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631- 589 -8100
73.08 -1 -51
BOX 27
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03405
BRUCE R.. - TOLEY.... _
.'' y�
DEPARTMENT OF HEALTH
1 Geneva Road
.Brewster, New York 10509
:LORFTiAi:ARI D �T N ..
wP.
Associate Public Health Director
Director of Patient Services
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
October 13, 1999
Ivor & Veronica Whitson
3 Miller Rd.
Putnam Valley NY 10579
Re: Addition - Whitson- Miller Rd
No Increases in Number of Bedrooms
(T) Putnam Valley Tax # 73.8 -1 -51
Dear Mr. & Mrs. Whitson:
I have received and reviewed the plans for the proposed addition to the above - mentioned
residence. The proposal for the addition has been approved as per plans, bearing the approval
stamp from this Department dated October 13, 1999 The addition is approved with the following
conditions:
1. The total number of bedrooms must remain at Four without prior approval by
this Department.
2. The area of the existing sewage disposal system, and its expansion area, must be
_ ' ..+�. .. .... _. . �T-..: ._...- ..— ;- .... -.. a. ^.aw... :i wY....S'__.. n-i. ..... .. u.. ...`:9 ...`. �. ..� -. -v_ .r. ..: . .....+er. .. , � N._T- .x.. �'...M..— ..-..:. ..a --.- u.. ..✓ar ...ter... -... ... _..p<.•..>y.p .
3. All plumbing fixtures must be updated with water saving devices, i.e., new low
flush toilets, restrictors for shower heads and faucets, etc.
Any other permits or variances required are the responsibility of the applicant and the jurisdiction
of thelown of Putnam Valley-
If you have any questions, please contact me at your convenience.
Very truly yours,
Michael Luke
ML:kg Public Health Technician
cc: BI
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
Tel. (914) 278-6130 Far (914) 278- 7921
PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY)
to" r' "M
STREET 3 *L eA /Za&a TOWN \44 t-zzl TX MAP#
ZVO/L 79— VEXOaic'q
NAIvE T4 osv PHONE r i PCHD #
MAILING ADDRESS J Alle t
CPA
Public Health Director
DESCRIPTION OF ADDITION Fw i� a g. �A c.6 /� ,E M ,�/ �
NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS
(FROM CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILDING INSPECTOR)
*Any addition which is considered a bedroom requires formal approval of plans (Construction
Permit) prepared by a Professional Engineer or Registered Architect in accordance with
applicable sections of the Putnam County Sanitary Code.
.r.n.r+a .... :w...fl-..e �-'TC�'+r�JS..� y.,.... ..].�: . -.,- -» .... F.e A.. .s .._..- . «�.,y.•w .. .— ...-�, v...4 .—.q -..w +. �,m..e• r ..,.JM_ «wr... �» —�{
Please submit this form and th% following to Putnam County Health Dept., 4 Geneva Rd.,
Brewster, NY 10509, Phone 278 -6130.
1. Certified check or money order for $100.00
2. Sketches of existing floor plan (drawn to scale, all living area including basement)
* Non - professional sketches are acceptable
3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #)
* Non - professional sketches are acceptable
4. Copy of survey showing well and septic location, to the best of your knowledge. Include date
of installation if known. Label all wells and septic systems within 200 feet of the property line.
Contact this office with any questions.
5. Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal
bedroom count of dwelling.
OFFICE USE
Comments
Feb 98
.ten v -- _ .. ._ tL L u. :.e1 n w�.. - i!•1 ='a� .� w9 �� +tn
DEPARTMENT OF HEALTH
Division . Of Environmental Health Services
4 Geneva" Road, Brewster, New York 10509
(914) 278 -6130
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
Re:
Residence
Tax Map 73g- I — SI
Town P-, a.— n1ILU�
Gentlemen:
BRUCE R. FOLEY, R.S.
Acting Public .Health Director
According to records maintained by the.ToNvn, the above noted dwelling
IS NOT
in compliance with Town code and the total number of bedrooms on record
is 4
This information has been obtained from:
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:
OTHER
(Q "Ijl�
Building Inspector
PUTNAM COUNTY DEPARTMENT OF HEALTH L = -
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION/REPAIR FORM
SECTION A: GENERAL INFORIMATION
Name of Project %"?i' (,- " '� (T)(V) !' TMrr
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. L.�Hilly ❑Rolling L`�Steep Slope 9Gentle Slope ❑Flat
2. ❑Evidence of wetland Clow area subject to flooding odies of water
❑Drainage ditches ❑Rock outcrop
ES NO
3.: Property lines. evident? _.... �, .
4. Water courses exist on, or adjacent to parcel. ❑
5. Existing ' individual wells w rtlun 200ft of th e existing ?
❑
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. ❑Level Gentle Slope ate6p slope
B. ❑Well drained DModerately well drained
❑Somewhat poorly drained OPoorly drained
r'
C. Area available for SSTS. (Primary & Reserve)
❑Extremely limited ❑Somewhat limited aAdeaquate —ft x ft
D. INSPECTION Date 0 3 9 f Inspector
o eridence of failure ®Evidence of failure ®Evidence of seasonal failure
CA
M
M
J
HOUSE
i
(1) Indicate location of SSTS
A. Size and type of septic tank gallons
Illetal OConcrete OPlastic
B. Type of absorption area
1. Fields ft. 2. Pits 3. Gallies ft.
(2) Indicate setbacks, front street, backyard, and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streamstwetlands)
�i
SECTION E. EXISTING WATER SUPPLY
CIPWS []Shared well Individual well
DDrilled ® above ground
0 D g
COivBENTS :
REPAIRS ONLY:
As Built Inspection Required:
Status:
As Built Submitted:
As Built Inspection Done: Inspector:
,CAc,,I.r "o,--
Cjr—A— VALt-ev My
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TN
7-9.. -7;?
1;
74- x
VA-4e-
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Ydf- ckow-1144
PUTNAM CGUIM WAKNINT OF HEALTH
HOUSE PLANS APPROVED FOR
I
A-L
BEDROOM COUNT ONLY,
VIR
% BEDROOMS
Signature & Title Date
U,
A /2 CoivB./7/eivErtS 46
0,AV
TV
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Cjr—A— VALt-ev My
t-
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TN
7-9.. -7;?
1;
3,yvILLER ROAD 1'voic yNU V <R o�vicH WyiToSp„/
Pi , NAM VALLEY -7-
UPSTAIRS / q x MA 10 _J
`Je
:a
4,
!, OPEN S
\ V O
OVLI§ ^
i' 10
BATFI( LOOM
5.9•y:9•�..
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ryJ
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7 `
BEDROOM
17.91 /2 ^S,1 1 •& 1 /21•
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16• &1/2
a
BEDROOM
a21 •s••a
PUTNAtvt COUNTY DEPARTMENT OF HEALTH
HOUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY;
BEDROOMS
.; PST
Sigrat:iie & Title Date
4
16.00"
- - -.
b
Cr2'8 ",+J
BATHROOf19: ��'
12.8.1/2'7C1Ts"
CLOSET
11 i
1
PUTNAtvt COUNTY DEPARTMENT OF HEALTH
HOUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY;
BEDROOMS
.; PST
Sigrat:iie & Title Date
8'6•X2' FOYER
10'2"
13'6"
DEN V5-X
LIVING ROOM
I79-1/2"XI413'
it'd
STAIRS A &o
3'5 "X 10'
POWDER ROOM
6
FAMILY ROOM
I8'1-1 /2")(13'9-1/2"
2`X9'I 0"
DECK
F
KITCHEN
eA
3 MILLER ROAD, PUTNAM VALLEY
OVERALL SIZE OF HOUSE: 46'21-A32'6"
(EXCLUDING GARAGE)
7A—X AllqP 73.
r.
pf
F.;
GAFU GE
25-5" ij:2 I
PUTNAM C.OUNTY.DEPARTMENT Oe"HEALTO
HOUSE PLANS APPROVED FOR
BEDROOM COUNT ONLY;
BEDROOMS
A.'—f Z 7*,61, /99
IM
F.;
LOT 13 �
3 ... At -
36' 01.34 Lr a
FT wo
o 4 /Ng GE F
e 4 SE =j- 198 31.
N LOT 12
m 15 Z
AREA = L0226 AC. t -
m
SEPf /c arSsEM /4R�A � ! w
�,�E of LEr i.vG iTREA Ar LEA3r / /!o X
o
a.
!G
rr Ile wall -
LOT 11
{! 669
4:
deck I ,
i t // ,
2,51111Y FRAME
d '
!� DWELLING ,
333 .
i
\C
0 Well
LANDS OF HOMEOWNER'S
ASSOCIATION
RESERVED FOR DRAINAGE
CONTROL PURPOSES
n
N /
---, 52.
F
R v. 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH
,.. Division of Environmental Health Services, Carmel, N.Y. 10512 J
Enggineer Mast Provlde� 1
P.C.H.D. Permit #—
Pen) 73, 3,l �
TIFICATB OF CONSTRU ON COMPLLANCE FOR SEWAGE DISPOSAL SYSTEM
Iota
at Ta>tMap Block Lot�T:
Owner/ cent Name -woo �/yeV�L1d0k ormerly �-1 Subdivision Name� fabdy. Lot #
MsWng ,Address !` Zip I. Date Permit Issued
Separate Sewerage System built by
.0 Address p,o�
Consisting of Gallon Septic Tank and
02 -y-TZwn Im VVA'
Water Supply: Public Supply From Address
or: ✓r Private Supply Drilled byWQ�Mj AN02115on Address 6' 0QX 654 PUT. L14V &
Building Type VJ'-5 WeQVII 44., Has Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?
( OJ TAAW K.!P .
Other Requirements �J
I certify that the system(s)— listed serving the above premises were constructed essentially as shown on th p ns f the completed work ( copies
of ahich are attached), and in accordance with the standards, rules and regulations a rdan with th 1 pan, the permit issued by the
Putnam County Depa tmelnt�of He 4th.
Date y / / —a-��— Certifi by p.E.� R.A.
Address No.
Any person occupying premises served by the above systems) shall promptly take such action as may be necessary to ure the correction of any unYnitary
conditions resulting from such usage. Approval of the separate sewerage system shall become hull and void as n as a pubt': sanitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes avallabic Such approvals are
subject to odification or change when, in the judgment of thhee C,.om,m,.isrsion'er of Healt ch revocation, modification or change Is necessary.
Data �� By Title f
PU NAM COUMN DEPAR24ENr OF HEALIH
Owner or Purchaser of Building
pe7IOrJ J) "ew PYn
Building Constructed by
H 1 Ut e. V-,j"
Location - Street
��t�►�nn V �.e�
Municipality
Building Type
°(02 ►1 3I
Seet
o Block Lot
kyv\'\")� VAv6-e,
Subdivision Name
\Z.
Subdivision Lot.#
GUARAMM 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
I• .._. _.....operate for._a._.pQd of_ two years immediately following the date of approval of the
�-_ �•.r °�°"-�`1:��`c:.]"'LilC'c�%�`C;f �. tRijL2 '�'isitvl7"�iiTi'iridtiGe`._:' iii °�i��"Scircz�"i'x:t��:,�'TS° 1%�stc'�it,.-'vi- �:,j�. r :_.. --
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 ie 'lding utilizing
the system.'
Dated this Z O day of 190)1
(Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Signature
Title
Corporation ame (if Corp.)
Address
/ C< Cm. t
WbLL L;U1vLrLL_11U[4 mrxuru
DEPARTMENT OF. HEALTH
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
/'00
WELL LOCATION
STREET ADDRESS:' wNi I I TAi GRID NUMBER:
0.
. t d" IL ke 'ter/
WELL OWNER
NAME. I V ADDRESS:
jpe 0 00 e I i
@,PBIVATE
USE OF WELL
1- primary
2 - secondary
V4ESIDENTIAL 0 &GLIC SUPPLY ❑ AIR/COND./HEAT PUMP 0 ABANDONED
0 BUSINESS 0 FARM 0 TEST/OBSERVATION 0 OTHER (specify)
0 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY 0
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST/OBSERVATTON ❑ADDITIONAL SUPPLY
�fEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL.
DEPTH DATA
WELL DEPTH fL
STATIC WATER LEVEL
91
DATE MEASURED
DRILLING
EQUIPMENT
Q ROTARY 0 COMPRESSED AIR PERCUSSION ❑ DUG
0 WELL POINT O'CABLE. PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED ❑ OPEN END CASING 0 OPEN HOLE IN BEDROCK 0 OTHER
CASING
DETAILS
TOTAL LENGTH ft
MATERIALS: 0�STEEL 0 PLASTIC 0 OTHER
LENGTH BELOW GRADE ft.
JOINTS: 0 WELDED CD-THREADED 0 OTHER
DIAMETER in.
SEAL: 0 CEMENT GROUT 0 BENTONITE UVHER
WEIGHT
PER FOOT Ib./ft.
DRIVE SHOE: OYES 9416
1 LINER: OYES EINO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (it)
I
DEVELOPED? .
FIRST
�
'
OYES NP.
A
_0
GRAVEL PACK
0 YES
0 NO
GRAVEL
SIZE:
DIAMETER
OF PACK - In.
TOP
DEPTH -ft.
BOTTOM
OEM It.
WELL YIELD TEST -If detailed pumping
-[WELL
METHOD: 0 PUMPED 1 tests were done is in-
9,C6PRESSED AJR formation attached?
❑ BAILED ❑ OTHER 0 YES 0 NO
If more detailed formation descriptions or sieve analyses
LOG are available, please attach.
DEPTH FaCM
SURFACE
1watir
Bear-
ing
Well
Dia-
M ter
Ine
FORMA71ON DESCRIPTION
coof
ft
it
WELL DEPTH
it,
DURATION
hr, min.
DRAWOOWN
ft.
YIELD
9pm.
jo y
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY. HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? o YES ONO
STORAGE TANK: TYPE -"11-y-l-'rd
CAPACITY GAT,.
PUMP INFORMATION
TYPE Ahb%q CAPACITY
MAKER ar.11/41 DEPTH
! H
MODEL VOLTAGE ME HP
WELL DRILLER NAME DATE
ADORES Aloylo"all 4s'idiff(TURE M_ AA/-
0 Adr
- 162Z7
111-10i
r /
LAB #
Yorktown Medical Laboratory, Inc.
Date Takeo
321-K�e _ r - �.� Ti ct: a Ti Me
Date Reported: 6 -25 -91 .'.
(914) 245 -2800. Collected By: H. We.ine&man
Director: Albert H. Padovani M. T (ASCP) PO /Client # 77-
Referred By:
r Sampling Site: Lot #12 Mitt et Rd..".'
PO Box Howand UJeine�eman �unt.in - Ridge Subd�.vtid.i -on
i •
Yokktown Heght4, NY 10598 Put- am V.�.2u Kitchen Tde
Phone (U4—) 132_62MO
1
L J
(For Lab Use)
REPORT ON THE UALITY OF WATER +'
SAMPLE TYPE:
I(Cheek.One)
INORGANICS (mg /L) MICROBIOLOGICAL
Alkalinity
Standard Plate Count
® Chloride
_
(CFU /100 ML)
Copper
200C
Detergents, MBAS
LE 2
Hardness, Calcium
Coliform & Related Organisms
® Hardness, Total
Iron
Circle Method • MF PN P/A
®_ Lead
® Manganese
✓Total Coliform
— Mercury
Nitrogen, Ammonia
- Fecal Coliform
—
- Nitrogen, Nitrate
— Fecal Streptococcus
Nitrogen, Nitrite
E. Coli
Phosphate, Total
--
Silver
—_ Sulfate
LT = G = Less Than
Sulfide
GT = > = Greater Than
Sulfite
NA = Not Applicable
Zinc
SA = See Attachment(s)
—
TNTC = Too Numerous To Count
PHYSICAL MISCELLANEOUS
P = Present (Positive)
N = Not Present (Negative),
PH (S.U.)
# = Also done because To-
_ Color (Units)
tal Coliform Positive
_ Conductance (uhms /c)
Odor (TON)
Turbidity (NTU)
REMARKS COMMENTS (Lab Use
__VNtable
Non- potable
OUTGOING:
(Check Each)
:r •
H2SO4
NaOH
ZnOAc
�. Na2S2O3
o.. Other:
(Check Each)
�LE
40C
GT
4 /1E 200C
—_ GT
200C
_. PH
LE 2
PH
GE 12
— Other:
NYS FLAP #10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NA) OF A
SATISFACTORY. SANITARY QUALITY ACCORDING- TO YORK STATE PUBLIC DRMING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DID NOT) ZA)C MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE DRINK-
ING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
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rill ea'oonstruetaA as shown on 21 a app►owd amandnialt tM►� to and b acco� dance with M standird; ruNS a r u nf'o JIM
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apaflnlMl alld a wrtttat',puarantia will OdrfurnishW tM owni► his NKaao► ;'`MNS w awgns-ey, "tM euilda►. thit .mid guile w will
tM'� oaWltbn anY'.pat Ot sa10 fawa�a$dlspotal�ayRsnl Curia/ t'ha�pwioA of tw0�(2) yaan`' IaNly foibwhq thiOaN of tM Ipu ` .�
ogt:ofktM?Ci►tflkatd o! Co"$trWbn7Con plNna olit4M ginalsystwn'er any npaNS,tMr o 2) t' ! tM d►ilhd wdll Aowiad 46ow ` t
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PUTNAM COUNTY
DEPARTMENT OF HEALTH
Date
To:
From: 1-5
Subject:
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John M. Simmons, M.D.
HEALTH DEPARMCNT-
Lj.Lv.L0.LvX4 OF rjL14% mvL1%vwA14JL4ftU HEALTH SERVICES
Deputy Commissioner of Health FIELD ACTIVITY REPORT Sheet of
INSPECTION
NAME
1:2 Orig. Routine
Orig. Complain
Z Orig. Request
No. Street m 11m No
Canpliance
Complaint Camp
MAILING ADDRESS Final
P.O. Box Post Office Zip Group Illness
Construction
TELEPHONE
Reinsjxaction
PERSON IN CHARGE* Field, Sampling Only
OR INTERVIEWED Field Conference
Name and Title
Other
DATE 21/7110 TYPE FACILITY
TIME ARRIVED 12 /0 TIME LEFT Explain
FINDINGS.:
1�
INSPECTOR: TELEPHONE:
Signature and Title
PERSON IN CHARGE OR
I acknowledge this Field Activity.Report. SIGNATURE:
6/86 TITLE:
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT- Sheet of
INSPECTION
NAME 49P7'71 - - - - Orig. Routine
MAILING ADDRESS
P.O. Box Post Office. Zip Code
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
1/5R �//-- � ' "Al I
X d W"
FINDINGS:
TYPE FACILITY
1 ` "-r%
Orig. Complain
Orig. Request
Canpliance
Canplaint Carp
_ Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
u
v
AM
/ -/' < ACS• GT' i
Opp-
INSPECTOR: TELEPHONE: ��s® 104r ' el
Signature and Title �, (P dap
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE: ®�
24l aYr. 'rstu�l9i9:abeunCYN�rip e4eA Af%*6 AZW
PUTNAM C06NTY DEPARTMENT OF HEALTH
C of .3ir4il� i af i^•riE " S err < p^ G�:.s♦ a W...e Sxi oxyrrr vc.
h . C laesTw
AFFIDAVIT — CORPORATE OWNER APPLICATION
FOR PEEL4IT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the 1111Milt--3r m atter of application for:
?el 6&1-e t� 6 J 6A)
I,
represent that I am an officer or employee of the corporation and am authorized
to act for ,06�7T�Di�
(Name of Corporation)
j d //( d(JJV
having off'ces at / //" %l?' 6U��
Whose officers are:
President: /7/('r
Vice = President:
Secretary:
(Name and Address)'
A � & -g&41 L)
A/W, (Name and Address)
Treasurer: , Qty / �—Z Ya
(Name and Address)
and that I am and will b
corporation with respect
thereto.
Sworn to before me this
of 0LC:(L
NJ d 70e-S'
A� /
e individually responsible for any and all acts of, the
to the approval requested and all subsequent acts relating
12> day Signed: ) %Qx'1-j
199,V Title: V, r
a ,
Notary Public
MAX L SAIDEL
Xft Public. State of New York
Oft 9820275
in Waftester County
OMMI Im Ex Im Nov. 30, 1989
8/84
Corporate' 'Sea'l
DEPARTMENT OF HEALTH
Division of Environmental Health Services
'TY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
�•iL � f 1 � � �9T I.\ Jr � _ .. . .� .._ ...�::. :•.:v ,. �.w4L Y�r�,i r : 5 \'Gl S � .• ,1 � � <R,
PCHD PERMIT #/ !// R�
WELL LOCATION.
Street Address TownVillage C ty Tax Grid Number
i e-r' -RoaA --?U+ yarn val !!�i a. - I I 81
WELL OWNER
Name Mailing Address a can �fPrivate
1 ✓Dn 1 JE �,,t,�-- t a G, Over-loa� Corr mans f 4}r, O Public
USE OF WELL,
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ❑ ABANDONED
0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
13 INDUSTRIAL O INSTITUTIONAL 0 STAND -BY Q
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED ? /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
ato SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
AAuJ z
WELL TYPE
DRILLED
13DRIVEN
ODUG
GRAVEL
O OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: u n
Lot No. / Z
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES c /PTO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
'i w _._. bUTk4CE-TO' RRG nRTZ ,FRUrrYvcA REST- ' li`iG:..,�.>...
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION �SEP TE HE
r={= 13
(date) / (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 b the Putnam County
Health Department. �_�,®
Date of Issue: f� 19
Date of Expiration: 19� ermit ssuing ffi a
White copy: H.D. File
Permit is Non - Transferrable Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
APPENDIX B
PUMNLAM CCUNrY DE2.WD= OF HEALTH - DIVISION OF ENVIRCNMR?ML HEALTH SERVICES
n1DIVIDUAL WAXER SUPPLY & SUEOURFACE SEM=- DISPOSAL SYSTEM-5
PM IT
DATE REVITDIM�
BY:
(Name of Cwn —er) (St=eet Lccaticri)
YES f NO DOCUMM
Permit ApplicationGr
Corporate Resoluticn
/ : e-
. o�
Plans - Three sets S/
Engineers Authorization
Design Data Sheet (ME) --Tu-B-�DIVT-SICN
Deep Role L,--g parc
-e Res- (3) Fill
Consistent Pero Res 1 11 -
---4— Perc Hole Depth cd
el,
I r-F I
L
House Plans Two sets
q:�j
Vari a�T �-Recues-
Legal S•7 Ddiivis,icn
ubdivision A-carcvai C1er c;
ac- approval SSMS Ad-�i. Lots Checkcad
Wetla.pid (Tcw-n/!)EC PS=-,2Lt-.R & D)
Data C-n DDS Plans, & Pe---,Liit-- Sa7ze
L7-- trendh provides- I REQUIRED DETATICS CN P=ANS
System Plan - (north ar-
=w
ft. rra i. I Se-wage System Hyc-raLfl- ic Prof .1 - Grave vv Flow
le-1 to contours Fill= "rile & Dimenslons - VbD-Mle
D o d,
100% em,. ;Tran6n/Galler k
y; PLzp piL.
C
F= SYS=
cl1aVbarrier
10 ft.
fill 11 notes
rlelq sue.
depth gauges
100 yr. flood el-ev_.-,'
200 ft. reservoir, etc.
150 ft. trigall/gall-. 4
- Size, U11M Size, F Vt�ll
Well Detail, Service L-*L,-le iff. . over
Cc n s t.rq&t 14 a t. ��s n,-;e,, r , r'-7.t e)
4-
D -s-
e ign Data: pert and deep res-,L'---s
Two-Foot Contours Existing & Proposed
Drive-Ray & Slopes Cut
Footina Zer
/Gat Drains (discharge CK)
Pere & Deep Holes Located
Representative of primary and e-=nsion
Expansion A-re--;shcw-n;gravitv flcw,suff. size
If Pt wed Pit & D Box SIicm & Detailed
House - No. of Be roans
Wells & SSDS's w/in 200 ft. of Proposed Systan
Pro.ae-rty Metes & Bounds
House Setback Necessary (Tight lot)
House Seqer - 1/4 " /ft. 4110; Ty ;e pipe
f No Bends; Max. Bends 450 w/cleanout
SEPARATION DISTANLICES SPECIFIED CIN PLAN
Fields
10' to P. L. I Drive-Nay, Large Trees, Top Of fi.
201 to Foundation Wails
100'.to Well; 2001 in D.L.O.D, 150' pits
Z 1001 to Stream, Watercourse, lake (inc. erx:
151 to Drains - Curtain, Leader, Footing
35,to catch basin,stL:ormdrain,ciped waterccur.
10, to Water Line (pits-201)
50' intemnittent drainage course
Septic Tanks
10' fran Foundation; 501 to w-e-11
15' Well to PL 9
• •' • � •• 1' 1� d• '1 ; �• Mme.
DESIGN DATA SHEET- SUBSUFACE SBgAGE DISPOSAL SYSTEM
FILE NO.
'
. � .. r -',r :::.a�: , :, v;..a.. �, •. ,rn�,,. •.a+ -.a s. � .... �.r •w. •..J.'.••.:.. � -'i_.y
ti�
v' .. .. n ..v-.....r.c.. •..:;•..�- .:,:.:• :.^{,,;
Owner e1i D51 Address
M TZSOVl
Located at (Street) ,1
S L Block Lot
(indicate nearest cross street)
Municipality l t
Watershed
SOIL Pg2U0LATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking ,(14, Date of Percolation Test 0
HOLE
NUMBER Qom' TIME PERCOLATION
PERCC A ON ,
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
^}
Q10
2 9OS- q35 .17
i 3 10•)0 uo . 1-7
4
5'
3D )
��
. —. -aws �.•�._�. o I� U� ! V // yam... . a. v .. wA �,c�.N... ��" ate.. ...�� .. q �++ vu�. Q w .. .. ... 7"w
V 2 7 T
1
2
3
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained it�each percolation test hole. All data to* be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE. SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
- .. _ -.y. . .o . ,•.ice. , r^ :.uP L -- .a. a,,. _...r - .�....'. .--.. .... .. w ;,.d•: ,r .. a•.: a•• ..p. .. „w ..>..: ... - .•. a.....- _:.�':.
G.L.
1 ° 16P-A4 ICJJ: AT 4'
2° n
3°
4°
5 ° �!
GL
61 if
7.0 r�
9°
.10 °
11°
12°
13°
14°
'GRCUviiTA i5 -r3' 00CJ Mic _..... _..._ ..,. _ ...... . __ . ti .._.. _
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING MMUNTERED
DEEP HOLE OBSERVATIONS MADE BY: / DATE:
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided. 10406
No. of Bedrooms - Septic Tank Capacity gals. Type
� of n,E� /
Absorption Area Provided By 8y L.F. x 24 �° width trench �� - �I (�o�
F
Other ! �+✓ "' S~ � o — �
Name / ` Signature'
Address SEAL cas�6e
a�ESSios+a
THIS SPACE FOR USE BY HEALTH DEPAR'TMEN'T` ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
I-AM,
T"__ -woo
ova "I
7"S
Mon. E0
IF C,
An
V1
all 12
7tt
WAS& Sol too 1 M%,"
No
-Wfy-
M. 01,
MA P
i
AMA-11
All"
1
fi
,nam County Department Of li"i dk
iivision of Enoironn9ntal Ilealth SerVIOVI�
SS noted for conformance with
Ipplioiblo gUles and Regulations
CpLt�ty Health Department.'
va..►.+»w► 3 Title UatA
am