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PUTNAM TY COUN DEPARTMENT OF,HEALTH
y
Divlaion of Envlronmeutal Health Serviced; Carmel, N:Y.10512
Engineer Must Provide
PXM D Permit # P
CERTIFICATE OF CONSTRUCON COMPLIANCE FOR SEWA
TI GE DIS OSAL-SYSTFM•• --
�' .�• ,6r. oa– P1 /�liL �✓!/�l r_;.:_ �` 2J(l Town or Village
Located at ,�A ..� � Qd Tau Map
Bloc Lot
Owner %applicant Name / /rte � �" ";'Foorrmerly Subdivision Name Sdtidv. Let #
' MaWng Address _
Ro /JOB ZIP- �� Date Permit Issued
Separate Sewerage'System built by O : e-- Address o�
Consisting of _ % Gallon Septic Tank and. '-' zd
Water'Supply: Public Supply From ,y Address
V 9
or._..�_Prlvate Supply Drilled by, , Address . h'�'� ✓mac
Building Type, ,L tf d ` 2`7 C.0 11" trosion Control Been Completed?
Number of Bedrooms- Has Garb Grinder Been InetaylledY `O t
..Other Requirements _ . _ ... ..
.- n 4• •.- � of
I certify that, the systems) as listed serving the above premises were conatructed:easentialas ;shown on he,pla of the completed work ( copies
of'which are attached), and in' accordance with. the standards rules and regulations, icprada NV h e: Ie an, and the permit issued by the
Putnam County Department �Of .Health �... t ' ♦ - -
Oate �� /�� Ce►, led by P.E. R.A.
—�
Address ' La 07S
Lfcense No.
Any person occupying premises served by the ova system(s), shall promptly take such action`r�nay nap q tq� �ro the correction of any unsanitary
condition's resulting from sueh' us$ge. .'Approval .of the separate sewerage .. $hill become'3ga Y >� +s a, pubt': unitary sewer becomes
available and the approval of the private water supply,. ;half become nu ntl Jo when a publle +NSbs`�upyaLBetari»s available Such approvals are
subject to modificattiiio7nor change when, in the judgment :o't the m o of Heal suc ota�tlon;.motlification or change is necessary.
Date G • By Title
m
C71
0
/� WELL U.V1v1rLL11VN Azrvr" Office Use Only
CIO .e DEPARTMENT OF HEALTH
�* ` �' - " - - Lsi:yi�Ic>1�Jf FrvaronmenraL Healttln: Se Vices• - V _
PUTNAM COUNTY DEPARTMENT OF HEALTH
TREET ADO / O TAX GRIO NUMBER:
WELL LOCATION
O 0
IL
WELL OWNER
NAME: 9 ADORES PRIVATE
❑ PUBLIC
RESIDENT ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ •OTHER (specify)
p INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O
USE OF WELL
1 - primary
2 - secondary
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED `_ /EST. OF DAILY USAGE gal.
REASON FOR .
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑, REPLACE EXISTING SUPPLY. O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ®� r ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING.
EQUIPMENT
ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
1 ❑ SCREENED ❑ OPEN END CASING.. OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH �_ ft
MATERIALS: 2N§TEEL ❑ PLASTIC ❑ OTHER
LENGTH.BELOW GRADE J
JOINTS: O WELDED )MTHREADED ❑ OTHER
DIAMETER y in
SEAL: ❑ CEMENT GROUT O BENTONITE HER
WEIGHT PER FOOT Ib. /ft.
I DRIVE SHO S ❑ NO
I LINER: 0 YESXN0
SCREEN
DETAILS ...
_
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
Fasx
rES a vD
=HOURS .
'SECOND'
._ .....
-
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL.YIELD TEST, ' If detailed pumping
METHOD: 0 PUMPED 1 tests were done is in-
NAILlf!) OMPRESSED AIR ,formation attached?
❑ OTHER : O YES ONO
WELL LOG of more detailed tale aton descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ling
well
;OIa'
Deter
FORMATION DESCRIPTION
cooe.
tt
fl
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
O e
o
WATER O CLEAR. TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK : TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE -
MAKER
MODEL
®
_ CAPACITY 9
DEPTH
VOLTAGr HP
WELL DRILL NAME DATE
ADDRESS
wo�
Yorktown Medical Laboratory, Inc.
LAB N " - - - - -- -
321 Kear Street
Date Taken : g��' y � � Time
Yorktown Heights, N. Y. 10598
Date Rc'd:
— Time
,(9.14.)_245 - 3203 -- =:7 -. �." .: _,. :D� a "P$ �`t;.�d
W Padovani M. T.
-
Director: Albert (ASCP)
Col l e e t e d By:
% /Ld To2y �
-�
Referred By:
T
Sample Location:.
r `=
Phone #
/l�S
Phone #
Sample Type:
L S��iiL 1-
Repeat Test? _
(check one)
I
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
V--"Standard Plate
(Agar Plate
Count (CFU /1.OmL)
8 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
�otal Coliform (CFU /100mL)
Fecal Coliform (CFU /100mL)
Fecal Streptococcus (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
_ Total Coliform: MPN Index.(per 100mL)
2 4 -o
E= e:c:pl ..Col1.'form- : "- 'MPff.:- Index .'(per` :1.O0.mh. °_
OTHER ANALYSES
REMARKS (For Laboratory Use)_
'Potable
_ Non- potable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
_ Na2S203
Incoming
_✓�E 4 ° C
_ GT 4 °C
Other:
KEY ZOR TERMINOLOGY
RDS = Recommend Disin.fec,-
tion of Source
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
LT Less Than (<)-
GT = Greater.Than (>)
N/A Not Applicable
LN s Less than or eaual to
THESE RESULTS INDICATE THAT THE WATER SAMPLE UWAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH ORK STATE D RINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, AIME OF COLLECTION.
x - G�4���fi /_
Albert H. Padova i, M.T. ASCP , Director
12 /85(RvsdT /8T)RWE
For Lab Use Only:
_ H/C to
ILAB OFFICE HOURS (Main Lab):
9AM -5PM, Mon'
on. -Fri.
9AM -NOON, Sat .
PUIN M COUNTY DEPARrIMfW OF f hEALI'H
Owner or Purchaser of B ding
/>
Building Con structed by
gal
Location - Street
Municipality
e/2; C
Building Type
Section Block Lot
Subdivision Name
i
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..,apprQVk-. -of, the,....
' °Cer1 f- i:cate o -Compliance" for the sec;idye disposal 'systan, or any
repairs madee 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 Environirental 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 �illl` e buil din - utilizin the system. , l?
Dated this_ 5 day of 19� Signa
✓ Title
eral n ra d (Owner) - Signature
Corporation Name (if Corp.)
Corporation Name (if Corp.)
Address
Address
rev. 9/85
mk
-r
PUTNAM COUNTY DEPARTMENT OkHEALTH: ;
Rev. '3 86 . Dtvislon of Environmental Health Seivlcea. Carmel" N.Y. 10512
r'td'Pro
1 vide Permit
on CE OF COMPLIANCE
CONSTRUCTION P ItMIT FOR SE AGE DISPOSAL SYSTEM / Permit
/� 0
„Lq.ted at��jQ t� Town or Village
Sabdhlelon Name y—s' ' Subd. Lot k ` T. Maps a'U Block
_ ❑
Renewal > Revlsion O
Owner /Applicant Name.<
p Date of Previous Approval
MaflingAddreas® p'C ✓`�/4��• Town Zip
Bulldlag Type j Lot Area Fill Section OnIY Depth Volume
P
Number of Bedrooms Design Flow G /P /D d O PCHD Notification is Required When FIR is completed
Separate Sewerage System to consist Of � Gabon S. Tank and 6 70 �¢ `1 W i dG/s et`t
To be constructed. by Address
Water Supply: Publlc'Sgpply From Address
or Private Supply Drilled by — Address
Otber,Requlrements ��
1 represent that I am wholly antl completely res 'risible for ttie design and location of the 'propo 1�m fit„ at the: separate - sewage ,disposal "system
above described will be constructed as shown on the approved amendment there to an - in accorq q it :the s��j d rules an regu a ions-' , e u nam
County Department of Health, and that on compleUOn thereof a "Caitificate of• Constructs GbpR °Op �f t¢ the Commissione► of Health will
be submitted' to the. Department, ' and a. written guarantee will be :furnished. the owner,. h w 4$3s ,. �9 s dhe' budder, that. said - budder will
place in good operating condition any part'of said sewage: disposal.system during thb, ridgy wo.(2)_` year. Y,����L,edi ly following the date o the issu-
ance of the approval of. the Certificate of Construction Compliance of the original sy; y• re therettP� 1 .the drilled well descnbetl above
will be located as shown on the approved plan and that said well will beinstalled .in accoitl ce rar' - t tls a ?'regu abons of the Putnam
County �Oap rtment of,�jH'ea %lth,
Date 5�9nad , r P.E. R.A.
y Address icense No
,,,,gyaapb �; o
APPROVED FOR CONSTRUCTION: is aD,Droval_expuesrewe year from the date i sued Vu Io�aB. uildidg has.been undertaken and is
revocable for ause or mby be amentled'r:niodified when con sider 'n ees y. by ,t o mi change or al ration of construrf, =s�.
requires a n w permit. Approved for disposal of done stic rani ar s ge, and/ pr'I t w .ono `
y
Date By
M3
yx
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL,'N.Y. 10512 (914) 225 -3641 tt`
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # � - �
WELL LOCATION
Street Addres
To Ville City Tax Grid Number
WELL OWNER
Nam Mailing Address iivate
%�f'_i�/ ars9 01�o�t f�i- a�0�/9 O Public
USE OF WELL
1 - primary
2 - secondary
%'RESIDENTIAL
® BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ❑ ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND, -BY
AMOUNT OF USE
YIELD SOUGHT . w' gpm /# PEOPLE SERVED g�' /EST. OF DAILY USAGE,i9n00 gal
REASON FOR
DRILLING
PIEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
®DRIVEN
®DUG ®GRAVEL ®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES A--' NO
I-F WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. /
WATER WELL CONTRACTOR: Name /►' O/�i'P J �i7 � ®� Address: %gc aw-
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES d/' NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
• - �•..�:.. _...... _ aJ .v.++. .. .p„ ...s'.... .. �a ,..... �...�..� y� � �... .�.. ....r ...y � -... _ r-.� � .�... rW�+�.•_f.. �.J.. u�.v w.. .-.�- .... .. ,.. —. �. �n� W } ✓.5.�.'. ....—
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION 2 � OV SEPARATE SHEET
97
date) °-j-; (sig r
PERMIT
TO CONSTRUCT A WATER WELL
f
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:
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 p rmit.
3. Submit a Well Completion Report on a form p o,id b u nam County
Health 'partment.
Date of Issue:
Date of Expiration: 19
`rmi t ssui ng Official
Permit is Non - Transferrable te copy: H. D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
REVIEW SHEET - CONSTRUCTION PERMIT ,���ff,,
DATE REVIEWED: U �•C- 1
BY: ---�
tSLreeL 1AcaLlon)
DOCUMENTS
- Permit Application 1
"Corperat� l�e��l:�ufv��:c�n= :, :'•:::...: - :: --- .. _ ��;.
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc Z..!r-_
Consistent Perc Results (3) Fill 7.
Perc Hole Depth cd -----
House Plans - Two sets
Well % permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - -Gravity Flora
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump'pit. details
Septic Tank - Size, Detail
Well Detail, Service Line if over !
Construction Notes
Design Data: pert and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion i
EStarision,'.,-Ar-e-,,i.;�shpwn,g;7avity--flow.Fsuff. size
If Punped Pit & D Box Shown &
House - No. of Bedrooms
Wells &. SSDS's Win 200 ft. of Proposed Systems ;
Property Metes & Bounds i
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe t
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN {
Fields
10' to P.L.,, Driveway, Large Trees,Top of fil'F
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan'
15' to Drains - Curtain, Leader, Footing
351to catch basin,stornx3rain,piped watercours'
101 to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
9
R,
r
x
- I
mca nf rk m r 1
REVIEW SHEET - CONSTRUCTION PERMIT ,���ff,,
DATE REVIEWED: U �•C- 1
BY: ---�
tSLreeL 1AcaLlon)
DOCUMENTS
- Permit Application 1
"Corperat� l�e��l:�ufv��:c�n= :, :'•:::...: - :: --- .. _ ��;.
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc Z..!r-_
Consistent Perc Results (3) Fill 7.
Perc Hole Depth cd -----
House Plans - Two sets
Well % permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - -Gravity Flora
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump'pit. details
Septic Tank - Size, Detail
Well Detail, Service Line if over !
Construction Notes
Design Data: pert and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion i
EStarision,'.,-Ar-e-,,i.;�shpwn,g;7avity--flow.Fsuff. size
If Punped Pit & D Box Shown &
House - No. of Bedrooms
Wells &. SSDS's Win 200 ft. of Proposed Systems ;
Property Metes & Bounds i
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe t
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN {
Fields
10' to P.L.,, Driveway, Large Trees,Top of fil'F
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan'
15' to Drains - Curtain, Leader, Footing
351to catch basin,stornx3rain,piped watercours'
101 to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
9
R,
r
PUTNAM COUNTY DEPARTMENT OF HEALTH
:I..
N
-- DISION -01 Ei1iitBiiFNfTcN''AI1:,HEALTI3 :SEFtiES, �._ .�.; =: "'� -.
Date 4'//Y/ 9-
Re: Property of / d�'� / 9"-� �® ®�
Located at
(T) ��� 4 Section /,?-d -Block Lot �d
Subdivision of ��� /�� IlYlloi
Subdv, Lot .# Filed Map # Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer or registered architect
(Indicate
to apply I "or 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
to: super i:se -tilde. °cons r:uction o a-- .
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.:
7-
Counters!i�
P.E.
Add ess
/ 41/
Telephone
;?1;
Very truly yours,
C
Signe
1�vner of Proper
Address
Town
Telephone 5- K /II '
DIVISION OF ENVIRUM71AL HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE S5gAGE DISPOSAL SYSTEM FILE NO.
own ... =:� %� �' /4 q� �d Address
Located at (Street) /4/0 0 P /�� /VA o� !� Sec. Block j Lot
��((ijindicate nearest cross street)
Municipality /� , / QVly / Watershed
I
Date of Pre- Soaking Date of Percolation Test
HOLE
NU MER CI= TIME PERCOLATION
PERCOLATION
Run Elapse Depth to Water Fran
Water Level
Tim No. Ti Ground Surface
In Inches
Soil Rate
Start -Stop Min. Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
to j6p LS'
2/0 'le
Wz, // '3v -, ///�4-
4
..., �--- ,�- •':::`2���,�jo:.7�►.::.• �= .,.�., , e.s.� ��w�.... : ;�- e�:.. /�.,w.- ..'_�- ':' -::': w '_ .....�.xi„_ � �o.:�..•�� ..:t . . - .:,:. ,;.;, o. ..
4
P?
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.
2
>_
w � ,
�0
3
4
�.
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 HOM NO. HOLE NO. �° HOLE NO.
1'
3' G
4'
5'
6'
7'
go
9'
10'
11'
12'
13'
14'
S'r_ 0W
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER.BEING ENOOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: �j•L/ �� . DATE: a
DESIGN
Soil Rate Used i Min / 1" Drop: S.D. Usable Area Provided OG'
No. of Bedroams Septic Tank Capacity gals. Type Y�oi-
Absorption Area Provided By Z ,7O L.F. x 24" width trench
Other
Name 7o
Address � W;0
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: o
Soil Rate Approved sq.ft /gal. Checked by Date
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Yutua® County Vej aii 6ax ui nuu (ti,
Division of Eavironm
an, tsllHealth" .Servious
;.
4PDroved as noted for coarornmaoewith
applicable' Rules and H.egulations; or the,:;
Pu County Health Department p
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