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'` PUTNAM COUNTY DEPARTMENT OF HEALTH
Rev. 3186 Dlvieloo of Envlronmental:Health Serviceai, Carmel, N.Y 10512
Engineer Mnet Provide
`(,�L1 �;,. _ • P.0 D •Permit N � � _
TIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
y y e
Located _
at /v ®/� / . l/i �N. /� T" Map Block Lot
c
Owner /applicant Name iYl'1i�lE ' Formeely Subdivision Name Su.bdv..lot N A.
1,Q ✓i
MaWrig Address � ROW fig* Z11-D Date Permit Issued
7VWAeWZ 42 lei
Separate Sewerage System built by' i' /l���'� a Address �� BOx /X, 1% //�c��j `�
Consisting of ;I �JG Gallon Septic Tank and s !��WA0� `�V 0
Water Supply: Public Supply From Address
or :Private Supply Drilled by Address
Building hype l //C% Has Erosion Control Been CompletedY YG
Number of Bedrooms Has Garbage Grinder Been installed?
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 requlati a in accordance: with th filed cal n, and the permit issued by the
Putnam County Depa tm t Of Health G�
Date �o�/ - Certified by / �� �/� /� P.E. R.A.
Address /`dam; l � 0 lC� IV IQ�'G l.lunse No. 19 v
,Any person occupying premises served by the above system(s) shall promptly take Such action as may be necessary to secure the corrodlon of any unsanitary
,conditions resulting from such 'usage. Approval of the separate arage system shall become null and void as soon at a publro sanitary awe►. becomes
available and the approval of the .private water supply shall.betome u11 and void when a public water supply becomes available. Such approvatt are
Subject to modifi lion or .change when, . in, the judgment of the ommis nor of Ith, such revocation, - modification or change IsIIs�n�ec�esssarr�y.
Date �� ��� By Title`-' ' " -
`Q 2& 1.
�� -ry
a, *
�c
W Y�
WALL lVP1rLA11Vly itLrVitl
DEPARTMENT OF HEALTH
Division Of Envirdnmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREE ADURESS: /Vf 1 I Y TAx GRID NUMBER:
WELL OWNER
NY': // ADDRESS:
'11 l 'i/tk i
PUBLIC
O PUBS
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION [JADDITIONAL SUPPLY
'MEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL A 11
DEPTH DATA
WELL DEPTH r_9015�'_ ft.
STATIC WATER LEVEL af_� ft.
DATE MEASURED
DRILLING
EQUIPMENT
O ROTARY LS COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING '9..QPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH _ ft.
MATERIALS: STEEL ❑ PLASTIC O OTHER
`
LENGTH BELOW GRADE ft.
JOINTS: O WELDED THREADED ❑ OTHER
DIAMETER � in.
SEAL: O CEMENT GROUT 0 BENTONITE 150THER
WEIGHT
PER FOOT P7 Ib. /ft.
I DRIVE SHOE"S4ES ONO
I LINER: ❑ YES ONO
SCREEN
DIAMETER (in)
-SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
DETAILS
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK In.
TOP
DEPTH tt
BOTTOM
DEPTH It.
WELL YIELD TEST (If detailed pumping
METHOD: O PUMPED i tests were done is in-
COMPRESSED AIR r formation attached?
O BAILED ❑ OTHER ; 0 YES O NO
1f�lELL LAG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROr`+
SURFACE
water
Bear-
ing
Welt
Oia_
Imefer
FORMATION DESCRIPTION
CODE
it
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAYIDOWN
It.
YIELD
gpm.
Surface
WATER IWLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? &YES O NO
ANALYSIS ATTACHED ?YES O NO
STORAGE TANK : TYPE
CAPACITY \,01 � 1 GAL.
PUMP IMF MATION 1
TYPE u i 5 � ` CAPACITY
MAKER ! elp_a DEPTH
MODEL 3 VOLTAGI� H
WELL DRILLER NAME OA
a oRES�"-i u rS� sIGUMA E a8 v
A
3/ LSy
z��
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245 -2800
Director: Albert H. Padovani M. T. (ASCP)
r
TORLISH & SONS
PO Box 271
Armonk, NY 10504 -0271
L -j
LAB # _ -.:. i �c r• =::�: i ;7
Date taken: y dYo- 90 Time: .k,'.0 #9'f
Date Rc'd: Time: ,'a5- X"
Date Reported:
Collected By: D. Tor ish
PO /Client #
Referred By:
Sa pling Site : d /V.
i 11Q,v, Go / 3 -
D
-Phone ( 914) 273 -3448
REPORT ON THE QUALITY OF WATER
INORGANICS mg L) MICROBIOLOGICAL (.p '100mL
—.Alkalinity
_
Chloride
Copper
— Detergents, MBAS
_ Hardness, Calcium
— Hardness, Total
Iron
— Lead
— Manganese
— Mercury
_ Nitrogen, Ammonia
— Nitrogen, Nitrate
_ Nitrogen, Nitrite
_ Phosphate, Total
_ Silver
_ Sodium
_ Sulfate
_ Sulfide
_ Sulfite
Zinc
PHYSICAL MISCELLANEOUS
— PH (S.U.)
_ Color (Units)
_ Conductance (uhms /c)
Odor (TON)
Turbidity (NTU)
_ Standard Plate Count
(CFU /1 mL)
Membrane Filtration Method
Total Coliform
Fecal Coliform
_ Fecal Streptococcus-
Most Probable Number Method
— Total Coliform
Fecal Coliform
Fecal Streptococcus
Presence /Ahsense, (PA)
Total Coliform P A
KEY FOR TERMINOLOGY
CFU = Colony Forming Units
IT =
%�' =
Less Than
GT =
> =
Greater Than
NA =
Not
Applicable
SA =
See
Attached
TNTC
= Too
Numerous To Count-
REMARKS/COMMENTS For ab Use
(For Lab Use)
SAMPLE TYPE:
(Check One)
Potable
_ Non- potable
OUTGOING:
(Check Each)
HNO
—_ HC13
— H2SO4
_ NaOH
ZnOAc
Na2S203
Other:
INCOMING:
7 (Ch ck Each)
_ LE 40C
_ GT 4, /LE 20 o
_ GT 200C
PHLE2
_ pH GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS (WAS NOT) (NA) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THE'NEW YORK STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED; AT THE TIME OF SAMPLE COLLECTION.
THESE RESULTS INDICATE THAT `THE WATER SAMPLE (DID) (DID NOT) (NA) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STATE PUBLIC DRINK-
ING WATER CODES, FO11 _ THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
/x/ �d�'lfkl�� l C�lt�� �� %�j �?' 7 /87(Rvsdl /90)RWE
A Bert H. Padovani', A , Diredtor
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16r -1 SC-8 Tr=L I.�- -r �S
uwner or rurcnaser oi- buiiaing
Building Constructed by
Location - Stree
.Building Type
Municipality
ty
Section
I
Block
37 E-0 7
t
GUARANTY OF SEPARATE SEWAGE SYSTE14
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 guaranty to the owner, his succes-
sors, 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 de-
termination of the Director of the Division of Ea vironmental Health Ser-
vices of the Putnam County Department of Health a.s to whether or not the
failure of the system to operate was caused.by the willful or negligent
act of the occupant of the building utilizing the system.
Dated this day of _R, 1980 Signature
Title /6-1
(If corporation, give name
and address)
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEtf.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health Services, Putnam County Department of Heal
PDTNAm COUNTY DEPARTmm OF HEALTH
NT
o Division of Environmental Health Services. Carmel. N.Y. 10512
weer to ProvMe'Peemlt N
do CERTIFICATE 0
F
' PermN
CONSTRUCTION PER1Yli! FOR SEWAGE, DISPOSAL SYSTEM
\V yyam�.
Located at M&.06 pt f v. jo, M00givy Nlw er.. Town or VUlage
Sabdlvlefon Nome E_A,% R PEW MAlaoe Subd. Lot N 1 - Tai Mop 1 Block 1 Lot . 1C -
Renewal_ O Revision ❑
Owner /Applkwnt Name - aol _tc Si-es R�ssoe+,acres
Date of Previous Approval
Maging Address ZIP 10594
n
Building 'Type tGt$SlnraJC.6 Lot Area 147.y 3l 1 S. V. FID Section Only
Depth -Volume
r.# , Number of 'Bedrooms Q Design Flow G P D 800 PCHD NotMeadon Is Required When Fulls .completed
Separate Sewerage SYetem to consist of 12.60 on Septic Task anal 500 I.. �. Assofef'rio►1 --rogAwJ 4
To be constructed by Bff `DWTM r uwlt Address
Rev.
1/87
Water SuPP1Y: Pdbllc Supply From Address '
on ��C Private Supply Drilled by ro Sts wear. address
sue. ta.....tp......�.
I represent that I am wholly anq completely responsible -tor the design and location of the proposed system(s); .1) that the separate sewage disposal system
1. above described will-be :constructed`as: shown on the approved amendment there to and in accordance with the standards, rules an, regu a Ions -o e u nam
County .Department of.- Health, and that „on completion thereota "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 thedats of the issu-
ance of the approval; of ..the Certificate of Construction .Compliance of the original system or any repairs theist ; 2) that tha'drilled well described above
Will be loutett'as shoavn:on the aDD►overl, plan and that said id well will be installed in a eordanee with stsridar Ylef and regu a lonr of the Putnam
County. Department of Health. -
Date Signed p.c V1 R.A. _
Address ��°^ -��I� Hsst�l4s"T8'� -7- ®�s'n1Y 10512. License No Z"-000
APPROVED. FOR CONSTRUCTION: This approval expires two. years / m the date issu d unless construction of the building has, been undertaken and is
revocable for cause or .may be amended or modified when considered eSSary y the. ommissioner of'Health. Any change or alteration of construction
requires a neel permit: "Approved fo disposal of domestic sanitar s wa and/ o at r
Date `J �� BY _ Title
Putnam County Department of health
Division of Environmental Sanitation
AFFIDAVIT - CORPOItI.TE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HDILTH DEPARTMENT
TO:.Commissioner of Health - In the matter of application for
I, - - �frlNl2 /1 ^l! %� �C.� -► -C c�- .- - - - - - - - — - - represent
that I am an officer or employee of the corporation and am authorized
to act .for l. _ - ... _ _ _
(name of corporation) - - - -
having offices at - /O_ oclljv�al� l�ati{ j-21 N L G
Whose officers are
President - �r�1ivl� J �/ fZi�ic.tic c.� _%D ilocr" _PU!�o(_ l�ioId -
(Name and Address)
Uii � —sent ��v7�ONy `/ r<vrect - �3&i,46- etev�i ��H-c_2ye d:<oo�r
1
(Naiur and ' ress)
Secretary - - - - - - - - _ __
(Name and Address) - -- - - - - - -
- --
Treasurer _ _ _ _ _
- - - (Name and Address)
and that I;.am and will. be individually responsible for any or all ects
of the corporation with respect to the approval requested and all sub-
sequent acts relating thereto.
Sworn. to 4efor e me this day ' ' Signed
f
of i :/ 19 Title
No�ar�Publ'ic " -
KELLY H. WILSON
NOTARY POBLLIC, NEW YORK STATE
N. QUALIFIED
COMMI
COMMISSION RESS7121JU
Corporate Seal
ae
------------
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. '10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL 44
PCHD PERMIT #
WELL LOCATION
Street Address
M o2 )j t"toonjP_y tAI u. 1zU.
Town/Village/City Tax Grid Number
A,"- rMR*.orj 1- I- L9
WELL OWNER
Name x Mailing
S�' s50Cf.dTS
Address
P o. ay. las -7 JY
Wrivate
O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL ❑PUBLIC SUPPLY QAIR /COND /HEAT PUMP
O BUSINESS O FARM 0 TEST /OBSERVATION
0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY
0ABANDONED
❑ OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT "jd 5 gpm /#
PEOPLE SERVED M /EST. OF DAILY USAGE gbo gal
REASON FOR
DRILLING
KNEW SUPPLY
OREPLACE EXISTING SUPPLY
❑PROVIDE ADDITIONAL SUPPLY
ODEEPEN EXISTING WELL
[3TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
E]DUG
[]GRAVEL
OTHER
.IS WELL SITE SUBJECT TO FLOODING? YES 1<_NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
P
� i2JIts%d M,a.loe Lot No. t%
WATER WELL CONTRACTOR:
Name '%„
Address:
IS PUBLIC WATER SUPPLY
AVAILABLE
TO SITE:
YES NO
NAME OF PUBLIC WATER SUPPLY: dlg TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON REAR OF THIS APPLICATION In ..
X00 A 6
(date)
PERMIT;`\.
TO CONSTRUCT A WATER
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 there . ments of the Putnam
County Health Department attached to this pe it.
3. Submit a W 11 Completion Report on a form pr vided y t Putna un
Health De rtment.
Date of Issue: 19
Date of Expiration: 1 e mit Issuing Official,'
Permit is Non - Transfer able White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
APPIRN U B
PLMr! CCL'NI" -' DEP- RIlA= OF E F -ALZ:i - DIVISICN OF 24V RCNM_EN ar. HEALM S,2ZVIC`'S
=r_=LrAL WATER SJPPrZ & SUBSr -MFACr S-EUA_ DISFC.. U SYSTEMS
( Tne of Cvne_r )
RE'JIETni S= - CGNSl=ICN P_r gM_IT
S tr eet
DATE R 7-1- 'v
BY:
Lcc ticn)
DCCCu'`�F'VTS t
Permu.t Application
Corporate Resolution
Plans - Thrzz s`+-s
Encin -rs P_ut'=orizaticn
Des_ n Dates Sheet- (JCS)
Deem Foie Lac
Cons? s t =Z t Pero Res;i t. (3 )
P_rc able Dept-
SurD TV TsICICI
c
House Plans - `iivo se__
Well �e_mlut;
variance Rea:es t
L= al Sai:�visicn
Suomi °vision Accrovcl C_e =kzd
E-_ _•rcva_ SSCS A--:-:. Lct.
We =' a_nd (T(----,-/DEC P =_ = R & D)
cat-. Gn DCS plans & °e_r_«i `_ Sa._
REr,'U= -= DES' TT C CN Fr,]`S
&Fwage Svs Elm Pian
S�.�ace Syst`n nvdY_tLic P=or_l= - _ - - F =.
Fill Profile & Dimarsicnis -
D or J Ecx;T= =nGh/Gallery• P'= pi= de`iic
S -2 =c Tank - Size, Dr*_: -
We_'
Well Detail, SerJica Li::c if cva_
Cans :zuc-'=icn Notes (cr:nder rte)
Ces'_cn Data: perc and ce_p
T r2s:s
wo-Fa t Contours Exist-g & P=E-Csed
Drivevav & Slopes Cat
Fcotin /Gattar,C=t in Drains (discza-rge CK)
Pero & Deep Holes tzc= te✓
Repre_scntat_ve or pr rv=y a_ra e_Y_ ensicri
fisp..ansicn As =s; shcwa; gravity f- C'W'saf- ..size
I` Pmped Pit & D Box Shcw-n & De rmi led
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. Of Proposed Sysc;
Proper-ty Metes & Bounds
House Setback. Necessary (Tight lot)
House Serve= — 1 /4" /ft. 4"0; J`1`_�Te pi e
No Bends; Max. Eends 45° w /clearcut
Sr.P =RATICN DISTAti�S SP EC?FT= CN PLAN
Fields
10' to P.L. , Dr_ve'.vav, Large T_ sjoo Of f
20' to Fbunr�=ticn Walls
100' to Well; 200' in D.L.0.0, 150' pi`s
100' to Stream, Watercourse, L_ka (inc. et_-
15' to L&=_ceY, Fcoting
35'to cm-tcZ hasin,storrirain, of wate-rccu
10' to ttiat_r Line (pits -20')
50' inte- nitLent dr' i r_Qe course
Sentic T-nkc
10' from Foundrt_icn; 50' to well
15' Well to PL
c
WIMM COUNTY . DEPAFM . C1F HMTg
DIVISION OF ENVIRCWENIAL
Her n H bLEVIUZ
DESIGN DATA SHEEP- SUBSUFACE
SEWAGE'DLSP06AL SYSTEM• FILE W.
Owner' I -AQPAM S� �.s�ocacre^S
Address oft I8� - TJNO��.luloo�. IJY
To=ted at (Street) NLa.lo2
F
Sec: 'I Block _ Lot 19
(indicate
nearest
cross street) ' I o-r tit° 1'5'
Municipality "tea, -r�� so,/
Watershed �o,�,J .
'. SbiL PhRco =w TEST
DATA .gagui
2P9 To HS sung= WITH APPLICATIONS -
Date of Pie -Sq�g A. 21 ee
Date of Percolation Test -4' Zz • es
HOLE l'
NU-mm C= TIME
PERCOLATION PERMLATIW. ..
Run Elapse
Depth
to Water From Water Level
No. "Tithe
Ground Surface in Inches Soil Rate
Start Stop Min..
Start
Strip '' Drop In Min/In Drop
Inches
Inches Inches •
23 3 /0' '
2 9 o0 -gr33 s3
zo
2.5 3 J
3 9'a3 -lo:09 ��
20
Z3 3 IZ
9
23 3 - -- Iz
5 10'45- II:'Z1 $Cp'
21J
23 12
1>�45 -4'18 33
Z1
Zq 3' Ii_ •
2
3 q: 6,4- lo•3o ace,
21
Zvi 3 -- Iz
4 1o•so- 11oto 3[�•
Z I
- -- 2�1 3 I Z
5
2
A
5
tJOTF�,S: 1. Tests to be repeated at same
depth until. •apprm mately equal soil rates ,
are ' obtained at each percolation test hale. All data to* be • sub nittOd
for review.
TEST PIT aWA REQUIRED TO' BE SUBMrrM) W= APPLICATION
DESCRIPTION OF SOILS EX)DUNTE= IN TEST
.H=S
DEPM HOLE -NO. I HOLE NO.:
HO NO.
G.L. ... ,.
.. ... ..
.. 1'
-r Aso � �
•
3'
4'
5,
_71
9• '
IMICA.TE LEVEL AT WHICH GROUNDWATM IS ENOOtJNMUD
2DDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENXLMERM
�,j IA-
DFEP' HOLE OBSERVATIONS MADE BY:
DATE s
DESIGN
Soil Rate Used Min/1" Drop; S.D.. Usable
Area Provided ,�000 o
Nc. of Bedrocns .4 Septic Tank .Capacityi tz5o gals. Type mk_Kl�
Ak-,orption Area Provided By 5o.o L.F. x 24" width trench
O-tier
CA - —
Nave �.SN,►�soc,A -r�s' c Signatiire
SEAL
Aabaress
ijy
r ✓o '���,5/�ii
7�t:.Sj.r,
alriSi SPACE FOR USE BY' - HEALTH •D3PAFaMENT ONLY:
=� 'toll 68
•od w.
N � � 7�.Zi3 . Ste° 29,- :O
14.62'
52 =cry -34� HL as-r.go'
r
cb -.ga'6
�i .►N2 "OD- E 91.9®' 5s),00'
,t 7
R
5. �.
�..i.S.
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<,•..
Z
AD
Id
o -3s zl' -iS°
• s � °- '� Mil
Z
�g iy''�ilh� �2('•`1la' o- 6o- 6S'-14".
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r.
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