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Home My WebLink About0005DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 1 -1 -5 BOX 1 r , , .; - �� - , { �, �♦ � T . V L IL r' � 00005 Rev. 3/8r�'!j (0� L� A PUTNAM COUNTY DEPARTMENT OF HEALTH . Division of Environmental Health Serviced, Carmel, NX.4012. p Engineer Must Provide P . 11, g % ji P .-C.H.D. Permit H—. :— . - -- 3. l F CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Located at M AW d f- j�Ofl D F &T,ri_ f2S o/v Town or Village / 9 Tax Map I Block- t Lot Owner /appUcant Name � � A4CS r M 6 5SO Formerly Subdivision Name Fi+r:v,Ew a`^'"'c iSabdv. Lot H Nailing Address r 13--x Z95 —zip-/0-6-q4 Date Permit Issued 1 Z% 16 I S 7 Separate Sewerage System built by Address M A3 I 'O jOA-C AJ Consisting of ('ZS -U Gallon Septic Tank and % Water Supply: Public Supply From Address or: —/< Private Supply Drilled by TO (LL-1 5 Ff Address 13-2iu otu g Al i Building Type s //) G L F/!-jt 1 , Has Erosion Control Been Completed? ' Number of Bedroom@ Has Garbage Grinder Been Installed? ` Other Requirements 3 L 1 V 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 regal tiona, in accordance with the filed plan, and.the permit issued by the Putnam County D partment Of Health. ! '-71) Date Certified by " ' L'Y� P.E.4— R.A. Address License No. 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 vold as soon as a pubt'= 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 mo ifieation or change when, in the judgment of the Commissioner of Health, such revocation, modification or change Is -necessary. C ��y Title Date =AL SITE. ENSPEC iCN La t_ ` Ins -teed bvwdfl"l c:vi9,..�_R _ -_- .� 2, T CR SU�DZtr_SIC�i LOT I YES rIC 5�— rAGZ DISPCSAL PREk a S. der 1Cr ='"`J' as a a =rcyed rdans c Size Cf c =:aLl 3/4 = _ 1-n r _ b _ f 1 saw i cr, - Date or piac-nerit 2:1 be- i�ar . I _rq 7- w_7_,Jfiri �- C_ soil r_ct s tri rDed I I d_ S`.^.r_e, bra , e , create_r tncn 1 _5' f_Cm SDS ar=- - =c.= i al, V — .3 . A! w P? o easi_v aC== 5=1ble iGc?rC1° to crace . e_ 1C0 -i a_rds. I I I a. S_Dtilc tanti s_C_ - 1, 000 ` b. SeCtic tom._ i ^�1 leT.el I ✓i`- I c. ; :min .*lit -:: =_ _ _=_ r,=_t_cIn G. N_- 90' ban_C_c, C_--nCLiL W1.11 lC Z. CL C�a LcaC I I Lv , c -_ � �� -I CL'L� °__. G Same E� °_ JG L '1 _C - G L- r L = -�- -- 2 Prot =C 2 -- Cr' C- -1 cti,.i l bc� ean CCn anc PT zC = i `- i „s 1 L= -c L Dis = ^_C° ZZ • ir!� -- i I -. ^r^'�'- 'rL =_..!C L ^v`v L'Zr c LicnC° Cam___ LC C_:L_ - CT Cic C= 1/32 1 = /Ccc I I C -10 LrCC�T" t i 1_ - 20 L=' - 2C.tLT:� ? Gros I .. ' ._ I ,=-fac° I � T7. V. h. 8- Rc Cl c! ! C';c� :Cr E -Z.:-'r!S-*Cr_r 502t, c Size Cf c =:aLl 3/4 = _ 1-n r 1211 7 U r J tZ C C_ ll _ , i tz c __12 OR Dc_ EYE= LS 1 .Size' cf L =::.-, C 2. liver =1C'.G tam-, =c.= i al, V — .3 . A! w P? o easi_v aC== 5=1ble iGc?rC1° to crace . 6. Cycle wi` - ,1 cc lc<=-t Derr a- crcvea yla-ls ECu b. WVr•.,. a _ Si' CC`L =z as r;-=-r a trove- ml_ns b _ D_= r'iC° f_= SLR a=== Jr.== 11 a:..LVc CrcC: G_ .c.:- -'==C° we!-, _ C-L� r�.0 P!Q.17 a _ F: -zes b- AL mires C _ _ piC =S f_I'. i Wi t-! inside CL b= I11.Lt i I CCnta?Z_ stones < c111 = i ri C.ra i i ^. c 1 1e5 acC^rd _ ^.c LO Ci Sl f _ C=tain drain C: f=.11 orctar ze, & di .to etc S e_ -C:cu- h _ Gc_- "Ce yvcL ='" C�cL = _? C. ^. aCE =Le i _ =_cn c_n mac! crcv i C`- cn slcces c�. =ter t'a 1� _ - WELL UUP'1rLL 11U1v K r•rvtcl a .t' DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only p` STREET ADURESS: TOWNIVIL III TAX GRID NUMBER: MAVor A1_T-rzA1 WELL LOCATION WELL OWNER 14 E: r ADDRESS: j PSIVATE 11011PUBLIC USE OF WELL 1 - primary 2 - secondary 'RESIDENTIAL 6 PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ 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 '9• NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL Q;?/ ft. DATE MEASURED 4�. DRILLING EQUIPMENT 0 ROTARY `'6.COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. ) ,OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH --- — k MATERIALS: IM STEEL ❑ PLASTIC ❑ OTHER LENGTH .BELOW GRADE ft. JOINTS: O WELDED 'S THREADED ❑ OTHER DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE I&OTHER WEIGHT PER FOOT Ib. /ft. DRIVE SHOE: ❑ YES `6ZNO LINER: ❑ YES ❑ NO DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? SCREE S SCREE FIRST O YES ONO SECOND HOURS GRAVEL PACK ° YES O NO GRAVEL SIZE: DIAMETER OF PACK in. tOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed um in pump 9 METHOD: 0 PUMPED i tests were done is in- COMPRESSED AIR ; formation attached? O BAILED O OTHER CI YES O NO 1�IELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FRartil SURFACE Bealrr ing well Dia- In FORMATION•DESCRIFTION CODE, ft. l 1f. WELL DEPTH It. DURATION hr. min. ORAWOOWN ft. YIELD 9Gm. land Surface. WATEIT ig CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? N4YES ONO ANALYSIS ATTACHED? YES ONO STORAGE TANK: yy TYPE tell .1.7MATION CAPACITY �L TskoL GAL. PUMP IHF B TYPE- �r� CAPACITY MAKER DEPTH MODEL � VOLTAGE 21-2 H1� WELL DRILLER NA E OA ADORES' I� S3- So tj� i RE 0 * all) / • r-i c r r Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -3203 Director :, Albcrt H. Padovani M. T. (ASCP) r � TORLISH WELL DRILLING PO Box 2T1 Armonk, NY 10504 L J LABORATORY REPORT ON THE QUALITY OF WATER i LAB // b Date Taken: Time: 3_ Date, Rc' d : 'l,( �s � � Time: ; 19 -. Date Reported: 1988 Collected By:. Duane Torlish Referred By: Sample Location: r�•c.� =tea `�z,�-` Phone 11 2T3 -3448 Phone # S ample Sample Type: Repeat Test? (check one) INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL) Acidity Alkalinity _ Chloride Detergents, MBAS.' Hardness, Total Nitrogen, Ammonia Nitrogen, Nitrate Phosphate, Total _ Sulfate _ Sulfide Sulfite METALS (mg /L) Copper _ Iron _ Lead Manganese _ Mercury _ Sodium Zinc MISCELLANEOUS PH (units) _ Color (units) _ Odor (TON) Turbidity (NTU) GENERAL BACTERIA / L �/ Standard Plate. Count (CFU /1.OmL) MEMBRANE FILTRATION TECHNIQUE C' Total Coliform Fecal Coliform Fecal Streptococcus MOST PROBABLE NUMBER TECHNIQUE Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY N/A = Not Applicable LT = Less Than ( <) GT = Greater Than (>) TNTC= Too Numerous To Count CON = Confluent ( =TNTC) NR = Non - reactive ' REMARKS /COMMENTS (For Lab Use) /ti°ot a b 1 e _ Non- votable _ STP INF _ STP EFF Other: Sample Status: (check each) Outgoing — HNO3 _ HC1 H2SO4 _ NaOH ZnOAc Na2S2o3 Other: Incoming LE 4 °C _ �GT 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 T N YORK STATE DRINKING WATER STANDARDS, FOR THE.-PARAMETERS TESTED, AT THE TIME OF COLLECT IOIL. THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STAT KING WATER CODES, FOR THE PAETERS TESTED, AT THE TIME OF COLLECTION. 2 /86(RvsdT /8T)RWE Owner or..Puurchaser of Building llolieS l" �5 Sc�Cil�TfS,1a� Building Constructed by Location - Street Aarl- easoAj Municipality Section Block l Lot Subdivision Name 5M Jt - -le F#4011& -7 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 willfl�or/r�egligent act of the occupant of the building utilizing the system;/ i Dated this day of 19 Signature Title c s 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 0 • RE 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. PUTNAM COUNTY DEPARTMENT OF HEALTH `\\ Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit N on CERTIFICATE OF COMP CE CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit q Patterson Located at Manor Road Town or village Subdivision Name Fairview Manor Smbd. Lot q 7 To Map 1 Block 1 Lot 19 Owner /Applicant Name Fairview Manor Development Corp. ,Inc Renewal_❑ Revision ❑ Date of Previous Mailing Approval P.O. Box 285 Thornwood NY 10594 Mang Address Town � Zip Building Type Single Family. Lot Area 3.327 Acres Fm section only L X J Depth _31volume 600 cy Number of Bedrooms 4 Design Flow G P D 800 L PCHD Notification Is Required When Fm Is completed Separate Sewerage System to consist of 1250 Gallon Septic Tank and 571 L F x 2411 Tile F i el d s To be constructed by To Be Determined Address Water Supply: Pdblic Supply From. Address or:_ X M ate Supply Drilled by To Be Determ1nwlidrees Other Requirements 3 feet - 600 c.y. fill required I represent that I 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 the date 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 accordance with the standards, rules and regu a iii ons of the Putnam County Department of Health. // /� Date 11/6/87 Signed TrMa Rarnn 11{ �L P.E. XL_ R.A. Addressfor Baldwin & Cornelius, P.C.. Brewster; NY 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 ay be a Tdod or modified when considered necessary by the Co issioner f Health. Any c ange or alteration of construction requires a ne perm��pr /or disposal of domestic sanitary sewage, an "r pr' e water ply onl V. l 17 Date By tie PUTNAM COUNTY DEPARTMENT OF HEALTH I represent that I am wholly and completely responsible for the design ano aitprn�lr 6,F►sPOSed system parate sewage disposal system above described will De constructed as shown on the approved amend a1i th dente with (dn d s0 regulations O e u nam County Department of Health, and that on completion thereof a',� date' On n yt Comp tom ommissioner of Healthwill be submitted to the Department, and a written guarantee will =niS+ n� ?W h ce S. a iJ4 4u or, that said builder will place in good operating condition any part of said sewage dij�dl dystern during the' pe Af wo rs immed folio ing thedate of the issu- ance of the approval of the Certificate of Construction Comptia"e• of t e original system or L y re irs then the th drill well described above \ will be toe�tpd as shown on the approved plan and that said well v�lld(b just the stands and r u a ns of the Putnam County 06pbrtment of Health. = m . �Date Siahed _ E. —Y R-A. Address ED 6, Rate 22. '10 Lice �4 43791 10 APPROVED FOR CONSTRUCTION: This approval expires two yearVrom tile. date• issued Of— � p of��l1,hh��jjtlyllild' � ern undertaken and is revocable for cause or may be amended or modified when considered AFIssary the C issioner `hTsy'c g r Iteration of construction requires a nqyepermlt. A, for disposal of domestic sanitary se r. f at ter s PV Rev. rrn7 Date ��d B Division of Environmental Health Servlees. Carmel, N.Y. 10512 Engineer to Provide Permit N on CERTIFICATE OF C8111PLIANCE Permit M � I I CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM ty-) D Patterson M Located at Manor Road own or village Fairview Manor 7 1 1 19 Subdivides Name subd. yet # Tax Map Block Lot Owner /AppIla tName Homesite Associates Renewal— ❑ RevWon ❑ Deft of Previous Approval Mailing Address P.O. Box 285 Town Thornwood , N.Y. Zip ' 10594 Building Type SinQle Family Let Aree 3.327 Acres Fm s 7 Depth Volume Number of Bedrooms 4 Design Flow G P D 800 PCHD Notification is Requited When Fm Is completed vTo separate sewerage system to consist of _250_Ganon septic Tank and 571 If x 2411 t i 1 e fields New York be constructed by Hekla Address Mahopac, `) V) Water Smppb,. PoHc Supply From Address x Torlish Armonk, New York �` or: Private Supply Drilled by \ — Address Other Requirements 31011 fill was placed m, I represent that I am wholly and completely responsible for the design ano aitprn�lr 6,F►sPOSed system parate sewage disposal system above described will De constructed as shown on the approved amend a1i th dente with (dn d s0 regulations O e u nam County Department of Health, and that on completion thereof a',� date' On n yt Comp tom ommissioner of Healthwill be submitted to the Department, and a written guarantee will =niS+ n� ?W h ce S. a iJ4 4u or, that said builder will place in good operating condition any part of said sewage dij�dl dystern during the' pe Af wo rs immed folio ing thedate of the issu- ance of the approval of the Certificate of Construction Comptia"e• of t e original system or L y re irs then the th drill well described above \ will be toe�tpd as shown on the approved plan and that said well v�lld(b just the stands and r u a ns of the Putnam County 06pbrtment of Health. = m . �Date Siahed _ E. —Y R-A. Address ED 6, Rate 22. '10 Lice �4 43791 10 APPROVED FOR CONSTRUCTION: This approval expires two yearVrom tile. date• issued Of— � p of��l1,hh��jjtlyllild' � ern undertaken and is revocable for cause or may be amended or modified when considered AFIssary the C issioner `hTsy'c g r Iteration of construction requires a nqyepermlt. A, for disposal of domestic sanitary se r. f at ter s PV Rev. rrn7 Date ��d B PU11M CaUrY DEPAMiEt?r OF HEALTH DIVISION • 09VIRONMUMil, HEALTH SERVICES DESIGN DATA SliEST-SUBSUFACE SUIAGE DISPOSAL SYSTEM FILE NO. owner HOMESITE ASSOCIATES/ Address P.O. BOX 285, THORNWOOD, NY 10594 AiRVIEV -PrAMOR Located at (Street) MANOR ROAD Sec. 1 Block 1 lot 19.- (indicate nearest cross street) I•junicipa.Lity PATTERS ON Watershed SOIL PERCOLATION TEST DATA PZQU= TO BE SUBMT1 WITH APPLICATIONS - Date of -Pre-Soaking 6/15/88 Date of Percolation Test 6/15/88 3 HOLE 2:30-2:47 17 24 6 NL14BER CLOCK TIME RCO=CN PERCOLATION Run Elapse Depth to Water Frcxu Water Level- 6 No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop 6 3 Inches Inches Inches 5 5 1 1:57-2:29 32 24 27.75 3.75 9 2 2:29-3:01 32 24 27.25 3.5 10 3 3:01-3-:31 30 24 27 3 '10 4 5 6 1 2:00-2:30 30 24 6 3 2 2:30-2:47 17 24 6 3 .3 3:02-3:18 16 24 6 3 4 3:18-3:35 17 24 6 3 5 2 C 4 V -b 1. Tests to be repeated' at same depth until approximately i',eqdn soil rates axe obtained at each percolation test hole. All data to* be sulm'Litt(4 for review. 2. Depth measurements to be made from top of hole. P1 0 T 0 PU11MM COUN1Y DEPARTMENT OF BEALIE DIVISION OF /• •• ' ID Y• L HEALTH SERv.&wK DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. owner HOMESITE ASSOCIATES / Address P.O. BOX 285, THORNWOOD, NY Located at (Street) MANOR ROAD Sec. 1 Block 1 Lot (indicate nearest cross street) t.Wnicipality PATTERS 0 N Watershed SOIL. PERCOLATION TEST DATA RDQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of'Pre- Soaking 6/15/88 Date of Percolation Test 6/15/88 10594 IN HOLE NUMBER C i= 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 7 1 10:07 -10:37 30 24 25.5 1.5 20 2 10:37 -11:07 30 24 25 1 30 3 11:07-11:37 30 24 25 1 30 4 5 22 1 2:08 -2:24 16 24 30 6 3 2 2:24 -2:44 20 24 30 6 3 3 2:44 -2:59 15 24 30 6 3 4 5 23 1 2:11 -2:26 15 24 30 6 2 2 2:26 -2:36 10 24 30 6 2 3 2:36 -2:46 10 24 30 6 i I / 5 'fir r'• ... • .ti` ;ice `. v f o-N ' N7IT5: l.. Tests to be repeated' at same depth until approximately "dual are obtained .at each percolation test hole. All data to' be submittW'' for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL f-? PCHD PERMIT WELL LOCATION Street Address M Tax �own/Village/C'ty ft � - I Grid Number / WELL OWNER j_Name Address `ice 11 S C ke�S I IIiC VtXj,1W0oC> IV 00 ClPrivate 0 Public USE OF WELL 1 - primary 2 - secondary ❑RESIDENTIAL 0PUBLIC SUPPLY QAIR /COND /HEAT PUMP ❑ BUSINESS O FARM O TEST /OBSERVATION ❑ INDUSTRIAL U INSTITUTIONAL O STAND -BY DABANDONED CI OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /16 PEOPLE SERVED /EST. OF DAILY USAAC gal REASON FOR DRILLING ONEW SUPPLY OREPLACE EXISTING OPROVIDE ADDITIONAL SUPPLY SUPPLY ®DEEPEN EXISTING WELL OTEST /OBSERVATION DETAILED REASON FOR DRILLING WELL TYPE ,®DRILLED DRIVEN ODUG O GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS .LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: P'IP,41 f W r) Lot No. 7 WATER WELL CONTRACTOR: Name j AE Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 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 SEPARATE SUET (date) (signat re) 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 th Putnam County Health Departtmentt(, la Date of Issue: ! 19 Date of Expiration: 19 ermit Issuing Officia Permit is Non - Transferrable 0 APPENDIX B PU=M COUNTY DEPARDIRU OF HEALTH DIVISIM OF &WnMENTAL :1E• is SERVICES REVIEW SHEET - CONSTRUCTION PERMIT REUZEI]�. J , BY: ' tion) DOCC�S Permit Application. Corporate Resolution Plans - Three sets Q__._.... s/s q Engineers Authorization Design Data Sheet (DDS)' SUBDIVI— S vOI Deep Hole Log Parc - Consistent Perc Results (3) Fill '3 i ole Depth ca�'` Two set s , pe_*mit; P4vS letter Request bdivision ion Approval Checked Ex- approval SSDS Adj. Lots Checked Wet-land (Town/DEC Permit R & D) Data On DDS Plans & Permit Same REQUMED DETAILS ON PLANS Sewage System Plan -' (north arrow) Sea -age 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 note=) Design Data: perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footin /Gutter,Cur in Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area; shcwn; gravity flow,suff. size If Pumpers Pit & D Box Shown & Detailed House - No, of Bedroans Wells &_SSDS's w /in 200 ft. of Proposed System Property Metes & Bounds House Setback Necessary (Tight lot) House Seger - 1 /4" /ft. 4 "0; Type pine No Bends; Max. Bends 45" w /clearout S��IRATICN DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, large Tre-es,Top of fi 20' to Foundation Walls 100' to Well; 200' in D.L.O_D, 150' pits 100' to Stream, Watercourse, Lake Unc. eta 15' to Drains - Curtain, Leader, Footing 351to catch basin, stormdrain,pipe`1 waterccur (Name • - -- • • f�sOWJ MMIIMA� wMm IMM Mm _. _. .f _ - s a ®� _ FILL SYST&MS I� 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL PUi'NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONME2?AL HEALTH SERVICES AFFIDAVIT- CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PU NAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: ti -✓(Vj)M gty0& — L,nr I, Anthony 7 Ami curri represent that I am an officer or employee of the corporation and am authorized f :i 2 to act for Fairview Manor Development Group, Inc. (Name of Corporation) having offices at P.O. Box 285 Thornwood, New York 10594 dose officers are: President: Daniel A. Amicucci, P.O. Box 185, Thornwood, NY 10594 (Name and address) . Vice - President: Anthony J. •Amicucci, •P.0. 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 A',P day Signed:aff,-7 of ' �� 19 rIl Title: At BUTY L ESPOSIio Notary Public, State of New York No. oua:ificd in u:rsu: County gj% Conit% C:zpir_s Ap:il moo, 19. Corporate Seal J —, t- d Q 4 D 'I E :xB A. r e� -w y�K SCALE: I "� Zo' DATE: f3 I Z 88 JOB NO.. -772.0' DWG. NO. I ° L -W 147' A- F -z' r3f (04.5 Zk H 14' 13 -H 84' A- 4' 4g 4 .1 °IS' 0.rr; A- 1 ' -rte' Im A- t: 41' A -L- 13 O -t, I0(' A- M' 40' A -M rl 10-111 114' Q - D j5_0 I i 41 Putnam County Department of Health .A- P' I5;,� A -f 99' e -p Iao.j�, )ivision of Environmental Health Servioeb A- Q' Mc 4 q d/ S 'oi�ormance o�, pproved as ro ed for with .pplieable Rules and Regulations of the 140' a-� `1lt 5' t3 "5 I 1 ? utnat County Health Department.., A =T' 14e; a -T �9 0 -T 4- U °I�' C7--U ►2 I' 1_¢na F,ur. e k Ti till Tl�t :xB A. r e� -w y�K SCALE: I "� Zo' DATE: f3 I Z 88 JOB NO.. -772.0' DWG. NO. I °