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BOX 26
03281
- :.'•-' "� r
PUTNAM COUNTY DEPARTMENT OI? HEALTH
Division of Environmental Health Seivlces, Carmel, N. 10512 j
IEngineer Must Provide ,
I 1, P.C:HD PeiWtH
I a
GERM OF;CONSTRUCTION: COMPLIANCE.FOR SEWAGE DISPOSAL SYSTEM
'".
Located at i Tom. Bloc si Lot, t
OwnerLapplicGat Name l ',r Formerly _ Subdivision Nsme L bdv Lot #
MaWng Ad ss, ; �'G{ !�%l�Ttl.�pl� �Ob»/Y1E1AtS - 'ZLip �8 Date Permit lssaedUGI Z �5
Separate Seweeage Syatem butlt'by i? `fir Address
A•MC�'
Comsis of i 3. —7 S% L 1 ) �� �'� O I ° IG ' 1U/ .
ling Gallon Septic Tank
Water Supply: Public Supply From Address
ors ✓ Pdyate Supply Drilled by Address AMOn 7K : h►
Buildldg Type M ` Has Erosiou`Comtrol Been Completed?
Number of Bedrooms Has Garbage:Grinder.Been Installed?
-i
Other Requirements �� nl '?i2�1 ►.� . s,•�, b }
I certify that the systemj(s) as listed serving the alcove premise§ sere constructed'eswntially as shown on a lans.of the completed'wo,i.'( copies
of which are attached) and,ih accordance "'with •the- etandards,:.rplas and requlations,.in accord a with Udp and the permit issued by the
Putnam County Department(Of- Health
- _ ..
tie- ► 6 I jc� �l
Date —= Certified by
Address / License No.
Any person oeeupying premises sewed by'the abovs`system(s) shall promptly take Such action as may bs neeessar 6 secure ihevorreetlon of any unsanitary
conditions resuRjng from such usage Approval of; the separate sewsragsYsyitsm shop, become null and void as soon as a pub,% sanitary »wer,bacomet
available antl th6,approval`of thef'p►Ivate wale► suDp�Y shall become -null and,.void when a;public wale► supply.'bicomas availabN. Such approvals are
subject to modiflrJtion or change:kwhen,'in the judgment :of the Commissioner of "*a th. su
%eevocatloh, 'modlfteation or change Is necessary.
Date
PU`I'NAM COUNTY DEPARTMENT OF HEBLTH
�D SSON. OF ENVIRORRO TAL iiFAL
1I SyIC%F _.
Owner or Purchaser of Building
Building Constructed by
(Yn u.4�12oa.n
Location - Street
Section's Block Lo
Subdivision Na
Municipality Subdivision Lot
(0
Building Type
GUARAI<t= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the loca
workmanship, material, construction and drainage of the sewage disposal s,
serving the above described property, and that it has been constructed as she
the approved plan or approved amendment thereto, and in accordance witl
standards, rules and regulations of the Putnam County Department of Health
hereby guarantee to the owner, his successors, heirs or assigns, to place in
operating condition any part of said system constructed by me which fait
operate for a period of two years immediately following the date of approval o:
tlCe ficate.: ,. :Cor�6tructaon- Coinpl-iance" f -or- the sewage disposl'- Osten, :e.-
repairs made by me to such system, except where the failure to operate proper.,
caused by' the willful or negligent act of the occupant of the building util
the system.
The undersigned further agrees to accept as conclusive the detenninati
the Director of the Division of Environinental. Health Services of the Putnam G
Department of Health as to whether or not the failure of the system to operat
caused by the willful or negligent act of the occupant of the building util,
the system. CQ
Dated this L day of /t/ 19 0 Signature
Address
rev. 9/85
mk
Tittle
06
aC C
Address
�DLY;aw //'
T)
WZLJLA UurirLr'ILUM. REPO L
DEPARTMENT OF HEALTH
Division . Of Environmental Health Services
Office Use Only
WELL LOCATION
STREET ADORE S; TOWN/ VILLAC41CI I TAiGRIO NU 861:
tur 0 1 1211L,19- _jQ0_r
WELL OWNER
NAME: ADDRESS:
_�QNVO- rJ C-D I' r rJ I a
C1 PBIVATE
❑ PUBLIC
USE OF.WELL
1- primary
2 - secondary
`t& RESIDENTIAL 0 PUBLIC SUPPLY ❑ In 1HP* PUMP 0 ABANDONED
0 BUSINESS 0 FARM 0 T ' ESTIOBSERVATION 0 OTHER (specify)
❑ INDUSTRIAL 0 INSTITUTIONAL 13 STAND-BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
'**rSNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION
ERVATION
o REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.1
STATIC WATER LEVEL ft.
AO�T
DATE MEASURED
DRILLING
EQUIPMENT
0 ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED 0 OPEN END CASING. ***'ROPEN HOLE IN BEDROCK 0 OTHER
CASING
TOTAL LENGTH fL
MATERIALS: **IS STEEL 0 PLASTIC 0 OTHER
GRADE ft.
JOINTS: OWELDED 'b--THREADED OOTHER
DETAILS
_LENGTH.BELOW
DIAMETER (D —in.
SEAL: 0 CEMENT GROUT 0 BENTONITE **WTHER
WEIGHT
PER FOOT —lb./ft.
DRIVE SHOENYES ONO I LINER: OYES ONO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH
(ft)
DEPTH To SCREEN . (ft)
DEVELOPED?
FIRST
0 YES ONO
SECOND
HOURS
GAVEL PACK
11 'YES
❑ NO
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH - ft.
BOTTOM
DEPTH - It.
WELL YIELD TEST If detailed pumping
METHOD: 0 PUMPED 1 tests were done is in-.
1
❑ COMPRESSED AIR formation attached?
0 8AILE0 ❑ OTHER 0 YES 0 NO
It more detailed formation descriptions or sieve analyses
HELL LOG Are available, please attach.
DEPTH FROM
SURFACE
water
Bear.
ing
Well
Oi4-
meter
FORMATION DESCRIPTION
Coe.
ft.
WELL DEPTH
tl
DURATION
hr. min.
ORAWCOWN
It.
Y YJ E L 0.
–
Land
Surface
— 7cf
19 al'i
TV
T
WATER 0 CLEAR 'TEMP.
W T 8
QUALITY 0 CLOUDY HARDNESS
A
QUALITY
U TY
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? ❑ YES 0 NO
rMA
STORAGE TANK: TYPE
CAPACITY GAL. A
UMP INFORMATION
UM P
PUMP 11
TY PE
MO EL
CAPACITY
DEPTH
VOLTAGE HIP
WELL DRILLER VAME • OAJ�)
SIG RE
;V�
C.
T. MICAAE1, DALY, P. E.
Comultiny Enyince-t
91f l628 -0
BOX 243
• SHENOROCK, NEW YORK 10587
CA -
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Yorktown Medical Laboratory Inc LAB " -
321 Kear Street Date Taken: -
Yorktown Heights, N. Y. 10598 Date Rc'.d : 1_
-
(914)245-3203_ _ .. -s ..e =..� o.rts -d_�.-
' .i�T..... -. .� n •1.1 4•t ....Y' •s .- •T+y- �+•4- ..vk: �%�.��..:.+. �••.. -n. +#
Z�irectoi Albert H. 1�ad�ovani M. T. (ASCP) Collected By .
Referred By: r
T- -1 Sample Location:
STEVE ADAMS PLUMBING 8c HEATING b(?A)&A b 2, /P.I alb m 6
P.O. BOX 459,INLAND RD.
CARMEL,NY. 10512 .
L
Phone
Phone
J Repeat
LABORATORY REPORT ON THE QUALITY OF WATER
Test? _
INORGANIC NON- METALS (mg /L). MICROBIOLOGICAL (CFU /100mL)
— Acidity
_ Alkalinity
Chloride
_Detergents, MBAS
Hardness, Total
Nitrogen, Ammonia
Nitrogen, Nitrate
Phosphate, Total
Sulfate
_ Sulfide
Sulfite
GENERAL BACTERIA
_ Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
Total Coliform
Fecal Coliform
_ Fecal Streptococcus-
METALS (mg /L)
MOST PROBABLE NUMBER TECHNIQUE
_ Copper
Iron _ Total Coliform Index
Lead
Ma,ng�aes•e___... w. -. -- Feea1 <•G,o -ifarm Ind—ex- -
_ Sodium KEY FOR TERMINOLOGY
Zinc CFU = Colony Forming Units
MISCELLANEOUS
pH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
N/A = Not Applicable
LT = Less Than ( <)
GT = Greater Than ( i)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
Time : .2 ,1E5-PM
Time:. 104-01
._ �• R Cam• AL-'.�
Sample Type:
(check one)
Potable
_ Non - potable
STP INF
STP EFF
Other:
Sample Status:
(check each)
Outgoing
_ HNO3
_ HC1
H2SO4
— NaOH
ZnOAc
Na2S203
Other-
u LE
4 °C
GT
4 °C
_
_ pH
LE 2
_ pH
GE 9
pH
GE 12
Other:
REMARKS /COMMENTS (For Lab Use) IELAP #10323
THESE RESULTS INDICATE THAT.THE WATER SAMPLE WAS (WASN'T) (N /A) OF 'A
SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE NKING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
2 /86(Rvsd7 /87)RWE
iovani, M.T. (ASCP), Director
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PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Envkonmental Health Services. Camel. N.Y. 10512 ProvWe Permit N
on CERTIFICATE OF�4yp�IPIdI
CON ON PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit N
Co �1 J, ,- j
own or e
Subdivision Name 11�L� li `� Subd. Lot N Tax Map V-2 L---1 �Block�_Lot
Owner /Applicant Name
QC qf) "g7o�� Renewal— Revision ❑
Date of Previous Approval (��
Matllog Address : Q &— AMPS IU >,own L�7uA � Zip t can 4)
Building Type F- i �� a L' Lot Area e S8 �. Fla Section Only Depth 3. 5 Volumo
Number of Bedrooms Design Flow G P D 0 PCHD Notifiation is Rwphvd When FN is completed
Separate Sewerage System to consist of Al2-V Galion Septic Tank and 2 76 W 9 Fr OF- -77 -14A. -Qi
To be constructed by Address
Water Supply: Pdbllc Supply From Address
on Private Supply Drilled by --address
Other Requirements
I represent that I 'am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules an regulations O s u
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will
Place in good operating condition, any part of said sewage disposal system during the period of two (2) years I medlately following thedate of the issue
ance Of the approval of the Certificate of Construction Compliance of the original system or any repairs ther ; 2) that the drilled well described above
_will be located as shown on the approved plan and that sold well will be Installed in accordance with the sta ar , ule nd regu a� oil ns of the Putnam
County D tit Health.
Oats Signed P.E. R.A. �_
Address "f
License No 8" J
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless con-Auction of the building has been undertaken" and is
\ revocable for cause or may be amended or modified when considered n&-- essary by the Commissioner of Health. Any change or alteration of construction
requires a ew permit. Approved for di oral of domestic nitary r�wa an �r' aterr supply only.
i .
'' ; � Date
1
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
' Cr'. =. t. . ;�!-;" .. x_,..�....- -Y,'.'.M '. :_. •__ s..« � .�z ie .r > . .... r1=z n:.r <,.: v'
APPLICATIO_y . N TO CONSTRUCT A WATER WELL
PCHD PERMIT
WELL LOCATION
Street Add r -ss
Town Village City Tax
"?U U
Grid Number
Name
NArA
Mai li g Address
Private
WELL OWNER
O Public
USE OF WELL
GIESIDENTIAL
OPUBLIC SUPPLY OAIR /COND /HEAT PUMP
0ABANDONED
1 - primary
® BUSINESS
O FARM O TEST /OBSERVATION
O OTHER (specify
2 - secondary
® INDUSTRIAL
❑ INSTITUTIONAL O STAND -BY
® _
AMOUNT OF USE
YIELD SOUGHT
gpm/ # PEOPLE SERVED _e /EST . OF
DAILY USAGE C-; 7 gal
REASON FOR
SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O TEST/OBSERVATION
DRILLING
OREPLA E EXI TING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
[2t-RILLED
[]DRIVEN ®DUG ®GRAVEL OTHER
t
IS WELL'SITE SUBJECT 'TO FLOODING? YES t/' NO
i 1
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF. SUBDIVISION:
''�Lti�i;
Lot No.
WATER WELL CONTRACTOR: Name Address:
T
IS PUBLIC WATER SUPPLY AVAILABLE T.0 SITE: YES L% NO
.NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
., . _ q .�. ....a .,... ..... .....s.r y....._... _ -_ -. -. __. -... ...... r ._e �.. . ,.._... V ^__a .- a.. -..a. .... a +� r__.. ., r.__ _— ._s . r -.. --. -. r.+ r.. .{ -_ ►..
DISTANCE TO PROPERTY. FROM NEAREST WATER MAIN:
LOCATION SKETCH-.& SOURCES OF CONTAMINATION PROVIDED
1�I ON REAR OF THIS APPLICATION ®'o S
(date)
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.
2.
3.
Date of
Date of
Pump the well until the water is clear.
Disinfect the well in accordance with the requirements of the Putnam
County Health Department.attached to this permit.
Submit a Well Completion Report on a form provided by the Putnam County
Health De artment. R
Issue: � 19
Expiration. 19 '41W ermit ssui fficia
Permit is Non - Transferrable
2/87
White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner VeDd6a -s.r-T'' Address l4
T�
Located at (Street) N1, Cvr�SiL lv �. Block it Lot 9 (s
(indicate nearest cross street)
Municipality Watershed
SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking C�;L.-F 1964- Date of Percolation Test qDcrt- 4--
HOLE
NUMBER Cl= 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
4
E
Z 3 io -o, in' 3� SO
4.
5
1
2
3
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 submitted
for review.
2. Depth measurenents.to be made from top of hole.
rev. 9/85
TEST PIT DATA REIQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENS IN TEST HOLES
DEPTH HOLE NO. ..HOLE NO. HOLE NO.
. - � a`] a - \'�•MC- Y.mke:Jr. _- - f Y.. ..y _ _ _
Go- L
f(
21 u (2��r✓1
3'
5, °f
61 t3L�iG� ALv
7'
8°
9'
10'
11'
12'
13'
14'
INDICA'T'E LZ1EI AT -WHICH IGROUNDRATER 1S FTNMUN'i�
INDICATE LEVEL TO WHICH WATER LEVEL, RISES AFTER BEING MMUNTERED
DEEP HOLE OBSERVATIONS MADE BY: �� �d�i. c_1 DATE: 0,---r 19eQ--
DESIGN
soil Rate Used' Min/1" Drop: S.D. Usable Area Provided z-Z,ry
No. of Bedrooms mil- Septic Tank Capacity 1 7,5V gals. Type
Absorption Area Provided By L.F. x 24" width trench
Other
Address' 2.x}-3 SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved s4-ft /gal. Checked by Date_
PUTNAM COUNTY DEPARTMENT OF HEALTH
.... .� i3TVISTOlti OF..EN` ITRON -iMEI NTTAI,.•HEALTH:.. SERV ICES> .. ' .. —.,-
Date
Re: Property of
Located at low Z&o C d
(T) c� S 2- . Block /. / Lot J
Subdivision of
Subdv. Lot # Filed Map # -a Date
Gentlemen • CONSULTING ENGI -NEEF
• P. 0. BOX 243
This letter is to authorize %"ENOROCK.N.B. I®587
a duly licensed professional engineerz_"",—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
i
C.
Y;
I:
c
i
Department of Health, and to sign all necessary papers on my behalf in
ec supervise t -h-e
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.
Very truly yours,
Si ned AG'JA
Countersi % Owner of Property
P.E. , R.A. , /# ' Z-G' �1/ IZL G� /C e0e2g1naxj
Address
T. wGIIAEE l r
Address 'a'CONSULTING ENGINEER
P. 0. BOX 243
SHENOROet N. r, 10581
Telephone
Aoc
Town
APIOM &b,v ale,`
Telephone
1
r
PUTNAM. COUNTY DEPARTMENT OF.. HEALTH
Diviiito'n-: oi,tnvironmenial"iffaiiii"te�4i'ei'--
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAIM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
7cnl & 12 JUd d I- VQ .0 Al 14
represent that I am an officer or employee of the corporation and am authorized
to act for
(Name of Corporation)
having offices at
6!
Dale
eo P" /Y!
(Oi�
iq In '6"
I-:-Au
0/0,
X . k' -Z,0u1$V
IYEL-7,14
7, ` X/, Y
Whose officers are:
President:
4f 12S /I q e /t/ e 12 /Y7 a AJ
(Name and Address)
Vice-President: MA12 g
Secretary: 17V 4,/,
Treasurer: A0A 6�c i,
- t'_j
ame and Address
ame and Address
11 -L I it
L I L i L i (
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 Title:
6 14111
Noertary Public
SHERYL SAIDEL
Notary PVWW, State dNWy4*
ft 4743051
Qualified In We*hO"
TOM EVIMS matt so, IM
A/AA
rutuam County Department of Health
,ision of Environmental Health Services
proved as noted for conformanoe with
Qicable Rules and Pegulations of the
nam County Health Department.0
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NXI,
7
rutuam County Department of Health
,ision of Environmental Health Services
proved as noted for conformanoe with
Qicable Rules and Pegulations of the
nam County Health Department.0
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it
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