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WLLL 1,V1"1ri1n11UN rkzrval
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
STREET AoURESS: WNIVI T I Y TAx GRID NUMBER:
/Vo. ,�, ✓r�
WELL LOCATION
WELL OWNER
NA : ADDRESS:
,C_ /' v r4,,,� t� 1105,
PRIVATE
PUBLIC
USE OF WELL
1 - primary
2 - secondary
`&RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/ OND. /HEAT PUMP ❑ A NOONED
O 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
`p NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH � ft.
STATIC WATER LEVEL 'e'." ftj
DATE MEASURED I
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT O CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED • ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH tL
MATERIALS: '%STEEL O PLASTIC ❑ OTHER
CASING
DETAILS
LENGTH.BELOW GRADE ft.
JOINTS_ ❑ WELDED .THREADED O OTHER
DIAMETER 16 in.
SEAL: O CEMENT GROUT ❑ BENTONITE`9OTHER
WEIGHT PER FOOT lb./ft.
DRIVE SHOE O YES _S NO LINER: O YES O NO
SCREEN
DETAILS .
DIAMETER (in)
SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (It)
DEVELOPED?
FIRST
0 YES ❑ NO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
OEM tt.
BOTTOM
DEPTH ft.
WELL YIELD TEST + It detailed pumping
METHOD: O PUMPED i tests were done is in-
SfikCOMPRESSED AIR , formation attached?
0 BAILED ❑ OTHER ; ❑ YES ❑ NO
It more detailed formation descriptions or sieve analyses
IPI�LL LOG are available, please attach.
DEPTH FROM.
SURFACE
Water
Bear.
ing
Well
Oia-
meter
FORMATION DESCRIPTION
COOE.
ft.
I ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
ft,
YIELD
gym.
Land
Surface
CmA
WATER 16L.CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ❑ NO
ANALYSIS ATTACHED? `DYES ❑ NO
STORAGE TANK: TYPE LW77ro �• , I
CAPACITY L ' J— 5 GAL. `F
PUMP IHF RMATION s,
TYPE a) � CAPACITY
MAKER t;' DEPTH
MODEL � YOLTAGtG_1H(' - �1L
WEL CHI EA�n ME
-Afi /fit /"1" J� 5► i1fTURE
Yorktown Medical Laboratory, Inc..
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245 -3203
Director: Albert H. Padovani M. T. (ASCP)
F
TORLISH WELL DRILLING
P0, Box 271
Armonk, NY
10504
L J
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC NON- METALS (mg /L)
Acidity
Alkalinity
Chloride
Detergents, MBAS
Hardness, Total
_ Nitrogen, Ammonia
Nitrogen, ,citrate
Phosphate, Total
_ Sulfate
_ Sulfide
Sulfite
METALS (mg /L)
Coone'r
Iron
_ _Lead
Manganese
Mercury
Sodium
Zinc
32. 014785
LAB j/
Date Taken.:" =,2;% Time:
Date Rc' d : �'�'p Time
Date Reported: � 1868
Collected By: Duane Toi•lish
Referred By:
Sample Location: '7/W'
A2
Phone # 273 -3448
Phone # — I Sample Type:
Repeat Test? (check one)
MICROBIOLOGICAL (CFU /100mL)
GENERAL BACTERIA
_ ✓Standard Plate Count_
(CFU /1.0mL)
MEMBRANE FILTRATION TECHNIQUE
✓ Total.Coliform L�
Fecal Coliform
Fecal Streptococcus
MOST PROBABLE, NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A = Not Applicable
MISCELLANEOUS LT = Less Than ( <)
GT = Greater Than (>)
pH (units) TNTC= Too Numerous To Count
Color (units) CON = Confluent ( =TNTC)
_ Odor (TON) NR = Non - reactive
Turbidity (NTU)
REMARKS /COMMENTS (For Lab Use)
Potable
_ icon - potable
_ STP INF
STP EFF
Other:
Sample Status:
(check each)
_Out Roinz
— HNO3
_ HC1
H2SO4
_ NaOH
_ ZnOAc
Na2S203
Other:
Incoming
t�LE
h °C
_ GT
4 °C
_ pH
LE 2
pH
GE 9
_ DH
GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER - SAMPLE WA5 (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTIQ•NOENKING THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
L�'ls /�-�
�x/ c �t�G��,_,2��' � � 2 /86(Rvsd7 /87.)RWE
Albert H. Padovani, M.T. (ASCP), Director
/ PUTNAM COUNTY DEPARTMENT OF HEALTH
5 I� )� Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to Provide Permit If
on CERTIFICATE OF CO LIAN
CONSTRUCTI011imlT, FOR SEWAGE DISPOSAL SYSTEM Permit #
PATTERSON �.
Located at Mooney Hill Road Town or Village
Subdivision Name Fairview Manor Subd. Lot N 18 Tax Map 1 Block 1 Lot 19
Owner /Applicant Name Amicucci Development Renewal_❑ Revision ❑
Date of Previous Approval
Melling Address 10 Rockhagen Road Town Thornwood, NY Z(p 10594
Building Type A Single family Lot Area 1.837 ac FW Section Only Depth - Volume
Number of Bedrooms 4 Design Flow G P D 800 PCHD Notification is Required When Fill is completed
Separate Sewerage System to consist of 1250 Gallon Septic Tank an, 44,-• LF of .24" trench
To be constructed by to be determined Address
Water Supply; PdbOc Supply From Address
or: X Private Supply Drilled by to be determine ddrees,
Other Requirements
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 a pproveda mend ment 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 accordance with the standards, rules and regu a ,Z'�I ono of the Putnam
County /irt�f Health. 'Vr`'
Date / � /y/ Signed _-t" 1t /A/i%_��✓ P.E. _ R.A.
T' D-II A —, Q f-"_-14_ _ P C R 22 D
APPROVED FOR C STRUC710N: Tnis approval expires two Years
revocable for cause O may be a e ed or modified when consitlered r
Rev.
requires a new �ppr ve f disposal of domestic sanitary
1/87 Date By
ev' 31 6
CERTIFIC
located at
Owner /applicant
MaWn Address
rewster License No
,e date ' ued un is construction of the building has been undertaken and is
ry by a Com s' r of H ny change or alteration of construction
age or pr;vat a s pl o ly
Title
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide
P.C.H.D. Permit k --
OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
��n y� p Town or Village Q
I Y1 w S s, 4� ' f / � I cL n c r t? xl .-_ J �/ 11 ac!aQ I u.1 �'D)aa Map C Block Lot I
�.e 1-4 o „z S , ?-e As Sn f . Formeriv Subdivision Name "sO r Subdv. Lot #
P. it , c3v , 2".S S-
os- +f Date Permit Issued
Separate Sewerage System built by 14e i't J z Address LEc 2C fU
Consisting of / Z 5—c> Gallon Septic Tank and r— L' � Z (`� S 6
Water Supply: Public Supply From Address
or: X Private Supply Drilled by 7 c , / r S dt Address r /'j t 0_1 di A/
Building Type S f n 2 e z 1`1 � � Has Erosion Control Been Completed?
� OF NE Y
Number of Bedrooms Has Garbage Grinder Been Inptadl�'d��tt''��yy° °]]e �.
`ti... \,a7Lu f GJ YC��1 EAR
Other Requirements /, -
I certify that the system(s) as listed serving the above premises were t:oo ,tavi5b d� gsaAht� �•ly'<% 'thown on t e plan &q ; fhe compl ted rk ( copies
of which are attached), and in accordance with the standards, rules and= zvegulations, in accord the;f1 ad .she pe it sued by the
Putnam County epartment of Health. ;^..•„( -” •,
Date Certified Dy` ~ry7 �° y P.E� R.A. -17V z
Address ;y J� J LhAn�e N
, w ,,7'
G_
Any person occupying premises served by the above system(s) shall promptly Aaka such att(tia'•�sihey �e`necesury ttf�sy(5urs tha.. tl any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shill' eedms null4nd void as soon iiu-js� �� ry sower becomes
available and the approval of the private water supply shall become null and vofd,,whenC$ pubi 4r,"ter supply beco`fnasi,,pva . Such approvals are
subject to modification or change when, in the judgment of the Commissioner oi'Miea revocation, m fiction or change Is necessary.
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
IS WELL SITE SUBJECT TO FLOODING? YES x NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Fairview Manor
Lot No. 18
WATER WELL CONTRACTOR: Name (to be determined) Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: Over 1,000'
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION x110 °SEP EET (see SSDS plan)
5/5/87
(date)
(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 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 p vid by t o Pu n o Ly_
Health Departm nt.
Date of Issue: 19 l I'M
I s l
Date of Expiration: 19 rmit s u i g f cia
White copy: H. D. File
Permit is Non - Transferrable
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
Street Address Town/Village/City Tax Grid Number
Mooney Hill Road Patterson 1 -1 -19
WELL OWNER
Name Mailing Address OPrivate
Amicucci Develop., 1(J Rockhagen Road, Thornwood,NY105&-Public
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
(3 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
® I.NDUSTRIAL 0 INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT 5+ gpm /# PEOPLE SERVED 4 -5 /EST. OF DAILY USAGE 800 gal
REASON FOR
'DRILLING
MNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
NEW RESIDENCE
WELL TYPE
xODRILLED
DRIVEN
ODUG
OGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES x NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Fairview Manor
Lot No. 18
WATER WELL CONTRACTOR: Name (to be determined) Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: Over 1,000'
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION x110 °SEP EET (see SSDS plan)
5/5/87
(date)
(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 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 p vid by t o Pu n o Ly_
Health Departm nt.
Date of Issue: 19 l I'M
I s l
Date of Expiration: 19 rmit s u i g f cia
White copy: H. D. File
Permit is Non - Transferrable
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
APPENDIX M
POTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
;n
AFFIDAVIT- CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO PUTN M COUNTY HEALTR,DEPARMM
5M
TO: Commissioner of Realth M
In the matter of application for:= r¢i�?d�,sif- I/fjt/��' Sv/S�, v�s� c✓
I, Aom l e" I I . -tm, cA4 Cel
represent that I am an officer or employee of the corporation and am authorized
to act for Qeve ton;
(Name of Corpora
etc"- CURc'I
having off ices at 10 (?o oei- m,6 env ;2 -. Th e ✓elu w ao a ltk t-7 /05771/
Whose officers are:
President: l'oexrmg eNAJ A O IZAJ; UZ70 mil, 11!
(Name and address)
Vice - President:
(Name and address)
Secretary: -
(Name and address
Treasurer:
1326o/e, k/-" tl
(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 subsequent acts
relating thereto.
Sworn to before me this /��' %day Signed: ,
of l9 (/, Title: S .
K, T71
BETTY L. ESPOSITO
Notary Public, State of New York
No. 4125303
Qualified in Putnam County
Commission Expiras April 30, 19.,
20
Fairview Manor tsLates
• TEST' PIT DATA IIEgUIRED 'I10 13—V SUP1 M!77ED 1dITH APPLICATION
DES- GIIII "1' T 011 OF' SOIL; E1000PTERM I11 TEST 11011',3
DE17I1 11012 IIO: 182 HOLE 110. 17?
sandy 1nam _]nam
,6u•
1211
loll
J
3!' 11 �
40211 3.5' to rock
413"
51111
6u 11
6611
7211
78"
U�1t1 7' to rock
110LP, I40. 192
I1IDICA'1'E I.I VEL AT 1.1111011 GROUND WATER IS ENCOUNTERED
IIIDICATE LEVEL TO W1iiC11 WATER LEVEL RISES AF!'ER BEING ENCOUNTERED
TESTS MWE DY Date
DESIUN
Soil Rate Used b1livi Drop: S. D. Usable Area Provided
11o. of Bedrooms . Septio Tank Capacity Gals. 'Type
Absorption Area rov dec By ' L.F.x2411 b width rreench.
Other
Tame Signature
Address SEAL
THIS SPACE FOR USE BY 11CAI.,'1'11 DEPAIi'1'ME -14T ONLY:
Soil flaLe Approved Sq. Ft /Cal. Checkod by Date
CF nE
Baldwin & Cornelius, P.C�>L Wyo 0wne,r �,�ip ''r.Vte Assoc., Inc.
RD 6 Route 22 `�P '.'�
l ��r•P 134, o Loca �on•�TF�1 ign�ry" =J1ill Rd. Patterson
.Brewster, NY 10509 L ,o C (1�-- F' cp;
�1L C-)=
fe
6.5'
to
GW
7' fn
rnr'k
•t
I1IDICA'1'E I.I VEL AT 1.1111011 GROUND WATER IS ENCOUNTERED
IIIDICATE LEVEL TO W1iiC11 WATER LEVEL RISES AF!'ER BEING ENCOUNTERED
TESTS MWE DY Date
DESIUN
Soil Rate Used b1livi Drop: S. D. Usable Area Provided
11o. of Bedrooms . Septio Tank Capacity Gals. 'Type
Absorption Area rov dec By ' L.F.x2411 b width rreench.
Other
Tame Signature
Address SEAL
THIS SPACE FOR USE BY 11CAI.,'1'11 DEPAIi'1'ME -14T ONLY:
Soil flaLe Approved Sq. Ft /Cal. Checkod by Date
CF nE
Baldwin & Cornelius, P.C�>L Wyo 0wne,r �,�ip ''r.Vte Assoc., Inc.
RD 6 Route 22 `�P '.'�
l ��r•P 134, o Loca �on•�TF�1 ign�ry" =J1ill Rd. Patterson
.Brewster, NY 10509 L ,o C (1�-- F' cp;
�1L C-)=
fe
6.5'
to
GW
7' fn
rnr'k
I1IDICA'1'E I.I VEL AT 1.1111011 GROUND WATER IS ENCOUNTERED
IIIDICATE LEVEL TO W1iiC11 WATER LEVEL RISES AF!'ER BEING ENCOUNTERED
TESTS MWE DY Date
DESIUN
Soil Rate Used b1livi Drop: S. D. Usable Area Provided
11o. of Bedrooms . Septio Tank Capacity Gals. 'Type
Absorption Area rov dec By ' L.F.x2411 b width rreench.
Other
Tame Signature
Address SEAL
THIS SPACE FOR USE BY 11CAI.,'1'11 DEPAIi'1'ME -14T ONLY:
Soil flaLe Approved Sq. Ft /Cal. Checkod by Date
CF nE
Baldwin & Cornelius, P.C�>L Wyo 0wne,r �,�ip ''r.Vte Assoc., Inc.
RD 6 Route 22 `�P '.'�
l ��r•P 134, o Loca �on•�TF�1 ign�ry" =J1ill Rd. Patterson
.Brewster, NY 10509 L ,o C (1�-- F' cp;
�1L C-)=
fe
1'i111'VleVJ 1•1dIIUI L"JI.aLCJ
PIT 11!1TA 1t1"QUIREI) '1'U L'► h:J.TH APPLIGATiUll
: lll✓��C11II "1'iU11 OF' SOIL:; IN TE."T HOLE","
DEPTH ROLE 140. 163 . J10iE, HO. 17 1 ' .
IIGL.r _, IdO. 181
G.L. sandy loam sandy loam sandy loam
1211
loll
21111
J
112"
u
51111
—4.51 to- rock
60 "
66"
72" 6' to rock
7811
131111 7' to rock
JUDICAT13, LEVEL AT 1111ICII GROUND WATER IS ENCOUNTERED
111UICATO, LEVEL TO WJLICII WA'T'ER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS I•lliDE BY Date
Soil Rate Used blitV1 "Drop: S. D.. Usable Area Provided
11o. of Bedrooms Septic Taiik Capacity Gals. Type
Absorption Ai.•ea—Trov dec By L.F.x24'l b"— width e :c :I
Other
]tame Sigtiature
Address
'11113 SPACE FOR USE LAY Jll?A.L'1'J1 DEPARTMENT ONLY:
Soil Bate Approved Sq. Ft /Cal.
Baldwin & Corneli use,
RD 6 Route 22
Brewster, NY 10509
SEAL
Checkod by
P . C %Ir�E c� n,E ty ro,Q
0+ �_o
,IJ
Wte
C, O IJ A/
OwnQ,f•1 �.- Home_4'a,e Assoc. , Inc.
at egri: �"Mooriey-.` ll Rd. Patterson
m - 1
•...n •.un•• •./4J.I. J.vuv
VUU1111 U1110 11U1LU111U, UAIU,ILL;. Il. Y. 1U512
JAUIVII LILF111U1S •V1U1'0SnL WHIBI•I 11111A flu.
Uurroi` _ naateaa
LUCUIala ul;-
(Utivut
of
Ueu. — bitiuk — Lut:
jliiill�uGt�`Iie &iiini:
ulwaa nE1:56V)
CD
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IIE'aU11tLU '1'u UL t3UllII1Y'1' ' 111111 nl
ILIt,'n'I'1yIIJ
FARIVIEW MANOR
Iluml�� „•
t,'LvUI; '1'1tll;
I'L4IUULA'1'IUII
ItilyUTATIUll
Ilut
'I'_lniv
11'run, U1,vwia• tlurfaue
l.0 1-, 1:Irea
Uv11 hobo
IJLul'I;
-Ul;vp
Iall.
Ubtirt; LAV 1
Ut't111 i11
Ittll. /Ill dt'ull
Illollua Liu1len
Lr�lrea
18A 1 139
- 200
.•21
21 24
3
7
2 202
- 223
21
2'1 24
3
7
232
- 2.5 3 .
21
2.1 2 4 '. '
3'
7
18B I .139
- 201
22
2.1 24`
3
7.3
2 204
- 226
221
24
3
7.3
} 227
- 249
22
21 24'
3
7.3
I
I •
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Hutt! r I j 'fmit” t;l, Im >t• p rated at- (11 um tleli'li uu1;11 nt� 11 11
it Lo ttt'U vUbu�.uoa u1: euuli ilei•vV1pb:�uu I;eu� livle. A au�u I;v l,v uu�lml�,�e�
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' . Wpl;-h wouuuremeuLn to he made 11-via top v1' hule.
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• APPENDIX B
PUTNAM COUNTY DEPAFa]MENr OF HEALTH - DIVISION OF ENVIRONMENMAL HEALTH SERVICES
INDIVIDUAL Vv21TEI2 SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
n7vi EW SHEET - CONSTRUCTION PERMIT
(Name of Owner)
� v �
DATE
BY :
(Street Location) C/.
DOCUMENTS t (j
Permit Application
Corporate Resolution __
Plans - Three set��
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
s/s
Consistent Perc Results (3)
Perc Hole Depth
SUBDIVISION
Perc
Fill
cd ---
House P ans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Etc- 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 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 Pumped Pit & D Box Shown & Detailed
House - No. of Bedroans
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
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
351to 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
I
- --
Owner or Purchaser of Building
ge5 /TP X75 "5ycit97-e5,_1N[
Building Constructed by
MPIN'61� 124.
Location - Street
AJ7Tt250A_,/
Municipality
Building Type
Section
Block
Lot r
Subdivision Name
Subdv. Lot #f,
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 willftA'-)oegligent act
of the occupant of the building utilizing the syste / �
Dated this day of 19 Signature
Title
t
n
HEKLA CONSTRUCTION INC.
Excavation • Trucking • Equipment Hauling
• Septic Systems Specialist
Top Soil • Fill • Gravel • Black Top
Bucksholiow Rd. RFD 9 Box 474
Mahopac, New York 10541 (914) 628.5738
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES 0,
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
NO. 1 DATE
JOSEPH MERRITT & CO
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HIM
.A -D
61'
B -D
44'
A=E::
126'
B -E
S3'' ..
C_f
77'
B -F
59'
C -G
83'
B -G
64'
C -H
89'
B -H
69.5'
C -I
95'
B -I
74.5'
A -K
138'
B -K
97'
A -J
115.5'
B -J
73'
C -L
92:5'
B -L
84.5'
'-"C -M
113'
B -M
101'
W
57'
W -K
142'
=D
.W -J
112'
C -E
71'
REVISIONS
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4pplicabloMi:nles ;anti Re, - ulations of the
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