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PUTNAM COUNTY. DEPARTMENT OF
Services, Carmel, N.Y. 105
Dlvlslon of "Orowneittal H6" So k m
-777
CE A QF CONSTRUCrION.COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM AAoi t
Located st
Own6r/appfipleut Na�nile' Formerly Subd vlxlou�T4.�"� §tibdV., Let,#
Mann Address
-4wa 6d 4 e C, Zip Data Permit-lsiued
sep*!#" Sewerage Sy*zn,-built *_ 021 -Address Aa /4'e
Con4l iting Z
of rL Gallon Septic and
Water Supply: Public Supply Prom - nn Address
art Private apply Drilled by Address j V 4-
ve,
BulldIng Type `_]4as Eroslim Control Been Completed?
er BeelulustAid?
Number of Bedi6onllli Has Garbage A/a
Grlud..
Other, Requirements '
77
I certify that the �'systeow, as.iisted`sikiring,the 4bovft prezmises were' c oinstru'cteq_ easential;y ae,sh ' oin?, On the plans qf.th6 completed work copies
gu t'i an, and the'p ermit issued by the
of.which are atiached),_and in accor"aanic-6 w:ith- the. standards,; rules iind%.i6` 1", in ac6ordinc� wit* the fil
un
a Z10- i
Putnaii Co t . D tM t Of Health.. pl
Certified' b X-1
Date RE'. R.A.—
Address fir/ A", License No.
Any person occupy , Ing promises served by the above systems) shall p ro' rript ly, 1; . a . ke; such % actionis may be necessary to secure the correctlo n 0 . f any unanitary
conditions resulting from ',such. usage. Aoprovil of the separate sewers
ge-_Wstern shall become null and -void as soon as a pubV: sanitary rower becomes
avaliaiiie and -the ipproiial* of the, private water supply shall became T149 'and ".Id,.Whqn �a, public �watw supply becomes available. - Such approvals are
subJect t: mod It IG'at li6n':or change When, , in the jqd9rriefit of the- Comm'1$si6nuqf, Ithi Such revocs Ion, modification or change is noces"i"
_ '"eq I I � � modification . . y.
Date 13
Owner or Purchaser of Building Section
.
Building Construc'tea' by Bko k"
Al
Location - Street �- Lot
VAC X12
Mtinicipalit3f Subdivision Name
Building Type Subdv. Lot #
GUARANTEE OF SEPARATE SEWAGE 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 success-
ors, 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 initial use of the sewage disposal
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 occu-
pant of the building utilizing the system. ;
The undersigned further agrees to accept as conclusive the.determin-
atioY -u of -the Director of- the- Di.vis.ion: -_o -.f Environmental. Health Services
of the Putnam County Department of Health as to wetlier`'or iottiie' xa'l'
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
Dated this f day of (if 19 '70 Signature _/c ��-
Title�J�j� -
Corporation Name if core.
ZL
'Address
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
Gat_
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DEPARTMENT OF HEALTH
uvirs-i�r� °G` irr'viio�EU�e�ra rIealth Bervie:.:;,
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
�-� =' - -
WELL LOCATION
STREET ADDRESS. wN! 1 ! I Y TAX GRID NUMBER:
Wood St PutnamdValley,NY --
WELL OWNER
NAME: ADDRESS:
Kevin Ronald;84 Circle Rd. MaYiopac, NY 10541
® P8IVATE ❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
El RESIDENTIAL G PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS O FARM. ❑ TEST /OBSERVATION ❑ OTHER (specify)
p INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ❑ADDITIONAL SUPPLY
[3NEW SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 225 ft. I
STATIC WATER LEVEL 30 ft.
DATE MEASURED 5/24/90
DRILLING
EQUIPMENT ..
91 ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING 12 OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 152_ ft.
MATERIALS: EI STEEL ❑ PLASTIC ❑ OTHER
LENGTH BELOW GRADE 1 1 ft.
JOINTS: ❑ WELDED El THREADED ❑OTHER
DIAMETER 6 in.
SEAL: 12 CEMENT GROUT ❑ BENTONITE D OTHER
WEIGHT
PER FOOT —1,9
Ib. /ft.
DRIVE SHOE ® YES ❑ NO
LINER: 0 YES ® NO
SCREEN
DETAILS.
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (}t)
DEVELOPED?
FIRST
-HOURS. No-—
..
SECOND :.
_
GRAVEL PACK
❑ NO
GRAVEL
SIZE:
DIAMETER TOP
OF PACK. in. DEPTH
ft.
BOTTOM
OEM It.
WELL YIELD TEST If detailed pumpin g
METHOD: ❑PUMPED i tests were done is in-
t
* COMPRESSED AIR formation attached?
❑ BAILED ❑ OTHER '0 YES O NO
i
YYL� LOG
If more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE.
water
Bear-
ing
well
Oia-
meter
In
FORMATION DESCRIPTION
COPE
It.
ft.
WELL DEPTH
It.
DURATION
hr, min.
DRANI00'+VN
ft.
YIELD
gFm.
Surfa ce
it
ing in overburden clay & bld
s .
225'
6
205
20
H't
ock at 95'
152--.....Eriding
in rock set casing grout
d.
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? ❑ YES ❑ NO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPEWellXtrol 250 .
CAPACITY 44 GAL.
WELL DRILLER NAME P.F.. Beal & 6ons \ Ine 0 E
PO Box B 6/27/9
aoo Brewster,NY 10�
PUMP INFORMATION
TYPE subwe -si bl a CAPACITY_
MAKER _ _Gould DEPTH 180'
MODEL 7EHO5412 YOLTAGE23OH�2
J/ VJ
a
l
z ,BREWSTE-R' LABORATOKMS --
Box 224 - BREWSTER, N.Y.
(914) 279 -4945
-- WATER ANALYSIS REPORT -
TEST WELL
SAMPLE NO. 7742
SOURCE: Kevin Ronald
Wood St.
Putnam Valley, N.Y.
COLLECTED: 6 - 2 2 - 913
BY: P.F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
6 -26 -90
��b „ PUTNAM COUNTY'DEPALZPMEPIT OREMALTH
vi x
1 Dlvleton o4 Ebvlrobmentel Hoa146 S ®ivloesi. Carmel. x 1051? Englneor to Peovide Permit #
CERTIFICATE CATS OF CO CE ::
Permit 4 s
IONSTRucnoN PERAUT FOR SEWAGE;MSPOSAL SYSTEM
e-s . � at•FI
Sabdlvlilon —Name !Y l� �a • bL D / l� fo � i P ' Subd. Lot # � Tax Heap ' �•r Block At i
/ Renewal_ ❑ . : Revision ❑ .
Owner /Applicant fileme A160" % D n s� / .
Date of. Previous Approval
Mailing Address � � Ga! r a / � ° ti �.. Town
87
Bpllding Type 1 ` r% CIA Lot Asa ' Fiv section only lame
Depth Vv
PCHD,NotiBcatlon is Required When Fig a completed
Number of Bedrooma 3 Design Flow G P D _
_r pob CA
Separate Sewerage System to conslet of ' _Gallon SeRdt Teak and
To be constructed by Td A4 J-e' °/ h* i n C j Address
Water SoPPb,: Mile Supply From /Address
or Private SnPPb DrWed.bsGi �° ef/MAO "Addeeea
OiberRequiranients
I represent that I am wholly and-completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system
above'.described. will bekonstructed as shown on the approved amendment there 'to and in: accordance with.the standards, rules and regu a _ions o e u nam
County Department of Health, and that on completion thereof a •Ce►tiflcate of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department; and,a written'guarantee, will be furnished the owner, his successors, heirs or.assigns,by the builder;'thaf said builder Will
P lace -,in good ope►ating' condition any part of said -sewage, system. during the period o} two (2) ye following thedate of the Issu-
ance of the approval of the C_ eititicate of Construction Compliance of the'oi al system or any .re s thereto; 2).that the diilled iwell deseribetl above .
will be located as sficrro'on,the approved.plan'ahtl that said well will be installed accortlanee it ndards, r es and regu as ions the Putnam
Date .Health - ..�I
Date ofd Signed P:E.� R:A.
County
9
License No
APPROVED FOR CONSTRUCTION.This approval expires two yesi�,the date issued unless construction of the building has been undertaken and is
revocable for cause or may be. amendetl•or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction
requires b O a eww permit. , AD /provetl %for disposal 'of ni
poestie sanitary swage, /or private water supply only.
Date, � �� `/ /( /. ! / U, gy i' j _�' - -Title , 3�
El 13
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