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HomeMy WebLinkAbout4600DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.07 -2 -10 BOX 35 1.11 r n jr - , - . ' . - L 1.11 Located at Owner /appUcant Name NWIlm Address f Fee Enclosed PUTNAM COUNTY DEPARTMENT OF HEALTH Dlvlaton of Environmental Health Services, Carmel, N.Y. IOSlZ� Engineer Mast Peovkle P -r -R -D Permit N . 72 ,i - / // e'en Amount -,p U Go Separate Sewerage System ballt by Consisting of j o Gallon Septic Tank and i Town or VRbge Tax Mapes '_7._ Block 2; Subdvislou Name Subdv. Lot Date Permit Issued Water SmppLy: Public Supply From Address on Private Supply Drilled by1V+����� -'�''� Addressci�7✓1�i7J ....Type /���r'%��GrIGY Lot Size %/ Has Erosion Cnntrnl Rppn fnmi ptpd? Number of Bedrooms Has Garbage /Grinder Been Installlled? - / A10 Other Requirements Ylf�o �°.n_7 I certify that the system(s) as listed serving the above premises were constructed essentially as sham on the plans of the completed work ( copies of which are attached), and in accordance with't:he standards, rules and regulations, n accordance with plan, and the permit issued by the Putnam County Department Of Health. Date 7 17, / 5'� E C--- p--- �tifkW.by P.E. RA. Address • '���'�r roue No.Z LJ Any person occupying promises served by the above system(,) shall promptly take such action as Conditions retuning from such usage. Approval of the Separate saw &" shall become available find the approval of the private water supply shall become null old hen a pub tub)ect to moolfkatk)n or Mange when, in the Judgment of the Conuvll of NMnh. ie NOW M WWAU 111e sew Lamtlai ate ", — �� .•� �-- �` �!iG �� �a a (S stun of any ununnwy unitary ewer becomes Such approvals we Title PW yl' cc m V C( L . TWWE R Vilifte r =.. r jar ► +w� p -. L2t® .'•e�8. � ` :_ a�. �-.: : ,...Lot ptitse /A�Ilssnt i1 ► ' �i y�/UY'ci �' 1'1 lewd ❑ Ra.ws. ❑ 0 1ti1 v rt'_ d P� Dab of Pm wku Approval news Atkin.. (,3oX `i .Z 1"1 � r }�) t. A-Y e�v, xA e Tow. M v k ,4 a.c N `1 Sep i 0-5-4 1 natP Suhdivision Annrove(L __ - Fee Enclosed Q Amn ,nt _2500 IQs Ana ' ✓`G Flo Sectiam Omb LJ Depib Vede Nmbw d B.tiettosa Dealo Flow G P D Efs 00 PM Noma" b Romand When M b a4191sid Minute Swamp Syatam to a mi14 of d stem Tma torsi c'� f7 V i , � c7 2� " w c � r � r tit �► � To be: aesb111ded 4 Address Water FRM Adam an Stiff+ Ind by Adhm 1 ropreamnt'.that 1 am wholly and comp& Sly responsible for the design and location of the proposed systemtgs 1) that the aapuate sewage disposal system abow described will be constructed as shown on tho approved amendment there to and in accordance with the standards, rules a ragu to o County Dpis"I W, of HnRl% and that on completion thereof.a °Cwtnicate of Construction Compliance'• satisfactory to the Commissioner of N"Khwlll be sibmilm to t11e Opertmernt. and a written it want" will be furnished the owner, his successor or anions by the bulkier. teat amid Sunder will plus in good .spwatkq condition any on of amid sewage dispoul system during the period mediatNy followbe thedete Of the bsu- saes of tin approval of tin Cwtiflceto of Construction Compliance of the original system 2) that the d►nled well dewaW a6a trio be NwAN as ttsarnl on tin approved tWn end that amid wen will be Installed accordance mad rsguTaiTo of the Putnam cwaty Opartrloeat Of "$OIL 1/ Address.-1 `Y ` ( License NO_-- APPROVED FOR CONSTRUCT1pN: Th appvo�al expires two s 1r the date issued' u building has been undertaken and Is rovoeeble for ceuso or boa or modified when can y by the Comm f y1 change or alteration of construction gawk" a ne permit. Approved for disposal of domestic San a or or teA; G Rev.. 2) � .., r- Title 10/88 °ice °" _ WnLL 4,UrLrLL11VN Zr1runi .e DEPARTMENT OF HEALTH Division -._Environmental Health, Services, V'­ NO PUTNAM COUNTY DEPARTMENT OF HEALTH office Use Only v- --7 WELL LOCATION. 'STP9,40UREW: I -TOW—WIVILLACLICOY TAX GRON!M 11. 4r ES �WBIVATE PUBLIC WELL OWNER USE OF WELL 1- primary 2 - secondary I XRESIDENTIAL ❑ PUBLIC SUPPLY CO3 COND./H T PUMP 0 ABANDONED 0 BUSINESS ❑ FARM ❑-TEST/OBSERVATION 0 OTHER (specify) C1 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE.LO-0— gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY ❑TEST/OBSERVATION ❑ADDITIONAL SUPPLY WEW SUPPLY (NEW DWELLING) E]DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. I STATIC WATER LEVEL —ft. I DATE MEASURED 11X01f DRILLING EQUIPMENT AROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG 0 WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK 0 OTHER CASING DETAILS TOTAL LENGTH ft. MATERIALS: &STEEL ❑ PLASTIC 0 OTHER LENGTH BELOW GRADE ft. JOINTS: OWELDED JRTHREADED OOTHER DIAMETER in. SEAL: CEMENT GROUT OBENTONITE 0 OTHER WEIGHT PER FOOT ib./ft.- I DRIVE SHOE- &YES ❑ NO LINER: DYES 4 NO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH.(ft) DEPTH TO SCREEN (it) DEVELOPED? FIRST 0 YES ONO HOURS GRAVEL PACK 11 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK In. I TOP DEPTH —ft. BOTTOM DEPTH — It. WELL YIELD TEST If detailed pumping METHOD: ❑ PUMPED tests were done is in- • COMPRESSED AIR formation attached? • BAILED ❑ OTHER 0 YES 0 NO It more detailed formation descriptions or sieve analyses VELLIOG are are 2V3il2ble. please attach. DEPTH FROM SURFACE Sear- ing Well Dia- meter In FORMATION DESCRIPTION case ft ­— WELL DEPTH It. DURATION hr. min. DRAWDOWN It. YIELD 9pm- lane Surlace L WATER CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS 0 COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? 0 YES 0 NO STORAGE TANK: TYPE CAPACITY GAT.. PUMP MIFGRMATION TYPE A' _ JXI.�, MAKER MODEL�.�IA-6 4 I-IL A CAPACITY 15" DEPTH , I VOLTAGE2W HP / V 1 WELL DRII.ER N E W DATE ADORE SlGiIXTURE F L;�Iy- I d /70 CCCJJJ j/ ov YMI. ENVIRONMENTAL SERVICES 321 Keay Street Yopktow n Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovanj, D LAB #33 32.408277 CLIENT #-' 5169 NON STAT PROC PAGE I "-- ------------------------------------- --------------------------------------- GILMORE, HOWARD DATE/TIME TAKEN*. 07/06/95 07200 BOX 572 DATE/TIME RECD: 07/06/95 14:45 MAHOPAC, NY 10541 REPORT DATE' 07/11/95 PHONES (914)-628-3290 F.A.PLING SITE., #3 PROVOST PLACE KITCHEN TAP P - SAMPLE TYPE..' POTABLE "MAHOPAC, NY PRESERVATIVES2 NONE BY HOWARD GTLMORE TEMPERATURE...' < 40 NOTES ... : COL IFORM METH MF 14,4—j----------- --0- -- -- p ----- --------------------------------------- DATE FLAG PROCEDURE RESULT NORMAL - RANGE 07/07/95 MF T. COLIFORM ABSENT /100 Ml- A13SENT COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATEW (WAS (WAS NOT) OF A 4, SATISFACTORY SANITARY QUALITY ACr-l3RDfN6- THE NEW YORK STATE AND EPA FEDERAI. DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. SUBMITTED BY: ---- Albe Director ------------- - , M.T.(ASCP) ELAP# 10323 I•.. � �. ' PUTNAM COUN`T'Y DEPARTMENT OF HEALTH _ DIVISION OF ^ ENVIRON�MrAI4 HEALTH SERVICES. 'Y :v:. '.r'w� ,er: ,.ei...p...s '".�.:._._ t, e,,�:�. -�.r ..'ji .�'. r.er... ...�= ::�..':p.n •: 'r•� :..:�.' /74 g,'�/- Owner or Purchaser of Buil ing Building Constructed by Location - Street Municipalit Building Type 7 Section Block Lot Subdivision Name 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 approval of the "Certifi cate...of Construction -Compl_ian_ce'Y for ,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 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 Title 1 General Contractor (Own ) - Signature J!Le Corporation Name Ul Corp.) hl Address rev. 9/85 mk FrMIAM Corporation Name-(if Corp.) /3' 1", Address f � r ° noaaaau® aanD boa aaaaaaasaaaauanaaa son a soon aaa nag aaaa gongs ana gongs aaaaaaoaaaoaaaaaanaGo Dan oa wise=aflIlQ h _ � :� : . ..'t7.. :, . . � r',.f_ _...... �'�.s.:' R ~ � . � _ . x _a _...s _ r K :Y�: I; -F , 1'w...-Y 4 �'` � e_. � •o°= -. 2756 WALNUT HILL 1 1512 SQ.FT• -1i U U u CLO BATH q2' DRESSING \ AREA DINING ROOM BREAKFAST NOOK KITCHEN • O BEDROOM yl IO'- tr312' -8' 0' -0 "310' -4" 11'- 0"310• -d' O °n3 t°r PAN C UN / ATH 01 / LO n.cC 2756 0.a W° s WALNUT HILL 11 HALT: i « i CLO 1512 SQ.FT. Lag--;) UN U1'ING ROOM BEDROOM #S - BEDROOM q2. 21'- 8"312' -8' 1l'- 0 "3B' -4�' CLO `+sF�Jm��ei �;lv;la'r�vO'l�iixl`� EJ��'cia. � cloy j � �,.'� . -__ � .� �- b�•.� 'isG. // p {�r 1` a.t" iiL'Y�.x1 {Lrl iii \.. irl:. if; if: _a ..." .. BREAKFAST NOOK BATH p2 BEDROOM 31 1 /� ROOY �N pl } IAN , IsROOz• - BATH ! 2756 - -- — WALNUT HILL IV map-, 1512 map-, r CLO /� UN UVING ROOM BEDROOM p9 ' BEDROOM d2 38' 312' -8' • d OYER CLO CLO 1EXCEr e- 0/ F MANUFACTURED AODULAR STRUCTURES "We're Building ®nip° Repo anion R.R. 112, Box 683 o Liverpool, PA 1704$ ��%%�� Building eL[l g �i 1 -800 -343 -6767 With Your Home." D® DDaaaDDalIOaDDDADDDDD6® aaDDO® aDDBD6® D6DaDaDD80D0DaaaaDODa® DDDDaDaaaDDD60Da0aaaaaaDaDaDDODODDaaDODDDDaDDD080aaaD ®Da ®DD ® ®aD ®D ®a ©Dana d.r.. .. ..L. ., .•..•, ..,.,n :, .r <.•. ucu ..uu4u�autuh: PC -1 PUTNAM COUNTY DEPARTMENT OF' HEALTH .. ,..� .• ...;. ,.. ,.,...; - :.A -Pt I :, FOR. ARPROVAL. OF. PaI ANS -.FOR, A MASTEWATE is =DIS OSA _ . ,. j.., : : - -: F 1. Name and Address of Applicant: 4rv�•'� 2. Name of Project: Jam- �.�% 3. Location T /V /C: / C, 4. Project Engineer: ' �l / ✓�''� 5. Address: %7Lr�JGr�s/ 1 License Number: ���� Phone: 6 . Type of Project: rivate /Residential Food Service Commercial Apartments Institutional Mobile Home Park .Office. Building Realty Subdivision' Other (specify) 7. Is this project subject.to State Environmental Quality.Review (SEQR)? A10 Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 9. Has DEIS been completed'and.found acceptable by Lead Agency? ........... 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, �or othar ' offd c AI s . .or..d jitames� ...... ... r. 7 �. ., a.o .aaaa -a a.,a..a •aca- ... -s.a .aa �.�• ayspa.iyy. a .� • a. a.q i.1 .a .a. a. a.a .a. - - sue.... -.�. � ...., r. 12. If so, have plans been submitted to such.authorities? .................. V 13. Has preliminary approval been granted by such authorities? Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water P"" Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........ 17. Is project located near a public water supply system? ....... ............ Ala 18. If yes, name of water supply.', Distance to water supply/`��� s 19. Is project site near a public':-sewage collection or disposal system ?..... �6 20. Name of sewage system "' Distance to sewage system 21. Date observed: 23. Name of Health Inspector: 24. Project design flow (gallons per day).......... ..................................... 2. SPDES}:-Writt 64CE 26. Has SPDES Application been submitted to local DEC Office? ............... �V_ 27. Is any portion of this project located_aithin a designated Town or State wetland? ......................... ...... ... .....................ao........ A/O 26. Wetland ID Number ....................................................... 290 Is Wetland Permit required ?......... ... A� Has application been made to Town or Local DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? ................... /1/G 31. Is or was project site used for agricultural activity-involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ........ YES or NO �G 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? ? .:. __35d- Are..any sewage- ¢ispcsal:.areas in =exves5`#3- �lopa ? =. . .....::.. 36. Tax Hap ID Number ...................... ... _ .......................... 37. Approved Plans are to be returned to: ................ Applicant Engineer If the application is signed by .a-person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. X hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as "a Class A Misdemeanor pursuant to Section 210.43 of the Penal Law. SIGNATURES & OFFICIAL TITLES:° MAILING ADDRESS: - -- - - naj'ust f xEGEIPT REQUESTED ' Date - � Tr. - . BuildlAg��Itspector't.� , _, _;_ ... __ ., . : -�; _.- -...� - � .. > . , : t -; �� ::•,:, �.e;- _... . - . -, =. ;_„ - . _ ��.. y:: - =. - '� -- - - - - - - - - - - - - - - - - - - - - - Re: Construction Permit for single family residence Applicant _.f�G -f3/n r1 _1irlsi� -- Street Y►��rAt�S -- Torn / - - - -- ----- - - - - - -- ��/l Dear Llr - -- � ----- - - - - -- This Firm Q am) submitting an application to coAxtruct a sewage disposal system serving a single family residence on the above captioned property, to the - Putnam County Department of Health. In order to. process this application the Health Department requires that the following information be obtained from your office: 1. Prior to your issuance of a building permit A) Is Zoning Board approval required for any variances? Yes - - -� - -- HO --- - - - - -- B) Is any portion of the parcel located within a regulated wetland or its control area, and if so is a wetland permit required? Yes-- - - - - -- No -- 7` - - - -- C). Is any other local permit or approval necessary? Yes- - - - - -- No -- - = - - -- '� -'° ' �� '�'If• the -- answer' to''ariy -of t?�t "�uerations - above "is 'yps;"pTease contact` t)ie�'}leslt?��"v °' � -« � �`" Department in writing or by phone, 278 -6130 within 15 days of the date of this correspondence. If the answer is no, you need not respond to this correspondence. Very truly yours, Name --------------- - -- Health Department Inspector Engineer, Architect, Owner JK /jp vetland bhp mow.. �Z /� A -3 APPENDIX 3 PUTNAM[ COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS rREiLIEV/: SI-IEU fgr CONS'IlRUCTION PERMIT NAMEOFOValER STREET LOCATION BY DATE ��(� ��13 TAX MAP #� DOCUMENTS. —T_ t� Y kq PERMIT APPLICATION PC -1 W WELL PERMIT;LU PWS LETTER W.ENGINEERS AUTHORIZATION DESIGN DATA SHEET(DDS) DEEP HOLE LOG CONSISTENT PERC RESULTS (3) PERC HOLE DEPTH ORPORATE RESOLUTION PLANS THREE SETS HOUSE PLAINS - TWO SETS M VARIANCE REQUEST GENERAL LEGAL SUBDIVISION MSUBDIVISION APPROVAL CHECKED PERC RATE FILLREQUIRED RCURTAIN DRAIN REQUIRED mSTANDPIPES EX-APPROVAL SSDS ADJ. LOTS WETLAND (TOWN/DEC PERMIT R & D) DATA ON DDS PLAINS & PERMIT SAME PRE- 1969 - NEIGHBOR NOT•IFIFICATION _ R BI/LBA i0 YRYR:'FLOOD ET..EVAITON SWAGE SYSTEM PLAIN - (NORTH ARROW) SSDS HYDRAULIC PROFILE m GRAVITY FLOW / J BOX M TRENCH/GALLEY m P- PIT DETAILS SEPTIC TANK - SIZE, DETAIL LL DETAIL, SERVICE LINE IF OVER CONSTRUCTION NOTES (GRINDER RATE) DESIGN DATA: PERC AND DEEP RESULTS - T CONTOURS EX-I j G & PROPOSED & SLOPES CUT F G %GUTTEi" URTAIN DRAINS COMMENTS: -, DISCHARGE (OK) � P�RC &DEEP HOLES- ' ' PUMPED PiT I1 fi[lx SHOWN &DETAILED OUSE - NO. OF BEDROOMS ✓ELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM PROPERTY METES & BOUNDS L_°I.J .HOUSE SETBACK NECESSARY (TIGHT LOT) ffXOUSE SEWER - U4" . 4 "0; TYPE PIPE CZJ /NO BENDS; MAX. BENDS 45 W /CLEANOUT FILL SYSTEMS CLAYBARRIER 10 FT HORIZONTAL: SLOPE 3:1 TO GRADE FILL SPECS DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME TRENCH r7hLF TRENCH PROVIDED EE,Vo FT MAX 2&L- [dJ PARALLEL TO CONTOURS Mon EXPA�LSIO E.RQYU)ED .. ._... .cam • :i .. -_ K. W' TO P.L DRrg&AY LA GE TREES, TOP OF FILL TO FOUNDATION WALLS W 100 TO WELL, 200' IN D.L.O.D., 150' PITS 00 TO STREAM WATERCOURSE LAKE (INC.EXPAN) CATCH BASIN, 35' STORMDRAIN, PIPED WATER V TO WATER LINE (PITS -20') R10'TO 0' INTERMITTENT DRAINAGE COURSE 00 FT. RESERVOIR, ETC.m 150 FT. GALLEY SYSTEMS SEPTIC TANKS E3JI01 FROM FOUNDATION; 50' TO WELL WELLS 15' WELL TO P.L. REGISTERED ?FAIL RETURN RECEIPT REQUESTED Building Inspector j ----------------------- ----------=------ - - - - -- Dear /%- 011 jv° // C-Ded, Date _ ._? = . --�� -2- 1 Re: Construction Permit for single family residence ApplicantN!o Street Town / - - - - -- _ _U- _ - - - -- THE This Firm (I am) submitting an application to consiiUct a sewage disposal system serving a single family residence on the above captioned property, to the Putnam County Department of Health. In order to process this application the Health Department requires that the following information be obtained from your office: 1. Prior to your issuance of a building permit A) Is Zoning Board approval required for any variances? Yes No B) Is any portion of the parcel located within a regulated wetland or its control area, and if so is a wetland permit required? Yes No -- - - - - -- --- - - - - -- C) Is any other local permit or approval necessary? Yes - No If the answer to any of the questions above is yes, please contact the Health Department in writing or by phone, 278 -6130 within 15 days of the date of this correspondence. If the answer is no, you need not respond to this correspondence. Name --------------- - -- Health Department Inspector JX/jp � wetland bh Very truly yours, / r Engineer, Architect, Owner 150 - I g I 435 8 ae ��.'•� 150.35 c icc I S I too I I I 1 I N I O Im a C I �.n I 30.59 I x II 3 o 15.68 AC. I 1 e v I I _ 14 — 1.00 AC. P�Q IS 1.84 AC. 16 e 3.70 AC. 4T?.75 IT 0 cams 445.38 18 0 19 1.4T AC. s 0 1.60 AC 21 e 133.0 0 1.04 AC.MANpPAC CENTRAL 1�9.n SCN� GENTRAI SCNfl' 22 0 1.44 Ai 23 0 1.29 AC. 24 0 1.04 AC. DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 piYPI,ICATION TO CONSTRUCT` "A "WATER WELL PCHD PERMIT WELL LOCATION Street Addr ss Tgwn 'Village City Tax Grid Number ry s-o� 7/Q7Ge 114111CIA,,A " -- a - to WELL OWNER Name Mailing Address L /d y✓� �� C�% �r gPrivate O Public USE OF WELL ,1 - primary 2 - secondary RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP BUSINESS' O FARM O TEST /OBSERVATION ® INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT �r gpm /# PEOPLE SERVED 4- /EST. OF DAILY USAGE gal REASON .FOR DRILLING 0 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION CIADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING)- ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE L4DRILLED DRIVEN [:]DUG C]GRAVEL 0OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name Address: / p 10ty Lea% y IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1/ NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY ..DIS•TANCE TO PROPERTY FROM NEAREST WATER ,MAIN:' ��-, �J_, :.-. _,.:,... _ .. _ .. -. : � .� - .. . .F ... - �' _ ._ , � • LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ,ON SEPARATE SHEET �Z4,0�� (da e) (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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well dri operations be contained on this property and in su h a manner as not to degrade or other conta i ate surface or groundwater. Date of Issue: 3 Zi 19 Date of Expiration 19 �� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller a PUTKM COUNTY DEPARTME14T 017 HEALTH DXVXSXDlq. 09P SNVXRGNNWTAL HEALTH SERVICES Proyerty of i-K? /,-,j Located Mt Lot (T subdivAolom of subdv. Lot Nap Thio lottme to to GuthOWIL&O C7,03 a duly ltc@MQGd prosomalonal 08asinser r reglotZrad yChitect G to apply for M Co'notructiom ftault for a MyQt8m, to oorve th@ abovs agdt@d property An QccordancG with the atandmrds, rulea or regulation@ ag prosulagagad by the co=taotonsr of the Putnam Cowmty geyertment of Healtho @nd to oign all mo@moaary ympero on any behalf Am @onnsciioia with this sattOr and to supervio@ the con@truction of aeld aystem or aystsm@ In confogsity with tho provl@lona of Article 145 or 1470 Education Lmwo the ftblia Hemith Lawo and the Putnam County Sent- 0 4/ vory truar W?urao slgno 13e x- Addr(oa@ - I PUIMM COUNTY DEPARTMENT OF DIVISION OF •• •• bis v L HEALTH SERVICES DESIGN DATA'' SHEr.'T SUBSUFAC E "S'IIVAGE DISP . SYSkI' f Owner cq i!' r Y1') O / �. r Address ; 5ox,,4A 2— i yA d e— Located at (Street) ph'v °� �►`® �- C� Sec. 7 Block 'a-- Lot 10 ( indicate nearest 1cross street) Municipality P" �d � V :Ci {� ) !!SA Watershed SOIL PERCOLATION TEST DATA RDQUIPM TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking 1A Z 6 1 9 21. Date of Percolation Test 1 �- HOLE NUMBER CLOCK TIME 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 lr- 130 -30 % z� �a 3 4 0 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be submitb�d for review. 2. Depth measurements to be made from top of hole. TEST PIT DATA RDQUIRED TO BE SUBMITTED`WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH -HOLE. NO. 0 ,HOLE N0. .:p :. .+ -.�- �•:i'�%si., .. ^ _ ,TV•' .1r'.i-�'�9 .. _ � 1^;: .. G.L. 2' La 3' '► D7 Acce. i yy 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' 'INDICATE LEVEL AT WHICH ~GROUNDWATER IS ENMUNTEREDy INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING E[MUNTERED DEEP HOLE OBSERVATIONS MADE BY:— M'S W, V ® i V DATE: o � 7f DESIGN Soil Rate Used �=� Min /1" Drop: S.D. Usable Area Provided 6 0ot.V No. of Bedroans Septic Tank Capacity ©� gals. Type Absorption Area Provided By 5�6 4 L.F. x 24" width trench Other U Nam C� % 111 V041 Address > f:�. r y) Cr ,�� THIS Signature Soil Rate Approved sq.ft /gal. Checked by Date RM M COUNTY DEPARTKENT OF HEALTH DIVISION OF EW1 RONMENML HEALTH SERVICES. 4DLUA- SHED'= SUBSLi.FACE.SEWAGE DISPQSAS T,.ZYSTR+....�-' . �;:FPI:E -1 :'::��. h.• Hot Owner 6 �! c; d i 7Y1 r C Address Located at (Street) o ��-we '1- Sec. $ . Block 2- •- Lot (indicate nearest cross street) Municipality ��. �`y, Gf wl i� �+ 1'ec,i Watershed SOIL PERCOLATION TEST DATA RDQUIRM TO BE SUBMITTED WITH APPLICATIONS w. Date of Pre- Soaking Date of Percolation Test HOLE NUMBER CLOCR TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 1 2 3 5 2 3 4 5 1 NUS: 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 from top of hole. r'j TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES i DEPTH HOLE NO.. .. H OLE N0. HOLE NO Y -.. ,.. •,- a . F>''$' . .. - --, - _ ,t-..q _ - .. �r r. - i 9•'. 1`a` - • CL'�e -i_ a < —47-. G.L. 21 I-e4-4 1° 3' 4v i 4° 5' 6' 7' 8' g° 10' 11' 12' 13' 14' INDICATE LEVEL, AT WHICH GROUNDMTER. IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: c, i.c Ii DATE: DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity gals. Type Absorption Area Provided By L.F. x 24" width trench Other Name ')'—' �t 1) 1 1 Signature Address 9 7 1�9�� s,) terns VIA' P7 'jr- V' y THIS SPAC9 FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq <ft /gal. Checked by Date a K,• :rya,+ 7 :..: , , .,.:.uu - ��.. . *o. , cG o-, r,.p•, w -F. >:x z:�. -„a •+.`':...i'• -• cy„` .� .:,, ..n: aCta•. �r�a, -• dais vi • a�,. w , . , J,, • ".� .. ar t w i yt ' h ` J 1 f441 T1 �S` kA }k c a' dtaw(��o i 69M R* >` 2'4„ 4 a '�rsh' ¢1 .^. h. ,.; x •,�,�.; t,.t ,� ..F '''a +� 6x '�` .• } uJ s arF.:.1,,a' ; A r� v k t Y C r 3 � }j..ti`�rer L'd" �..� , :t ,tom ' ��I� ;r 'C..'.:r�a F�',x+twcs+ �'�>.'�•'e .r�;s`,,�y � ' � r x-` ant of Health Putnam County', Depaz tm Division of Fy "nmeutal Hea1tII Se'vioes Of 'NEW for oordormame °i Approved as noted H lations of the * r aDable .Hstlee and e6n . Health Departmaat/•._ MIS to R AL Y•� j -SUBD U I JQS ?N' . S .lI�ANz; 3 y x, YORKTOWN' 1= f�tC�tl'S, .. ':NE YOGIC