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04414
• PUTNAM.COIINTY; DEPARTMENT OF HEAL
TH
L 86 `
Divbilon of Erivlrodmental`Health Services, Carmel, CY 10512 '
EngWeer Must Provlde c�
o[ /¢ P C:H D Permit M
lg
.. va.a.
Located a<
Owner /applicant Name
MaWng Address =�
Separate Sewerage System built by_
Consisting of 6
ON_ COMPLIANCE, P R SEWAGE DISPOSAL SYSTEM / f/i j161a f►'%, Q / ,�
tw' . 0 Tax Map • /l,� stock �. ,.3 �t .
s O Formed Subdivlslon'Name'� u��Sabdv Lot B 6
y
as zl Jaio
p • Dafe Pernilt'Ieeded.
J—� Gallon Septic Tank and S'
Water Sapplsyi - Pdblic' Supply Fiom Address
ors /P, r�ivhte' SaPPiY Drilled by O �- l Address orJ7 k
Bagdlu / U+ G� Has Erosion' Control Been Completed?, "!
_ B. TYPO a
Number of Bedrooms : 'Has Garbage Grinde Been Installed?
• i
_
:Other Regn... m.......__
ireente
I certify that.the'system ( s).ae listed`serving: the abbove premises were,ticoni.' tad essentially as shown on. the plans 'of the completed work f copies
of which are'ittached),:and in accordance: with the standards rules a ���uD�t n acc�qep the f ed plan, and the permit issued by the
Putnam County De�Ftment`0 H�'th
Date / / !`.. rtified by P.E. R.A.
Add►ett / / License No�
(.
t c �r �qs
Any person occuDYiny premises - served by. th above systems) shall py ,� iiy ttgl s may be neoerwry to secure.the'cor►edion of any unsanitary
conditions resulting from such• usage. Approval of the separate 4 y b @ire null and void, as won as a pubt.: Unitary "ei becomes
availapli and the approval of, the;privste "water auppiy ahalf become'.nall�a� „ ilgltlt�a � aQiubIf, ' watar- supply becomes available., Such sppiovals are
subject to modification or change wren., in the Judgment of the Com h suc rev tion, modification or change it ;necessary,
' SSIOii
Data 0 8Y ;, , Title
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wrjLji� U.Vr1zijr�1j_VV4 Lxx1KV1x.L Office Use Only
DEPARTMENT OF HEALTH
:Division - .Of, ronmental Health.Services
77
PUTNAM COUNTY DEPARTMENT OF HEALTH
ST _T AO ES wNivt TAx GRio NumsER:
WELL LOCATIO N
WELL OWNER
tQwlo_es� I
NAME/ r
PRIVATE
f ❑ <PUBLIC
USE OF WELL
1- primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR ND
/CO PUMP 0 ABANDONED
❑ USINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
)(NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH "d ft.
STATIC WATER LEVEL f ft.
DATE MEASURED
DRILLING
EQUIPMENT
-d ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG 74
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. XOPEN HOLE IN BEDROCK ❑ OTHER
CASING
BE-TAILS
TOTAL LENGTH ft
MATERIALS: ,STEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE Sll.
JOINTS: 0WELDED jZqHREADED CIOTHER
in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE AQTHER
—DIAMETER
WEIGHT PER FOOT Ib./ft.
DRIVE SHOE: ONO
[ LINER: OYES MO
SCREEN
-DETAILS
DIAMETER
'SLOT SIZE
LENGTH
(It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
SECOND'
GRAVEL PACK
0 YES
0 NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH -ft.
BOTTOM
DEPTH It.
WELL YIELD TEST 1' If detailed pumping
I
METHOD: 0 PUMPED 1 tests were done is in-
COMPRESSED AIR formation attached?
X
0 BAILED 0 OTHER 0 YES 0 NO
more detailed formation descriptions or sieve analyses
WELL LOG 'a' re available, please attach.
- -7
DEPTH FROM
SURFACE
Water
Bear-
ing
Weli
Oia-
peter
Ine rl
FORMATION DESCRIPTION
j
CODE
ft.
ft
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
it.
YIELD
9PIn-
SL2,nedac,
U7
P
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? 0 YES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK:
CAPACITY a GAL.
PUMP I RMA110H
TYPE
MAKA,49!
MODEL
CAPACITY
. DEPTH
VOLTAGe!_-0:_:::HP HP
WELL GRILLER NAM 70fJ704-p, DA
I
ADD S SiGRATURE
00105*
Yorktown Medical Laboratory, Inc. LAB # ;
321 Kear Street Date Taken: Time
gwn I- ieighls N ^Y:E)598: .- A_ „te...c
(914) 245 -3203 Date Reported: - aC�
Director: Albert H. Padovani M. T. (ASCP) Collected By : &,'=,a.cz_d
Referred By:
T_ %% 1 Sample Location: 4 `.
r�..�..j� � �461L_j 6 /`e, --k8 i 1 I&Y
> -Phone #
f ,�.� Phone # Sample Type:
L J Repeat Test? _ I (check one)
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
Acidity
_ Alkalinity
Chloride
Detergents, MBAS
Hardness, Total
Nitrogen, Ammonia
Nitrogen, Nitrate
_ Phosphate, Total
_ Sulfate
_ Sulfide
Sulfite
GENERAL BACTERIA
Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
tal Coliform
Fecal Coliform
_ Fecal Streptococcus
METALS (mg /L)
Copper
_ Iron
Lead
_ Manganese
_ Mercury
Sodium
Zinc
MISCELLANEOUS
PH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
MOST PROBABLE NUMBER TECHNIQUEI
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
CFU = Colony Forming Units
N/A = Not Applicable
LT = Less Than (< )
GT = Greater Than (>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
REMARKS /COMMENTS (For Lab Use)
-'Potable'
Non- potable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
— HNO3
HC1
_ H2SO4
_ NaOH
ZnOAc
_ Na2S203
Other:
Incoming
L E 4 ° C
_ GT 4 °C
_ pH LE 2
_ pH GE 9
PH GE 12
Other:
ELAP #10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A MEET THE
SATISFACTORY CHEMICAL.QUALITY STANDARDS OF THE NEW YORK STAT INKING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.'
Albert -H. Padovani, M.T. (ASCP
, Director
2 /86(Rvsd7 /87)RWE
PUTNAM COUN'T'Y DEPARTMENT OF HEALTH
'DWISION;: OF - IUMRQNME=Zs;�TH
:-er or Purchaser (of Building
IV
Building Constructed by
_. , :.ation - Street
ie
Municipality
gilding Type
// /';P 3 Z
Section Block Lot
4 r,e- " - ' r-e-_7 C/ -, e- -4
Subdivision Name
Z
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
T represent that I am wholly and completely responsible for the location,
worloT,anship, material, construction and drainage of the sewage disposal system
serving -the above described property, and that it has been constructed as shown on
L' = approved plan or approved amendment thereto, and in accordance with the
- idards, rules and regulations of the Putnam County Department of Health, and
:reby guarantee to the owner, his successors, heirs or assigns, to place in good
o,;.:.rating condition any part of said system constructed by me which fails to
opera -, for a period of two years inTnediately following the date of approval of the
- "Cerf4:f i afe -• of = Cons- truc,t.lon..Comp� dance "" .for: = the' s v ge dispbsal- •systian�s or: any;, .
rs made by me to such system, except where the failure to. operate properly is
. -ed by the willful or negligent act of the occupant of the building utilizing
system.
..:e undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental Health Services of the Putnam County
r--: =.rtment of Health as to whether or not the failure of the system to operate was
_.ed by the willful or negligent act of the occupant of the building utilizing
system.
�4
Date;, _ihis r I`� day of I—rA 19� Signature
Title
7erar l—tontractor (Owner) - Signature
Corporation Name (if Corp.)
..VI.L ess
rev. 9/85
mk
Corporation Name (if Corp.)
Address
t r :4_ T "� '•f� rS�. «,- ,i.•� -...r. .r�.�. _ _Yr ..
PUTNAM COUNTY DEPARTMENT OF''HEALTIi w j
. Rev. . + 3186'0 Division of Environmental Health Services d" I 7 Y.1051? Engineer to Provide Permit q ; .
' on CERTM CATE OF COMPLIANCE
NSTRUCTION PERMIT FOR, SEWAGEpISPO$AL;SYSTEM P, C
�.
.7
. � o'er
Town or VIIIag
r
dvsiou Name'
Subd. - t r
Tax
.+t .aye, ++. r:�r �•,tia -:.: is r ,�i,..'
, Block Lot,
Odd _
Renewal p Revision p
Owner /Appiicaat Name ' �/ %%
R.
Date "of Previous, Approval `
/.9,
Melling Address Town
Building Type Lot Area Fill Sectlon Only De p th Volume
Number of Bedrooms Design Flow WPM 40 49 V PCHD Notification Is Regaired.When FIB is completed
n
Separate Sewerage System to consist of _n Septic Tank and
•To,be constructed by 11. Address
Water Supply: bile Supply From Address
ort
Private.Supply DrWed by _Address:
Other Ike galrements
1 repiesent that'1 a•m wholly and.completely responsible for the design end IOCatt/M _ rVi e i��" d 1) that the separate.'sewage disposal system
above described will:be constructed as shown on the'a'pproved bmendment there -to and i e� Iahce wj t derds, rules an regu a ions o e, Putnam
County Department of .`Health .and that on completion thereof a ;Certiiicate 'of Co i eel factory Ito the Commissioner of Healthwill
be submitted to the. Department, and a wntten guarantee will De furnished: the o e,, *,, or igns by the builder, that said. builder will
1. place' in "good operating' condition any part of, said sewage' tlisposaP,- sy�tem duri +thd god of two.l rs.l mediately following the date of.the Issu-
,' •ance of the „approval :of, the'Certificate.,of, Construction Compliance'. of the:oiig or repbir rrt` 2). that the drilled' ell descrtDed above
'will: be located qs shawn on the approved plan and that said well will be9nstalled .i d 'tan s;' les an iegu a�Ons 0f the Putnam
County Oepart of Of Health !�
Date'. signed -
P.E.__ R.A.
Address License No
APPROVEO FO NSTRUCTION: ,. is approval expires ear r m't .' ate i i:the buildhig'has.been'undertaken and is
revocable for ca se r m A e a end or disposal °of domestic s'd ifar n sew as
`a y th '' Iv F o Any change alteration. of construction
requires a ney4 nly,
Date •�'A' BY E Title
r v
FINAL SITE INSPECTION Date
Inspected by Lq-j
STREET ICCATION 66Z-
Ar(.0") CWNER,
A 1/, 9 qW 'M n-D crmnl Trro
T71 A-rM A -r t,
II.
IV.
V.
&A
l(
v
77-
SEWAGE DISPOSAL AREA
a. SDS area located as per approved plans
-A
T-
b.
Fill section - Date of placement
2:1 barrier. LGTH WIDTH AVG. DPTH
c.
Natural soil not stripped
d.
Stone, brush, etc., greater than 151 fran SDS area.
e.
100 ft. fran water course/wetlands.
. SEWAGE DISPOSAL ZYSTEM
a. Septic tank size - 1,000 el:, �2 5P
b.
Septic tank instal-led level
c.
101 minimum fran foundation
d.
No 90' bends, cleanout within 10 ft. of 45* bend
e.
DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
3. Minimum 2 ft. original soil between box and trenches
f.
JUNCTION BOX - properly set
g.
TRENCHES
1. Len required - installed
2. Distance to watercourse measured ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 1/32 "/foot.
6. 10 feet fran propex-ty line - 20 feet - foundations
7. Depth of trench < 30 inches frcm. surface
8. Rom allcwed for excansion, 50%
9. Size of gravel 3/4 - li" diameter
10. Depth of gravel in trench 12" minimum
/.9.
11. -Pi ends capped
h. PUMP OR DOSE SYSTEMS
2. Overflow tank
3. Alarm., visual/audio
4. Pump easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health Department
estimated flow per cycle
HOUSE
a. House located per approved plans.
b.
Number of bedroa-ns
a.
Well located as per amroved'-plans
b.
Distance fran SDS area measured 15e)?o ft.
-r-ade.
c.
Casing 18" above
d.,
Surface drainace around well acceptable.
.OVERML WOR1MSHIP
a. Boxes properly grouted
b.
All pipes partially backfilled
c.
All pipes flush with inside of box
d.
Backfill material contains stones < 4" in diameter
e.
Curtain drain installed according to plan
f.
Curtain drain outfall -protected & din to exist.watercoursr=
g.
Footing drains discharge away fran SDS area
h.
Surface water 2r-O ection adequate
i.
Errosion control provided on slopes greater than 15%.
l(
L.-
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO� ~CONSrTCT� A WATER WELLai'
PCHD PERMIT
WELL LOCATION
Street Address
Town/ llage Cit / . Tax
Grid Numb e
7
p i
n/
io n �� /y
- -3._
WELL OWNER
ame
Z'MO� A'
M iling
� KrO
Address
/.l /��a,JX✓i���. �
rivate
O Public
USE OF WELL
RESIDENTIAL
O PUBLIC SUPPLY
O AIR /COND /H AT -PUMP
D ABANDONED
1 - primary
0 BUSINESS
O FARM
O TEST /OBSERVATION
❑ OTHER (specify
2 - secondary
13 INDUSTRIAL
0 INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
�j gpm /#
PEOPLE SERVED 14- /EST. OF DAILY USAGE ®0 gal
REASON FOR
UK& SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O TEST OBSERVATION
DRILLING
OREPLACE EXISTING SUPPLY
ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
RILLED
DRIVEN
DDUG
®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES P"' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
116 ee Lot No. �,�
WATER WELL CONTRACTOR: Name � X03 Address :,Xe,.*� w- A1 G_—
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES P0' NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
ot
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: ,�� _
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
.�
[]ON REAR OF THIS APPLICATION ON SEPARATE SHEET
(da e) (sigpnure) _
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 s.hall:
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 Co pletion Report on a form provided t e Putna o t
Health Depart, en .
Date of Issue: 19 /
Date of -Expiration: 19 , mit _Is'9-RWg Of f 1cia
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
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-. ,:. .; � - `, ,<.. � �-'- , -_,- .. _,� _ ,•a.- t , � � an�e th t£T5: etan3�ad xs..
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cr U c k t d Pu ir.m :Gear. 4 Y spa
p '.r rules -`and ragu,t�t�,t D rtment
iS , y r? aie'P gP.H�¢7.th." x
e -for upaltsi =aM the y, _� :t f
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AS BUILT S -A
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4
_ - - - --
ru tinam Coun' ;
ty Lepar>;menc oS.•'riealcp. •" p /
Y division of Environmental Realth.Services `�l A Ile
%li
Approved se noted for- .conformance -with
aPplicable Rules and Regulations "of -the �a t/?d!Y1 :y! o / /5=r' j
_ Putnam -County..R9alth -.Department..-- -
f `t i•
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