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BOX 28
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03580
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Re V. 31 86 PUTNAM COUNTY DEPARTMENT OF HEALTH "
Divislon of Environmental Health Services, Carmel, N.Y. 10512
�. Engineer Must Provide �.;.._ _...
P.C.H.D. Permit fl -= - - -_ --
RTIFICATE OF CONSTRUCTIO))
Located at ✓ °' �i '
Owner /applicant Named
MaWng Address
FOR SEWAGE DISPOSAL SYSTEM � �-�l 1W I%7
Town or Village
Tax Map Block Lot 4
LFormerly Subdivlsioti NamQ lra, 4 :S, "Z9ubdv: Lot #
Zip S Date Permit Issued 'n;� e'
Separate Sewerage System built by Address
r y /
Consisting of Gallon Septic Tank and
Water Supply: Public Supply From Address
or: Private Supply Drilled by Address ry r-.
F J •'
Building Type r / lL ge," 'Y Has Erosion Control Been Completed?
• NG
Number of Bedrooms Has, Garbage Grinder Been Installed?
Other Requirements
I certify that the system(s) as listed serving the.above. premises were constructed essentially as shown on the plans of the completed work ( copies
I f which are attached), and accordance with the standards; rules and'regulati in ac rdan th. he fi d' lan, and the permit issued by the
Putnam County Department bf Health, t
Date + _ ertified by P.E. R.A.
.�.—
Address �S,• I" " 4 Licence No.
Any person occupying premises served by th above system(s) shall promptly take such action as be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Ap rovsl of the separate sewerage system shall become null and void as soon as a pubti: sanitary sower becomes
available and the ap royal f the private water supply shall become null,.and void when a public we wpply becomes available. Such approvals are
'subject to modifi Ion o change when, in the judgment of the - Is rier. With, s r Ion, modlflcat n or change is necessary.
Date /�' / BY ` Title
ry ..
YM L EnAronmental
servicea
w4{ 321 Kear Street, Yorktown Heights, NY 10598
FLAP #10323 (914) 245 -2800
RUSIN, RICHARD
81 ELIZABETH STREET
SCARSDALE, NY 10583
(914) 792 -4199
COL'D BY I MR. RUSIN
NOTES
X
ANALYTE
RESULT
UNITS
r
S.U.
ALKALINITY
mg/L
mg/L
AMMONIA
mg/L
mg/L
CALCIUM
mg/L `.
mg/L
CHLORIDE
mg/L
rrtg/L
COLOR
Units
mg/L
CONDUCTIVITY
umhos /an
mg/L
COPPER
nV/L
NTU
CORROSIVITY
LSI
LAB NUMBER 32.0048001
DATE /TIME TAKEN 9/16/91 10 AM
DATE /TIME RC'D 9/18/91 11:50 AM
DATE REPORTED 2 9 9
BASIN:
SAMPLING 316A BARGER STREET
SITE PUTNAM VALLEY, NY 10579
For Lab Use Only
w'-'Potable _ HNO3 _ pH LT 2 <4C
_ Nonpotable _ NaOH _ pH GT 9 _ <20 >4C
_ HCl _ Na2SO3 _ >20C
— STAT• H2SO4 ZnOAc
DETERGENTS
mg/L
S.U.
FLUORIDE
mg/L
mg/L
HARDNESS
mg/L
mg/L
IRON
mg/L
mg/L
LEAD
rrg/L
rrtg/L
MANGANESE
mg/L
mg/L
MERCURY
mg/L
mg/L
NITRATE
mg/L
NTU
NITRITE
mg/L
mg/L
ODOR
TON
LAB NUMBER 32.0048001
DATE /TIME TAKEN 9/16/91 10 AM
DATE /TIME RC'D 9/18/91 11:50 AM
DATE REPORTED 2 9 9
BASIN:
SAMPLING 316A BARGER STREET
SITE PUTNAM VALLEY, NY 10579
For Lab Use Only
w'-'Potable _ HNO3 _ pH LT 2 <4C
_ Nonpotable _ NaOH _ pH GT 9 _ <20 >4C
_ HCl _ Na2SO3 _ >20C
— STAT• H2SO4 ZnOAc
11410) 11 o MF) NIl'N P/A
i
ANALYTE RESULT UNITS
pH
S.U.
PHOSPHOROUS
mg/L
SILVER
mg/L
SODIUM
mg/L
SULFATE
rrtg/L
SULFIDE
mg/L
SULFITE
mg/L
TURBIDITY
NTU
ZINC
mg/L
SPC
per 1.0 mL
TOTAL COLIFORM
per 100 mL
FECAL COLIFORM
per 100 mL
E. COLI
per 100 mL
FECAL STREP.
per 100 mL
These results indicate that the water sample WAS] [WAS NOT] [NA] of a satisfactory sanitary quality according to
the New York State Sanitary Code, for the phkaploers tested, at ae of sample collection.
These results indicate that the water sample .[WAS] [WAS NOT] f a satisfactory chemical quality according to
the New York State Sanitary Code, for the parameters tested, at of sample collection.
i NA = Not Applicable N = Not Present (Negative)
SUBMITTED BY - -� P = Present (Positive) SA = See Attachment(s)
= Also done because Total Coliform was present
Albert H. Padovani, M.T. (ASCP) TNTC = Too Numerous To Count
Director > = GT = Greater Than < = LT = Less Than
b
Vr4 5 �y
�� =0..
t •yam
a, .e
WELL UUrirLLT1VW "rvKi
DEPARTMENT OF HEALTH
Division'Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: W TAX GRID NUMBEk
VALLEY
WELL OWNER
NAME. ADDRESS. SCA9115 PBIVATE
MR. AICWMA T mnerl PUBLIC
USE OF WELL
1. - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY 0 AIR /COND. /NEAT PUMP O AB NOONED
O BUSINESS ❑ FARM E3 TEST /OBSERVATION 0 OTHER (specify)
O INDUSTRIAL 0 INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT _ gpm. /N0. PEOPLE SERVED EST. OF DAILY USAGE A=til.
REASON FOR
DRILLING
)SC NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION
0 REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATICVATER LEVEL ft.
DATE MEASURED 5718-i[2
DRILLING
EQUIPMENT
0 ROTARY• RCOMPRESSED AIR PERCUSSION ❑ DUG
0 WELL POINT O CABLE PERCUSSION 0 OTHER (specify):
WELL TYPE
0 SCREENED O OPEN ENO CASING, OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH _cV- ft
MATERIALS: IWSTEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE a ft.
JOINTS: 13 WELDED ,KTHREAOED OOTHER
DIAMETER in.
SEAL: MtEMENT GROUT O BENTONITE C3 OTHER
WEIGHT
PER FOOT 1b./It.
I DRIVE SHOE.XYES O NO I LINER: O YES RMO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE LENGTH (ft)
DEPTH TO SCREEN (n)
DEVELOK07
FIRST
o YES oN0
HOURS �....
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL DIAMETER
SIZE: OF PACX In.
TOP
OEM K
eOTTOra
OEM IL
WELL YIELD TEST I( detailed pumping
METHOD: O PUMPED tests were done is in-
COMPRESSED AIR formation attached?
O BAILED O OTHER ; O. YES O NO
it more detailed formation descriptions ors eve analyses
WELL LOG are available. please attach.
DEPTH FROM
SURFACE
Water
stir.
ing
Well
04.
meter
FORMATION KSCRrPT0N
c*
ft.
WELL DEPTH
ft.
DURATION
hr. min.'
ORAWDOWN
h.
YIELD
qCm.
Surqu
AL
gcd
I
I
MATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
II MATER
"ry
CAPACITY
DEPTH
- VOLTAGE HP
WELL DRILLER NAME - ,a,� O f DATE f .
le ST
1 Al ylcU-1y -
PUTNAM COUN'T'Y DEPART OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Ila/
Owner or Purchaser of Building
Building Constructed by
Locat' Street
Municipality
Building Type
Section, Block Lot
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE. DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
workmanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal systan; 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.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environmental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building utilizing
the system.
Dated this % day of 19 Signature
Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
R- -
rev. 9/85
mk
Corporation Name (if Corp.)
ess
C
TA
*
PUTNAM COUNTY HEALT H 'DEPA RTMENT
1•la' GOiMBRfl
rr
DIVISION OF`ENVIRONMENTAL
HEALTH SERVICES
Ak
z
John M. Siirunons; M. D.
Deputy Commissionei:of Health
- FIELD ACTIVITY RE FORT =
Sheet j'. of
INSPECTION
NAME Ru5!!J
x
Orig. Routine
~
Orig. Complain
ADDRESS BARbC -2 srRC -f
PuT1;IRM° VAS
—_ Orig. Request
No. Street
Municipality
(T)4(V)(.C)
Gompl'iance
.Y ' '' .,'
- , . Y. ...' ;
Complaint Comp
MAILING ADDRESS
Final
P.O. Box
Post' Office
'-Zip. Code „'
Group Illness
Construction
TELEPHONE
ti
' ✓ Reinspection.
PERSON:' IN. CHARGE-
_
.:
-
Field, Sampling Only
OR INTERVIEWED
Field Conference
'.: Name-and Title
Other
: :'DATE 0 1$ . $10 :TYPE FACILITY
_
q5
TIME.ARRI.VED �J.-'.
;. TIME LEFT
IL
Explain-
FINDINGS,:
tlovsE ts` 'ML[_" VaDFtZ
E NT�:ua7 WNAhn
F1 At, ITje�t ;
S iIC '!'Aar- Wk.
Be
'AS' T" nro6
Na ASSa2P"RoN �EtDS
` wE SPot<Fe�pr 'i1RFu
N DETAILS
C3EE- REYip-q 'FbR.
A F[kA L " I N S PFcit� "N .` ` iV FAR
" W1 KT..$ TIM �, L:F i�
id IN 'P G.
H D' ' A'tV D I� GO�[TACt- itT f 4t.
NEi�65 .
v Y
a
_
"PECTOR• '
INS
C- f�Vi2e�('M`C�RRTAt..
NEWlN AIDS
TELEPHONE:
Signature.and ltle
PERSON IN' CHARGE'- OR ;INTERVIEWED:'
�J °acknowledge - receipt of a copy. of this , SIGNATURE:,,
Field Activity Report. ...:
_T:ITLE
ln: `of'A
Budding Type 4r-,f-- CIP17
'Lot, Ar
N Design Number of Flow G/.P/D
2 f
Sejiaiitil��ew6rage System �t '0
To be,coAstructed by
'Water St.jpply:
Priyate Sqpp.ly,ao,,6e drilled_ .
-7�
Address..,
Othei •Requireme his
I represent that I`,anj':wholly 4nd..eoiii'pletely iisoonSibief o •
.:above de scribe d will
.b--e c6A struc ed' asshown on t
e'approy
County:' - Department ,of Health, that on1complition i
,,:6e,,Su&,mitfed to.. the.'Departmeni.:-incl a;,Wrlfteh '9U;aiant
N
will be located as-.'shobkh 'th
pn e.appi
Date
-Ada
'APPROVED FOR CONSTRQCTIO
requires a.-new permit.,. 'Appcovp
Date
e
j
7
.I_L,-
� ftVq'8j
#
N_T7V`IiEPARTME .:HEA H �0 ql,,050 �, r-:.it -' - . -- &V-1 ), '. -
-H# fih IUD CC
Vi
Carmel N Y_ 10592 l
M,
L
9'6T, E
l M
Town orV
!10, k�
C
illage
Tax c
';Silbd; Wt
Renewal :R_eviifon
Date; Of Previous.,Approvaji
rilr,Section 6fil Y ❑
W P.-q. H. O.'•otification Requir;d
G
777777.,:,`�, a i� Septic Ta a
and
%
Commissioner of Heilthwill
builder, that 'seid� bu-ilde_r will .
ol 10 W in
9 the.Cliti'o the , issw-
,grilled well described above
P.E.". R.A.
."U'cense,,No.
nsii 1 '0. the building,has beeh undertaken,and is
0"! h
,0, A ny c. a ge�C joirtiration of construction
pply only
d
'Title
Y r PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner. ,3 i. A. U,- l �j ti�4ddre s s �j ���,,q�� 1,
Located at ( Street* • e,1 Sec. Block Lot J ,/
� nd e nearest cross street).
Municipality ,f w OkW7 Y 1.) 11:4 Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run apse
Depth to a
er Water Level
No. Time
From Ground
Surface in Inches
Soil Rate
Start -Stop Min.
Start
Stop Drop in
Min. /in drop
Tnches
Inches Inches
4
34 zI q�/j- )2,- -___7V -Z-> 4
4
5
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. A11 data to be subriiitted
for review.
2) Depth measurements -to be made from top of.hole.
2-
34 zI q�/j- )2,- -___7V -Z-> 4
4
5
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. A11 data to be subriiitted
for review.
2) Depth measurements -to be made from top of.hole.
w
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G. L. ✓ t> �+ % /
Of
12"
18 "cow
24
30..
3611
42"
48"
54
60"
66"
7211
781f
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED c "�!" e-
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTE7
TESTS MADE BY -� 1/a j) "+ ylcz�i► Date i % DESIGN
Soil Rate Used_y_Min/l "Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity /O0 s,, Gals. Type 1 -011 i
Absorption Area Provided By Z±-e L.F.x24" 3b width trench.
�— j } t Other
c \ ei .S �t?n'k F- �V J 1 i fC 'eA� �'AsO° ��.�
Name v 5igna r
Address l vnj
,• o
.Q4 •V•.v 2481 000-0-4? -
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: ��.,,`' °•'•�Pti o�
Soil Rate Approved Sq. Ft /Cal.
te
Checked by a �`` �t Do
:1
Tm'& 16 to cerc fir that the :he seraSo df,^ oEai
tryst
'br plan, a
G=am nluo 's lild cm. ad -1 thT nd na.
�=�;t tea
vas - i i. .. yor.
n4 J ., b,,rifbl�o' It ms 0 red
A wa- iv', A1-1 �staf;Ao
.:M-9,e!k t,� i'�- d aocordanao will
aa6l ie�Ulat I ozifl-of the Pu'nam County .D°pfxrtlOnt.
'th a the b-t 6f _' fe'al't' h
md e Dc-,partzo,
AS BOLT -SEWAGE. DI-SROSAL.,,SYSTE
ftt=a uounvy usparTmenz ox. v�ppw
'Health
jUVISIon of jhvironmeptal Beeft
6 r�;ied for.c6nformnce with
6f the JOSEPH' F..SU�LI,VRNP.E.
4plicable ffideS and RsgulstlOne.
..t
ktmLm County Healt"pr - ment. x -YORKTOWN -HFjGHTS,.',NEW YORK
ro .0
;i- t .404, k
j
% I
3
_ 77".
of- Yo
lov
Tm'& 16 to cerc fir that the :he seraSo df,^ oEai
tryst
'br plan, a
G=am nluo 's lild cm. ad -1 thT nd na.
�=�;t tea
vas - i i. .. yor.
n4 J ., b,,rifbl�o' It ms 0 red
A wa- iv', A1-1 �staf;Ao
.:M-9,e!k t,� i'�- d aocordanao will
aa6l ie�Ulat I ozifl-of the Pu'nam County .D°pfxrtlOnt.
'th a the b-t 6f _' fe'al't' h
md e Dc-,partzo,
AS BOLT -SEWAGE. DI-SROSAL.,,SYSTE
ftt=a uounvy usparTmenz ox. v�ppw
'Health
jUVISIon of jhvironmeptal Beeft
6 r�;ied for.c6nformnce with
6f the JOSEPH' F..SU�LI,VRNP.E.
4plicable ffideS and RsgulstlOne.
..t
ktmLm County Healt"pr - ment. x -YORKTOWN -HFjGHTS,.',NEW YORK
ro .0
;i- t .404, k