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Home My WebLink About3172DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 72. -1 -24.11 BOX 26 � „ '< < ' Wo 03172 Re%-; 3/86 _.. __L'ER2'�ICATE OF.0 Ia�ted at� Owner /applicant Name PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services, Carmel, N.Y. 10512 C Engineer Must Provide _ _ P.C.H.D. Permit N— ANCE FOR SEWAOEMSPOSAL SYS MM _,f'wl'nd /YI fit/ Taa,MePi� B1.1, Subdivision Name A/V�'9n ubdv. Lot iii , * Date Permit Issued «gam Separate Sewerage System built by �� '/1'" / Address Safr�C Consisting of / O 'V'59 Gallon Septic Tank and eq d e Water Supply: Public Supply From Address or:�Prlvate Supply Drilled by Address Building Type 27,024f _/21-22 t-:e' Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? N y Other Requirements I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulation in ac or QF he f ed plan, and the permit issued by the Putnam County Department Of.Heaallth. Datej. ----- titled y / P.E, y R.A. License No. Addreu Any person oecupying premises served by the ove system(s) shall promptly take such act .:e me tsar cure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewerage syst she becordp d as a pub!: sanitary tower becomes available and the approval of the private water supply shall become null and old hen a pubec t omes available. Such approvals are subject to modifi tion chJsp9e when, in the judgment of the Commit'sl nor Health, sue oit. Ifiution or change 1s y. Date I By ✓necces Title s 1<14701 �jL �e —'STREET WELL LOCATION WGLL �,vru L,>;x v►v arc rvni r Off ice Use Only DEPARTMENT OF HEALTH Division Of Environmental Health Services' r PUTNAAi COUNTY DEPARTMENT OF HEALTH ADDRESS: WNI VILLA C 1 I I Y TAX GRID NUMBER. rjq R � v r o h ally to afft u WELL OWNER NAME: ADDRESS. r fivr.�d o �% �PBIVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary (24ESIOENTIAL ❑ PUBLIC 9UPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED O BUSINESS. ❑ FARM ❑ TEST/ OBSERVATION O OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gala' REASON FOR DRILLING ❑REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION [ADDITIONAL. SUPPLY WEW SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH o?._ SKo ft. STATIC WATER LEVEL -? ft. DATE MEASURED % DRILLING EQUIPMENT Q4ROTARY ❑ COMPRESSED AIR PERCUSSION E3 DUG ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): lrlr'ELL TYPE ❑ SCREENED PEN END CASING ❑ OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH _____&,eft MATERIALS: rMEEL O PLASTIC .C] OTHER LENGTH BELOW GRADE xS (t. JOINTS: 0WELDED p.THREADED OOTHER DIAMETER in. SEAL:'] -C- tNT GROUT ❑ BENTONITE OOTHER WEIGHT PER FOOT lb./ft. DRIVE SHOE: O YES UNEFL OYES DP SCREEN tF?Ai�S . DIAMETER (in) SLOT SIZE LENGTH (It) DEPTH TO SCREEN (11) DEVELOPED? FIRST O YES .,ONO SECOND. GRAVEL PACK 1 O YES O NO GRAVEL SIZE DIAMETER OF PACK in, TOP DEPTH H. BOTTOM DEPTH tt. WELL YIELD TEST It detailed pumping METFj00: O PUMPED ;tests were done is in- W,COMPRESSED AIR , formation attached? O BAILED O OTHER i ❑ YES 0 NO WELL LOG if more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE. Water Bear- ing We!I Dia- �eter FORIAAnoN DESCRIF ION poE tt, tt. WELL DEPTH ft. DURATION hr. min. DRANIOO WN It. YIELD gpm. Land S � 6 age 6 r WATER O CLEAR TEMP. QUALITY Cl CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? O YES O NO STORAGE TANK: TYPE CAPACITY GAL._ WELL DRILL NAME 0 {wlp,,,.Ct�rSc�„ Std WrATURE ADDRESS 'A,Y r PUMP INFORMATION TYPE CAPACITY MAKER DEPTH MODEL VOLTAGE HP 31oi I 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES y Owner or chaser of Building o� Building Constructed by /�•'�n /sir //b e� �'G��/ Location - Street P Avg Municipality Building Type 'X C// 2, y Section Block Lot 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 "Certificate of Constru.ctiQn..Cpmpli.ance" for, the sewage disposal:_.s_ystem, or any; rcade- uy° me-, to- Stich - spsttaii, '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 1Z day of 4�4 19 Signature Title General Contractor (Owner) - Signature Corporation Name (if Corp.) Corporation Name (if Corp.) Address Address rev. 9/85 mk YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 ` (914) 245-2800 Albert H. Padovani, Director LAB #: 32.402809 CLIENT #: 4311 NON STAT PROC PAGE 1 KURITZKY, KENNETH DATE/TIME TAKEN: 10/28/94 10:00 79 HORTON HOLLOW RD DATE/TIME REC'D: 10/28/94 14:30 PUTNAM VALLEY, NY 10579 REPORT DATE: 11/01/94 PHONE: (914)-526-3787 SAMPLING SITE: SAME AS ABOVE SAMPLE TYPE..: POTABLE : PRESERVATIVES: NONE . C0_'D BY: KENNETH KURITZKY TEMPERATURE..: { 4C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE / 10/31/94 MF T. COLIFORM ABSENT /100 ML ABSENT COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN E NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, -OR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. �� SUBMITTED BY:__ Albert^H. T,adovani, M.T.(ASCP) ` Director ` ELAP# 10323 %lk q V, � "I il\c \\k,� , to � q A 5ea't d �'• t,y sNxap e ; � � � ( i AT a 3 P 3 3. p s d°%i`, �a i . a + Ag 'NAN 11 C 4 PP t b t kye. i5 �� sr' 'a.0�' r'9 brt r 1.1,11 R, x a - + 8 � UZI T J a WTI 44, '-YM Ss art ip i{P+ t, s � r § 3. ap Wo 10% x t Hai SidaRFlN� U ��4� .1 t 4 k t {. y. A 7 1 c 1 - - ._ -, . ,. 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