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631- 589 -8100
73. -2 -10
BOX 26
..
low I
IN 11
1 r -U oil '9
r. r +.. IN r
03287
Yey. 3186. PUTNAM CoU
q Divlelnn of EnvhronmE
i =�EItTIFICATE+ CONSTRUCTION COMPLIAP
Located
Owner/ Resat Name
Ad d /: n --
� Mailing Address � Z N 4
0
F F a `;
1 / Separate Sewerage System built by
' J Consisting of l a Gallon Septic Tank and
zip �� Date Permit Issued
1 Water Supply: Public Supply From Al.-CM Address
or. " = ' Private Supply Drilled by Al. -Cq 9-:2 ZPIIA " !!� Xddress _ 156 4'- 6:( /�� {� ♦��� f''
Building Types �'/ C� "�� ee Has Erosion Control Been Completed? •�'
Number of Bedrooms 44 Has Garb a Grinder Been Installed? �
Other Requirementb 1.
I certify that the system(s) as, -listed serving the above premises were constructed_esse aalC� n the plans of the completed work ( copies
of wtiich are attached), and in accordance with the standards, rules and regulations, filed plan, and the permit issued by the
Putnam. County Department of itealth.
Date. "� I Certified by * P.E. - R.A.
Address
Any person occupying premises served by the above.system(s) shall promptly take such a
conditions resulting from such Usage. Approval of the separate sewerage system'shall b
a aliible `and 'the -approval of the private water supply shall become null and void when a
subject to otlificatfori or change when, in the judgment of the Commissioner of Heslth
Date ? e
of
License No � � S
IVI (gyp► o secure the correction of any -unsanitary
d soon as a publi: unitary sewer becomes
no becomes available. Such approvals are
modification or change Is necessary.
�1° Title
J� a WELL CUMYLET1UN tcr.rvtci
DEPARTMENT OF HEALTH
Division Of Environmental `Health `Se vit:es'
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
T"
WELL LOCATION
STREET AOURESS: WNJVILLAG1X4Y TAX GRID NUMBER:
,
WELL OWNER
NAME: ADDRESS:
a-PBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
I� RESID IAL ❑ AIR /COND. /HEAT PUMP O ABANOONED
❑ BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED `� —% EST. OF DAILY USAGE _��Lo gal.
REASON FOR
DRILLING
0] _PLACE EXISTING SUPPLY ®TEST /OBSERVATION []ADDITIONAL SUPPLY
EW SUPPLY (NEW DWELLING) ® DEEPEN EXISTING WELL
DEPTH DATA
c�o
WELD DEPTH ft.
STATIC WATER LEVEL ft:
DATE MEASURED
DRILLING
EQUIPMENT
R ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING 0 OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS .
TOTAL LENGTH _ _ it
MATERIALS: O STEEL O PLASTIC ❑ OTHER
LENGTH BELOW GRADE ft-
JOINTS: gWELDED THREADED ❑ OTHER
DIAMETER in.
SEAL: CEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT / Ib. /ft.
DRIVE SHOEgIES ONO
I LINER: ❑ YES ONO
SCREEN
z
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
o YES ONO
SECOND-
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE_
DIAMETER
OF PACK In.
70P
DEPTH ft.
BOTTOM
DEPTH IL
WELL YIELD TEST ' If detailed pumping
METHOD: O PUMPED i tests were done is in-
COMPRESSED AIR , ` ormation attached?
O BAILED ❑ OTHER ; Cl YES O NO
WELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
DIa
meter
FORMATION DESCRIPTION
coot
ft.
ft.
WELL DEPTH
It.
DURATION
hr, min.
DRAWOOWN
ft.
YIELD
Land
Soo
WATER . LEAR TEMP.
QUAU O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ONO
STORAGE TANK: TYPE
CAPACITY GAJ,
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAM DATE
"l
� j�� SIGNAT
ADDRESS/ S`-' URE
GcG�
3/89 U If
~ YML ENVIRONMENTAL SERVICES
^
f' ` � 321 Year Street
Yorktomn Heights, N.Y. 10598
(914)'245-2800
Albert H. Padovani, Director
`
LAB #: 87.304091 CLIENT #: 2745 NON STAT PROC PAGE 1
VADO-CORP , '
DATE/TIME TAKEN: 12/17/96
128 PUDDING ST DATE/TIMEREC'Dk 11/17/96 10;40
'PUTNAM VALLEY, NY 10579 ' REPORT DATE: '12/19796
PHnND (914)-528-1108
SAMPLING SITE: 468 PEEKSKILL HOLLOW RD SAMPLE TYPE-.: POTABLE
: PUT VALLEY ` PRESFHVATIVES: NONE
COL'D BY: MANUEL VASQUEZ ^ _ TEMPERATURE..: Q4C
NOTES.,.: ' ' COLIFORM.METH: MF
DATE. FLAG PROCEDURE RESULT ' NORMAL - RANGE METHOD
`
ABSENT 12/17/96 MF 1. COLIFORM; /100.ML ABSENT
COMMENTS:
BAS THESE HES0&S IN�D�ICA]E THAT THE WATEH ,(WAS NOT) OF A '
SATISFACTORY SANITARY QUALITYACCOHOING TO THE NEW YORK STATE.
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR TH&PAHA.ETERS
TESTED, ATTHEJIME OF COLLECTION.
- � -
'
SLUBMITTED BY
_ _ _ ___________ .
Albert H_ Padovani, M.T.(ASCP) .
Director B-AP# 10323
.
`r
PUTNAM COUN'T'Y DEPARTMENT OF HEALTH
_
DIVISION-OF - -
_..._._�........,; - _ ��t -..,
�... AL HEALTH - SERVICES -:
Owner or Purchaser of Building �—
Building Constructed by
Location - 'Street
Municipality
Building Type
� 2. rl5- `�f
Section / Block Lot - )
Subdivision Name
Subdivision Lot #
GUARAFPI'EE 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
"C_e_rt_ificate 'o_t- CQn t uct _ori.-Complfiance" f_qr the_sewage:di:s isaT` system, - "or _`a:ny, > -:�-
_c 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 Aje-d 199�1
General Contractor er) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Signature
Title _ �/�' //� S i L) V IV T
Corporation Name (if Corp.)
Address
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ivieion of- vironmental Health, Service
` proved ae noted Yor aonYormance witb
� �",, � r�` t .tpli.cablekRulea and Regzlatione of rthe r a s `'� �
imam County H[efilth Department
�14i.?lre 1k Tit1e �
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ivieion of- vironmental Health, Service
` proved ae noted Yor aonYormance witb
� �",, � r�` t .tpli.cablekRulea and Regzlatione of rthe r a s `'� �
imam County H[efilth Department
�14i.?lre 1k Tit1e �
„
WAN
F a E6 W Y;
WAN
F a E6 W Y;
PZMW MR =WAGS
o..ad.piresild
FVINAN CODL'f!Y DBTAR' WWrOF HMM
="M dR vbemmmmm Rsa11111 s r 9bm Cant NL N.Y. low b p"NUM P"" t
on CIR RISC ►TS OFCO -
STSTM Fait / N
.S.id. Let 0 T" KV Ca Z Big&
Lee An& L4,
4,
Sevemb SSWGMV Symbols to Comm of I lag aeYw Spa Teak • w 44'4 L I AJ �T(t) -ZA "—Mat e- t'
To be aealidae- b –F� -6' 1) Addleae
warm Pddk SM* Way Add ien
on :5W a . Sw* DldRed bYr: i ,J Addis..
C�"711
1 represent that 1 am wholly and completely responsible for the design and location of the proposed systern(s). 1) that these rata sew dt sal scam
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ns ream
County Depertmant of Health, and that on completion.thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of "with will
be submitted to the Department. and a written guarantee will be furnished the owner, his successors, hairs or assigns by the builder. that said buNder will
Place in pod .operating COndRion any part of seed to . disposal system during the period of two (2) yews Immediately following the date of the l au-
anp Of the approval of tho Certifir s of Construction Compliance of the original system or any repair t o; 2) that the drifted well daacribed above
W N be lasted as s1 11 on the approved plan and that Yid well will be Instal nos wilth the r s and rall'u ns oof the Putnam
County
D f rtmeflt of
Date
ff }}CC��,, (-' syned P.E. R.A.
Address License No
APPROVED FOR CONSTRUCTION: This approval expire two yews from the data issued unless construction of tre building has been undertaken and is
revecable for cause Of may be amandFd Or modified when considered nWGMrX by the Commissioner Of HeRh. Any change or alteration of construction
.O/$8 � lees . /Nwr� mi� A�ditPOY�of :onestk sanitary sewaN. an Pr eta water yply only.
.:...i: r.<.„.,..,,,, •re+::•r - «�;-"- -,..,. „...,...,. _ r... 2° >F.^c ,.d' s^. Y r, t r;4. -z •a�"`'- ,�'"'-�."-•- ct�'S• g., c ., ......:r
F6miiM 000N iY D�l�l1 OF O�.AL�H k y
ti DIsYw ait 8tsteaala`Itl' SaeAlaaa. teal. N.Y SY3U C is
Ftmvlda Fawttt!
F CO�AM(�
• w :, TS O
ap _ Yd FED FOO;S�WA� DISlOSAL SYSlS�1il
r i
pot 9 i/f' rTaa Bop` 3 • yak �' tea _�!: -
�Ct �1 es l�y t1 /� 4 Gov A/ Reotowgl �ovleiee
Om m /�An■eaot l�s p
Date of @revkaii'Appaoval
Addee. C v..�%J717 O �' u°Z / y Town /'cfrl . l�a // �P . / d = ✓7
9�
Harp Subdivision Approved ��' %,n. Fee Enclosed ® a,nn „rit
lyp G; ' lot Airoa / 3. i 9 fL` F� Smdlee oebr Depth vatome_
�.at Heroes : ; Dealgn Flow G• P. D ....5� �G P,CHD;Nof�oUoQi Ii 8aq�e4 W6en'FID b oaspiq>ri
Sepwaits SawmW Sloam M f O
oepatoi e[ Ga9ae Sapaec Task wig
®Ya6er fib'~ Falbde Fidrd Addreas
an y.fa.ee Sew hY •A&m .
®Iran Riq�hstale•' `ice i/7rGt ✓r+
1_►epresent' that 1 am wholly intl,complataly nspon'tibN for,ths tlaspn aotl location of the propoiatl systfrm(s) !) ,that thm eopara4e :Nw tlispolel stem
avow dast►i0b will mt tonst►ucted at shown on the'approwrl,"iinlant there. to,and in accordance witty eras, rules a rpq . ns na
County Oepsrtmant Of. tNanh,'and that on comONtion thereof a CSM Nciita of Construction Com ry to;tho Commissioner of Health will
� tubmnta0 ;to tM bpartnlant, ane a writtM euannteo will ba lurnishatl the owner, his sucoet s„ ' by tho builA�►, that ssio builder will ,
OYca` ih pOO:;OPafatilp eondnlon any port pP ssid sawaaa tlisposal system alurifle the pa.iotl of ttly followinS tMd•ta of the issu-
Or1ia o/ tM appaNl of tM CeKnkata Of ConsCiudion COmpllanci of tM orginal system hM t this drilNd will AeuriOad above
win M iocatetl as Mlawn on tM approvlo p1Gn and that taitl israll will ba,Instelled in a i4ince ith �, reA aTiions of itio Putnam
CouHealth' nty Adtlrs .;: ,, ,/. .: .M!' :. ; • �, `'
IRA.
Lcense No Data Pro %
z
R,”' OVED FOR CONSTRUCTION Th approval expires two years o the. data issuetl less c lading has been undertaken and is
revocabla•fo► ass or y boa or_r"i!"::Wheii eonsida► y by the CO omr q1;_ Y ehaiga of alteration of construction
reeuiroi a M parmi Oath f0► 'dl epOYl Or domistk MM[ a1W /01, Or at supply orA�/.
Rev. Gate �, �[ By / Title _
10/88 W
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New-York 10509
(914) 278 -6130
._:APPLICATION_ TO — ON.STRUCT .'A: WATER —,- ,WELL =.
PCHD PERMIT #
WELL LOCATION
Street Address Town Village Cit Tax Grid Number
WELL OWNER
Name }''ailing Address {
fly". Z
Private
Public
USE OF WELL
.1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O BUSINESS O FARM O TEST /OBSERVATION
O INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED_ - /EST. OF DAILY USAGE Soy gal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION M ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
ODRILLED
DRIVEN
EIDUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES k' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
// Lot No.
WATER WELL CONTRACTOR: Name A1 Address: �l� nJ 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 PROVIDE
ON SEPARATE SHEET
7
(da ) (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
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 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 drilling operations be contained on this
property and in such a anner as not to degrade or othe se contaminate surface or groundwater.
Date of Issue: 0 1/. 19
Date of Expiration 1 19 Permit Issuing Official
Permit is Non- Transferr ble White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
a rv^c +:.r.. _: v..:s :.::rtr ,.. .- ;:._ s;•�i' : �acr -:..x .a :.-._ � _. (•-`^ . _. �— _- �'--- ...�.. w..,.nr o.......:,�4,,.. ,r .., ..-x. . .:r-n.. ii .. = vr�.cer.a-s.w.•s. i�,c: _--
JOSEPH F. SULLIVAN, P.E.
CutaEEta�.ti� ;n,P,?h
2972 Ferncrest Drive
Yorktown Heights, New York 10598
(914) 962 -4248
July 30, 1994
Putnam County Health Department
4 Geneva Road
Brewster, New York 10509
Gentlemen:
Enclosed please find a construction permit for a Sewage Disposal
System for Vado Construction Company's lot on Peekskill Hollow Road
in the Town of Putnam Valley (Lot No. 14 Hunting Ridge Subdivision).
Also enclosed, please find an application for a water well for the same
lot..
The construction permit for this lot was approved in 1988 (Your File
No. PV 21 -88).
From a field inspection, there have been no changes to affect this
design.
Very truly yours,
,Joseph F. Sullivan. P. E.
88 -104
4 l t
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CODIf1 Y Sanisas. Coal.
t lQliiAl[. DEt OF
DNYM d)� "irw�taltl BM11�
` w C�l1FiC.ATS OF 00
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n
a.%arltla. ut r� Tam
t.k.
- Date aI
1iwWaa
D l a1
11iis Aaia><a++ - , Tows ,
Subdiwis:ion ,Any robed Fee 'Enclosed ❑ Amr;,,Tt_
5"m6 0* Valoa
Q-'
Abe : PCHD N�atlM b tared PtD b o+:M+ted
F)ow G P D
_�w!Pp.S7 n traa�it a[ Sa lle
Talk, odd
ly'ia aaaa4�eW b � rJ, —�' Adlhau.
Ratele PltYls Sa!!�I F►r
o
�1 ✓tl.t..�. � Dtid k' �'�• r -mss -
Otltalt
1 rp►is+„t tliait 1 am wholly a►nd eompNtay nsponsit►» for tM Wsi/nind on-9 Ma proposed systam(s)i 1) tMt tM ' ab sew di YI stani' ,
aCOrp dsaaiWA�w111,Ofa corstruatsst as shown on tM approw0 an,and,m,at thpl,to and ,M aCCO►Gnw wttn tM stanWrds, ru»f a r ns o m
�.
'oouKy WpMttnMlt,,o1,'`NMkA; "an0 tAt?on Con�pMt»n tliMiadf a!1C�iti /icata ";;of Co��t►udbe Compllinp' Ytidactwy to °tM CommiYloeNr of wlll
M ,tilOfnleta0';to tM'WpNtnlMt +nd wrRtM ta,aarantM'wtll M furnishaA;tM O,NM! his sucpwon, s aftipnt t►Y; tM OulkUi th+t 21116 OuUAM w111
plat'- iw`peA, opwathl� oofWitbn any Dart of .YW Ywa/+ Aispot+l ,:Yfbn1 -dwk,� t11a parklat'of two' _ I Y f MmmOiatNy f011owin� tMAKd Of tM'tYw
MN ,Of tM ypfoval' of tM GrtMicat� `01 Conriru,;tbn Ganpl»nei OI tM Ml/inil ofn :any r Ns t of Z) thot'tM -diNNd wNl'Cisakn0 above
ssNl M IOCabd as llblw On tM aoprarM Yl+n an0 tUSt saki will will hri`» nei 'ith t M><; 'r »s •ifid rNuTai Oros Of lM PYtM111
f:O11MY Oap�rt M, tlaalth. �,
5
P E,
i
Ll insa No
ApPROVEO }fOR'CONSTRUC,TION: Tt►it'.aop►ewl;a ■ pMat twe years :from tM' dab ,Ipuad un»st conihurtbn of M tiulktina t,as :ta.a„ uiWtartaksn atiM is
fNOCauN toi -fJ11N a nHY e� anw,daa er ,r,odMlaO whm'eonsidMfaO nKasYry, Oy _tM', COe,rnistiOnar of NaaiRh. Any Change or alta►atgn of oofptru,:tk,n i
pimak a w parmR . AOpreiiad f0/ Iitpowl ot- donwstk s.nR ry tawa1 an0 /or . Waits wale w00b , MY•.
11 M
REV. TROB
Date
10/:8.8 _
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (_914) 225 -0310
APPLICATION TO.CONSTRUCT A WATER WELL'
PCHD PERMIT # #,N
WELL LOCATION
Street Addr s
Town Village C ty Tax Grid Numb r
J�v Z- i l� . l,1 ta-
WELL OWNER
Name
'i
Mailin Address
. 1 9 1�!
7
OPrivate
O Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
® BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
Q AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT S .gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE ��,gal
O RVLACE EXISTING SUPPLY. O TEST /OBSERVATION M ADDITIONAL SUPPLY
B-NEW SUPPLY (4EW DWELLING ® DEEPEN EXISTING WE LL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
GRILLED
®DRIVEN
®DUG
OGRAVEL
® OTHER
IS WELL SITE SUBJECT-TO FLOODING? YES ✓NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ,100 —M.Q l
Lot No. f �.
WATER WELL CONTRACTOR: Name- v i�:� Address:
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 & WRCES OF CONTAMINATION PROVIDED
SEPARATE SHEET
wz/" w-,
(date) signature) /7
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 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 drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue:�G��%
Date of Expiration 19 Permit Issuing Off cial
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
_ •it1... t. _. ... ... a �� .: _►•ii- —•2 �_' -Sow r•��•• '+�' �.Y/Oa.rt.� '1f�Y.i�:i'iili�i:1! .. ._ .,. �.7.: � �.:.T1
PUTNAM COUNTY DEPARTMENT OF HEALTH
�- 3kivs:sian .,o f-. Envaron�aentl- etbr�Serrrsices-
...- ,- :.�._e_�,.;;,r.,.... tea.. -•- —
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PEL41T APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
VA-
represent that I am an officer or employee of the corporation and am authorized
to act for
Name of Corporatic
having offices at 7J l`�u �-7( n1G,
�CiTt�t�t.
Whose officers are:
President:
Name and Address')
Vice - President:
-(Name'-and . Address').:__._'_...
Secretary:
(Name and Address)
Treasurer: I" 0
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
of 19q
Notary ub is
Nagy. itC, $teie Of 18W Ndfdt
- ! Nb: 4878911
bualitied 1n.Westchester County
pmCniRSior+ Exr)..irps Noupr,her 11) ' A9V
h
c/o/.
Signed:
Title:�st f-
Corpbralue Seal
r
r
i
PUTNAM COUNTY DEPARTMENT OF HEALTH
- --
_.
y.I - � I ON.:0.1♦, _EN
- - VI120 -= ?fib' fl:- :�R�IFs��a- .- .:��:;.F.- _ •�. _:.,.;.- - c.�.. -..-. � „ ....
?` T
Date V
Re: Property of 1//, -2Cn �&Cp
Located at
(T177i31_1) AYx V4CL (0 a Block Lot
Subdivision of
Subdv. Lot # 4- Filed Map # Z7-16 Date
T. MICHAEL DALY, P.E.
Gentlemen: CONSULTING ENGINEER
This letter is to authorize P. 0. BOX 243
� N.B. 20387
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
connection' with `thi =s matter and to..supery _s'e . tYie. =_c_�o is_ ruc:.ti'on. o.f._.s.aisi__,
t _ .
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,
> s)
gn e d �i
^'
'Owner of Pro ert
Countersigne�� p }'
P.E. , R . , # 7 7L�' Ad
• Add , ess
T. MICHAEL DALY, P.E.
ONSITINI C ENGINEER t- l/c s 7 �as� .
Address P. 0. BOX 243 Town
SHENOROCK, N. Y. 10537
Telephone
Telephone`
PUTNAM C0= • E• • r = OF
DIVISION OF ENVIRONMENTAL EEAIAH SEMCES
DESIGN DATA SHEET- SUBSUFACE SFWAGE DISPOSAL.SYSTEH FILE NO..
r:; .3eK--- •- ^CS•. : "%z �.4 ��'_t:= .:- .e..:.� ,- `�'<; t,.;= ,'.��'T.s,-�.. .. . >s :. .. .:••:- '�,..;,,�.: s.-... aa��: y�:- � .,.:...n..r..- er—_r- ..+c -,... r. .nc ,m -v... .r .. ><
Owner rl a n� �Gt"� S Address a ^
ii 7 iS /y
Located at (Street)'?-K', Ki ;_L lda��r ` 4 . S� � Block _� Lot jt1lZ
(indicate nearest cross street)
municipaiity Watershed,,5wsx,/ - d�-
y iP�.�l S
SOIL PERCOLUION TEST DATA RBQUII2ID TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking
Date of Percolation Test
HOLE
- /ASS'
NUMBER CZ= 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
153
.j 2 1/40 -/rx-5' .s J0 a3 3 F. "' .
j 3 -40 ,013 3 if
4
5
1 le —,
- /ASS'
-20
i
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 measurements to be made from top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES.
&Y%YT
LLr iLl AVLY: LVL/ IIVLLi~NOo -Ci —1VlJ.
G.L.
2'
3' ,� v
41
5' a ��
6' r, M
7'
8;
9'
10'
11'
12'
13'
,14'
INDICATE LEVEL AT WHICH GROUNDWATER IS.ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED aaer 9
DEEP HOLE OBSERVATIONS MADE BY: - DATE: jo �
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided 60,00 '¢
No. of.Bedroams 3 Septic Tank Capacity % 000 gals. Type N19,S,017 y
Absorption Area Provided By :3-?3 L.F. x 24" wi N
�y ti� r.1Ci-I,C�C� 0,4
Other -71 f l i niAl wAi n1
Name ! iii mss_ a i. Y Sig e
Address
S 0 048 �� F.
P�OFE S S 1n� �~
nd�nU,K Al I/ AO50 7
THIS SPACE FOR USE BY HEALTH DEPARUTM ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APP LOCATION TO CONSTRUCT A WATER WELL , + �
Drun D,. Dwrm u
WELL LOCATION
Street Address Town/Village/city Tax Grid Number
ar✓� q le, q 45�a - l% -%d /?
WELL OWNER
Name Mailing Address `a
/,tlo 4,1
rivate
O Public
.SE OF WELL
1 - primary
2- secondary:
RESIDENTIAL ❑PUBLIC SUPPLY ❑AIR /.COND /HEAT PUMP.
O BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY
❑ABANDONED
O OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT_ gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE�G'�7 gal
REASON FOR
DRILLING
EW SUPPLY O PROVIDE ADDITIONAL SUPPLY
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
En LL TYPE
BILLED DRIVEN
DUG
®
GRAVEL
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES i,,-' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name /ifrx. Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A*�NO
NAME OF PUBLIC WATER SUPPLY:
DISTANCE TO PROPERLY ~FROM'NEAREST WATER MAIN:
TOWN /VIL /CITY
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
n oN REAR OF THIS APPLICATION ON SEPARATE SHEET
( at ig e)
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 requ' ements of the Putnam
County Health Department attached to this perm t.
3. Submit a Well Completion Report on a form prov ded y th P t unty
Health Depar ent.
VA
Date of Issue: 19
Date of Expiration: 19�_
Pero Issuing Office
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
rw-m -- - T.7-11 r%__1 1 __
JOSEPH F. SI` LLIVeANe P.E.
&niQdi W4 &*PLB"
2972 Ferncrest Drive
Yorktown Heights, New York 10598
(914) 962 -4248
July 30, 1994
Putnam County Health Department
4 Geneva Road
Brewster, New. York 10509
Gentlemen:
Enclosed please find a construction permit for a Sewage Disposal
System for Mr. Perry Victor's lot on Barrett Circle West in the Town
of Kent. I have also modified the design plan to conform with the
regulation of a minimum of 100 linear feet of 24" wide trenches per
bedroom.
Also enclosed, please find an application for a water well for the same
A construction permit for this lot was approved in 1985 (Your File No.
K 2 -85).
From a field inspection, there have been no changes to affect this
design.
84-226
Very truly yours,
_�. -..... �....... • �...r . s _ . .._� ., .. _...... � � , .� ._ . _ ... ..
APPENDIX B
PUI -NAM CCUN Y DEP_AR`M= OF HEALTH - DIVISICN OF &WnRCNMENTAL HEALTH . SrRVICES
IN DWIDUAL WATER S'JPPUi & SUB-cMM CE WAADISPOSAL SYSTIIvS.
REV= .,.S'r1EE'1'. -- CQNS=CQ`ION.'.PERNlIT _
.. n ....... ! l�..�.. p 7.��
BY:
(Name of Cwne --) (Street Lc mticn)
CCM-M.
YES
[,-NO I
I,
I
I
I
i I
I
I
I
I
i i
I
i
I'
Lt' trench prOVLde^_
re—ui: -
60 ft. rm::. _
Parallel to ntours
100% e-,=
i
r
I
i'
I
I
I
I
r
i
FI✓ SYS • S I
,
clav ier
(�
10 ft.
f L not is
ne:v sue.
depth gau es I
I
100 vr. fltSd elev.
200 ft_ rese_ oir, etc.
150 ft. triga i /call.
DCC[J =S
L.
Pe=dl- Application l
Corporate Resoluticn ( j
Plans - Three 's`ts (Z _
i
Engineers Authorizati cn
Desicn Data Sheet (DC�) Su7 Dr1ISICN
Dew Hole Lcg parc
Consistent Perc Res-.is (3) Fi11 --_
Per Hole Depth a
x Ily
Hcuse Pl- s TWo se S - _
Well Fe mic; F,Y� 1e- t =r
Variance Reauest
C�-L
La-c-al SuLdivisicn
Subdivision Aonroval
Fx -a_ p rcor 1 SSDS Pd-� L :Ls Ch rcer
WET' and (Tcw --/DEC Pe ii t R & D
Dam Crn DDS Plans & Permi` c-
REQL -= DMI TT c CN pry
_ =cS .vcge System P'an rw)
Servace System Hydraul ? c
-F-i-1-1 Profile & Dimensicns - Vc-L �.
D or J Eox;TrenGZ /Ga11_ry; _P�.�� pi. der: its
Septic Tank — Size, De*-=-,l
We-' ! Detail, Service Line if ever
Ccnst�-ucticn Notes (crinder rte)
_.��1CI1 I)dL�:,l prr ariC�GS J resU• =L
Two -Foot Contours Existing & P_oresed
Drive ay & Slopes Cat
Footi n /Gutter, Curta i n Drains (discharge CK )
Perc & Deep Holes I,ccated
Representative ' of pr; wry and ex_...ansicn
Expansion Area; shoran; gravity flcw, s'uf= .. size
If F,mu)ed Pit & D Box Shcr-n & Detailed
House - No, of Bedroans
Wells & SSDS's w /in .200 ftC.. of Proposed Syst`-
ProperLy bites & Bounds
House Setback Necessary (Tight lot)
House Sever - 1 /4 " /ft. 4 "0; T_�ce pipe
No Bends; Nix. Bends 45° w /c_eancut
SEPPIRATION DISTAL'3C�'S SPECIFIED D CN P12 -IN
Fields
10' to P.L., Driveway, I rge T: as,Tcp of f:
20' to Foundation Walls
100'. to Quell; 200' in D.L.O.D, 150' pi-
100' to Stream, Watercourse, Lake (inc. e-'K
15' to Drains- CA=' --in, Leader, Footing
351to mtca basin, StOm rain,cipei Ovate -'ccu
10' to Water Line (pits -201)
50' intenn.ittent drair-age ccurse
Semtl.c T:aiks -
10' fran Foundaticn; 50' to we:,.'
15' Well to PL 9
WP
.hy.-mako, juglogy'nowwom •
It •' • � •- •' 1� Y• •1 D1• Mme.
rn�,= F.SIGN_".SS!TAGE::DISPCISAL SYSTEri - FILE .NJ
Owner Address
f,
Located at ( Street) ,��5 /ii/% h4Acj vtJ &ec - Z-2 Block /% Lot
4
5
1 /l� V
4
5
1
2
3
4 _
5
NOTES: 1. Tests to%be repeated
are obtained�at each
for review'.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. All data to'be submitted
be made from top of hole.
(indicate nearest cross street)
Municipality
IC7c4 � �111e- ,;e
Watershed
SOIL PERCOLATION TEST DATA REQUMED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking i _ Date of Percolation Test � f �
HOLE
NUMBER CIDCR
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
a
2-7
2���ry�
4
5
1 /l� V
4
5
1
2
3
4 _
5
NOTES: 1. Tests to%be repeated
are obtained�at each
for review'.
2. Depth measurements tc
rev. 9/85
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
---DEPTH - H9T,�E
.et- _ aw•a:.. . - _ .. ._ -.r �- :.+!: rsc�:.,+.e:••Mc _. r. -.. n -: -..: ••et. _ cu-..a s++ -tisr_ :.�� +s r.�►.o
G. L.
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED'
INDICATE LEVEL TO 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���'�
No. of Bedrooms Septic Tank Capacity gals. Type����'�
Absorption Area Provided By L.F. x 24" width trench
Other i
Address 7i
6f,,
THIS SPAPE FOR USE BY
Soil Rate Approved
Signature, v a FRANC/ s
A11V WI-7
DEPARDTM ONLY: `"p#OFfS`S N
sq.ft /gal. Checked by Date
# »:
,• b�V �1 ®F ®� . ®� �� {�WUYT i1i �Y_1 ty>' } �t51.19VtiVCC® X
A6,$rraND
, V ���� 4�4\ fix 4F •.�
,Q,ccATro� ,
�
FORq► {PER.HIT, ABf}k.I ��p M ily
�- r` ±� "a •-rti= •vn..:i wv+%u.sm ....: a,.. .'C V�7 �'�1/L� s"�4'r . *`.u.siv r.+A�. n -.w.. .-q9 •-rs
ission of Health 3S ,
TO: Comm er �tig5 ?yty�t err Gus S L 4
ra r a
in `.the matter of 41PPIlcati f ,> X11 y �;` ' ,ty,
i Y
i
i authorized
,'• rem to eet�.e� kr fie` rat�.on sand a�
represent that I am aa.'officer 0 P Y
3
to adtt #or oration
e rP
14 am
of Co
having offices At r
Whose officers are'
P ;Asident: (N u
. ame and .Address) .. .. '
Vice- President v
(Name and Address)
Secretary:
(Name.'and Address)
Treasurer srnd Address _ '• - '
«- - - --- -' - r
and that I am.'
m' .and will b
e: individuahy responsible for any and'all ,acts ;oi the. }t
corporE'ion with .re'spect.'to the approval.Yequested and all subsequent acts relating
Y }
µ ry
thereto. r
Si ned
Sworn to before me this day $
Title:
Of l
r '
Notary
�r§�{
' z j t'7��,OWs
rYa��� Vof 3
yy Li 'Y�1kC1-'' ry {,
3i P 1', 1 LY 4 i d{ 4!- �'•S .I t
Ek
�7`.y. `r^ J\ „. ?r
-` 6ty-sr .EIS •]'^t:
'h hHYsyas..
r xr + •' l"'d'S'�`yY�'?"ckita +x^tt,.';s„
tit
.v •..' � '� 3 •., M' y" � � 'S' +., i ''�„P rM Y ",k ��4 � 5 "5..4 _- Y JC �tA � �C 4�
•:; { 3r 4 Q,yvrL... df t4 t{ t✓SA cbrr ?1
* ix,
yW"�i
8184 v y
u 1.� Rtr R!N�a,X�, kx dSy"3'r IV
c;} ssi'tc's�`'fi r,. �r+„•-
John M. Simmons, M.D.
;P V,il` M' `�^ 5!� �' i.,r� �t � Y,L'.W . PK�
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet ► of l
/l�I � INSPECTION
NAME /1U��� /�(i / tl�� 5-ol • _ Orig. Routine
_ // f� / / Orig. Complain
ADDRESS��5'/�/ / C �'TaL� ®!,� �(/�• (J�L ��� Orig. Request .
Town
MAILING ADDRESS
P.O. Box Post Office Zip Code
Gylppf;C"I
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE 0 ®Y V TYPE FACILITY
i :cc 1O R
TIME LEFT
FINDINGS: i
Canpliance
Complaint. Comp
Final
Group Illness
Construction
ZZ/ Reinspection
Field, Sampling-Only
Field Conference
Other
Explain
INSPECTOR:
Signature "and Title
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE: