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BOX 1
Is I Is m 'P
1111
PUTNAM COUNTY DEPARTMENT OF HEALTH
Rev. 3185, Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer. Must Provide
P.C.H.D. Permit #—_L_1
)
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM PATTERSON
Town or Village.
Located at MOONEY HILL ROAD Tax Map 1 Lot . 19
Owner /applicant Namtiomesite Assoc., Inc. Formerly Subdivision Name Fairview Subdv. Lot b 6
Mauing Address P..O. Box 185, Thornwood , NY —Zip 10594 Date Permit Issued 12/10/87
Separate Sewerage System built by Helka Construction, Inc. Adaresa BucksHollow Road, Mahopac, NY 10541
Consisting of 1250 Gallon Septic Tank and 667 LF of 2411 Trench
Water Supply: Public Supply From Address
or: - X Private Supply Drilled by Torlish Addre.. Armonk, NY
Building Type Single Family Has Erosion Control Been Completed? N/A
Number of bedrooms 4 Has Garbage Grinder Been Installed? NZA
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County De artment Of Health.
Date - -- Certified by- P,'E. R.A.
AddreuBaldwin & Corneliussjk, Brewster, NY 10509 license No,T-'
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a pub!:: sanitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water Supply becomes available. Such approvals are
subject to modificatio or change when, In the judgment of the Commissioner of H"40, such revocation, modification or change Is necessary.
Date /����5 y��' Title IS
8
WELL COMPLETION REPORT
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only )
WATER 'CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? *1WES ONO
ANALYSIS ATTACHED ?YES ❑ NO
PUMP INFORMATION
TYPE S ob• f r s ,;.; CAPACITY
MAKER MQ r T I DEPTH *i_ MODEL VOLTAGi
STREET AOURESS: IUWN1Vy1jTCI1y TAX GRID SER:
VELL LOCATION
14" -
N ADDat s:
WELL OWNER
1 �,
p PUBLICS
USE OF WELL
RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
1 - primary
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
2 - secondary
❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY O
,MOUNT OF USE
YIELD SOUGHT s gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal,
REASON FOR
'5,NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING
❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH : - ft.
STATIC WATER LEVEL � ft.
DATE MEASURED 41i:lh? F
DRILLING
C1 ROTARY ---I& COMPRESSED AIR PERCUSSION ❑DUG
EQUIPMENT
O WELL POINT 0 CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
_
LENGTH. �.
STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE ft.
JOINTS. O WELDED ,THREADED O OTHER
CASING
DETAILS
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE'�SOTHER
WEIGHT PER FOOT — 1b./ft
I DRIVE SHOE: O YES�NO I LINER: O YES ONO
DIAMETER (in)
'SLOT SIZE
LENGTH
(11)
DEPTH TO SCREEN (ft)
DEVELOPED?
SCREEN
DETAILS
FIRST
O YES ONO
SECOND
HOURS
GRAVEL PACK
❑ YES
GRAVEL
DIAMETER
TOP
BOTTOM
❑ NO
SIZE
OF PACK in.
DEPTH ft.
DEPTH It.
WELL YIELD TEST It detailed pumping
D P 9
It more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
I
METHOD: O PUMPED i tests were done is in-
DEPTH FROM
water
We11
❑ COMPRESSED AIR ,formation attached?
SURFACE
Bear-
Dla'
FORMATION DESCRIPTION
CODE_
O BAILED ❑ OTHER :OYES ONO
ft. it.
ing
meter
WELL DEPTH
DURATION
TDIRIAWOOWN
YIELD
lane
ace
ft.
hr. min.
ft,
gCm.
I
-
WATER 'CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? *1WES ONO
ANALYSIS ATTACHED ?YES ❑ NO
PUMP INFORMATION
TYPE S ob• f r s ,;.; CAPACITY
MAKER MQ r T I DEPTH *i_ MODEL VOLTAGi
STORAGE TANK: TYPELkxLC.i—rd"0L
CAPACITYQ+ L(_-*•Tro 1, GAL.
.Mn "RILL NAj+IE
I.S '1 `4` )vs. Stet AE
40* A 1q'1 I --�—�
iv,-, �sl '
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245 -3203
Director: Albert H. Padovani M. T. (ASCP)
r
TORLISH WELL DRILLING
PO Box 271
Armonk, NY
10504
L J
LABORATORY REPORT ON THE QUALITY OF WATER
LAB
Data Taken. r"~ �, Time:
Date Rc'd: :';i ; ;I Time: =7 3,
Date Reported: JUL PONAR
Collected By: Duane Torlish
Referred By:
Sample Location:
Phone N 273 -3448
Phone N Sample Type:
f
Repeat Test? _ I (check one)
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
_ Acidity
GENERAL BACTERIA
_ Alkalinity
3o
Chloride
Standard Plate Count
_
— Detergents, MBAS
(CFU /1.OmL)
_ Hardness, Total
GE 12
_ Nitrogen, Ammonia
MEMBRANE FILTRATION TECHNIQUE
_ Nitrogen, Nitrate
Phosphate, Total
1y -/Total Coliform
_ Sulfate
Sulfide
Fecal Coliform
_
_ Sulfite
_
Fecal Streptococcus
METALS (mg /L)
MOST PROBABLE_ NUMBER TECHNIQUE
Copper
_ Iron
_ Lead
_ Manganese
Mercury
Sodium.
Zinc
MISCELLANEOUS
pH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A = Not Applicable
LT = Less Than (C )
GT = Greater Than (>)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
REMARKS /COMMENTS (For Lab Use)
' Potable
_ Non - potable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
_ HNO3
_ HC1
._. H2SO4
NaOH
ZnOAc'
_. Na2S203
Other:
Incoming
E
4 °C
T
4 °C
pH
LE 2
_
pH
GE 9
_ pH
GE 12
_ Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TXE NE Y YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE T OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT DR NKING WATER
CODES, FO METERS TESTED, AT THE TIME OF COLLECTION.
X/ V-7--�— 2) 2 /86(Rvsd7 /87)RWE
11�s,.+ .Akv.w4 M T ACr•pl 7)4rAn *nr
`)ydi•,�SiTC ° 4-1,5 0 C' 414, S � we .
Owner or Purchaser of Building
j70r4t6/7P
Building Constructed by
/nAA,1 a
Location — Street
Section
Block
l
Lot
!/H7T� /c! Sam bwi / /4v1ecj M4+0LjoR .
Municipality Subdivisio Name
5'Ve' le
Building Type Subdv. Lot #
GUARANTEE OF SEPARATE SEWAGE 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 success-
ors, 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 initial use of 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 occu-
pant of the building utilizing the system.
The undersigned further agrees to accept as conclusive the determin-
ation of the Director of the Division of Environmental Health Services
of the Putnam County Department of Health as to whether or not the fail-
ure of the system to operate was caused by the willf or� egligent act
of the occupant of the building utilizing the system% // L%
Dated this day of 19 Signature
Title
t
HEKLA CONSTRUCTION INC.
Excavation • Trucking • Equipment.Hauling
• Septic Systems Specialist
Top Soil • Fill • Gravel • Black Top
Buckshollow Rd. RFD 9 Box 474
Mahopac, New York 10541 (914) 628.5738
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES 011CM999=1
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
II.
IV.
V.
VI.
FINAL SITE INSPECTION Dated
Insper -t6d by>
~;rATION �i dam' 0 'r'�f - C7WNER
TM 4 OR S'[7BDIVISION LOT # s
YES
NO
CCY� S
Sr RM DISPOSAL ARFA
a_ SDS area located as per approved plans
b. Fill section - Date of placement
2:1 barrier _ LGM Tn mm AVC.1
c. Natural soil not stripped
d_ Stone, brush, etc. greater thgffi) 15' rc*'n DS area.
e. 100 ft_ fran water course /wetqanos.jy
EdIP.f E DIS. -OSAL S'YSTE'M!
a. Septic tank size - 1,000 250
b. Septic tank instal-led level
o
c. 10' minim an Fran foundation
Q
d. No 90° bends, clearout within 10 ft. of 45° bend
e. DISTRIBUTION EOX
1. All outlets at same elevation - water tested
0 4 �
o a p
2. Protected be? cw frost
3. Minimum 2 ft. original soil between box and trenches
I qd
f. JUNCTICN BOX = rocerly set
t
g. Z�rS
1. Lenath r=--Ti red - Lznath installed
2. Distance to watercourse me=asure ft.
( ,�
3. Installer according to plan
4. Distance centa..r to center
5. Sloce of tre_nc:h accep_ table 1/16 - 1/32 " /foot.
6. 10 feet fran prcpe-- line - 20 feet - foundations
I
I
7. Depth of trancz < 30 inches fran surface
I
I
8. Roan allawed for expansion, 50%
I
9. Size of travel 3/4 - 1 " diameter-
10. Depth of gravel in trench 12" minimum
`
11. Pine ends ca-Coe
h. PLC' OR DOSE SYSTEMS
1. Size of pum ah---fiber
2. Overflow tank I
6 A
3. Alain, vis'aal /audio
IW /'F�p
4. Puma easilv accessible manhole to grade
5. First box baffles
.�-p.
6. Cycle witnessed by He=alth Denartne_nt I
estimated f1cw per cycle
HOUSE
a. Hcuse located per acoroved plans.
b. Number of bedroansa
WaL
a. Well located as per approved plans
b. Distance fran SDS area measured ft. I
c. Casing 18" above grade_
d. Surface drainage around we-11 acceptable.
I
OVERALL hiORKM.ASHIP
a. Boxes rocer-ly arcuted
O "
b. All e
ics `i ally bac-kf illed
"
c_ All ipes flush with inside of box
d. Faetcfill material contains stones < 4" in diameter
/ff
e. Ctiirtain drain installed according to plan
f. Cstain drain cutrall protected & dir.to e_xist.watercours
✓
g. Fcoting drains discharge away fran SDS area
h. Surface water protection adequate
i_ E` control provided on slopes greater than 15 %.
,..... , .. .. ..... ., ,aa,.,....cs ru+� X,�e�,.
:! u r
i
1
A
.j�
•'
�.
r
-�
�.
NO. DATE REVISIONS
JOSEPH MERRITT n CO
L,0CATION
CHAP,,,,T
�,_F
G�.sj'
.�. -k.
ems'
� -H
�7•s'
A-&'
92'
A- M
57.5'
F3-
9 1'
A 1..1'
loo'
A -L
914'
p- J
qS
A-)
lo4.5" A -5
9�
0-
^-.1
111'
A- M
q 9.5'
13� - L
A- IL'
114'
A --r
19'
!3- M
I o�
A -L'
116
F3 -E
44'
e�- W
A- M'
IZ &'
s3-F
8)'
o
sue"
A-6
66'
B- N'
44'
B - rp
slal
Ce
q 3'
A- H
72'
03 F'
51'
5 - !z
9 7'
A -b
7)'
- �'
S7'
I5-
I or'
A -I
A -P
7 L�
1� -s'
�9"
c. W
609"
A- J,
01 - ?l
�5'
p- W
72'
NO. DATE REVISIONS
JOSEPH MERRITT n CO
CONSTRUCTION
Located at
Sobdivbbn Name
PUTNAM COUNTY DEPARTMENT OF HEALTH Engineer Peovlde Permit q .
Divbion of Environmental Health Services. Carmel. N.Y. 10.512 8ineer
OR SEWAGE DISPOSAL SYSTEM
irview Manor
Lot N 6
on CERTIFICATE O COMPLI %n%,T1
Permit N
Patterson
Town or Village
Tax Map 1 We& 1 tot 19
Owner/Applicant Name
Homesite Associates Renewal— ❑ Revlalon 0
Date of Previous Approval
Melling Address P.O. Box 285 Town Thorriwood, N.Y. ZIp 10594
Budding Type Single Family iAt Area 3.771 Acres Fm Section only Depth vobtme
Number of Bedrooms 4 Design Flow G P D 800 PCHD Notffintlon le Required When Fill Is completed
Separate Sewerage System to consist of 1250 Gallon Septic Tack and 667 1 f x 2411 tile fie 1 d s
. To be constructed by Hekla Address Mahopac, New York
Water Suppb,: PsbHc Supply From Address
or: X Private Supply Drilled by Torlish _Address Armonk, New York
Other Regtieemente I —nil Fj 11 --PI Aced
1 represent that 1 am wholly and completely responsible for the design and I%gtienl ofil ;he proDOSed wyst s(�,tr h
above described will be constructed as shown on the approved amendmentoh a �d)rcror=. wi t A s s
County Department of Health and that on completion thereof a " OR CAM f "4 y�n Com is a" i ioG �� e
be submitted to the Department, and a written guarantee will br ioC,is; yl vvner,<fy't�fycce s, r sss;gns b1 e
place in good operating condition any part of said sewage dispp ysi iTa �•p �1 wo )y � ately fi
ante of the approval of the Certificate of Construction CO us ,Ot the original y . - ► f0 Ira th O It the
will be located as shown on the approved plan and that said well w l�i Ihstall accordance'wi the stand re
County Department of Health. _ Q ; A
Oats 7/1/88 Sit
Address
APPROVED FOR CONSTRUCTION: This approval expires two v
revocable for cause or maybe amended or modified when conssd,
requires a new permit. Approved for disposal of domestic $al
Rev.
1/87 . Date
BY
•by. the Comr�tt3sione
*d /or priyptie water
r:,rur1111, W.
Title
ssioner of Healthwill
that said builder will
i the date of the issu-
well described above
s of the Putnam
fl-.A. -_
been undertaken and is
;oration of construction
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental 110M Services. Carmel. N.Y. 10.512 Engineer to Provide Peewit #
�.` � LATE OF �_
P(�NSTR ON PE MM FOR SEWAGE DISPOSAL SYSTEM /
�� at Manor Road
Patterson or V116ge
Subdivision Name FAIRVIEW MANOR SUM. yet N 6 Tax Map 1 Block 1 Lot 19
Owner/ApplkantNun Homesite Associates Renewal_'° R °vl°l°° °
Date of Previous Approvig
M.mngAaaroea P.O. Box 285 Town— Thornwood, NY 05 ZIP
Rev.
1/87
Baudhtg Type Single Family Lot Area 3.77 Acres � Section Only X Depth 3 voluae1000 cy
Number of Bedroom, 4 Design now G P D 800 PCHD NotlHtation b Required When Fill Is completed
Separate sewerage system to consist of 1250 Gallon Septic Talk and 667 L . F . x 2411 Tile Fie 1 d s
To be constructed by to hp f1Ptermi npld Address
Water SuPPlY. Pdbile Supply From Address
or: X Private Supply Drilled by to be deter g
Other Requirements
1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(s). 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and In accordance with the standards, rules and regulations of e Putnam
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will
place in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately following thedate of the issu-
ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be Installed in accords with the stand ds, rubs and regu aaTlp oof the Putnam
County Department of Health.
Date 2:110/Q 7 Signed T7TTYr] Pr3TYYl P,E. i�_ R.A.
/ / -�- Address for P,aldWin & Cornelius, PC, RD6, Rte.22,Brewster,NY1019 License No 43791
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered n esar by the ommissio er of Health. Any change or alteration of Construction
requires a new permit. Approved for disposal of domestic anitar sew , and to w or sujp only. IT /�
Date ��V� BY ��'� Title
L
lY
BY
Q%me+of Owner). (Street Location)
COMMENT'S YES I NO DOCMaUS
Permit Application '
required
Q 60 ft. max.
Parellel to
FILL SYSTEMS
cla barrier
10 ft.
fill notes
new s
de a� es
100 yr. flood elev.
`I
200 ft. reservoi etc.
150 ft. trigall /i
Corporate Resolution
�- Plans - Three sets
Engineers Authorization
s/s
Design Data Sheet
(DDS)
SUBDIVISION
Deep Hole Log
Z% Perc 0
Consistent Perc
Results
(3) Fill
Perc Hole Depth
__cd -�
House Pl - Two
sets
Well permit;
PnISS
letter
Variahce Request
Aegal Subdivision
Jubdivision Approval Checked
,ZK-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 Flcw
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 rate)
Design Data: Perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
FootinJGutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flow,suff. size
If PaTped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Server - 1/4"/ft. 4'10; Type pipe
No Bends; Max. Bends 45° 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' fran Foundation; 50' to well
15' Well to PL 9
PUrNAM COUNTY DEPARTMENT OF HEALTH
J
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
AFFIDAVIT- CORPORATE OWNER APPLICATION
FOR PERLRIT APPLICATION SUBMITTED TO PUTN M COUNTY HEALTH DEPARTMENT
TO:. Camiissioner of Health
In the matter of application for:
I� Anthony J. Ami riirri
represent that I am an officer or employee of the corporation and am authorized
to act for Fairview Manor De
(Name of Corporation) NOW KNOWN AS HOMESITE ASSOCIATES
having offices at P.O. Box 285
Thornwood, New York 10594
Whose officers are:
President: Daniel A. Amicucci, P.O. Box 185, Thornwood, NY 10594
(Name and address)
Vice - President: Anthony J. Amicucci, .P.O. Box 185, Thornwood, NY 10594
(Name and address)
Secretary: f
(Name and address)
Treasurer:
(Name and address)
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subs ent acts
relating thereto. `
Sworn to before we this Signed:
of fo �� 19 Title:
BETTY L. ESPOSITO
Notary Public, StWe of New York
No. 4- ,13-.13
oualllleJ In r'u'nari County ryo
Comn:ic;;cn C%Pires April 3o, 19.;•
Seal
20
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD.PERMIT * / ��
WELL LOCATION
Street Address
Kings Way
Town/Village/City Tax
Patterson
Grid Number
19
WELL OWNER
Name Mailing Address ®Private
Homesite Associates P.O. Box 285 Thornwood NY 105947Public
USE OF WELL
1 - primary
2- secondary
® RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND/HEAT PUMP
O FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY
D ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT
5+ gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 800 gal
REASON FOR
DRILLING
10NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
Drilled Well Serving New Single Family Residence.
WELL TYPE
0X DRILLED
DRIVEN
DUG
GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
FAIRVIEW MANOR Lot No. 6
WATER WELL CONTRACTOR: Name To be determined Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: . YES __�L_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION E] ON SEPARAT SHEET
(date) (sign ture) rma Baron, P.E.
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 y th Putnam Co my
Health Departm nt1.v
Date of Issue: I Z: 2-� 19
Date of Expiration: 19
rmit Issuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 nrancsa mnv- Wall nri 1 1 ar
TAn4-
97a
A9-W,
C W-Avlt
140
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\vtIM
. 39
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