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BOX 34
04439
5", PUINAM�CODNTY :D OFHEALTB
V
R 'T 1.
Division 8i
-P
-,T.Irtww, C&FORGMAGE
e-
7
lAmftd
5
t Fortherly. Swk
MaWng NIROD
e
-Address 'm I
Date Pinhh:
:%
Gaaistlns of.
GaffonS
eptic Tank and
Wster Su"01 P6bfi.'S A Address
on P Y: Supply 10
O000ic:::�,
'Su
Jd _pO1j.DrWeJ 6y Address
Balldln�'Type Has Erosion con-irw liken Completed?
Number. or,'B,edrooms .�.,Ii".Garba'e .',Grlidei-BeeiiLmstaffed?—
%
q
F
I certify that ith Mjj'.�he .abov_e.:premises were constructed esse lane of ,the . work copies
t
of "Icft' errs , ac ch c
the standards re one.. AM the:0iiiift'isgued by the
County De :
Putn* rtment,of He&
4�4- P.E: _ R.A.
7 w
'06sn ho.
Add . re , , _ _ .,"W� .
as
, 1A
h
Y'CLatmw
1v
Any person oteupytnq pnmisas served [ty -the ove systems) shslt,'promptly take wcn action;,_ "ry`3WaeWs thorioriecklon of any unsanitary
cond1to rs resulting Approval the a OCOM
P s
"Cvol -
War
beConse
available and - I r an a-PU IV Mai a viliabe Sueh .:ijprovals an
subject to modifwstion':Or change 'Wfie in ` n t •of fire ComrnIssi0 of m-- 1tb c revocation, modO lention"or cha , 'if no'cessary.
F
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVI.RO:' MENTAL HEALTH SERVICES.
T? r_ �
. / <5e" � �;' )0 r" /IGi v- , '&r' /?--,
Owner or Purchaser of Building
L7 W"" ef'-
Building Constructed by
Location - St //r t
Municipality
/6 ;";
Building Type
Ii ,52 144.1 /
Section- Block Lot
/' / c7 a 9 -'-;'
U
S vision�.Name
Subdivision Lot #
GUARAN= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
worlananship, 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
= : _:.' -`C -i. -i 3tP- �f'ConsTr.c`act or; Compliance' °: fgr.. die',. age °: S O I_syst 1 0 " y
^'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 the building utilizing
the system.
Dated this _ day of 19 `d
General Contractor,( . a) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
A
Signature �'.1(�J�'j•� t7����L ✓ y,�n�
Title
Corporation Name (if Corp.)
Address
WZ.UJLJ UVr1rjjziiV" Ax!ruai
DEPARTMENT OF HEALTH
0 PUTNAM COUNTY DEPARTMENT OF HEALTH
office Use Only
WELL LOCATION
STREET AOUR Ss. TAX GRID
C I fti A
WELL OWNER
NAME: ADDRESS.:
h Cf
WBIVATE
0 PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY ff'AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM 0 TESTIOBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
DREPLACE EXISTING SUPPLY ❑TEST/OBSERVATION [:]ADDITION . AL SUPPLY
M-NEW SUPPLY (NEW DWELLING) E]DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.1
STATIC WATER LEVEL —9c> ft.1
DATE MEASURED
DRILLING
EQUIPMENT
OYAOTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED OKPEN END CASING ❑ OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 136 ft.
MATERIALS: CWEEL PLASTIC 0 OTHER
LENGTH BELOW GRADE 1311 ft.
JOINTS: ❑ WELDED HREADED ❑ OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROLIT' .;.0 B'IENTON11t 1WHER
WEIGHT
PER FOOT Ib./ft.
1. DRIVE SHOE: ❑ YES Q.N,01'
LINER: DYES OM
SCREEN
DETAILS_
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?,
FIRST
—0-YE5 ONO
HOURS -
SECn
GRAVEL PACK
0 YES
0 NO
GRAVEL
SIZE:
DIAMETER
OF PACK in. I
TOP
DEPTH _tL.
BOTTOM
DEPTH — It.
WELL YIELD TEST If detailed pumping
METHOD: 0 PUMPED t tests were done is it,-
• COMPRESSED AIR formation attached?
• BAILED 0 OTHER 0 YES 0 NO
If more detailed formation descriptions or sieve analyses
VELL LOG are available, please attach.
DEPTH FROM
. SURFACE
water
Bear-
ing
Well
Dia-
meter
In
FORMATION DESCRIPTION
CDOE
ft.
I ft.
WELL DEPTH
it.
DURATION
hr. min.
DRAWDOWN
ft.
YIELD
9prn.
Land
Surface
c_ If,
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? 0 YES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE, CAPACITY
MAKE H
MODEL VOLTAGE ,1_0 HP -31*
ri
WELL DRILLER NAMEA/dw, ,ko #k tj4r S A
AI)OFIESS.P.C) 0
101-4 14 A 1MU4(,4
a/ 0:1
LAB
Yorktown Medical Laboratory Inc
321 Kear Street Date Taken: ' 6/25/'90 Time: 8 AM
Yorktown HeiQh�� X,_I059g. ....Y- Date RC' d : �} Time: -
: -. a*;' %.•s�Y. '�- ei.'ir ;r+• :T.4:..• ".'=i":.%..:Y -m=..Da6`.-" RF' i' �r�' i 'l.A'
(914) 245 -2800 Collected By: VAN HOV E
Director: Albert H. Padovani M. T. (ASCP) PO /Client #
r -I Referred By: C70SSROADS PHARMACY
Sampling Site: BASEMENT TAP:
CROSSROADS PHARMACY CINDY LANE, PUTNAM VALLEY, NY
POB 16.1
PUTNAM VALLEY, NY 10679
L .J
REPORT ON THE QUALITY OF WATER
Phone ( 914 ) 528 -0097 (VAN HOVE)
INORGANICS (—mg /L) MICROBIOLOGICAL 100mL
— Alkalinity
Standard Plate Count
— Chloride
_
(CFU /1 mL)
— Copper
— Detergents, MBAS
Membrane
Filtration Method
Hardness,,Calcium
—
_ Hardness, Total
/Total-Coliform
Iron
—
_ Lead
— Fecal
Coliform
— Manganese
Fecal
—.
Streptococcus
— Mercury,
— Nitrogen, Ammonia
Most Probable Number Method
Nitrogen, Nitrate.
—
— Nitrogen, Nitrite
Total
Coliform
— Phosphate, Total
Silver
_
— Fecal
Coliform
Sodium
Fecal
Streptococcus
. -.._. . .
_ Sulfide
Presence /AbsensesJ(PA)�
Sulfite
_
Zinc
Total
Coliform P A
PHYSICAL MISCELLANEOUS KEY FOR TERMINOLOGY
— PH (S.U.) CFU =
— Color (Units) IT =
Conductance (ohms /c) GT =
Odor'(TON) NA =
Turbidity (NTU) SA =
— TNTC
Colony Forming.Units
< = Less Than
= Greater Than
Not Applicable
See Attached
Too Numerous To Count
t fly : ; . - � 111NI�i►�I�F.3 • _ • �
THESE RESULTS INDICATE THAT THE WATER SAMPLE Q
-SATISFACTORY SANITARY QUALITY ACCORDING TO TH$
WATER CODES, FOR THE PARAMETERS TESTED, AT THE
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID)
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW
ING WATER COPES, FOR '1,'F�E P4RIV TESTED, AT THE.
(For Lab Use)
SAMPLE TYPE:
(Check.One)
f,/ Potable
_ Non- potable
OUTGOING:
(Check Each)
HNO
_- HC13
— H2SO4
_ NaOH
_ ZnOAc
— Na2S2O3
Other:
.INCOMING:
(Check Each)
v;ILE �40C
_ GT 4 /LE 200C
GT 200C
_pHLE2
— pH GE 12
_ Other:
(WAS NOT) (NA) OF A
YORK STATE PUBLIC DRINKING
OF SAMPL2COIJECTION.
TION.
(DID NOT MEET THE
YORK STAT DRINK -
TIME OF S
7 /87(Rvsd1 /90)RWE
L � N
t
CONSTRUCTION` rPERMIT'F
Subdivision
ts. f
Owner /Address
Building Type
Number of Bedrooms _
Separate Sewerage'System `to con
To be' constructed by
Wate► Supply ` 'P.ub�lic 5
'` ,Private ,
_ ';Address /:
Other Requirements ,
I representahat I sin wholly and cc
above described will be constructed
County Oepart`meni of Health -a
be submitted to the Department;
pWce in' good operating conditio
arice of, the approval of the Cert
will be located as shown pn the app
County Departure t of Health
Ad'c
APPROVED FOR CONSTRUCT!,
revocable.for cauge-"or may be,amei
requires'a new perms Approves
Date r-
Rev 9r81
.�"ayf"���'"`°.. .•aw, 2FF°T';✓'�-- '^'"'Fyt y�4 lh� .�.
pC,S
PU ,NA'M COUNTY MEPARTMENT OF HEALTH ' 1
Drvis>on of Environmental Health Services Carmel N Y 10512
,'SEWAGE'QISPOSAL SYSTEM ' �iA'7v
Town
i'
Tax.
Subd Lot R - /
Renewal' Revision
{ '
. ' r
Fill Section Only ❑
� �;A-� l�
iqn Flow G/P /D �
P C H� D Notl Yication _Re ired_
,9u
f §
.//
3 17;_
9rL..e[ Lot
5 3
of o 't✓ �+L� G
Gel Septic Tarilc a
antl �
{ '
'Addiess .
K
Ny From h
h
ply toy be drilled by -
-�` '
letelv`� resoonsitileaor the Ae`sian and location. oi - tlie-`er000'sed. systemtsl. rll that t
the .
1� "' -.1, *�,� '� z . %_ "
year fom the <
d necessary t
mta y, age a
:. ..
I* rules an �egu a ions o e _a u nam ,
Ito the Commissioner of Healthwlh' $
igss `s he builder that said builder wilt, t,
following thedats of;the isw=
of tli -sit .drilled well described above
rul d r u a ons :of the L Putnam
PE RA
°t:1ie�Ejhse No .�
�e °p}tik�fn9 has been `undertaken and is, ,l
9A'�ya?Ige atbn of construction= f
iaau .
_• Title �/ :
y
. ny
�,— _.......,...,..«- P- v..........o.,•....«- ., -m.�n .-, Kma+.,* ar., r.-. a,,r:. »........- ,.,...n:c_- +n«^*-'": •,.w �caZ- :c- r:ti.�,.,- ;� --*'- x,.-- �;,,.;.�..:�,...,r
/ i I� PUTNAM COUNTY DEPARTMENT OF HEALTH Permit e '
Division of Environmental Health Services, Carmel, N. Y. 10512
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
( _ ow_n or age
oc'tera 614- Tax Map ~Block Lot
Subdivision _ 6 ����' C ✓� Subd. Lot P Q Renewal _[3 Revision _13
Owner/Address '�� S 1 4° rim
� r cc
Building Type Lot Area
Number of Bedrooms _ Design Flow G/P /D O
Separate Sewerage System to consist of 900 Gal. Septic Tank
To be constructed by
Water Supply:
Public Supply From
Private Supply to be drilled by
Address _
Other Requirements 5 ) ( ss ' ya. r ko + ✓t Dur-a i
Date Of Previous Approval
Fill Section only ❑_
P.C. H. D. Notification Required
and j�
and 40C% �.- 2 Jt ,5 VV Y f' `Y-e'• ytC_ 1 %e,�S
Address
I represent that 1 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 be constructed as shown on the approved amendment there to and in accordance with the standards, rules and—regulations o o u nam
County Department of Health, and that on completion thereof a "Certificate 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 asslgns=by "the builder, that said builder will
place in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately. following thedats of the Issu-
ance of the approval of the Certificate of. Construction Compliance of the original system or any repairs ttrereio; 2) that =the drilled well described above
will be located as shown on the approved plan and that said well will be installed In accordance wit the standards„ rules ^.anC; regu,a ,ons. of the Putnam
sa n
County Department of H Ith. yy '/ ,!� Date Signed v I / ' d 0."
.E R.A.
�f q Z . l j a
Address ? / l r o, , Lt Lic'
ense ~No.
APPROVED FOR CONSTRUCTION: This approval expires one year from the date Issued unless stru¢tion of the biAl iii has5bebn undertaken and is
revocable for cause or may be amended or modified when considers ecessary by the Commis ' r of 1- 14lih., A6r, changcorialt�ratlon of construction
requires a new permit. Approved for disposal of domestic ar age, and /o private er supplyTgn'1,� °'- ,.' =}b ^a5?a'
Date / d By
Rev. 9 -81
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION..OF ENVIRONMENTAL HEALTH SERVICES
" OOUNTY -OFFICE BUILDING, CARI�IEL;
DESIGN DATA SIFT- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
owner J ; : lam- :� ��,�! /
Address Z -d -eAf,,
Located at ( Street� Sec . /1 !� Block Lot /
�'Tncucate/neprest cross street)
Munici lit rs >Tl7tr���' Watershed
?�' Y
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
��
33 33 If
4
5
1
2 ..
3
5
lotes:' - "1) t4 s to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2 ) Depth measurements to be made from top of hole.
Hole'
Number
CLOCK TIME
PERCOLATION
PERCOLATION
Elapse
Depth
to Water
a �,er ve
No.
Time
From Ground Surface
iri Inches
Soil Rate
Start
-Stop
Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches.
Inches
Z%
/
/ 2-
2-3j2-
2,
f 2-
�% .
/ ..
z-
��
33 33 If
4
5
1
2 ..
3
5
lotes:' - "1) t4 s to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2 ) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
D_E_..F_ qA- OIE ` N0 < y. : • ;K.e HOLE `V0 HOLE* .;iN:. _.
T
G.L. _ ✓ S�' %' /
.6��
12"
18"
301
361
42"
48"
5411
60"
66"
7211
78"
84 '
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
, INDICATE...101FL_: TO WHICH .WATER LEVEL- RISES AFTER •_ ..ENC�UI�ITFRED -
-TESTS MADE• BY ..... - ;� 1 i �('r� =✓i Date , ��
DESIGN,
Soil Rate Used 1_5 Min/1 "Drop:. , S. D. Usable.. Area Provided !6—c-PG'G +
No. of Bedrooms Septic Tank Capacity T0 Gals. Type K_a� V �, r
Absorption Area Provided By c,o L.F.x24" width trenc .
Other C. 'ID .S
Name h Signature
Address `2, 7 Z _n EAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by Date
�., a.. d'..qt o_,
a
D'EC 15 1982
PUTNAM COUNTY
KEPI Pty HEALTH
JOSEPH F. SULLIVAN, P.E.
YORKTOWN HEIGHTS, N. 10598
(914) 962-4248
RECHVER.)
SEP 2 7 1990
PUTNAN11 COUNTY
OEPT. OF !'%'EA!TFj
- PUTNAM COUNTY HEALTH DEPARTMENT.
ya q - 4 y'a ' .1h"i EMc
;DIVISION OF ENVIRONMENTAL HEALTH SERVICES
>:
John M.. Simmons,.
- Depu y-, Commiss onerfof Health :" - FIELD ACTIVITY REPORT
: Shee.t. of
..
INSPECTION
-NAME VA Af Navy
nOrig. Routine
,Orig. Complain
ADDRESS uNDY LAWS .. MWAM VAUZ -Y-
Orig. Request .;
No: Street
Municgality'(T)(V)(C)
Compliance
R
Compl aint Comp
: MAILING ADDAES'S
__
'Final
s P.O. Box` .
4 Posit_ Office. = :. Zip Code
Group Iliness
�KGonstruction
TELEPHONE.
Reinsp_ectioh-
,PER50N; IN CHARGE'
-Field Sam T in :0, I
P:. g' q
: ,..
OR INTERVIEWED ,MR
.4
V}tipf }dpy l
Field Conference`
-
Name and Title.
-
Other
DATE off° /$ - $lo
TYPE FACIZITY
`pro,
TIME 'ARRIVED ° ' :., %Q
'.TIME LEFT /�
- Explain
FINDINGS-:
yA tdit
`.M :- ur5' SVS "C!►9 ra/s- PAt,IED rr tie Pi
APPjjO 6 tA-ST %FAGi.�9
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% r 15'
f L'I
DEPT, OF 'HEALTH .
szl %4r /l/,,�` nc S
Se nioj e-
4Jf sCrj A7174'G+We
i'C �i2nr'F :�ti4�..,�.%�.� d,� °�`n� rv��,•Y / //? +iii *
/L° SSAE�ypNClS�gi �/
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