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CERTIFI TE OF; CONSTRUC
Owner /appllcant'Name , 2-t
"M�g Address ° : f� � • g
Separate SewerageySyetem built by_
`ConeistinB of
Water,Supply Pabli
• or. �C
Balding. Type 5:l = ;�(G.-
Number of Bedrooms
Otber Regatrements
�Y certify'"that the syetem(s) as iii
..of Nhich are attached) •and in acc<
:Putnam Co' y pa rat Of Healtht
;pate -
Date
C D Permit H� 1 v u tt j
T
AL SYSTEM
F pTownaor Vill
w age
Tai 1VIap
. - Sabdiyislon Name �' � r" �Q"o � � Sabdv :Lo[ k-
9 ` Date Permit Iaeaed
.�w
-
Aaa�eas %�.r ►+top .:K " �► y _
ompletedY ..
ucted:essenEiQly . as sh on ���lans oi` ompl ed work ( copies
rations in ace Nth a file and_.t pe. 4it i ued by the
a
��'IV Y04
WELL UUr'1rLt tUA B -LrUAI
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM. COUNTY DEPARTMENT OF HEALTH
Office Use Only'
w'
WELL LOCATION
STREET ADDRESS:
Y2 Ka
T"NIVILLAMICIM, TAX GRID NUMBa-
&0, Tj
WELL OWNER
ME ,
ADDRESS:
'7" >�'1 I .'y`Sf)N N
PBIVATE
O PUBLIC
USE OF .WELL
1.- primary
2'- secondary.
`SkRESIDENTIAL O PUBLIC SUPPLY ❑AIR CnNO. /HEAT PUMP O A ANDONED
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (spei:ify)
O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
A.MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED % EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
)!�,NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL.,
DEPTH DATA
WELL DEPTH
ft.
STATIC WATER LEVEL Ste. ft.
DATE MEASURED
DRILLING
EQUIPMENT
O ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
0 WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑.SCREENED O OPEN END CASING. OPEN HOLE IN BEDROCK O OTHER.
CASING
DETAILS
TOTAL LENGTH
_ tL
MATERIALS: %WTEEL O PLASTIC ❑ OTHER
LENGTH.BELOW GRADE
� ft.
JOINTS: O WELDED "9 THREADED ❑OTHER
DIAMETER
in.
SEAL: O CEMENT GROUT O BENTONITE *Q OTHER.
WEIGHT PER FOOT
1b./ft.
DRIVE SHOE OYES '6�N0 LINER: O YES ONO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (11)
DEVELOPED?
FIRST
O YES ONO .
HOURS
SECOND
GRAVEL PACK"
° YES
O NO
GRAVEL
SIZE
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
OEM It. .
WELL YIELD TEST If detailed pumping
P P 9
METHOD: O PUMPED i tests were done is in-
COMPRESSED AIR formation attached?
❑ BAILED ❑ OTHER i ❑ YES Q NO
It more detailed formation descriptions or sieve analyses
'WELL. LOG are available, please attach.
DEPTH FROM
I SURFACE
Water
Bear-
ing
well
Dia-
meter
FORMATION DESCRIPTION
CODE.
ft.
{t
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
9Cm.
Lure
surface
air 10 14
T4
WATER '*I9.CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? O YES ONO
ANALYSIS ATTACHED? YES ONO
STORAGE TANK: TYPEbW47-?bLs
CAP ACITIAj1% 'e�;id.'3�ib1., GAL.
PUMP HF RMATION
TYPE I C-� ➢ CAPACITY
MAKER I(Yl0`Rk`I DE,PTTHH•,
MODEL %� VOLTAGP —�—
WE fill. ER N E 0 TE
t. _. ,, 8
A0Q #i �_ Z"�') IGt RE
P- - -��
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.
105o4
1
t 32.014784 (. ;+..
LAB N I k:
Date Taken: F r/Time: 9#
Date.Re'd: Time: 9.1 /may
Date Reported: JUN. U1 ;pgs
Collected By: Dwane Torlish
Referred By:
Sample Location:
7�L--V,
Phone # 273-34418
Phone # Sample Tvue:
L J Repeat. Test? (check one)
LABORATORY REPORT ON THE QUALITY OF.WATER ,/ Potable
_ iton- potable
INORGANIC NON - METALS (mg /L). MICROBIOLOGICAL (CFU /100mL) _ STP INF
_ STP EFF
Acidity GENERAL BACTERIA _ Other:
Alkalinity
Chloride v- Standard Plate Count
Detergents MBAS
_ Hardness, Total
_.Nitrogen, Ammonia
Ni.trogen, Nitrate
_ P dspha'te, Total
_ Sulfate
_ Sulfide
Sulfite
'METALS (me /L)
Cooper
Iron
Lead
Manganese
Mercury.
Sodium
Z,
inc
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
_.V_�Total Coliform
Fecal Coliform
Fecal Streptococcus
;MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A = Not Applicable
MISC_LLANEOUS. LT = Less Than ( <)
GT Greater Than ( >)
Sample Status:
(check each)
HNO 3 .
HC1
_ H2SO4
_ NaOH
_ ZnOAc
— Na2S2Q3
Other:
Incoming
,/LE
L °C
G
4 °C
_
�H
LE 2
_
- pH
GE 9
DH
GE 12
P;: (units). TNTC= Too Numerous-To Count _ Other:
Color (units.) CON .= Confluent ( =TNTC)
_ Odor (TON) NR = Non- reactive
_ T.u.rbidity (NTU)
-REMARKS /COMMENTS (For Lab Use)
THESE RESULTS INDICATE THAT THE WATER SAMPLE a (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING.T0 T YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF.COLLECTIO.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A) MEET THE.
SATISFACTORY CHEMICAL QUALITY STANDARDS OF.THE NEW YORK STA NKING WATER
CODES, FOR THE PARAMETERS TESTED, AT TH_E.TIME'.OF COLLECTION.
Lx/ I' f i %Ji -� 2 /86(Rvsd7 /87.)RWE
Albert H. Padovani, M.T. (ASCP), Director .
`�Lc.rFS /Tc' ��iS�C, volt° S .1 Pic
Owner or 45urc aser of Building
gCjITP
Building Constructed by
Location - Street
Municipality
Section
Block
Lot
Subdivision Name
`� /dJG- f Q �� /ti•t i /mil I /
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 s.uccess-
-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 X- )o egligent act
of the occupant of the building utilizing the syste /
Dated this - day of 19 Signature
Title
a
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
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
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1 PLAN
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1250 CANC-
S Sep -Cie, Nk
P I4
well-
5T.7L
P��y�ING 52
by llePars,egealth $elaL °sue
rO Q J c once Yb0
J1 r° �les f re tions
as Fns tment
vea '.
De-P
a tnez COUntY gealth � � G
0
NO. ' DATE
LOCATION CHAJZT
A =C
14.5
P -C
15,:0
A =D
60.0
B -D
42'.0
A -E
62.0
B -E
45..0
A -F
50.0.
B -F
50.0
A -G
70.0
B -G
56.0
A -H
74.5.
B -H
61.5
A -I
79.5
B -I
67.5
A -J
85.0
B -J
73.0
A- K.
42.0
-B -K
59.0
A -L
72.0
B -L
82 ..0
A -M
131.0
B -M
10,8.:.0
. A -�
115.0
B -N
8:9;.:0-
a -W
114. 0,
Q -W
t7; 4)
C0RNF�%
-�' SEAL
198 1
REVISIONS L,
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
'k : s 4
To Village City Tax Grid Number
s
WELL OWNER
Name ..
/
Mailing Address" f?p, .��C "� (Private
6' TNO F,K1a 0, OP ublic
USE OF WELL
1 - primary
2'- secondary
10- RESIDENTIAL
O BUSINESS
11 INDUSTRIAL
❑PUBLIC SUPPLY. 'Q AIR /COND /HEAT PUMP 17 ABANDONED
O FARM `O TEST /OBSERVATION O OTHER.(specify
U.INSTITUTIONAL D STAND -BY O
AMOUNT OF USE
YIELD _ 'SOUGHT �_gpm /�� PFOPLE SERVED /EST.. OF" DAILY USAGE *74V gal
REASON FOR
"DRILLING
NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
0REPLACE EXISTING SUPPLY. ❑DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE.
0DRILLED
DRIVEN
DUG a GRAVEL C1 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
4Ahe V 1fiW lWl*JOW Lot No. I
WATER WELL CONTRACTOR: Name Tp 4 _—)W1 1AJAQ 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
s v3
[]ON REAR OF THIS APPLICATION
/ �
(date)
PROVIDED
®ON SEPARATE SIMET
(signature)
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 Comp etion Report on a form prov ded y the Putnam County
Health Department
Date of Issue: 19 7
Date of Expiration: 19
/ ermit Issuing Official
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
6
Ir Anthony l" Amirurri
represent that i am an officer or mployee of the corporation and am authorized
to act for Fairview Manor Development o uRr Tnc _ —_
(Name of Corporation)
having offices at P.O. Box 285
Thornwood, New York 10594
Whose officers are:
President: Daniel A. Amicucci
x 185. Thornwood.•NY 10594
Vice - President: Anthony J. Amicucci, •P.O. Box 185, Thornwood. NY 10594
(Name and address)
Secretary:' I.
(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 me this �� day Signed:
Of �o ��•� 19 Title:2e -
BETTY L ESPOSITO
Notary Public, State of New York
No. 4526303
OualifieJ in Putnam County �{
COmmissiOr, Expires April 30, 19.;.
Corporate Seal
0
• • n �� Uwe DIDI;4,1 N fi M00 Mfff n :+ r: 1- - -MflKW7 go I M DIN •- •; M: 'tar tea.
t i• n u• r• v�• n• - � : n• ti . r• a � • •. • va
_�L ( - ; C
(Name of Owner)
DATE REVIEWED:
BY:
(Street Location)
DOC[IIENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc 3.c
(3) Fill
cd `�-
House P - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wet and (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
RBQUIRED DETAIL ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flora
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 notes)
Design Data: perc 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 Pimp 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 Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
Sr.MARATION 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. e-xpxn)
15' to Drains - Curtain, Leader, Footing
351to catch basin, stormdrain, piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' ram Foundation; 50' to well
15' Welt to PL
a