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BOX 35
NT-70
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- CERTIFICATE:, OF
L-ocated'1
NTTD OF 'HEA'LTI
IiNE'EsR'
MIT
UCT.LON COMPLIAN.C,E �FORySE1NAG.E, DI &POSAL SYSTEM , ='.Jw ..p'rr7a /�'�h
ove o n i v ape
T _ JII
a ✓ , Y C
?'Block 1.. z
Fozmerly Tax Map LotIN._ :�° Subd Lot 9
Separate Sewerage System, built 'by v {� � � 1'x � pAdilres= ��
f 4
a t
4:
Consisting. of„ l3al.:,Septic, Tank
a
,�
-
Water Supply Public Supply From
,7 t
�P►ivate SuPPIy Drilled
� a
i
Building;, 7Type Wog `ot ,bedrooms '
Has Erosion :Ontidl Been Completedt " Has garbage grinder bi
I certify that• the system ( s) - as- listedaerving the above,premiaes were constructed essentially ,+
of which are attached) ,and Ln accordance with the standards rules and requla`tions in aac
.,Putnam, County Department,;Of
}
Date �' Cerht + b M
r Y
Address
`Any person occupying premises seivetl by the ov 4ystem(s) shall promptly ;take weh io s m
%conditlors resulting from .such „usage Ap` royal tot the iseparateaseweraye system shall
available and the approval' of the- -p►ivate, water supply shslC;Deeome .nul and'';void pwAen
subject to modification or', change when, An the1udgment of tho:Co Isii- of Heal
4IJt..
Date By -
Rev. 6/85
a
4
Date Permit Iswad' y ����,
F t+
ahown'on ths'plana cf a completed. work ( copies
Nr filed, plan and tha permit issued by the
IC s
P E. R.A.
ff�l in Tltb
.._.�. .. - . .._.� % ^. t' .. _- .. .r. u .� i. Sr .A � ... _...... s. c: ..4a. � -r. - ... -,ra -',y•p y '• .\� .y •�, .. ,.., ..`�.
WELL LOCATION
WELL COMPLETION REPORT
DEPARTMENT OF HEALTH.
Bivi Aicrr+.-,Of-_Envir_onmental. Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
�v
office Use On,
TAX GRID NuMaEiL
17ffi�, �7 ! 1/1 WIMPRO. WMA *10'=Al [E-2:30HUM
USE' OF WELL
( RESIDENTiAL
�/O PUBLIC SUPPLY O:AIR /CONDJHEAT PUMP
❑ ABAKDONED
1- primary
O BUSINESS
❑ FARM ❑ TEST /OBSERVATION
O OTHER (specify)
2 - seco6dary,
O INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY
❑
MOUNT OF USE
YIELD SOUGHT
gpm. /N0. PEOPLE SERVED /EST.
OF DAILY USAGE gal.
REASON FOR
NEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY
❑ TEST /OBSERVATION
DRILLING
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
YIELD
DEPTH DATA
WELL DEPTH _! ft.
STATIC WATER LEVEL eft
DATE MEASURED t.-`Pd -? d
DRILLING
,Q ROTARY
❑ COMPRESSED AIR PERCUSSION ❑ DUG
Lv�i
EQUIPMENT
0 WELL POINT
❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE ❑ SCREENED. ❑ OPEN END CASING. )(OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH ft MATERIALS: STEEL O PLASTIC .0 OTHER
CASING
DETAILS
SCREEN
Y . :'n'ET*Ii:s , .
LENGTH .BELOW GRADE
DIAMETER
WEIGHT PER FOOT
DIAMETER (in)
GRAVEL PACK
11 YES
GRAVEL
O NO
SIZE:
WELL YIELD TEST
; If detailed pumping
METHOD: O PUMPED
t tests were
done is in-
ACOMPRESSED AIR
; formation attached?
O BAILED O OTHER
; Q YES
O NO
WELL DEPTH
DURATION
DRANlOOWN
YIELD
It.
hr. min.
ft.
gpm.
/., / b
7 OP"
Lv�i
J_
WATER ❑ CLEAR TEMP.
QUALITY O CLOUDY HARDNESS.
O COLORED ANALYZED? _ O YES ❑ NO
ANALYSIS ATTACHED? O YES. ❑ NO
PUMP WFORMATION .11 TYPE CAPACITY S
MAKER DEPTH
MODEL 2? VOLTAGR_i- HP
O tL JOINTS: O WELDED ,BTHREADED 'O OTHER
" in. SEAL: ❑ CEMENT GROUT O BENTONITE JROTHER
x (b. /ft. I DRIVE SHOE)ERYES O NO LINER: 0 YES �@WO
SL07 SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED?
O YES., ❑ NO
IDIAMETER ITOP I BOTTOht
OF PACK in. DEPTH tL DEPTH It.
ipy��I ®�
It more detailed formation descriptions or sieve analyses
WELL are available, please attach.
DEPTH FROM Water Well
SURFACE Bear- Dia- FORMATION DESCRIPTION CODE
ft. ft. I�g M ter
STORAGE TANK: TYPE t,(/,G��- �{ — %�.W' Q
OkPACITY GAL.
WEU42 NAME OI�E
AD ,��
D
LAB i��
Yorktown Medical Laboratory, Inc. r_fc� %ci.�,
321 Kear Street i //
Yorktown Heights N. Y. 10598 Date Taken: i / �� Time: o o . , �!
_ t R
Dae .c.!.d Time
_ - .,. �l�l� ��r �,•.
�s e'Riporte'd
Director: Albert H. Padovani M. T. (ASCP) Collected By : 14 /,f C—C
--� Referred By:
Sample Location: 4 .41Z6 Ago.
AA
Z 33 rlLEG/'r o �v r f �2
Phone M -
QCZJ /LJ/G /vim/ �✓C� �7oKJ� . /dS�b� Phone Sample. Type
L- J Repeat Test?
p (check one)
LABORATORY REPORT ON THE BACTERIOLOGICAL QUALITY OF WATER
WATER
GENERAL BACTERIA
V! Standard Plate Count (CFU /1.OmL)
(Agar Plate 8 35 °C)
MEMBRANE FILTRATION TECHNIQUE .(MFT)
Total Coliform (CFU /100mL)
_ Fecal Coliform (CFU /100mL)
_ Fecal Streptococcus (CFU /100mL)
MOST PROBABLE NUMBER TECHNIQUE (MPN)
_ Total Coliform: MPN Index (per 100mL)
.. ... ..^_. .. a.. .4 l •- Y!.. •.. _. ._' .` y.w .�i.e... :.�. ...gyp -.Q .:3re ... .y..�
Fa'�'ol"io'rm. MPN Index '(per
°ec.
OTHER ANALYSES
REMARKS (For Laboratory Use)
_ Potable
_ Non- potable
STP INF
STP EFF
Other:
Sample Status:
(check each)
Outgoing
_ Na2S203
Incoming
V'**'LE 4 °C
_ GT 4 °C
Other:
KEY FOR TERMINOLOGY
RDS = Recommend Disinfec-
tion of Source
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
LT = Less Than (<)
GT = Greater Than ( >)
N/A = Not Applicable
LE = Less than or equal to
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THE YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED$ AT•THE TIME OF COLLECTION..
12 /85(RvsdT /87)RWE
irector
For Lab Use Only:
_ H/C to
LAB OFFICE HOURS (Main Lab):
9AM -5PM, Mon. -Fri.
9AM -H00F9 Sat.
b
PUTNAM COU IFY DF2,VdMI T OF HEALTH
DIVISION OF ENVIRONNIl!NTAL HHAr,Ti! S]�RV�CES
Owner or Purchaser of Building
i/
Building Constructed by
../- �P" -e�1 13V4 2
Location - Street
Municipality
Building Type
Section Block Lot
a
. N V i ioSubdiv sibn ` ,.Name
•88 W�gisA�n. t #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYST&M
I represent that I am wholly and completely responsible for the location,
wc;rkmanship, material, construction and drainage of the sewage disposal system
sErying_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
c- erating 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
_..._ .• .:.: "_ :ext�f�: date .;of:•,,Con�tructiar�.:.Comp1 lah 6 '° f'or the-=sewaige �disp6sa3 liystem, 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 Environmental 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 S day of 19 K Signature e-
��_���._ Title
General Cojntracto ignature
Corporation Name (if Corp.)
a /4�
'Address
rev. 9/85
mk
Corporation Name (if Corp.)
Address
APPENDIX C
FINAL SITE INSPECTION Da 2_6
FON OWNER spected
WCATI
__rum, 1,-OR SUBDIVISION LOT#
SEWAGE DISPOSAL AREA
a. SDS area located as per a roved plans
b. Fill section - Date of placement
2:1 barrier- LGTH WIDIH AVG.DPTH
c. Natural soil not stripped
.d. Stone, brush, etc., greater than 151 fran SDS area.
e. 100 ft. from water course/wetlands.
SEWAGE DISPOSAL SYSTEM,,-
a. Septic tank size
A I jll�
b. Septic tank install &I level
c. 101 minimum from foundation
d. No 90* bends, cleanout within 10 ft. of 45' bend
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
14):LL
2. Protected below frost 0'
3. Minimum 2 ft. original soil between box and trenchekj
'1A 19V
f. JUNMON BOX - properly set
g. TRENCHES
1. Length required - 7A70 Length 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 from property line - 20 feet - foundations
7. Depth of trench < 30 inches from surface
8. Roan allowed for expansion, 50%
9. Size of gravel 3/4 - 1j" diameter
10. Depth of gravel in trench 12'.' minimum
11. Pipe ends ca
h.-PUIP OR--D0SE..Sv_STF1v1S-.
1. Size of pump chamber
2. Overflow tank
3. Alarm, visual/audio
4. Pum p easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health Departnent
estimated flow per cycle
HOUSE
a. House located per approved plans.
b. Number of bedrooms _,N0AAA4,ZAA1W,
WELL I q
a. Well located as per approved plans
b. Distance fran SDS area measured "V 00 1 ft.
c. Casing lF above 2rade.
d. Surface drainage around well acceptable.
OVERALL WOPIQ66ILTP
a. Boxes properly grouted
b. jill 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 & dir.to exist.watercoursg
g Footing drains7als7ch—ar
�ge away from SDS area
h. Surface water rotection adequate
i. -]Yr—osion control pwovided on slopes reater than 15%.
Rev 53 /86
COIdS1RUCPION PEA
r
- r
Snbdlvision Dleme 4
Owner %Applicant Nia
Aaa�et�s L
77wµ
wilding Type
BlambeP of wdeoome_
Sepe ate Sewerage Sye
' To�lie cone
6Vater; $apply`
' ra
- Other °RegniYement9_
represent tha'1 am'd
above- descnbetlMwill b�
County Oepartinent "�;
be-, sut>mitted,`.to`;,the's,
place ";yin good- ,operati
ante of the approval;
wi_ a located as Show
APPROVEi
ievocaD l`e -
requires 4
Date.,-
rmitq' a`'
►NCE' s.'� Q
.µ'
VUTNAM YAUET '
..'_... �.
MAAVIN O'DELL Pl7i'f�AfVI a/Y�ttE•Y, :M.�i:�
'Inspector (914).526 2377
TOWN OF PUTNAM "VALLEY
BUILDING, .ZONING, AND SANITARY DEPARTMENT
November 2, 1987
Robert Morris
Sr.. Env. Health Technician
Dept. of Health
110 Old Route Six Center
Carmel, N.Y. 10512
Re: Putnam Homes, Inc.
Laurel &'Walnut.Roads
Lake Peekskill TM #97 -2 -18.2
Dear- Mr',.- Morris:
Regarding the above noted property, the Garage shown
on plans remains the same use with one overhead door
removed: Said door is. replaced with a 3'0 "'entry door
to this area.
�. •.. ..c. . . `.� .- r.. .._ -u ... .. _ .r.J _ .y ... i.. .. ... .».... w .> -. .�, .ar .� -.. .. ..-- u b .. w. ..Y .. ♦•i u+.. ... ..•
Very truly yours,
MARVIN O'DELL
Building Inspector
M0'D:es
i•�v ^.w- r -v...a ..q— - i ,- -i:. -F �.c + .�C�:� -6:`. c i'- <au .. ..i, -tan. ...
PETER C. ALEXANDERSON
County Executive
F
JOHN SIMMONS, MD.
Deputy Commissioner
DEPARTMENT OF HEALTH JOHN KARELL, Jr., P.E.
Division Of Environmental Health Services Director
110 Old Route Six Center; Carmel, New York 10512
(914) 225-0310
October 28, 1987
Mr. Frank Sullivan
2972 Ferncrest Drive
Yorktown Heights, NY 10598
Re: SSDS Putnam Homes, Inc.
Laurel and Walnut Roads, (T) PV
Tax Map 97 -2 -18.2
Dear Mr. Sullivan:
A final inspection of the above - captioned site was conducted
on October 26, 1987 by this writer. Final approval cannot be
- granted--at this time until the-following commentsa -r-e addressed: -
1. Written comments are-received by Marvin O'dell, Building
Inspector of Putnam Valley, as to the removal'of the
garage and the construction of an extra room.
2 a...� . D, ue .tom_ -he. .unapproved cba ge. o� -h- `� _g3_ib�� _ .. _ .... ..
surface sewage disposal system, it must be demonstrated
that 100 feet exists between the proposed expansion area
and Lake Peekskill.
3. As fill has been brought in to change the grade, this
fill is to extended 10 feet beyond the absorbtion trench
and slope 2:1 to grade with an impervious barrier.
4. Ends of trenches to be exposed for inspection.
5. Large stone to be removed from backfill material.
Upon receipt of a submission, revised to reflect the above
comments, this application will be considered further.
Very truly yours,
6&1�k
Robert Morris
Sr. Environmental Health Technician
RM : amm
cc: Putnam Homes, Inc.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
II
=F�'C�FiD' �;� E�RM I T-'
WELL LOCATION
Street Address
To Villag C ty Tax Grid Number
WELL OWNER
Na a .,
�.+
Address rivate
/?C• l% Ga'wfA�o0 X/, Public
USE OF WELL
1 - primary
2 - .secondary
CIESIDENTIAL
0 BUSINESS
❑ INDUSTRIAL
0 PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ❑ ABANDONED
0 FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL 0 STAND -BY ❑
AMOUNT OF USE
YIELD SOUGHT
L�' gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 4-so gal
.REASON .,FOR
DRILLING
EW SUPPLY []PROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
[]REPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN E]DUG GRAVEL OTHER
'IS WELL SITE SUBJECT TO FLOODING? YES N NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name/f a/r 0)5/ oil aY/ 0A®/i -Address: /�o��d✓ P
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ✓' NO
NAME OF PUBLIC WATER SUPPLY: '-' TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: /45/190
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED µ
DON REAR OF THIS APPLICATION ON SEPARATE SHEET
Z
( ate) (s to )
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
Date of Expiration: 6719 VernVt Issuing fficia
Permit is Non = Transferrable
8/86
APPENDIX B -
_= PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL VPCER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
:REVIEW . 'H. - CONS UCTION PERMIT-•. _ -
. (Name of Owner) (Street Location)
COMMENTS XES I NO DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc
Consistent Perc Results (3) Fill
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.Systen 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
L)e-pigg- Data,:_.gerp 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
Expansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed System
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 fi'
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expa
15' to Drains - Curtain, Leader, Footing
/-. 35'to catch basin,stormdrain,piped watercour.
IF trench provided _
required-
60 ft. max.
Part-1 lel to
contours
s/s
10'. to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to wnal.l
15' Well to PL
i
i
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL %ATER SUPPLY SUBSURFACE SE AGE DISPOSAL SYSTEMS
77 ,, ..; FIE -'� -,INSPFCTION.:REUDU2T�
DATE: y V
� UV (� �f � L. 94k_ iSP. BY:
(Name of Owner) (Street Location)'
INITIAL SITE INSPECTION YES NO COMMENTS
Wetlands on /or proximate to property........
Property lines or corners found... .............
Can estimate house location .......................
Will driveway need cut .... ......................... I1
Must trees berenoved - note these ................
Deep holes representative of entire SDS area......
Additional deep holes needed..:....... ....
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
1-k A 4 A-4
Adjacent wells /septics..............................
D.H. 1 Lot-
Depth to G.W.
Depth to rock
Soil De
0 ft.
3 ft.
6 ft.
9 ,ft.
l2 ft
D.H. 2 Lot
Depth to G.W-.
Depth to rock
Soil Descri tia
0 ft.
I ft.
6 ft.
9 ft.
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 _ Lot
Depth to G.W.
Depth to rock
Descr
0 ft."
DATE..
FINAL SITE INSPECTION INSP.BY:
YES
NO
rCOMMENTS
House SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Room allowed for expansion trenches ..............
Over 100 ft. from. watercourse....
Natural soil not stripped or SDS area
unnecessarly graded .............................
10 ft. maintained from property line and
20 ft. from house ..............................
Distance well to SSDS (ft.) ......................
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ................
15 ft. of peripheral soil horizontally
from trench ..... .......:.......................
Boxes properly set ...............................
Could surface runoff fran driveway, roads,
ground surface,.etc., channel near SDS area....
Does lot drainage appear OK,,in' area of SDS::........
FINAL GRADNG OF SITE ACCEPTABLE ....
�'
Whose officers /are:
President:
(Name..and Address)
Vice - President:
(Name and Address)
Secretary:
Treasurer:
�kylllll�a,W7
ame..and. Add:
Name and Addr
Pp
and"�Chat I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts releting
thereto.
Sworn to 'before me this .�-G day
of
r ,
otary P is
Ablgail C: AWM
DMry Public, S4®QO 0 MW Yorb
J Qualified in PulPam Cwn
ibo.4�7t
4G7M Ex0res
,r / /iP��
Title: i
g
Cnrnnrarp Saal'
• .Fy.
8/84
TW \
0 .
PUTNAM COUNTY DEPARTa". bF $LALTH
tYa a =S�rvices Division of Environment — $e
h! f
�
y
y
_
_ "AFFIDAVIT. - �C F0 e'�tra• d4tR AA#4`ZA�'itf�.,. >.: .=� -
`. 2,c �. :,
_
.aYL r..a r.ts - "i MGIT ��•�- l'..�r�iG
-� .� .iii .r- � _ ''.7 1 I E t
- 1 ..
'
FOR PEPAIT. APPLYCATIQ ',1�UBA4ITTED` TO
PUTNAM COUNTY [iFA LTH° DEPARTkNT..::
TO: Commissioner
of �le�lth
#
In the matter
of application €or:tl�c°
(,.
11
,i
w.
'
represent that
I am an officer or employee; of the c0`,r., Lion end aim
authorized.
'ac
����'�
to eor
f"c�Cli� C
'(Name of Cor- poration)
if '
having offices
at %2��
Whose officers /are:
President:
(Name..and Address)
Vice - President:
(Name and Address)
Secretary:
Treasurer:
�kylllll�a,W7
ame..and. Add:
Name and Addr
Pp
and"�Chat I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts releting
thereto.
Sworn to 'before me this .�-G day
of
r ,
otary P is
Ablgail C: AWM
DMry Public, S4®QO 0 MW Yorb
J Qualified in PulPam Cwn
ibo.4�7t
4G7M Ex0res
,r / /iP��
Title: i
g
Cnrnnrarp Saal'
• .Fy.
8/84
TW \
0 .
PUTNAM COUNTY DEPARTMENT.OF HEALTH
DIVISION OF F ENVIRONM"ENTAL HEALTH SERVICES
-t!-" COY
Date
Re: Property of 4449 7,
Located at 7-1
.'(T) 1p;,4 ow Section Block , Lot'.
Subdivision of
.Subdv. Lot # Filed:Map # Date
Gentlemen:
This letter is to. authorize
a duly licensed professional engineer . or register*ed 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-.'-t'he -Commissioner of the Put . nam 'County:
Department of Health, and to sign.all necessary paper . s on my.beh6lf in
connection with this matter and.tp supervise the'construction of.- said.
y'sie'm *or' sys ems or.
s in conformity with the'provisi.ons of Article 145*
147, Education Law, the Public Health -Law, and the Putnam Count'y,S;ani--
tary Code.
Very truly yours,
;J
Countersigned:
P. E.
297 Z '0�1 �
Address
Telephone
Signed
OW 09i 0 ektir
f/0114
Address
ox
Town
Telephone
r• 6• 151• • • 6 . zo ini) -
e • �° is v •� �xv e
DESIGN DATA SHEET— SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
l a-,,( 00&7 ?0,. �D f �jGAddressOwner
Located at (Street) 'oe-6 . or /'W 4 a/— Sec. _ Block y Lot . /y,L„
(indicate nearest cross street)
Municil
Date of Pre- Soaking Date of Percolation Test $
HOLE
5
;
NUMBER CL=
TIME
PERCOLATION
2
PERCOLATION
Run
Elapse
Depth to Water Fran
water Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start -Stop
Min.
Start Stop
Drop Ih
Min /In Drop
Inches Inches
Inches
- 2/33
3Zif A'J
/,�;'
2,2,
4
5
3 ;to 6 L Z /j;F- Y2--
4'
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 suhmit.ted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
5
1
2
3
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 suhmit.ted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH .-HOLE, NO. HOLE. NO �- y-HOLE NO _
G.L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDGTATER IS ENCOUNTERED G/y
INDICATE'LFVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: l DATE I Z _
- - DESIGN
Soil Rate Used -Z�' Min /1" Drop: S.D. Usable Area Provided ®�
No. of Bedrooms Septic Tank Capacity %'� gals. Type �--foo y
Absorption Area Provided By 3�O L.F. x 24" width trench /
Other
Namey' ~"
Address F "
4.
F (JS t aC
THIS ACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq<ft /gal. Checked by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0�
APPLICATION TO CONSTRUCT A WATER WELL
°:r -.... " ' ... • . =Y i'.: ;:';r:,pjcase prllli'Of.tj'pC - ;, :�� .w:�.,':r;.` a...�•°,i`' '�' -. `t.' - PeI-iD Permit
Well Location:
Street Address: /� Town/Village Tax Grid #
3 ui LNU7" /'C j%� LAM6 Pa/ JX116 Pt/. Map- -- Block Lot(&.) ; -!Z)�-
Well Owner:
Name: _
�' h�• EiEA -�'1N G
Address: �2 S' — $ 5/yrI
13'-4 GwuT lQ0 ...
of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
rimary
Business Farm . Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought ,- gpm # People Served Est. of Daily Usage ?oo gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) _Deepen Existing Well
Detailed Reason
/1 L,L, lS77�►G /J aniA -6 ' i�> Al
E
for Drilling
Well Type
Drilled Driven, Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? ...................................... ............................... Yes No L
Name of subdivision Lot No.
Water Well Contractor: /UAQ/i1 lDg&N Address: 0CMUArn 1%A US
Is Public Water Supply available to site? .................................. ............................... Yes No b'L
Name of Public- Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date_ : Applicant Signature:
j._ — p. 1? ..... _ .,n .. _. .... •..-.- .'^ .�� a .p,�..,,� i. «.-
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of 'Article 10 of the
Putnam County Sanitary Code and 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 or their designated
representative 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. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well .to be constructed by a water well driller certified by Putnam
County.
Date of Issue 2 ` Permit Issuing Official.
Date of Expirati d Title: -.
Permit is Non -Tran err e
White copy - HD file; Yellow copy -Building Inspector; Pink copy -Owner; Orange copy -Well driller
Form WP -97
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