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HomeMy WebLinkAbout0009DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3. -1 -9 BOX 1 1. ' kQ f � r 1111! PUTNAM COUNTY DEPARTMENT OF EMALTH CATE OF CONSTRUCTION COMPUANCE FOR. SEWAGE DISPOSAL SYSTEM "_Towinkbi V111@410, Map Sewei&96 Systeul built by Address Condsling of I Liao Tank and wan Suwy: Public Supply From Address Building Type KIM M= Number of Bodrooms Has Garbage Grinder In 611.011? Other Ikequirerpento I ceriify'thn't'the sys� - amid) as listed serving the above piemises were cons ed s shown on plans of the completed war�,­( q4ies a attvhed "and _ in-accordanc a with the standards, rules and r'l plan, and the permit 'issued t Health. Oats Cartified by JA Any person occupying promises served by the above systern(s) shall, promptly take suc 8� Ion as may be necessary to L ure the correction of any u6moiltory conditions resulting from such usage. App . roval of the separate savvirs", system sh boon** null and void as soon as a pUbQz sanitary loWel b6coorM when Supply becomes 44allable, Such approval* we _6f.,the.private water suppjy shall become null �o�nd�yold,w if subject to rnodlikation -or 'phonge vv�ion. in. the judgment if thi 6mmISS16rotr 10 Is necessary. A01 This n �AM COG rr � WELL CUMYLE*f1UN Kt,YUKl * * DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAIM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION TAEci AOUAESS: wr+rva / 1 TAX GAtO N A+BEa: s0t i LoT 1 WELL OWNER NAME: AOOAESS: �1 \� •� �j ❑ PBIVATE ❑ PUBLIC. USE OF VJELL 1 : prlmar secondary RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP ❑ ABANDONED ❑BUSINESS ❑FARM TEST / OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT �� gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY []TEST /OBSERVATION ❑ADDITIONAL SUPPLY. EW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. I STATIC WATER LEVEL — _ tt. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY `&COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL .TYPE ❑ SCREENED ❑ OPEN END CASING — `9,OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH MATERIALS: STEEL ❑PLASTIC ❑OTHER /��_ --ft — LENGTH BELOW GRADE Y ft. JOINTS: ❑ WELDED THREADED ❑ OTHER DIAMETER in. SEAL`S CEMENT GROUT ❑BENTONITE ❑OTHER WEIGHT PER FOOT �i lb./ft. DRIVE SHDNYES ❑ NO LINER: G YES ❑ NO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (it) DEPTH TU SCREEN (ft) DEVELOPED? DETAILS FIRST ❑ YES ❑ No HOURS SECOND GRAVEL PACK ❑ YES O NO GRAVEL SIZE: DIAMETER OF PACX in. TOP DEPTH ft. BOTTOM DEPTH tt. WELL YIELD TEST It detailed pumping METHOD* ❑ PUMPED t tests were done is in- t "ELCOMPRESSED AIR , ' ormation attached? ❑ BAILED ❑ OTHER ❑ YES ❑ NO WE LOG Il more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE. Water Bear• inc MlcII Oia ne+er FCAI.IATtON DESCRIPTION Coot ft. ft. WELL DEPTH it. DURATION hr. min. ORAWOOWN it. YIELD 9Cm. Land Surface WATER " �LEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? `9.YE5 O NO ANALYSIS ATTACHED ?`t�.YES ONO STORAGE TANK: TYPE eu, -Cro)j , CAPACITY &150 GAL. WELL 0RILL NAME � s ADORES° �, SI HATUM tl A #_ N � r PUMP 1HFO�MATIO I TYPE CAPACITY MAKER DEPTH a MODEL 6SoS VOLTAG>a HP Section Block Lot Subdivision Name Subdivision Lot # GUARA= OF SUBSURFACE SEWAGE DISPOSAL SYSTMA 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, standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate:of Construction Compliance" 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 detezmination of the Director of the Division of Environirental 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. - 1 Dated this.. day of 19 Signature Title eral. Contractor (Owner) Signature S °' Corporation Name (if Corp.) j YMI_ ENVIRONMENTAL SERVICES. 3 "'21 tear• Street ` Yorktown' Heit#hts, N.Y. 10598 �4kx3i; ( 914) 245 -2800 Alber t H. Padovani, Director 41 t LAB #:-:33.400676 'CLIENT #: 114 NON STAT.PROC PAGE N NNNNNN NNN NNNNN.l I+ NN I +NNNNrl IlNNNIJ rl IJ Nr +IJ •l IJ IlN Nom!/ +•JNNN / +I+/+P, 4- ----IJ /+ -- ------------ IVNNNN ' , 12/03/4` 16m:r3--: q TQRLI SH g 80N8 DATETME TAKEN• PDX`.-- 271 DATE/TIME. REC'D: , 12/09%94 12:6C ATTENTION, DWAYNE TORLI'3H REPORT DATE 12/13'/94 ARMONK,.'NY 10504. PHONE: (914) -273 -3443 _- =`S:AMPLING.'.SITEe FAIRVIEW MANOR- LOT #11 SAMPLE TYPE. POTABLE: .,..`- �:`x- �s�_:• _._ _ __ - - -- -._ ._ . • - - - - -- _.._._._.._.,..._._ PR_ RVAT._IV _ ONE s- BY:. D. TGRLI SH .TF_MPERATURE.:: <.-4C." NOTES. .. • CGLIFGRM METH: M ------ -- YNIJNNNNNI ---- lN. +r +Nrl N IJ IJ /JNI!•! ♦J lJ/ I /+/JI+NrJNIJNI+IJIJN /JIIN /+NrJN rl N ♦!I!N /I /!rJ •JNN/lNNNNNr 7;f %:fc - ' r j DATE: FLAG PROCEDURE RESULT NORMAL -- . RANGE %/ 1 /7A' MF ._T . C4L I FORM ABSENT • / 100 ML . ` a< A$tiENT r'n � r.: CQMMENT� = : • ... ::: BACT.:- .,'THESE RESULTS INDICATE THAT THE WATER (WAS -�) (WAS NOT) OF A` ATISFACTORY- SANITARY QUALITY ACCORDI HE NEW: YORK STATE . ;'AND EPA FEDERAL DRINKING WATER STANDARDS. FOR THE PARAMETERS TESTED, AT THE TIME 0 COLLECTION. 4ySUBMITTED BY: --= - -- ------------------------ .Al bert H. Padnvani, M.T.(ASCP) Director FLAP# . :1 632= t 'y t s . ' .. - i FVIrkAM COUNTY LWEFARTNM OF HEALTH Dbrbla n d inlrue�W HiWIA S•evkea, CUMOL N.Y.16512 Eltsla..r to Phm*b P.a / SEWAGE DEPOSAL sum w CEHTMCATE OF COMPLIANCE Towle or vm.He %I I�IY 1 V Ww gf=_Swile11. Lot i ( Taw Map 1�; �"M�i� �� ��I �rG� Eeoowal._ ❑ 1levWsn_�� OurMd Nam._ Dab of Approvd 3 29 q q MsMm A&Wiea d To W t'1 vlr zip 10&0557 Date Subdivision Anvroved Fee Enclosed ❑ Amniint- FM Section Depth Vakdtb. Nlttib.r at H Design Flow G P D PCHD NOtI[katlon Is Requited When Fm Is c•ntieleted seP.&te s.wmy sy.ta t. o.a.bt d J.�GWIM Sq* T=ic •d �i 2 l,� / �PTI ski l � ►C To be oass.Dmeisd b D ��•� • ,►aa.e.. 1 represent that 1 am wholly and completely responsible for the deign and but above described will be constructed as shown on the approved amendment there County Department• Of Health, and that on completion thereof a "Certificate be submitted to the Department. and a written guarantee will be furnished plot• In good Operating condition any part of salt saws" disposal system ana of the approval of the Certificate of Construction Compliance of the WIN be located ss shown on the approved plan and that as well will County Department of Health. Date W I -7—KI S-1 ion of the proposed sYStem(s): 1) that the separate sewage di sal system to and in accordance with the standards, rules a regu MOOT Iri lrl�nafn of Construction Compliance,* satisfactory to the Commissioner Of HMNhwill the owner, his suctestors, half$ or assigns by the bulkier, that aid builder will during riOd years Immediately following tMdat• Of the isau- p nY repeir No; 2) that the drilled well described above i w h the sta ds, rules and rpu Mns of the Putnam APPROVED FOR CO STRUCTION: This approval expires two years from the date issued unless construction of th MrOeabb for taus a amerldad or modified when considered by the Corn issioler of HeaIt n' "Quires a MW _ m prOY r disposal of domestic star end /Or p r' • W •r supply Rev. / _. 10/88 Dat' By P.E. R.A- &Icense No building has been kiklulhd is change or alteration of construction Title rUTNAM COMM D1WA22TAI 1' Oil►HBALTH DIMM d Esv4amW Headb 4 M 11... Cad. N.Y.16512 t. P..dd.lp / PEUM FOR SEWAGE DMOSit►L STEM an CIMME LATE OF COIIIZIIAM M Two or Vft SWWNk- coda_ w / Tax MAP 150 Hoek 1N -9_ OwMdAPPHeant Nar,�bl � tL�'�� I�T�. L�S�i s E�wd an �HeeW ❑ Dab of Prevlong Appeovd U 2 MOMS AdiOJ ,Z COM&U 261SAD 0AX7 T.W. W uI -fg am p t.; 7Jp Date Subdivision Approved Fee Enclosed ❑ Amniint- BWM,bg W , nsI D 2 Miq Fm swim onk, LJ D"* vakem. N ON Derr Flow G PD Oa PCHD N Is Required Wbm FM Y eiapkebs& S " S. rm0 SY.ta b been d Z50 GaO.n S.ptke Tank an d Z To be o.asldmelad by �E yg6 I Addie.. -1 . Water S�pb. >�_ a.u— Psblll SrtPPb an X lsrleeae st4P4 Otb.f Regdl.ea.nb v!7l �) py t l y r� vv /�r T. ' si.�.�u�r D—• ��"' Cµ� �Vi - , t:_ . i^ i 1 represent that 1 am wholly and completely, responsible or the • design and location of the proposed system(s); 1) that the aparat• sewag! dispoahfllsteni_% above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and reguli M. or the— County D•paftnent of Health, and that on completion thereof a "Certificate of Construction Compliance" atisfact y to the CommialaWof F(iilthrlill be submitted to the DoWm•nt, and • written guarantee will be furnished the owner, is s, heirs or as f by the bulkier, that -ald bONder will place in goad operating condition any port of as faw+N disposal system during th of two (2) years medlet•ly folbwiftg tMdste of iM leap• ante of 1M app►OVSI of the Certificate of Construction) Compliance 01 the a s or any repairs ther o; 2) that the drilled well described •bow will be located as shown on the approved plan and that as well will be installed i with the stands fti rubs and r•gu ons of the Putnam County Department of Haelth. Date Signed P.E.- It �sC r Add►essY'� �� f✓ Z?" � License No O 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 of may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction "Quires /anow permit. � for JddiissposalCof` domestic sanitary sew /.•- n� gW t• water supply only. • DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL p PCHD PERMIT WELL LOCATION Address Street _ M Address Town/Village/City -3 Grid Number WELL OWNER Name Maili MSS g Address Private Z Ge8 191.E W14 1f6 nLS O Public USE OF WELL 1 - primary 2- secondary )d RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED D BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify, D INDUSTRIAL b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT 63 MltJgpm /# PEOPLE SERVEDjfj6M/EST. OF DAILY USAGE fa0 al 17 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION D: ADDITIONAL SUPPLY NeNEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ODUG GRAVEL. C] OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF.SUBDIVISION: EAJ r*1(eW MA -W©r__-, Lot No. WATER WELL CONTRACTOR: Name 1-n '66 � 'i � Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES Y, NO NAME OF PUBLIC WATER SUPPLY: N/4 TOWN /VIL /CITY DISTANCE TO PROPERTY FROM.NEAREST WATER MAIN:C` LOCATION SKE CH & SOURCES OF CONTAMINATION PROVIDED XON SEPARATE SHEET f� (date) PERMIT TO CONSTRUCT A WATER''WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt -• (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 drilling operations be contained on this property and in such a man r as not tog3e rade gi•ot. e,rwise contaminate surface or groundwater. Date of Issue: 19 Date of Expiration 19 -✓ : , :, ... Permit Issuing Official Permit is Non - Transferrable - Wh3te._co�y: HD File Pink copy: Owner 3/89 `'''Y61216w copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services.. Carmel, N:Y.1051? Engineer to Provide - Permit N n on CERTD� KATE OF CO CE CONSTRUCTIO RMIT FOR SEWAGE DISPOSAL SYSTEM Located at Moo/J/rY i4ILA- 4jtbrAc il 1;?0a6 Subdivision Name = rAL_41eW . i�Lowlo'r� Sabd. Lot N l I Owner /Applicant Name - MtE SI�7F3 id�►+o •/ikTL= Permit ♦Y mQ.7 Town or Village Tax Map I Block. L Lot 1 `! Renewal_ ❑ Revisibn ❑ Date of PPr- envious Approval Mailing. Address '• O . k l85 Town / .v 11�GO D L Y Zlp `10 4 Building Type .ti >EMAJ(:AF yet Area 101,0 WTI S • F FW Section Only Depth Volume Number of Bedrooms Design Flow G P' D X40 O PCHD Notification is Required When FIB is completed Separate Sewerage System to consist of iZrSD Gallon Septic Tank and �71� L• �B50ta("1"!O!J' �A'L[A/Cii To be constructed by 8�' Ni Al&t> Address Water Supply; Public Supply From Address Private Supply Supply DrWed by A O• !Address Other Requirements sT ,'% t,l•i`I DAj I, represent that 1 am wholly and completely responsible for the design and location of the proposed system($); 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,YUles an regu a ions o e - u nam County Department of. Health, sand that on t:ompletion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwm 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 issue Vice of -the approval of: the Certificate of, Construction Compliance of the original system or any repairs t re, o; 2) that the'drilled well described .above will be located as shown on the approved plan and that said well will be installed - in ccordance with the sta. rds, rules and regula —l'oni oR the Putnam County S artme�nn�tt Hpof H.eaallth. Data �J19tuC7 `' Signed: P. E. R.A.- , Address el f / _ .. _ _ License No Z&09D& APPROVED FOR CONSTRUCTION: This approval expires two ears from the date issued unless construction of the building has been undertaken and is revocable for cause or may be amended or modified when con idered noissarylK the Comm' sion -r f I I jftlth. Any change or alteration of construction requires a now permit. Approved for disposal of domes(' ni fewa ry e ly Rev. ` r 1 /87 Oata -��. BV PETER C. ALEXANDERSON County Executive August 8, 1988 DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 Cashin Associates Route 52, Seavey Plaza Carmel, New York 10512 RE: Fairview Manor (T) Patterson Gentlemen: Review of plans and other supporting documents submitted at this time relative to the above - captioned projects has been completed. Comments are offered as follows: 1. Lot 11 - Fairview House is considered to contain five bedrooms. SSDS design must be revised appropriately. 2. Lot 13- Fairview ENID L. CARRUTH, M.P.H. Public Health Director Show pipe in easement, if any. If not, show 35' to SSDS to any future pipe. 3. Lot 15 -Lot 12- Fairview The Department requires witnessing of two soil percolation tests in proposed sewage disposal area. House is considered a five bedroom. SSDS design must be revised appropriately. pon receipt of a submission, revised to reflect the above ommentsr, this application will be considered further. , V 1 • , 1 Vi rector, vironmental Health Services JK:Pt cc:JK File JOHN SIMMONS, M.D. Deputy Commissioner JOHN KARELL Jr., P.E. Director PETER C. ALEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225-0310 January 20, 1989 Chris Maravelas c/o CASHIN ASSOCIATES Route 52 Carmel, New York 10512 Dear Sir: ENID L. CARRUTH, M.P.H. Public Health Director JOHN SIMMONS, M.D. Deputy Commissioner JOHN KARELL Jr.. P.E. Director Re; S.SDS /WELL APPLICATION Name • Home -Site Associates (3 APPI i cati ons ) Street; Mooney Hill & Manor,_ . ad Lot #; T.M. 1 -1 -19 Lots 11,12 &15 Town: Patterson . Review of my files indicates no activity on the above captioned project for some time. Please advise the writer as to the. status of this project without delay. Failure to receive a response by February 6, 1989 will result in the file being returned to you, DISAPPROVED. ery tru yours John Karell Jr., P.E. Director, Environmental Health Services JK:cj cc: Owner JK File S w Pur,14Plm! c,--Tj ! DEP_ =xja7r OF HEALTH - DIVISICH OF EWIRCRAM7ML HEALTF_ SERVICES T.L 1VIDOM MATM SUPPLY & SJBSiIRF'aC✓ STr1�_C�- DISPOSAL SYSTEMS (Na-me of L'wmer) REJETni SHEi.T - CONSMU TICN P—^TT (Street Lecatica) M=S YES I NO � I I I I I I 1 I I I I I I I I I I I J I I I I I I I' I 1 L t _ncn prcv- `_a rwLli -w ��d 60 ft. r"- Parallel to contours 100!%- ex-_. I I I I I I I I i I I� I. i I I_ I i F= YSTEE MC I I c i a, ' -?-12r I 10 f . I ( I i;i1 ot�s I r_a . sAec. I I deotn Vauces I I 100 vr. fi elev. I ( 200 ft_ rase_ oir, etc. 150, ft. trical ll. ( I I I I I DATE ROV- BY: P t Application f / Corperate Resolution Plans - Three sat_s s/s E-nainee_ -s. Aut_hcriZaticn Design Data Sheet MCS) Sut.DIv SIC�v, De=n Hole Lcc p_rc Consist =nt Perc Res:ii =_ (3) F.; I Per-C Hole Depth C -- HCU.�..a Plans - Two se S We11 / Fe--n-it; P E 1 = = =a= VariauCe iec-i:Est C M-RA . Lc al Su3 div_sicn SiII:G'_`lislcn pSDrova1 C ecka" WE =' arld (Tcwm_/DEC P °__.u_ : R & D) Data Cn CDs Plans & pe=,i `- .CCT= System H_v raul? C P_or_l_ - C -r= r -- Fi Il Profile & Di _rsicns - Vc == _ D or J Ccr't?c T L K - Si7 , D✓t�il Well Cetai? , Service Lir__ if crc_ Ccnst-ucticn Not_S (cringer r;--_) Des_cn Data: Perc and deso Two- -Foot Contours Existinc & P_c_nc =_=� Dri ve vav & Sloces Coat FccLinQ%GLtt_r,C ?ur' ain Drains (c_zc jarge CK) Perc & DEep Holes L.^cat Reorasantative of pr? rv=y and expansion D.,ansice Area;shcv,,a;=ravitY flcl ,suf= ..size If P-mz>--d Pit & D Box Shcvn & Det. -i led House - No. of Ee :rams Wells & SSDS's w /.in 200 ft. of Proposed System Prone_' y Mattes & Bounds House Se- Ck Necessary (Tight lot) House Sete_ - 1 /4" /it. 4"0; `I' e pipe NO Bar-Ids; Max . 450 w /c! eanc t SELD"RATICN DISZ-tiC= SPECI'TED CIi PLAN Fields 10' to P.L. , Drivewav, Loge T_ estop of f. 20' to Foundation Walls 100' to tell; 200' in D.L.O.D, 150' pit-n 100' to Stream, Watercourse, Lake (inc. ems_ 15' to Drains C rt"a- n, L ceder, Fcoting 35'to catch waterccliz 10' to avatar Line (pits -20' ) 50' inta-mrLitte_nt Chain =c-e ==T -se Sent c T`a k- 10' f =cm Foundation; 50' to well 15' Wel I to PL 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 Town/Village/City Tax Grid Number ^'lo e 1 1►u. 6' t-t0hwV* L. WELL OWNER Name E S rE .4 Mailing Address oe a. t3o ley — Tt40kfJ o D ty-( 'Private O Public USE OF WELL 1 - primary 2 - secondary '6j RESIDENTIAL O BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY 0 FARM []INSTITUTIONAL O AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY 0 ABANDONED O OTHER (specify, 0 AMOUNT OF USE YIELD SOUGHT M,„ 1 5 gpm /# PEOPLE SERVED I i;tm /EST. OF DAILY USAGE goo gal REASON FOR DRILLING NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY [3 REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL OTEST /OBSERVATION -DETAILED REASON FOR DRILLING DN?i.o �uPF�I. WELL TYPE DRILLED DRIVEN E]DUG D GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: .► �dl i­/1,twQoz Lot No. WATER WELL CONTRACTOR: Name /v Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC MATER SUPPLY: ?J /A. TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: \ NJ L-ER LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION (date) PERMIT �' ter:' '•� ° =r TO CONSTRUCT A WATER WELL , "Iz. This permit to construct one water well as set forth above, r.'s -- anted 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 s.hall: 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 provi d by th utnam Coun Health Department. Date of Issue: 2- __& 19 Date of Expiration: 19 mgt Iss ial uing ffic - -`�� White copy: H.D. File Permit is Non- Transferrable Yellow copy: Building Inspector Pink Copy: Owner 287 Orange copy: Well Driller DESIGN DATA SHEET- SUBSUFACE SEWAGE'DISPOSAL SYSTIN FILE NJ. owner I- 1of�tt� o .��scra , _ ' Address ' P. o aox Is% - 1 t bpi t�a/op�' ►•lY 3 z9 Located at (Street) P u, tow_ izc_.,�, Sec: 't Bloch i Lot iq (indicate nearest cross street) ' G o-T e.:i'° i 1' . Murnicipality F3--r�o..l 5 2. O I 3' 3 1 9 y. -Watershed. ZA 5. 501m, PII cOO CN TjEST D ,RDQ(JIRFID TO BE SUEKE= WITA APPLICATZCNS Z2 Date of Pre -Sc aki.ng . Zv •'8g _5 Date of Percolation Test .4 • z I -'a6 2 9 51-It Zl ajp ZZ `�S' 3 i SOLE 1. 3il:z - i z =s 40 NU Q�QCK TIME' 3 PFRCO A.TICJN PF LATIGN .. Run Elapse Depth to Water From Water Level No. "Time Ground Surface In Inches Soil Rate Start-Stop Min.. 'Start Strip .' Drop In Min/In Drop Inches Inches inches • Z 9 3�1- 11 v i �`I Z I 2� 3 z9 3i 1 0l 24 3 3D 5 2. O I 3' 3 1 9 y. 1 ZA 5. 3p• 1 a 50 - 9 • -=,-t 8i Z2 25 _5 Z9 2 9 51-It Zl ajp ZZ `�S' 3 i 3n 3il:z - i z =s 40 25 3 3v . NOTFS: l.• Tests to be repeated' at same depth until .approximately equal soil rates are'obtained at each percolation test hole. All data to'be•submitted for review. TES'r PIT DATA REWIRED TO BE SUBMITTED WITS APPLICATION DESCRIPTION OF SOILS ENpOUNIEPZD IN TEST .F3C,TM DEPIU HOLE -NO. I ,HOLE M. r HOLE NO. G. L. .•. 1. 3 4' Losr -i 5' 6' I � 9' ' 10' 12'' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS FN00UNTERED I.l or lE INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOX NTERED DEEP' HOLE OBSERVATIONS MADE BY: DESIGN Soil Rate Used z i - 3v MirV^1 " Drop; S.D.. Usable Area -Provided �000 No. of Bedrooms -q Septic Tank .Capacity ;zso gals. Type r��oa Absorption Area Provided By o L. F. x 24" width trench �� gat. Ev^ Other uT10 r.i Name ,J ,�. c Signatdre Address Zoo-m- 2 r SEAL :1 THIS SPACE FOR USE BY*' HEALTH •DEPARMHENT QNLY: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of f>rj04e5 /T-r 455OC�G9T�S Located at Section Block 1 Lot �9 Subdivision of Subdv. Lot # Filed Map # Gentlemen: Date This letter is to ,authorize �G95 /� //u /��Sn� / <lT�'S'� /2. a duly.licensed professional engineer or or architect 1 • (Indioat0 , • • . to apply for a Construction Permit for a separate sewage system, to serve the-above noted property in accordance.with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary•papers on my behalf in connection with this matter and to supervise the-'construction-of said. system or systems in conformity with the provisions of Article 145 or '147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned P.E. , R.A. , # s Address C'j lq> S-2-S-8009 Telephone Very truly yours, Signed �•��ry -c ir.,.c -a.u�� �5. .Owner of Property Address T17 0 ,e"6u00 Town Y 7 l ;�5,30 K .Telephone Putnam County, Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPOR\TE agNER APPLICATION FOR PERTIIT APPLICATION SUBMITTED TO PUTNAM COUNTY HDILTII DEPARTMENT TO:.Commissioner of Health - In the matter of application for I — ...�''►Nle� -^(�7 - - — � - - — — — — — - - -- — — — - represent that I am an officer or employee of the-corporation and am authorized to act for _ — 1�8 v� c5! i-C 55br14T"S,�i�r, _ (name of corporation) — — — — — — -' having offices at Whose officers are President — ��ln! /e . 4p —, CA4if c� _%0 �oc.e�iv cv�o�— 1�ie��'_µ_��-c'1c7c� — TName and Address) _ -' Va— -- @—i:'ent 11v7�0A/.. `% _reuelC-t - �3&lq(5 -elfv� C�;a��[ 2ye 6."Coo� <ti��y! (Nay to and A'd'dress) — — Secretary — (Name and Address)— — — — — — Treasurer _ _ — - - - — — (Name and Address) — — — — — — and that I•.am and will be individually responsible for any or all acts of 'the corporation with respect to the approval requested and all sequent acts relating thereto. Sworn'. to 4efore me this `day, Signed of i 19� Title Notai�v/Pdbllc ` KELLY H. WILSON NOTARY PUBLLIC. NEW YORK STATE N. QUALIFIED COMMISS COMMISSION EXPIRES 121JU Corporate Seal y$ �f Io213ovsFz - 'yv '.2 a T 'A -3 �rl T~N _ i 7 4 . 5 q S C p{ f 3! 5 t S Ls was fiver, �.. r c REVISIONS N0. DATE J 1 e e DESCRIPTION PLANNERS ;; �., r:� i'. _ C�N�_ T � .{ `F' SH'M"j {y �vi� �. '.`� -y J.,:::.. �: '�:::<:, =;z; ij ,,.' r