi. OVERALL hi7R 909 P
a.
B-ees prcce._ grouted
b.
All pipes partially backfillEr+
c.
All pipes flush with inside of
'
d.
Eackfill saterial contains stc
-
e,
cur-ta- i n drain installed accord
f.
Cures i n dr i n cutfall protect=
ns
ft_
eptable.
s < 4" in diameter
g to plan
& dir.to exist_watercour
g. Fcot� na trains cascharce away tree SDS a*E=
h. Surface water rotection ade:te
i. Err =s? cn controE provides on slot
Ub
3 '
COUNTY °.DEPARTMENT OF HEALTf3
�1`�, Dlvisfon of Envtronmentel;Health Services Csrmel N:Y 1051? Eng1noei to Provide Permit q.
on CERTIFICATE OF COMP
CONSTRUCTION PE FOR SEWAGE DISPOSAL SYSTEM Permit q ;
L6mied at ! �! r _ VWage
/, !� Town or
c`1°�c'ax �•+...ar � ..Rhos ��"�� .::
SdbdlvlBion Name / ✓�� y _. Sabd, lot N Tas •,Map -3 Block rf t Lot r'' 7
�..
G evislon ❑
Owner /Applicant Name' ❑ R
• ti
Date of
Previous novel Al W
PP t
Malllng Addreiefi° ac Ga'u lyyrG �p0�
BaUding Type Lot Area , Fill $ectlon Only Depth Volume `
Number of Bedroome Alga
I)e Flow G P 1) ;� PCHD Notl9catlon is Regdred When le completed
Separate Sewerage Syeteni to consist o[�5�`Gallon Septic Taok,and
To`be constructed by, w Address
Water Soppl)Prihlic Supply From Addreea'
ors Private Sa ply`'DrWed �tir" { Address ' r
Other Renairemente . %3 .t� > f Q ' �'/ J ; •d' :'
r .I represent: that I am_ Whcilly :.and- completely responsible for �fhe des�gn.and location of tFie proposedl mO - ' separate sewage disposal; system ; 1.
above tlescribed will be.'constructed as shown omthe'approved; amendment there, to and in accordan Ia �pd%Mw"M �ds,/F� an regu a ions o e u nam
Qounty, Department of :Health, and that on completion thereof s Cert� /�cate; of Constructioii omplia QQ'A adtpr he Commissioner -ot' Healthwill
tie wbinitted.to_ the Department end,a -written guarantee will be furnished the owner, his cesseir° e7rsor ass�Y.by t 'builder, that -said builder will' '
Plice m`good- operating• condition any -part -o said, sewage disposal system during ;the parr ofii` (2) rsim lately ollowirg the date of the,iss.. '
ante of the' approval of -the Certificate. of ConstiucLOn Compliance of the:origmalsystem r!a" a to,tph 'drilled:well tloseribed' above will be,loeated sssharvn o_n the approved „plan and that sod well will D �nitalled m 'accot�da ee w' a 's ules'Gaiid 'r u a_ ohs • of the Putnam
County De�yt ent'ot Health.''o
Date : Y Signed: _.
se
• Address n No ,
.d -
,,APPROV.EO FOR ;COfJSTRUETI'ONi T s approval expUes two id ;fro eadate,�ssued_ unto oe ing ha ;been undertaken and is .
t
revocable for cause or may be amen d or modified when co Idere "necessary ,by the )Commission Inge Or alteration df construction.
..requires a .new :_permit Approved for disposal of tlomes•c n' .ry sewa e, :' n /ou ate'watersu fd a.
Rev..
1/87 , . g Y .
Title,.
�
` -r
0
YUIUN4 CUU11: hH AVII- 11'111 (,[ 111,A1,111
DIVISION OF ENVIRUiEIMAL JUALTH SERVICES
DESIGN DATA SHEET - SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
�Ckiiner :% - •ALLUeSS � �1`" i/ `y >_,/7",/`�: ,?'��.r, ..�;/:�.41
ice' ..
a � i
Located. at (Street) %j �f��C! ✓'�'� r Sec. Block 5f-- LotI
(indicate nearest cross street)
Municipality c; 2 42 � Watershed
Date ' of Pre - Soaking Date of Percolation Test
HOLE
NUM CT= 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
s
Inches
Inches
4
5
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until apprcximately 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.
rev. 9/85 %
- r
TEST PIT DNrA M-T)OIRF-D TO BE SUMMITI) W1111 APPLICATION
DESCRI.PTION OF SOIL ENODLUITMM IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
21
31
40
59
69
70
81
go
10,
129
131
141
-1NWJCk1'E LEVEL- AT- W-fija--j-
.W.N,TERU
INDICATE LEVEL M WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:* DATE:
DESIGN
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided a!
A-4
No. of Bedroans Septic Tank Capacity gals. Type
Absorption Area Provided By Zoo L.F. x 24" width trench
Other
Name S
Address
THIS SPACE MR USE BY HEALTH DEPAR24Etff ONLY:
Soil Rate Approved sq.ft/gal.
VOW
sa
Checked by Date
f
COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRObZffW1AL HEALTH bt.Kvl__=
INDIVIDUAL E'ER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REV SHEET - CONSTRUCTION PERMIT
DATE
34,ANAOC L BY:
Name
--
COMMENTS YES NO DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets s /s.
Engineers Authorization _
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc
Consistent Perc Results (3) Fill
Perc Hole Depth cd
House Plans - Two sets-
Well " permit; PWS letter
Variatbe Request
GENERAL
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
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flcw
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data: perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
r., Z[ JV, )...
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flow,suff. size
If Ptmtped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed System
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Iarge Trees,Top of f:
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. exp
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercou
10' to Water Line (pits -20')
50' intermittent drainage course
Septic Tanks
10' fran Foundation; 50' to cell
15' Well to PL
1(
PUTNAM COUNTY DEPARTMENT OF HEALTH
-LI V Iia1�/iV Vl L1V V 1.AV1V1.1L'l IAL YiLAL11Y ',:; iiiC': :: ✓'
Re: Property of
Located at
Date�� /' C
;�i✓
(T v 1� Section Block Lot
Subdivision of / ✓' c fwrJ
Subdv° Lot # Filed Map # Date
Gentlemen: r
This letter is to authorized
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
,� .w W-L i.ja tai a' iaa'"' . an%A t. supa v loE ���v ate'. Vii:S �.i -u:�: C10 L ti - -
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
P °E°
9 �ry
s3
Ct �a X, a 41
Adar e s s
Telephone
Very truly yours, �®
Sign
e
0 er of Property
� W 4ZZ®Oj
Address
elfegsnel , /t/. V cri-�
T�oown �qL d
'9// / V CP�- ipeV - 5'
Telephone
I
o
PUTNAM COUNTY DEPARTMENT OF HEALTH.
Division of Environmental Health Services
AFFIDAVIT - CORPORATE OWNER APPLICATION
"o -
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
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 7 - e, _' r
.461r,071 WS <457;�'(7 ,, �e
gSS ::
(Name of Corporation)
having offices at '4wo &Cwte- 41lewe
Whose officers are:
President: e4��.1111
e, Al�lLe' 7
(Name and Xddress
F/A
Or
0
Vice-President: C,;VKAM5_ or
(Name ands /Address)/j,
Secretarv: Ile
,0e,/0'
(Namp. 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.
41,
Sworn to before me this 30 day Signed:
ei�/
09
Title:
te
Notary Public
8/84
-0 A _ UZMA
laftv fthlc�ikie at-obw yok
NO. 4r2MI
MWORM in WNWMW
CWOMISSW Expires March 90 to -7
Corporate Sed- I
/V,
/C/
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
Stre t Address Town Vill ge /City Tax Grid Number
J"�
WELL OWNER
Name �
Mailing Address
_n e-
,., .«�f•�- , rivate
•�/j`� t� d �v.✓ At O Public
(tTqE OF WELL
1 - primary
- secondary
eIGIDENTIAL
® BUSINESS
® INDUSTRIAL
0 PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY .®
AMOUNT OF USE
YIELD SOUGHT 2_" gpm /# PEOPLE SERVED -�4 /EST . OF DAILY USAGE 9�' O gal
REASON FOR
DRILLING
SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ® DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING .
WELL TYPE
DRILLED
®DRIVEN
®DUG
11
GRAVEL ®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES il-' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. 7
WATER WELL CONTRACTOR: Name f'r►7'/ ? /a, welojeF 47 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
yDISTANCE TO PROPERTY FROM NEAREST WATER MAIN:.Yr�
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
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[]ON REAR OF THIS APPLICATION 23r05N SEPARATE SHEET
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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 ovid d by the Putnam County
Health Dep j 1prtment. Aygn�o
Date of Issue: 19
Date of Expiration: ; 19�
Permit Issuing --Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
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PETER C. ALEXANDERSON
County Executive
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DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Mr. Joseph F. Sullivan
2472 Ferncrest Drive
Yorktown Heights, NY 10598
August 31, 1987
JOHN SIMMONS. M.D.
Deputy Commissioner
JOHN KARELL, Jr„ P.E.
Director
Re: Proposed SSDS
Brothers Classic Homes, Inc.
Richard Drive
(T) Putnam Valley
TM #35 -4 -2.31
Dear Mr. Sullivan:
Review of plans and other supporting documents submitted
at this time relative to the above - captioned project has been
completed. Comments are offered as follows:
1. Subdivision filed map number to be provided.
2. Additional deep test pit holes are required. (7
_
3. _,Clay barrier to be shown on the three.
. -uf -the -pr*oposed fi'i 'sec
4. Septic tank location to be shown on fill plan.
5. Expansion area not shown.
6. All existing and proposed wells within 200 feet of
proposed SSDS and all existing and proposed SSDS within
200 feet of proposed well to be shown or a note stating
none exists.
7. System to split by means of a distribution box.
Upon receipt of a submission, revised to reflect the above comments,
this application will be considered further.
Very truly yours,
Robert Morris
Environmental Health Technician
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