Loading...
HomeMy WebLinkAbout3528DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 74. -1 -9.12 BOX 28 :� -� ,to r i6i ', - - ■ 03528 ......... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT on btrdetAL66i��. M, Mdaeb-j Looe- Z.- 1,116 hNil age':"" ;Iylpj" Va-Ile4d 'I'Map ax iRd W Block Lot(s) Well Owner: Name: * ' Address: ,960-7"t ZCL15 9 003 [a-n(f pl)*Vc" Vaal eg A)Y- 10,5-79 Use of Well: 1-primary 2-secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipme nt Rotary _ Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _ Open hole in bedrock Other Casing Details Total length 5'1 ft. Length below grade __'2Lft. Diameter 6 in. Weight per foot _Zy lb/ft. Materials: ,,/ Steel Plastic Other Joints: Welded .,'Threaded Other Seal: Cement grout Bentonite Other Drive shoe: --Yes No ILiner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test Bailed Pumped _ Compressed Air Hours Yield 5 gpm Depth Data Measure from land surface-static (specify ft) During yield test(ft) Depth of completed well in feet We , 11 Log If more detailed information descriptions or are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description . ft. ft. Land Surface C" rxj(- .10 Q, US 4A." If yield was tested at different depths during drilling, list: r Feet Gallons Per Minute Pump/Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Completed Putnam County Certification No. 003 Date of Report -7 I Driller. (signature) i,Nv it m Lxact iocation or well witn aistances to at least two permanent landMarKS to be proviclea on a separate sheevplan. Poyp�llwl& .10,141 Well Driller's 1jame,/ Ira &4d Address: C19 Z_ etk-md MY' 14S72 Signature: S I t � D � ae: _ L I – ­441Z e White cop�.`HD File; Yellow copy - Building Inspector; Pink copy-- Owner; Orange copy - Well driller Form WC-97 JUL -23 -1997 09:24 JOEL L.GREENBERG.ARCHT. JOEi: x AWI T GREENBERG Wo.hMSCWT..ROAD= I�tQR''H; =`.MAHOPAC'-�NEW XORK'> (DW - 628-6613 -'.FAX NW:628 91`4 628 2807 P.02 >•��Q Yut7iaus LuuzltZ i;ej)ar-Cm:irc of N.. ltiu 4 hvinion of Env±ro ^,mental Haalth So._rvi cob a- n �1 confer =lne aatb e t. iWicable _ f a ar. g ?ationa of tits ',, !.tatzlam County ., tart a r, t. ir -- s 4,o err - �- .R'`'`°--- e_r.�,• -r "— .-- ��•-� -�; 1w.O6tiea �� - ^� •rte— � % - • S�yI �^ ♦ •� � - •••� TOTAL P.02 JUL -23 -1997 09:23 JOEL L.GREENBERG ARCHT. _ nw ''nl:^li :. + :�l.M 1w --�1. ..�.�4 ♦v.)•t.. H'F :�� V� �•p�.•.r .AU01'I"bD a - ..- �lY :S."_� "r',� 914 628 2807 P.01 .. ••6: shat_.. �A1E'OO�f!!�'DIQAl�OSlfl' OPafiAL78 Oledr:tdim 4larrraaiB .d01,301kw.Ctr.d,N.Y.low wtawtiaflwwr MASVC1M P8 MR 99WAC8 MWOSAL mac' . Z.asla� 15 NORTH MEADOW BANE' ; TOWN OF' PUT AM ..VALLEX vatic. !lame .7 LIMPER % .. 'Lan / 2 pa %4 • Bit& l �� 9.12 .d;13 t).fffNAe�elurt. SCOTT LOOS Oaoa :of Pl..tew Apr '132.- OSCAWANA U .: &D . Town PUTNAM rVAI,x,EY; i�)l nAU Subdivision Avvroved 6'tl/45 Fee Enclosed a'-'-Aiilni,.,t ,/3o'0.00 '" jwmbs 'gip ONF FAM- RFS :' , 3.007 'AC. fib. D�V vailea / lY�Br of /ate�s 4 f1:dp Ylet. C P D S 00 P�HD r se4 NV b eafrlatad ". 1250. 500 L. F... Saprafa. sytt�r f..adut ai �-�- $mOtl 7ma Md OF '.LEA LNG FIELDS lb r. a..o�tatt b NC3T :SELECTED A . wtthr 4: p.�r. fh.i AAArm _ _. X NOT SEI, 'C"Y'Et j& y ' l ftprMOt that? On wAOUy and cofnaa.laly refponsole foe tla d"ien and loution, of: !M: syttefh(0; 11 that •th. taonat. a.wa .ilis t.l_�tt.n, abotrt,d —FAA 7,111 Oe mnttruct.d as mown oh pie alw►e.ad amsna,ntnt than to sr4 .Macaw Ctahtp 9"W1 2 Vf Noah, and that on evmp.tion t1wrear a - CenifUatt.'ef Conotrual h4 with tM itandrdo, ryiaf a ltia Orgli ul—i nea" tall aeeo.y to lM GommlfNonr 01 Naaltttwltl r n,4w�ttt.0 to lhaf0a0ertWhtfN, and a wr{IIp1 tMtanMea wlp, a tM ewutim ilia t tabs or tli�ns toy tM'"Imr, that aid bands, wtlt �ittt 40 vow oa►atMlo,comittwt ant, pan of aid ftoraPt dltpool ufbv file Per IwOli) hrad4tehr follttwtnP thedat..ef Me Itlw coca of tM 41101' el of tfq Cenittcate of xonetruf3teh' Celnptt..C. o . M Met Ryden, �.'.. #"airs t o; 2) the# tM d►ditl wail p.ttTlaad atto.a wlp.M W-00d n thew# "V_ apple plan and lnal.uld well will te must wits. and na'u en of IM rytMT Couhpr Ow"Ruat of NYlth. - DO' 2/24/97 Si ned ..e. _.-._. w,n.X Ado OR MUSCOOT RO NOR H PAC'f,, Y kemNe 1'1.056 ' APPROVED FOR COk%'rQuCTjONc fill% approtaf tapir, owe y rs f the e i uni,s:condru.tien of t ou;ldwq naa t,aan unOarbMth tilt H ra.eaatlq /er :raues.o. thaY.at anrnead orntodilNdwhanconMdtrtd t t -MMDh A ,�Ittatan of.aewstruatbn n.uaef •now perm# ApWO." for dispeni of defmdk mmita r wd o : Rev.: 1 i APPE'M I X C FINAL S l t INSPECTION DATE: Inspected by: �• o ��� CWNER PERMIT ; /01 Y- T7 TM OR SUEDIVISIOfd LOT 1.. SEnAGE DISPOSAL AREA a. SDS area located as per approved olans b. Fill section - date of placement 2:1 barrier LGTH WIDTH. c. Natural soil not stripoed d. Stone,brush,etc.,Qreater than 15' frcm e. 100 ft. from water course /wetlands 11 SEYtAGE D I SPOSAL SYSTEN a. Septic tank size - 1,000 b. Septic tank installed level c. 10' minim-m frcm foundation d. DISTRIBUTICN BOX 1. All outlets at same eievation - wate< 2. Protected below frost 3. Minimum 2 . t. oricinaI sci l between t e. ,A Tq,;F 1 ONd BUX - croper I y set f . TRE.NCFES 1. Lencth reruired - 50a L 2. .04s'-ante '-o watercourse measured Irstalied accordine to clan 4. Slcce of trench accectabie 1/16 - 1/32 TO feet ran property lire - 20 feet - =:x- 6. Decth of trench < 30 inches frcm surface AVG. 'S =yea 1.250 ested x and tret -- instal' ql- /Ov f i 7. Roan alicwed for expansicn. 100% Size of travel 3/4 - 17" diameter 'ciea_^ s9;- nth- of-- :c.—.ave -l. _ n. tr°rm._12 ". minirmn -- - -- 1U Pace e enes`carx�ed OR DOSE SYSTEMS 1. Size of comp chamber 2. Overflow tank 3. Alarm, visual /audio 4. PuTO easily accessible marihole to trade 5. First box baffled 6. Cycle witnessed by Health Department estimated flow per cycle HOUSE a. House located per approved plans b. Number of bedroans WELL a. Well located as per approved plans b. Distance from SOS area measured c. Casing 18" above -grade d. Surface draina,-ge around well acceptable OVERALL WORKK6J M I P a. Boxes proceriv grouted b. All oipes partially backfilled 9c All pipes flush with inside of box e. Backfill material contains stones < 4" 60 Curtain drain installed according to plan (. Curtain drain outfall protected & dir tr Footinq drains discharge away frcm SDS ar . Surface water protection adequate i. Eresicn c-ntrol provided f i YES NO 0Of"ff`1ENTS f v ALL i m Adv- AXIV ' Y RL PUTNAM COUNTY DEPARTMENT OF HEALTH �_r ._....:. . I N'J YWy,•.. Ni.: i .E'.� NT-A -L.:T. l " W TH .�. 1 SERVICE.. S I I v _... .. - �.+t•r,�!'n.. �.a.i.:c.�r �n�nJZ..: :.i ��. .: iPv ... ►ti CERTIFICATE OF CONSTRUCTION £COMPLI-ANCE>FOR SEWAGE TREATMENT SYSTEM Located at 15 NORTH MEADOW LANE Town 1wYftp PUTNAM VALLEY Owner /Applicant Name SCOTT LOOS Tax Map 7 4.. Block 1 Lot 9.12 Formerly N/A Subdivision Name Subd. Lot # 2 JUMPER Mailing Address 15 NORTH MEADOW LANE , PUTNAM VALLEY, N.Y. Zip 10579 Date Construction Permit Issued by PCHD 4/11/97 114 LESTER CLARI{ ROAD Separate Sewerage System built by GEORGE BELL Address NEWBURGH,_ N, y, 12 5 5 0 Consisting of 12 5 0 Gallon Septic Tank and 500 LF OF LEACHING FIELDS Other Requirements: 7 FT. CURTAIN DRAIN Water Supply: Public Supply From Address ROUTE 52 or: x Private Supply Drilled by BOYD Address CARMEL , N.Y. 10512 0r;: Nis erasioi corirol t�ee�x.co.y�pleted? .._._..yS _ t. I �-�- -r ... _ _ Number of Bedrooms 4 Has garbage grinder been installed? Me I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD onstruction Permit and approved plans and the standards, rules and regulations of the Putnam County Ike t of HeAth. Date: 7/6/98 Address Certified by JOEL GREENBERG (Design Professional) Any person occupying premises served by the above system(s) E. R.A. x License take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocatLmodification or change is necessary. By: 1 Title: Date: 73 White copy - HD File; llo - Building Inspector; Pink copy - ner; grange copy - Design Professional Form CC -97 I /," i �Ilt -. � "I _,V WELL (;Ur`U!LbT1Ur4 MirUNI 12. DEPARTMENT OF HEALTH Division '6f �nvironiti8nra "fi�ai S�dtvi vs PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION SiREEi ADDRESS: law-h-1vilultiam TAX GRID NUMBER: 15 N - tykaLO Lan 0 1 e- Pvhvarr Va-fleV WELL OWNER NAME: ADDRESS: &0_�* /_001S zoos Z"e— Pcl�-Ivam VO-Ilekl NY. /:;74TP1,UBLIC IBIVATE USE OF WELL 1 - primary 2 - secondary RESIDENTIAL 0 PUBLIC SUPPLY ❑ AIRICONDJHEAT PUMP 0 ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST/OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL 0 INSTITUTIONAL 0 STAND-BY ❑ MOUNT OF USE YIELD SOUGHT s gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING E]REPLACE EXISTING SUPPLY []TEST/OBSERVATION []ADDITIONAL SUPPLY f T'EW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA J A57 ft. WELL DEPTH 7u — I STATIC WATER LEVEL :�=ft. DATE MEASURED DRILLING EQUIPMENT CIROTARY /6 COMPRESSED AIR PERCUSSION ❑ DUG 0 WELLPOINT ❑ CABLE PERCUSSION 0 OTHER (specify): WELL TYPE ❑ SCREENED /ErOPEN END CASING Pq OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH ft. MATERIALS: )afTEEL 0 PLASTIC 0 OTHER LENGTH BELOW GRADE ft. — JOINTS: ❑ WELDED 0-fBREADED ❑ OTHER DIAMETER in. — SEAL: CEMENT GROUT OBENTONITE OOTHER WEIGHT PER FOOT Ib./ft. I DRIVE SHOE -OES ONO I LINER: rjYES ONO DETAILS SCREEN DIAMETER (in) SIZE LENGTH (it) DEPTH TO SCREEN (II) DEVELOPED? FIRST S ONO GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK fn. 70P DEPTH —tt. BOTTOM DEPTH — h. WELL YIELD TEST I -'If detailed pumping METHOD: 0 PUMPED t tests were done is in- ❑ COMPRESSED AIR larmation attached? 0 SAILED ❑ OTHER 0 YES ❑ NO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACEIBear- Water inq Well Oia- meter In FORMATION DESCRIPTION CODE ft. ft WELL OEM it. DURATION hr, min. DRAWOOWN ft. YIELD gpm- L Sand& c, 30 &CIL/ 30 OR rx x - -5 qj 5-5- . g/) i 51y 1 lo - I , — .76 1/015-1 0 A /i?_SS WATER CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES 0 NO STORAGE TANK: TYPE CAPACITY GAI,. PUMP INFORMATION TYPE CAPACITY MAKER a&10k,41V DEPTH MODEL .r y"I — VOLTAGE .23 0 HP =UZ V OATE WELLORILLERNAME )3,,j4( ADDRESS SIGPd TURF P_ }.,j �­/O) C,4jlm J ]PUTNAM,COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAL'T'H SERVICES . n1 r r x •.5:�-` -•f :�. we..... .Y .^'.�_. �..,: 'Y., �s.- F•�q+iov. -Y �wY.f.C. �. .:�V frof.. :nT W r:.: r''P�cf�f(T .. i •- �.. .. ot. ay,.�+.V 'dY�'..�'f'i:'. ��� � GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 7N 1 942 Owner or Purchaser of Building f Tax Map Block Lot Building Constructed by TownNillage Location - Street Subdivision Name wi: l .kt dc 4.1 Z- Building Type Subdivision Lot.# I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or, approved amendment thereto, and.in accordance with the.standards, rules an,cl- 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 Construction Compliance" for the sewage treatmdht,,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. 4 The undersigned further agrees to accept as conclusive the determination of the Public Health TT�� n +...... t T'l.,t «.+ r t-. Tl t f H 1tL, ' . • 'di t1: t t e oft _. t Dir'�.ctO of the Y uL110.r11 �.GUnly 1JEpa.ln1C11L GL lleallll a5'tG V1:11C L`Ll�,l or r1171 the f0.1lUrV Vi Lh J� SLelir to operate,,was "caused by the willful or negligent act of.thelo'ccupant of the building utilizing the system. .N Dated: Month Day f� Year o� r_ , . igna tore: .A&1gr4j o- 't Title: C - �Cjk�wl General Contractor (Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) Address: 15 NORTH MEADOW LANE State PUTNAM VALLEY N. Y. Zip 10579 Address: 114 LESTER CLARK ROAD State NEWBURGH N.Y. Zip 12550 Form GS -97 N f R _ .. ,.a;:� �_. .3..:t:. _ - - -• CT Cert:.�H -0¢Q4 's a, .' ., i=r.v .. .. +. ��. �t.c `:°F�. >.;.+.•t Xv �' •s ..•+�9i .. - ;:i..tl i NY eat: i471 (203) 745 -7903 - FAX (203) 748 -0652 LABORATORY REPOR T -- WATER 8UIlaP LIY T EsTnH G REPORT TO: BOYD ARTESIAN WELL COMPANY RD #5, Rt. 52 CARMEL, N.Y. 10512 DATE SAMPLE COLLECTED: 6/16/98 TIME COLLECTED: 12 :30 P.M. COLLECTED BY: S. BOYD DATE RECEIVED @ LAB: 6/16/98 TESTED BY: LAB# 11471 REPORT DATE: 6/19/98 SAMIPLIE SITE: 15 N. MEADOW LA., PUTNAM VALLEY, N.Y. SAMPLING POINT: HOLDING TANK SOURCE: WELL TREATMENT: NONE TEST PERFORMED RESULT: MA3M'AUM CONTAMINANT LEVEL BACTIERL4, L: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml PHYSICALS: PH 5.86 no designated limit Turbidity 0.72 NTUs 5 NTUs CH EIUSTRY: Nitrite N <0.01 mg/L as N 1 mg/L as N Nitrate N <0.50 mg/L as N 10 mg/L as N Alkalinity 21.0 mg/L no designated limits Hardness 22.0 mg/L no designated limits .... +.. ...: �.. Iron - <( ?.03= - Manganese <0.01 mg/L� 0.30 mg/L. [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 2.3 mg/L 20 mg/L ** Lead <0.005 mg/L O.u15 m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBIUTTEIID:6 /16/98 SAMPLE, AS TESTED ABOVE: MOTABLE or OINOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) a t _a4n ,� � Laboratory Director oNORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037° (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 o OUTSIDE CT: 800 - 654 -1230 I IMIAT 7318 21118 IN TO CUTtry 313T2:! '115 tt,:3TRUCiEb'h0 TADItAT60 ON THIN PLAN AND -THAT **7111C BYSTEN HIM - I"OPECTED NY. "a. sucn'c -IT RAN, coolmail! oyaq Till1l NVOCK VAN CONSTRUCTED IN ACCOROKU69' .WITH ALL STANDARn-RUJIlts AND ItEdUtAt-10" Or THW 1028AW COUNft'DEARTHENT' oilr'.H AFA 560, 001 _4zz _1 Cb '�4 Nr CIL - S- :_..... -.... .......... • 4r- -­7 rl ZKw &X 4Lr- 9 'OF It 4 ot J3 IV I I SEA /GAL 7' 1P A ft k, SA Mr- of Environmental Heap c as no ted for c 0 r.Q. 1 j 0 ab 1 14 RU_jsS and Regulations of the "all County I th Deowt, A D�Dartpent. Lk 20, 1+7 ftFD 40 5,=—= 1 NO. W, CLI!NT,- -NCF IS KEA R=5117= FOR. JOEL L. SR=�B_ .6 ARCHITECT Ab -AAP, _M 2 MCCOT ROAD NORIW 19V t -0-0-T-M .011 0 -P Q_ MMOPAC, H!M YOM WSQ OF C 1. DRAWING TITLE: A5 BUILT 5EKA15E 015F.05AL 5YMN I aL Zut J tJ LL 0 ki) O (Jfl O 7 I 01407 . Vi 11 A /A I Irg A 5 102 I. 304 11" S 700 W t 700, 7Y -3 4- 76" 175' & -70* 5e 7e 615' "1' 0 102 to 6) /,Z0 M. 10 118' 125 11 117` m0 It 14 JS 24? 480 17 1120 530 2V 35° 300 bcp lo 20-1 1 102 580 I 01407 . Vi 11 A /A I Irg 47— a .071 0�0 Cr 1)0 L F LY ��_P 401 7,' - ► -1 1: �-_. SE S 46 C, P \ V­ Joel Greenberg RA. Architect - Planner 2 Muscoot Road North Mahopac, NY 10541 P-s. SCOTT I-005 t, A W. PUTNAM COUNTY DEPARTMENT OF 'HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT :1vu t©! ctie ; •� LFQS: � Al15 - 1�1t°aGb v)e �a /tin t/aI1e T Wfid i Map Block Lots) Well Owners ` f •fir •, Name: Address: ,Scott Lc�s 9 ass Cane ; five y, . i�C 1/ 0Y. i0S' 79 EWelb- `. $iy ::: ndary / Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional. Standby . Drilling Equipment Rotary Cable percussion /. Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole iii bedrock:. "Other Casing Details . s' Total length S / ft. Length below grade SU ft. Diameter 6 in. Weight per foot i lb /ft. Materials: / Steel _ Plastic Other . Joints: _ Welded _ /Threaded Other Seal: Cement grout _ Bentonite Other Drive shoe: /Yes _No Liner .Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) ' Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield 5 gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log ::: If more.detailed information descriptions or sieve. analyses - - are available; please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft... Land Surface LIAM } redc •'� �5 - 4` �.�; -. . W 10 U1 10 y� If yield was tested at different depths during drilling, list:. Feet Gallons Per Minute. Pump /Storage Tank Information 5' Pump Type Capacity Depth Model Voltage HP Tank Type volu me a Date"Wel..Completed t t , Putnam County Certification No., OQ Date, of:Rep.Qrt ;'q t Well Driller (signature),...-.,:,,'-. Nu,i,E: Exact, to �0yy9 Well Drilldel Signature. ' White copA tion.of well with distances to at least two ermanent laic to s to f2e iovtded on a se arate.sheet/ l4h I? , l�. P P Air- �y 3W n v Addressc ` - CAr mP� �% QS12 Date: 7�1g� File'- t Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller ;.. Form WC -97 4 ". L- --' .' _'. tp W✓LL UUr1rLL11UV rUXUAl DEPARTMENT OF HEALTH N PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only 4-11 -1. 8C. r. WELL LOCATION STREET ADDRESS: TAX GRID NUMBER: 15 ea_ d Ian e PU warr WELL OWNER NAME: ADDRESS: k/o_ lekl SCOH 1.005 9 zm5 zo-yle pv,f-Wa,-Y7 Ny. ian* PBIVATE 0 PUBLIC rc USE OF WELL 1 - primary 2 -secondary g'PESI , DENTIAL 0 PUBLIC SUPPLY 0 AIR/COND./HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM 0 TEST/OBSERVATION ❑ OTHER (specify) C3 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT S gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE Sob gal. REASON FOR DRILLING ❑REPLACE EXISTING SUPPLY ❑TEST/OBSERVATION []ADDITIONAL SUPPLY jflgE'W SUPPLY (NEW DWELLING) DDEEPEN EXISTING WELL DEPTH DATA LIA -5_ WELL DEPTH TU ft. STA IC WATER LEVEL - ft. DATE MEASURED �Cllcn DRILLING EQUIPMENT ❑ROTARY COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE 0 SCREENED N' lzrOPEN END CASING IX OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH MATERIALS: )2fTEEL' OPLASTIC O OTHER " LENGTH BELOW GRADE ft.— JOINTS: ❑ WELDED 01HREADED 0 OTHER DIAMETER in. SEAL.)E(CEMENT GROUT OBENTONITE OOTHER WEIGHT PER FOOT /V 1b./ft. DRIVE SHOE JafES 'ONO I LINER: QYES ONO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (11) DEPTH TO SCREEN (it) DEVELOPED? FIRST OYES ONO SECOND GRAVEL PACK 0 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK — in. 1DEPTH TOP '_ft. BOTTOM DEPTH — ft. WELL YIELD TEST If detailed pumping METHOD: 0 PUMPED i tests. were done is in- 0 COMPRESSED AIR 40 rmation attached? 0 BAILED 0 OTHER ❑ YES 0 NO it more detailed formation descriptions or sieve analyses VELL LOG are available, please attach. DEPTH FROM SURFACE Water Bear- no Well oia- meter in FORMATION DESCRIPTION coat ft . WELL OEPTI'i ft. DURATION hr, min. DRAWOOWN ft. YIELD 99m. Land Sumac. 3 30 5– q1 Lj WATER CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? 0 YES 0 NO ANALYSIS ATTACHED? 0 YES ONO STORAGE TANK: TYPE CAPACITY PUMP INFORMATION TYPE S4 CAPACITY. S21Lk-1 MAKER &9J00111el DEPTH MODEL VOLTAGE2112HPY-6� WELLORILLERNAME OAT AooREss T SIGI TORE 19' ,5-g _W&hl 9"_14 Joel Greenberg, RA Two Muscoot No. RFD2 Mahopac NY 10541 Dear Mr. Greenberg: BRUCE R. FOLEY DEPARTMENT OF HEALTH Division of Environmental Health ServicesQ► 4 Geneva Road Brewster, New York 10509 Tel. (914)' 278 - 6130 Fax (914) 278 - 7921 July 13, 1998 Re: Loos As -Built , TM# 74. -1 -9.12 (T) Putnam Valley This office has received and reviewed the As -built plans and application for the above mentioned project. Prior to issuing compliance, the following items must be addressed. 1. Well Completion Report must be on Form WC -97. 2. As -built plan must be at minimum scale of V =30'. 3. When a garbage grinder is installed; it is to be considered additional_,. ._ gallon septic tank is required to be installed, and inspected. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact us if any questions arise. ASB :tn enc. Form WC -97, Marked up As -built Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer a � Joel Greenberg, RA . , Two Muscoot No. RFD2 Mahopac NY 10541 Dear Mr. Greenberg: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 rel. (914) 279-6130 Fax (914) 278.7921 July 13, 1998 Re; Loos As -guilt TM# 74.4-9.12 (T) Putnam Malley Public Health Director This office has received and reviewed the As -built plans and application for the above mentioned project. Prior to issuing compliance, the following items must be addressed. _ 2. Well Completion Report must be on Form WC -97. As -built plan must be at minimum scale of V =3U. "'WhGr. cc gz bid irrir Pr�ic i�jsi e_ _ ^i,Lis to b- considered. an additional,,;, bedroom for determining tank size. Therefore a 1500 (5 .bedroom count }µ gallon septic tank is required to be installed, and inspected. This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact us if any questions arise. ASB-tn enc. Form WC -97, Marked up As -built - r 7 *J 7 1 Q17},1G:1 'An VH,1 Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer I r""-- -- ---�y� '•-+ - ,.'--'c. -. ,fir--- =-- cit° - -"-. 7--s.- ..,,,. nT:; -T _ .. sx PDTNAM CO ®NTY DEPARTMENT OF MAU " P" DbMoa► d Iieell� Sesvloee. Cermmf, *.Y.16512 o� CSRTII+ICA CO C8,' co"MUMP I PiRilit FOR 'W*AGZ DEAL SYSTEM UT -AM• -15 NORTH MEADOW LANE TOWN OF P . LLEY .. N:4... or N �ltumlpEt` `7 '.-.. iv i.._..... �w:w'�.:+'�.. -'c T'.�..�T '�� .w. - -.• t� c+6 �n� - -r; O.Ax /ARYe.igt Name . . SCOTT 'LOOS Renewel_0 on Revlel o n Date of Prevbaa Approval s Ad�efi. 1.3 2 OSCAWANA' LK . RD. Totro PUTNAM 'VALLEY, NY -' Date Subdivision ApRroved 6/9/9'S Fee Enclosed: Amn„nt" 300;.00 'ONE FAM . RES . Lot A ea ­ 3 . 0 0 7 Al . Fm Seelion . � .. orb' Detltb Vobtme Ni bee of Heioopla 4 Deaigt Flow G P D $ O O Pt:DD PTaQOBotbn b Regahed When Pm b completed J _. sift Syatem to oomm of 1.'25 0 roar= g� Taol; -Ed 50 0 L.. F . OF. LEACHING FIELDS, To be emi meted by -NOT SELECTED Address . Wow Sgpt*. Pdbllc Sepply'Photo Addeeae an . , X •ft :St :Demedby NOT SELECTED O&w Reaailreasente 1 represent that I am wholly and completely responsible for the design and location of the 'pro systsm(s); 1) that the separate sew di sal s stem . above described will be constructed as shown on the approved amendment there to and in'accor n with'the standards, ruIa6 a repu ns O e ream County, Department of Meelth, and that on tompkition thereof a' CMfifieab of,Constru'eti molianee" sots aetory'to the Commissioner of Meelthwill be submitted to. the D"ahment, and a written ouaiantee will. qe f' tine. owner, IHs c saw; heirs or sagm by tM guilder, tM16 YW builder will place in 000d, operating condition any part of said sewage disposal ste urMq rho pet, - f two (2) year immediately followink the date of the imu- once of 'the .approvRl of 1669 Certificate of Construction Compliance o M o Mal. system or ny.repairat„ to; 2) that the drilled well aetaroed above will be located as shown on the approved pion and that said well will be.instal andar rules and regu aTi oni of the Putnam County t)ejirtment of Wealth. - - pato 2/,24/57 signed ' y ' :. P.E. _ R.A. X, Address TWO MUSCObT R.OA,6 NORTH PAC Y J License No 110 5 6 APPROVED FOR CONSTRUCTION: This approval expiies two year .f .m the - e issue . unless,, construction or th building has been undertaken and is revocable for cause or may be amended or;modifled when consideod n y the a o -M th. .An cha a or alteration of construction requires a new permit. Approved for disposol of domestic sanitary /ge; ma Rev . ' �' �-�` Title 10/88 wta �� T DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 P►PYLYCATIOItT} TO C'`C►fi�CT¢Pi WATER WE;—""'i.:' -- PCHD PERMIT WELL LOCATION Street Address 15 NORTH MEADOW Town/Village/City Tax Grid Number LANE TOWN OF PUTNAM VALLEY 74, -1 -9.012 WELL OWNER Name SCOTT LOOS 132 Mailing Address X3Private OSCAWANA LK e RD., PUTNAM VALLEY NY O Public USE OF WELL ® - primary 2 - secondary PRESIDENTIAL 0 BUSINESS 13 INDUSTRIAL 0 PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ® ABANDONED 0 FARM 0 TEST /OBSERVATION 0 OTHER (specify 0 INSTITUTIONAL 0 STAND -BY AHOUNT. OF USE YIELD SOUGHT 5 gpm/ # PEOPLE SERVED 4 /EST. OF DAILY USAGE 300 S&I 0 REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION DYADDITIONAL SUPPLY 23 NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING NEW RESIDENCE WELL TYPE ®DRILLED DRIVEN ®DUG ®GRAVEL '® OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF TELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: JUMPER Lot No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY _Y DlcaewrLr -Tn�r C�pfiv v' ua�t S VREK �.o-.....__. L- ......._.__. p:.„ � .......,....�_�._ �,-- .s..— ,......f�.. .:per. LOCATION SKETCH & SOURCES OF CONTAMINATION PROV 7;*( ®ON SEPARATE SHEET 2/24/97 (date) u PERMIT TO CONSTRUCT A WATER VYELL 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: M 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 cont a ce or groundwater. Date of Issue: // 19 — Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNT.Y'DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES %.y ?�'.. `:i=_�. -�%r i,� s. 3.. v: s: a' r`_: •�+:- -cl`i.::�.•.�.::;- :r,',... ,.. {.. ,y:.- "�t.�:—• v" v--• 1- ''y.:- <. ?i_,='t."i�..= : Ww'd -: "eat H►'..•4..s•'?+c',.r`d,,, r. ,., �%+;i•,'�:a:.. Date 2/24/97 Re Property of — SCOTT LOOS Located at 15 NORTH MEADOW LANE (T) PUTNAM VALLEY - Section 74• Subdivision of Subdv. Lot # 2 Gentlemen: JUMPER This letter is to authorize — Filed Map # Block 261 7B 1 ---Lot 9.12 Date 6/5/96 JOEL GREENBERG, R.A. a duly licensed professional engineer__ — or registered architect_X (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 `"connectori�witri `znis m'at+z�i°�a�ia''to szpe' v' se`` 7iC "c°t�n'strucc35n°o'aiu""'"" °"�' system or systems in con:Eormity with the provisions of Article 145 or 147, Education Law, the Public He�Llth Law, and the Putnam County Sani- tary Code. Coun SCOOT ROAD NORTH Addre MAHOPAC, NEW YORK10541 T�ephone ------------ - - - - -- Very truly yours, Signed - - -- – -��-z, - - - - -- Owner of roperty 132 OSCAWANA LAKE ROAD - -- Address --- - - - - -- PUTNAM VALLEY, N.Y. 10579 Town~ 212 987 -3605 Telephone N P O 1 PUT NAM C O UN TY D E PA R'I'M ENT O F H EAD T AR L:ICATT.ON. -FOR.- APPROVAL OF .P!�4NS��9 .A',WaSTi_S�'ATER . DT_SPnSA! ° SYSTEM . 1. Name and Address of Applicant: SCOTT LOOS.'; 132 OSCAWANA LAKE ROAD PUTNAM VALLEY, NEW YORK 10579 , 2. Name of Project: SSDS FOR SCOTT LOOS 3. Location T /V /C: TOWN OF PUTNAM ARCHITECT: VALLEY 4. Project X JOEL GREENBERG, R.A: .5. Address: TWO MUSCOOT ROAD NORTH MAHOPAC, N.Y. 10541 License Number: 11056 Phone: - 628. -661 3 6. Type of Project: X Private /Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building _ Realty Subdivision Other (specify) 7. Is.this project subject to State Environmental Quality.Review (SEQR)? Type Status (Check One) Type I.'. Exempt Type II. Unlisted X 8. Is a Draft Environmental Impact Statement (DEIS) required? NO 9. Has DEIS been completed and found acceptable by Lead Agency? N/A 10. Name of Lead Agency N/A 11. Is th.is.. project .in. an. area under. the_- �optrol of loca_l.:.planr.ing zoning, ,�.�_ruihc i'•_;Gl'i s'� ,.� ...............,~ �'Ee moo.. .,.c•..: 12. If so, have plans been submitted to such authorities? .. NO 13. Has preliminary approval been granted by such authorities? N/A Date Granted: N/A 14. Type of Sewage Disposal System Discharge...... Surface Water X Ground - Waters 15. If surface water discharge, what is the stream class designation ?........ N/A 16. Waters index number (surface) .. ....... ............................... N/A I7. Is project located near a public water supply system? .................. NO 8. If yes, name of water supply _ NIA Distance to water supply N/A 9. Is project site near a public sewage collection or disposal system ?..... NO 0. Name of sewage system N/A Distance to sewage system N/A. 1. Date observed: 2/8/93 23. Name of Health Inspector: MICHAEL BUD$INSKI 4. Project design flow (gallons per day) ................ ................... 800 2. 25, Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. No q Y '. � -'- :� �. -�.' c.:a •. �'.'K4�,.r - }�_ <. taf uY" iv ..0 .,,c pKSr_%:� .. r �.= +'.: r --.:. v -.�J ra stm Ya^}n �TC2`, .YF: c �... -. ti: t;:�Sa I.: V'W1zf•. Y.. - 26. Has SPDES'Application been submitted to local DEC Office? N/A 27. Is any portion of this project located within a designated Town or State NO wetland ?......... ...................... 28. Wetland ID Number ......................... ............................... N/A 29. Is Wdt -land Permit required? .............. ............................... NO Has application been made to Town or Local DEC Office? N/A 30. Does project require a DEC Stream Disturbance Permit? ................... NO 31+ Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO _ NO 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill; sludge disposal site or any other potential known source of contamination? ..............YES or NO NO DESCRIBE: 33, Is there a local master plan or file with the Town or Village? ........... YES 34. Are community water, sewer. facilities planned to be developed within 15 years? NO <...Ar�._ Iry _S:'.w�_��- .d_i.�s.��s,� i r�r?„ �. ����exc?sr� .�o.ir�.��-._S:J.C?pe �;.,. •:.� . _� �.,.���:�:��:;:��::::: �''-�r•� _ . 36, Tax Map ID Number ....... ............................... .... ... ... . .It, -1 -9x12 37. Approved Plans are to be returned to: ................ Applicant X LlnvgMeve r ARCHITECT If the application is signed by a person other'than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. F hereby affirm, under penalty of perjury, that information provided on this i fora is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Kf s"d nor pursuant to Section. 210.45 of .the Penal Law. SIGNATURES & OFFICIAL TITLES: 132 OSCAWANA LAKE ROAD MAILING ADDRESS: PUTNAM VALLEY, NEW YORK 10579 •' • •• •' i� v i �• tea•. �. _ ... �+j i�ESi�I�I "-C,A`ir� - Si�ii�i'�-.>JF�:3t ACr; •°J~L�i�7�i • rJ1J�.�. tTiL � JYJ..,.;���. � �. ^� •i:4� .'� '..... - r.. °..,..::, owner SCOTT LOOS Address 132 OSCAWANA LAKE ROAD, PUTNAM VALLEY, NEW YORK IU5/9 I Located at. (Street) 15 NORTH MEADOW LANE Sec. 74. Block 1 'Lot 9.19 (indicate nearest cross street) Municipality TOWN OF PUTNAM VALLEY Watershed HUDSON RIVER Date of Pre- Soaking 1/7/93 Date of Percolation Test 1/8/93 HOLE NUMBER CLOCK 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 TH 1 1 12:57 1:27 30 23 25.5 2.5 30/2.5=12 2 1:28 1:58 30 23 25.25 2.25 .30/2,:25 =13.3 3 1:59 2:29 30 30 25.25 2.25. 30/2.25 =13.3 4. 2:30 3:00 30 30. 25.25 2.25 30/2.25 =13.3 5 k.` H..� 1 1 -: 0 3 '1 .. 3 T.,. 3.0: Y_ 2.4 _Z.6 .-5 0-- - _ - - -:12: 2 1:34 2:04 30 24 26.50 2.50 30/2.5=12 3 2:05 2:35 30 24 26.25 2.25 30/2.25 =13.3 4 2:36 3:06 30 24 26.25 2.25 30/2.::25 =13.3 5 NOTES: 1. 2. rev. 9/85 Tests to be repeated are obtained.at each for review. Depth measurements to at same depth until approximately equal soil rates percolation test hole. All data to' be submitted be made fran top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH. HOLE N0. DTH 1 HOLE' NO +'DTH 2 HOLE NO. G.L. TOP SOIL TOP 'SOIL 11 SANDY LOAM SANDY LOAM n n 2' 3° if 4° 51 6° 71 8' 9' 10' 11° 12° 13' 14' ~INDICATE LEVEL AT WHICH GROUNa,,% ER IS ENCOUNTERED NONE INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED NONE DEEP HOLE OBSERVATIONS MADE BY: JOEL GREENBERG, R.A. DATE: 2/8/93 DESIGN Soil Rate Used1 1 -1 5 Min /1" Drop: S. D. Usable Area Provided 5 , 0 0 0 S . F No. of Bedrooms 4 Septic Tank Capacity 1250 gals. Type CONCRETE Absorption Area Provided By 500 L.F. x 24" width trench Other 7 FT. CURTAIN DRAIN Name JOEL GREENBERG, R.A. Signa Address TWO MUSCOOT ROAD NORTH S MAHOPAC, NEW YORK10541 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY < Soil Rate Approved sq.ft /gal. Checked by Date