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61
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Bill
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PUTNAM COtiUNTY DEPARTMENT OF HEALTH
Rev 3/86 Division of Environmental Health Services, Carmel, N Y 10312 t.
Eagtiaeer Mnst
RTIRGATE O1�11GONSTRUCnON :Cr)MPLLAlN(.E,FUK,bE'WAtsk UIJYVbAkbIbXAM . /J �,+� /j�7 -
<> . t .tom` y - wn or V e.`.
f'7
�7O ¢
Tau 103aPBlock
Located;at �—+4
_
Owner /applieadt'Name�' �° , 7 Formeely
Snbdivletoa ame ntidv t # -
c
MaUing Addreae . f '¢ S�D.'yJGp.Zs'+1 /�. Zip j 0 tr4 7
Date permit Issued
Me
Separate Sewerage system : built by; Af— r � 1 /i G Addr®ss tr
Cotisiating of k y ' G#Hon.Sepdc Tank aad
e.
Water Supply: Pnb11c Supply Flom
�t> `.Bra
Address
`�L%ts
or. Private Supply'DrWed;by �✓ /-�-r1 iJ
Addrms / ri / 9dl�i. f�4 , w
t✓ 5. Has Erosion Control Been CompletedY�
Bnlldipg;:Type
Number of Bedrooms .5 , Has Garbage Grinder Been InetelledY'
d
OtherRegnirement8 J
oF,NF
R.
I certify that the syatem(s) as listed serving the aboye'premiaesv4ire constructed ass
pat§�d plane of the completed work i copies
of which are attached) and in .aceoidance with the standards, ralee and regulations,
a ance i e f ed plan,, and the permit issued by the
putriam County .Department` Of Health:
-
Date l a t y ' ' C,a[jt�ifletl by
P.E. R.A.
$ it
a'
'
I: •'
1
16111f
�°
;+u
Llcena NO.
.r
ysa+ a 1 ed
Any person occupying Demises sorved by the boys systems) shall promptly take wch aetlo secure the correction of any unsanitary
conditions,zresulting from,, wch usage Approval .of the separate srweraye,systom shall beeo 11t 9 n as a pubs : sanitary sewer becomes
available antl the approval.of the.,prlvats;Waiei supply she r64coriie'fiull and':vokl when a public _ _ „, ly bieorria aysllabN: Such approvals are
1.
subject to Ifiatlon or �hannge*whheer, in the judgment of the ” Commissid "r-of,.Noslth;-
such�revoeatI n;'.modlilutlon or change Is necessary.
/. V
Title
Pate0 / !
m
d
Wr.LL lVP1rLA11V1V L�rVAt
:. •e DEPARTMENT OF HEALTH
* i . a Division Of.. Environmental. Healt:b c Serviwces_
'•;�.. {.� .� >..- o...- ...._- '�'X. -��'w «.r7'• °�' -�'; •.z».L^e- �-'�sv - ' -..-. �r _ -ro :•.ti »^' -•C. :ai&:.
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
_ �:�':^.wyRw..�' ac..� y�..� �p'.> :•ia,- ,:.F•o.
WELL LOCATIONz
STREET AQUA WN L W.GAIO NUMBER:
- G
WELL OWNER
r4,�S,__ E. - AO PRESS: Jo
b71% �t k .
PRIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary,
.RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ BANOONED
❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED –"— '-EST. OF DAILY USAGE gal.
:REASON FOR
DRILLING
O NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
D
WELL DEPTH ft.
STATIC WATER LEVEL 3 e ft.
DATE MEASURED /A01
DRILLING
EQUIPMENT
ROTARY . 0 COMPRESSED AIR PERCUSSION ❑ DUG
WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING . p, OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 4/,0 ft-
MATERIALS: gSTEEL O PLASTIC ❑ OTHER
LENGTH.BELOW GRADE eft.
JOINTS: ❑ WELDED THREADED ❑OTHER
DIAMETER ; in.
SEAL: O CEMENT GROUT ❑ BENTONITE JOTHER
WEIGHT
PER FOOT Ib./ft.
DRIVE SHOE-;91-YES ONO
LINER: OYES NO
SCREEN
.... _n�T�►ls ._. -.:.
DIAMETER (in)
SLOT SIZE
LENGTH
(f t)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
o YES ❑ Nq,
HOURS
:.. - �..
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: ❑ PUMPED t tests were done is in-
t
WCOMPRESSED AIR , formation attached?
O BAllEO ❑ OTHER YES ONO
lt more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Dia-
meter
FORMATION DESCRIPTION
caoE,
tt
ft
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
,JZI)
I/,
�►
Zz
WATEP ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? ❑ YES O NO
ANALYSIS ATTACHED? ❑ YES ❑ NO
STORAGE TANK : TYPE
CAPACITY dAL.
PUMP IHFOB ATION gyp_
9`rf- 3� 4A
TYPE PACITY
MAKER DEPTH A 0
MODEL.- rS .5 " VOLTAGEa HP
WELL DRILLER NAME 111A, -2-7�
ADDRESS �J ° `�f °I SIG 9TURE
f�
t
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION ENVIR - _
_. _. ,. .. - - _ a ,
,. ,.,�.., - ��.�.- - ~.ate. �.•.c,..�. Est L � "
1 �HEAI+T . .
Owner or //Purc))V�haser of Building
eei- /"WGs _o? C.
Building Constructed by.
Section Block Lot
Location - Street Subdivision Name
Municipality Subdivision Lot #
Building Type
GUARAFP= 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 af. Construction .Compliance "• for the' sewa F. disposal systeaiR °;or any::':
gr.
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 Signature
Address
rev. 9/85
mk
Title
/0s. 1
Corporation Name (if Corp.)
Address
3. 1-n-st l l ed ac"__rd i_q to vl en 157 I
4. Distance cwt, cr to c --nter
5. Slor_z of tencri acce=t�able 1/16 - 1/32 " /foot_
6. 10 feet from vrc— �,r 1? *ie - 20 f=---_ - zccul,:at'-i%crs IBC I I
7. Depth of t_`ncz < 30 inches f=an sarace
8. Roan z?lcw i for ex-- ar_ion, 50%
9. Size of cr_vel 3/4 - 1i" cia:tie.r (' f I 7
10. Depth of uravel in tench 12" mini= ( K 1 1
L. • Pine enss c-- -==e`i
h. PUMP CR DCSR SY.��S I j
� t Size of y=, c.'Ia- L er I
2 _ Cve*=flcsa t' -_niC
3. P? ate, v? -m i /a aii
4 P= e=s l y ac
5. Z-� ` bcx b-- led
6. Cvc-le w. _-:a s by
estimates flow
Iranh -cle to =de
rl-�r
M ECUSS ,
a. BR^Le located L-er zborcva3 vlar'.s.
b. Yhmher of be=rca s
V. 'r! T
a. Well as rer a-mra en y___
b. Dist-ance fran SLS area measure r156 7' ft.
C. C'as_nq 18" zrcve crzde_
d. Surface dz- ainace a=cur -. wen acre =ale.
4Z. C-VE-RA L WOR�SrIP
a- Ecxes properly crcut
b. JA_1 pines hecczIEea
c. P11 pines f f i2sh with inside of L-ax
d. Backfill material contains stones < 4" in diameter I
e. _0-, - tain drain installed according to plan I
f. Our`, ain drain cut=all prote=ted & di r. to ex st.wzt?rcoursd
g. Focti n e-`ins discha-zce away fran SLS arm
h_ Surface watar nrot_=cLion adern:ate �..
i. L:-_cs? cn c--n=oi vry ^ti ded cn s1cces cretar then 15ri . I cD
SZR._� ='T
ICC3TIC�N E C t.t� ^~' Ct�v�IF R
&,-\j
P�M?T
IL 2` OR = v
� �' �_ / a a
b� 2 p Su` Dr'ISICN LOT
� r
ISPCL
a.
SDS area located as re-- arcroved D1anS
b.
Fi11 s on - Date cf plac�.zt
2:1 barrier W —n AVG_DPM
c_
%tural soil not stri=jed
6Z I 1
d_
Stone, brash, et-c_, cram- t-m:n 1-5' fron SLS arm_
IS` I
e_
100 ft_ from wzte_r course /wetlancs_
I 1 1
11. � = DISPOSAL ��� *
e
P_
Sentic tank size 000 1,250
�.
b.
Sentic tank instil a�e1
c.
10' minim -an from four_ ti on
d.
No 90' be_*.rs, cle_=nc t within 10 J'--- of 45` be-id
( I
e.
DISMUMrj --TICN BC'X
11
p
1. KU Outlets at sari e elevation - water tasted
J
2_ Protsc-'_ belcw'f_cst 1
1
3. M? n i ,, 2 f = i cric n`l soil be ri�� box and tr= ashes
( 1 I
_
r.
Jc-a'-TICN Box - rroce —rl v eat
1- recu T
2. Dist-?nc_ to waterc:Jur =e Ifr--a--i —r-E-d " ft._
3. 1-n-st l l ed ac"__rd i_q to vl en 157 I
4. Distance cwt, cr to c --nter
5. Slor_z of tencri acce=t�able 1/16 - 1/32 " /foot_
6. 10 feet from vrc— �,r 1? *ie - 20 f=---_ - zccul,:at'-i%crs IBC I I
7. Depth of t_`ncz < 30 inches f=an sarace
8. Roan z?lcw i for ex-- ar_ion, 50%
9. Size of cr_vel 3/4 - 1i" cia:tie.r (' f I 7
10. Depth of uravel in tench 12" mini= ( K 1 1
L. • Pine enss c-- -==e`i
h. PUMP CR DCSR SY.��S I j
� t Size of y=, c.'Ia- L er I
2 _ Cve*=flcsa t' -_niC
3. P? ate, v? -m i /a aii
4 P= e=s l y ac
5. Z-� ` bcx b-- led
6. Cvc-le w. _-:a s by
estimates flow
Iranh -cle to =de
rl-�r
M ECUSS ,
a. BR^Le located L-er zborcva3 vlar'.s.
b. Yhmher of be=rca s
V. 'r! T
a. Well as rer a-mra en y___
b. Dist-ance fran SLS area measure r156 7' ft.
C. C'as_nq 18" zrcve crzde_
d. Surface dz- ainace a=cur -. wen acre =ale.
4Z. C-VE-RA L WOR�SrIP
a- Ecxes properly crcut
b. JA_1 pines hecczIEea
c. P11 pines f f i2sh with inside of L-ax
d. Backfill material contains stones < 4" in diameter I
e. _0-, - tain drain installed according to plan I
f. Our`, ain drain cut=all prote=ted & di r. to ex st.wzt?rcoursd
g. Focti n e-`ins discha-zce away fran SLS arm
h_ Surface watar nrot_=cLion adern:ate �..
i. L:-_cs? cn c--n=oi vry ^ti ded cn s1cces cretar then 15ri . I cD
�J \11 \ c
n\ti
CORtST$iJ N i?E�A!fPl' �+ ®l�_SE�
Located ®t
No C--Zkti /y
Subdivision Now
PUTNAM COUNTY DiPARTMENT OF HEALTH
Divlslon of Environmental Houltb Soevlm& Carme9, N.Y. YOSY? . Engiueer to Provide Permit #
on CERTIFICATE OF COMPLIANCE
Peumtt d
WS4L SYSTER$ /t� �1` Z3-97
own or Village
Lot # .2 Tax " /.70 Block fat A >2_
.�m�r�. r�Ii
Renewal— 0 Revlslen ]%
Owner /Applksnt Nerve ,
Malling Address i a Z 3 trZ
/W,41,4 e-
dS
Date of Previous Approval
Town Zip
Building Type 1;e _j /dam e4 Lot Area 7 f 4 9f 4h# F01 Section Only Lj Depth----- Volume
Number of Bedrooms Design Flow G P D / O O 0 PCHD Notification Is Required When FIR Is completed
Separate Sewerage System to consist of /5 Cd Gellon Septic Tani[ and G � � � d Ji/'9�c� GJ�I/%s
To be constructed by Address
Water Sappb•: Pubuc Supply Rom, Address
on Private Supply Drilled by ___Address,
Other Requirements
I represent that I am wholly and completely responsible for the design and location,of: the �Droposod system(s); 1) that the separate sewage disposal system
f +'
above described will be constructed as shown on the approved amendment there to ariy in accordaljce with the standards, rules and regulations o e Putnam
County Department of Health, and that on completion thereof a "CertificataiOpfc �fi'pn_COmpIIance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished th �s'stF 5���sabrs; heirs or assigns by the builder, that said builder will
Piece in good operating condition any part of said sewage disposal system ! t)cia porio (Q'two ( ;)'years immediately following the date of the issu-
ance of the approval of the Certificate of Construction Compliance of,'the r4fgin l^sy ;�,m�or a 4�rpairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be Installed .im ac •oralnce atith TMe standards, r les and regu aTiions of the Putnam
County Department of Health, i
i
Date '{ Signed G P.E. -R.A.
Adtlress 6 License No V ��
APPROVED FOR CONSTRUCTION: Th• approval expires
revocable for cause or may be amentl or modified when c
requires a new permit. /gyp cued for disposal of domes
ev. Date ✓ . - By _
years from th datg 1;m ue l'u s „eonstruction of the building has been undertaken and is
fared essery by. ;e�7C� i si,!er`of Health. Any change or alteration of construction
/niter sewage d pJi y, e. 1y/yar_ wpDIY Only. /A
s,Gll/s�C
Till �.J
r/ I ,t-"? "ra"- `,'-^� +-- -�°. -^r x- �r-aA� ,.., �, e:..,` a c T 'T"' n'.' ry`-� •'� •S` .� r� �l �#, 'F"'�s u�"""'.c: e — -- �.s_cr�' ,a+'. ... '
tJt J K COUNTY DEPARTMENT OF HEALTH _
PUTNAM r
D1vlaMti of Envlronmentel'Hodth Sotvlcee Carmel N:Y 1051? .H� _. M
CERTIFICATE OF COIVIPPLIANCE
CONSTRU PERMIT FOiI $EWAGE'DISPOSe►L SYSTEM 5
y,
r- 3 87
Oft11 / r To r Owe
I represent that J am, wholly anti. "completely responsible for the design and location ot,';the prod
:460'' veaescnbeq> will be: constructed as shown on the approved amendment thereto an'd "iTaceorC
County, `_epartment O6 Health, and that on compiitlon thereof a "Cartif -icate of Constructi,oi
be 'tubmitied to the Department,. and a written guarantee war. -tie furnished the owner; -his s
place -in' good- opL" _. g`: con0ition any pai of saitl sewage disposal, .system A ring owner
ante` of the approval ';oC the :Certificate ,,of Consir Au" Compliance of the- original "system,
will tie located;as Shawn on the approved plan and that said well will be i cords e'
County Department of Health.
Date -
�r �e
- Atldreu
APPROVED FOR CONSTRUCTION Thi .approval. expues t o,years' f m the APri, lued • m
revocable for cruse or msy be amentled or muddied; when s�de►ed eessary Commi
requires a TTew %pe d proved for disposal ot.domesanita `sewa9 v e
8'Y
tylE °.46iYs
to the Commlfsioner of Healthwill
builder, that said •builder -.Will
Q ye6rs
e ly- following thedite of the isw-
_;
eps` et'9 — the the drilled weWdescribed above
an d
ru in regu a ions of: the Putnam
P.E._ R.A.
icense No� 9 I
�qe Jding has been undertaken and is
fm. pt4i1o.
change or,.plteration of construction
Title
\� PUTNAM COUNTY DEPARTMENT OF HEALTH
Engineer to Provide Permit q .
Division of Environmental Health Services. Carmel. N.Y. 10512
on CERTIFICATE OF COMPLIANCE '
Permit q
CONS UCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
Locapd at���'0�.� y Town,. or_ V _ e _• -
P.. ,r-.,. _ ; .�.�.. -.... ._.. -..._ :_ ` { ter:. • J _y.'_ y r
Subdivision Name ��'��" /-s Y Subd. Lot N �� T. Map Block / :Lot
&&- � Renewal_❑ Revision ❑
Owner/Applicant Name /� !' tt/�, i
Date of Previous Approval
pMafg Address A6 aav Town Zip Id
Building , Type fflifL$ ' Lot Area ,7 Fill Section Only Lj Depth Volume
Number of Bedrooms Design Flow G P D �'OB PCHD Notification Is Required When Fill Is completed
a f7 / " ;
a
Separate Sewerage System to consist of Gallon Septic Tank and ' �'
To be constructed by Address
Water Supply; Pablic Supply From Address _
ors Private Supply Drilled by _Address _
Other Rooulrements
I represent that 1 am wholly and completely responsible for the design and location of the
above described will be constructed as shown on the approved amendment there to and in a
County Department of Health, and that on completion thereof a "Certificate of Constr
be submitted to the Department, and a written guarantee will be furnished the own ,
place in good operating condition any part of said sewage disposal system during e
ante of the approval of the Certificate of Construction Compliance of the original
will be located as shown on the approved plan and that said well will be Installed in acc d
County Department of Health.
Date Z Signed
Address
APPROVED FOR CONSTRUCTION: This approval expires two years from the ;vt ssue
revocable for cause o may De amended or modified when CO sidered Cefsary e C c
requires a new per it. Apr d for disposal of dome c ni sewag /or
g Date / S
'gysW that the separate sewage disposal system
w t t st ds, rules and regulations of e Putnam
,bBo
eta ory to the Commissioner of Health will
S, I ea i by the builder, that said builder will
two (2) dmm lately following thedate of the issu-
irs th fp;*) hat the drilled well described above
r ule and regu ronS Of the Putnam
P.E. R.A.
' License No
� e
rut n e building has been undertaken and is
. r ny change or alteration of construction
rases e
Title
PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Mr. Joseph F. Sullivan
2972 Ferncrest Drive
Yorktown Heights, NY 10598
Dear Mr. Sullivan:
March 24, 1989
ENID L. CARRUTH, M,P.H.
Public Health Director
JOHN KARELL Jr., P.E.
Director
Re: Revision - Revis
Mueller Mountain Road
(T) PV - TM #120 -1 -0/o 22
Permit #PV -63 -87
Review of revised plans and other supporting documents submitted at
this time relative to the above_ captioned project has been completed.
Comments are offered as follows:
1) Show property line and layout of expansion trenches
on 1" =20' scale plans. Fifty percent expansion area
does not appear available.
2) Show detail of cleanout.
3) What type of pipe will be used under driveway?
.._.t ;,.: he,�ya rg.th•,.da= v -ided. 3i .:the ,4i_d:1 h, o:�: th-6 -- se'pti->✓• -x�i<-
.must be greater than two and less than four. Septic*
tank design shown is less than two.
Upon receipt of a submission, revised to reflect. the above comments,
this application will be considered further.
Very truly yours,
r
Lawrence C. Werper
LCW:jr Assistant Public Health Engineer
l.. -.. -
PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Mr. Joseph F. Sullivan
2972 Ferncrest Drive
Yorktown Heights, NY 10598
Dear Mr. Sullivan
March 24, 1989
ENID L. CARRUTH, M.P.H.
Public Health Director
JOHN KARELL Jr., P.E.
Director
Re: Revision - Revis
.Mueller Mountain Road
(T) PV - TM #120 -1 -p /o 22
.Permit #PV -63 -87
Review of revised plans and other supporting documents submitted at
this time relative to the above - captioned project has been completed.
Comments are offered as follows:
1) Show property line and layout of expansion trenches
on 1 11=20' scale plans. Fifty percent expansion area
does not appear available.
2) Show detail of cleanout.
-t:yp °e -o z' pipe wil l be "used under" dri veriay ?` -
4) The :Length divided by the width of the septic tank
must be greater than two and less than four. Septic
tank design shown is less than two.
Upon receipt of a submission, revised to reflect the above comments,
this application will be considered further.
Very truly yours,
Lawrence C. Werper
LCW:jr Assistant Public Health Engineer
/11�7 C //. I
JOSEPH F. SULLIVAN, P.E.
2972-.FERNCREST DR[yg,
YORKTOWN HEIGHTS, N. Y. ICS9B
(914) 962-4248
J?le:
__4
Ile
ol/
IS
DEPARTMENT OF HEALTH
Division of Environmental Health. Services
TWO COUNTY-CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
XF lCk� IVN__ Or CONSTRUCT' A WATER WELL
PCHD PERMIT
WELL LOCATION
Street Adrdress Town Village City Tax Grid Numbber
H e,,1 i�Y J15 p ,1 '- P/p _>2
WELL OWNER
Name
Mailing Address
rivate
D Public
USE OF WELL
1 - primary
2 - secondary
GIRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT •PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
Q ABANDONED
O OTHER (specify,
®'
,AMOUNT OF USE
YIELD SOUGHT
;� gpm /•4/ PEOPLE SERVED /EST . OF DAILY USAGE gal
REASON FOR
DRILLING
NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
❑DRIVEN
®DUG
®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES I,-'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: --•
Lot No.
WATER WELL CONTRACTOR: Name Vlegi 1J/®•S Address: %j/2 =a1S
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTR _NC TO cROPERri-FR7iP "NEAREST"WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION []ON SEPARATE SHEET 4
(date)
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 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 permit.
3. Submit a Well Com letion Report on a form provid by he tnam Coun y
Health Departmen .
Date of Issue: Z Z-19
Date of Expiration: 19 er ffit Issuing fficial
Permit is Non - Transferrable' White copy: H.D. File
Yellow copy: Building Inspector
2187 Pink Copy: Owner
Orange cmw: WPi i rn-411 --
APPENDIX
. t 'MM COUNTY DEPARTMERr OF HEALTH DIVISION OF t' f' M E V• HEALTH SERVICES
INDIVIDUAL V!MI• SUPPLY t : tl' M SEWAGE !! DISPOSAL SYSYE L
REVIEW SHEET - CONSTRUCTION PERMIT t,
DAI' JEW Vii. - -e= r � •
(Name of Owner) (Street Location) f
DOCUMENTS l�v
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc
(3) Fill
cd `'--
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL -
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DErAIIS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
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 (grinder notes)
Design Data: perc and deep results
Two -Foot Contours Exi rig & Propose -d-
Driveway & Slopes Cut
FootinT/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area; shown; gravity flow,suff. size
If Pmped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's Win 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
.No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
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
35'to catch basin, stormdrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
9
PUTNAM COUNTY DEPARTMENT OF HEALTH
-EN- V.IROI\TMEN•TAIs, HEAETI -;� &ERV-ICES :
Date f � 1w
Re: Property of
Located at o e-
7
(T) �c✓ %16 Section % �O Block Lot pv �-
Subdivision of
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to authorize Q��'!�
a duly licensed professional engineer or registered architect
(Indicate
to apply for 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
c�rnsi�cti-on_. 1=i =;-th s- ^rria= tter -; and- :.':to..,sup-er�v.,i-ee°wtho- -e,o
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.
Countersigned
P.E. , R__ ,
Address
) /'!/ 7
9
_ Tel.epho e
Very truly yours,
Signed %fZ� 0�1� ° /`% ° �(p .�.✓1
pF 1YfW°b Owner of Propertyi�
APt ae.oes� yQ!
Address
4 Odom
loses
Town
?/,Y- 11.? 4 -
Telephone
ti
: Division Of Environmental H%h Services
TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225-3641
.WA 11EL
WELL LOCATION
SMEEI IAX GAW NUMBER.
Ai
24 10T2 �� ��� ���_ _�� z�
WELL OWNER
NAME. • AOORESS:
&� I
P�IVATC
❑ PUSUC
USE OF WELL
_ESIDENTIAL ❑ PUBLIC SUPPLY ' ❑ AIR /CONO.IHEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
2 - secondary
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY Cl
MOUNT OF -USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 0a oaf..
REASON FOR
P,�iW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TESTlOBSERVATION-
ORILLING
❑ gEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE
FZrDRILLED Ej DRIVEN DUG GRAVEL F-1 OTHER
IS WELL SITE SUBJECT TO FLOODING? _ YES V NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: '
/V el G %11eZ .%9%i' - le!'5 14.7 A5__- LOT NO _ :
WATER WELL CONTRACTOR: Name JV'.j�,t�Sy✓ Address: /�o�y,c�/jL j j/,
IS PUBLIC STATER SUPPLY AVAILABLE TO -SITE: _ YES Y NO -
NAME OF PUBLIC•WATER SUPPLY: — - TOFN /V /C
DISTANCE''TO PROPERTY FROM NEAREST WATER -.MAIN
- LOCATION SKETCH & SOURCES OF CONTAMINATION,
(d e) I (signature)
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
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
permit.
3. Submit a Well Completion Report on a form provided by
the Putnam County Health Department.
Date of Issue: 19_T e>s
• Permit Issuing Official .
Permit•-is .Non - Transferrable
. MJ1IUU1 ll.A7liI7 I It!',I;l.l`]lail ., ,,,'i.,12
x - DIVISION OF EM11 UtMMAL 1iUW111 SE31VICES
:i
DESIGN DATA SHEET:SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE Imo.
- � f :lei ���'��''�f'',` = '`��� ✓ %:.�" 'Aridress %- �:��,�:�/ -�.� ,���� (l,�rB.� �.,:r -: � - -
Located at (Street) �✓�/ ��� Sec. �� Block Loth
(indicate nearest cross street)
Municipality �Ca /�/G�%rJ ¢' Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking / Date of Percolation Test ® �'
HOLE
NU4BM (a='=
.
PERCOLATION
PERCOLATION
Run
Elapse
Depth to
Water.Fran
Water Level
No.
Time
Ground
Surface
In Inches
Soil Rate
Start- -Stop Min.
Start
Stop
Drop In
Min /In Drop
Inches
Inches
Inches
�-
2/e ;?e
/U sP !�
�'�
y ��
Z �1,
4
5
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated
are obtained at each
for review.
2. Depth measurements to
rev. 9/85
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 RfIQUIRED TO BE SUBMITIM W1111 APPLICATION
y DESCRIPTION OF SOIL ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. /1 / HOLE 'NO. HOLE NO.
;x.� •° V.L.' ...- i %' %:r��PsJ�_ +1,; .. .. -':� /�i1.t/- :',•o-= T,�ri�'' -• '•+,;:' -.., .. 'i-a.' ;.t- .::i;;5 •- .. „ " - -^
i
2' - -:a1 O /Ioy k, s
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
<.•.: � 1NDICATE=-.LE MTZ, :.AT, WRI.M- _CIRQG',NTA''M� I� � NQIII NTE '
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED ^-
DEEP HOLE OBSERVATIONS MADE BY: DATE:
- - DESIGN
Soil Rate Used �� Min /1" Drop: S.D. Usable Area Provided`°
No. of Bedrooms Septic Tank Capacity 12 -s-V gals. Type
Absorption Area Provided By L.F. x 24" width trench
Other
AWOf M� •
... .. a.�
Name y � Y Signal
•6•
Address �!� S''�'�% �"/ ' •
0, 24b
THIS ACE FOR USE BY HEALTH DEPARTMENT ONLY: ,,�FSS1on ,.••
Soil Rate Approved sq.ft /gal. Checked by Date
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