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1 -1 -18
BOX 1
f I '
�. h '
.A\\,
Located
6 PUTNAM COUNTY DEPARTMENT OF HEALTH
318.6
Division of Environmental Health Services, Carmel, N.Y. 10512
Engineer Must Provide 113 8
P.C.H.D. Permit N - -� —=
OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SY
M AN) a(; P, 0A
Owner /applicant Name f A I E V ! EW /N A1V 15 !� " fiery tea' �S r� % 55oG • -i �G
Mailing Address P O` f ox 2-'9 5 Zip I U T 9 4
740amwuc:v , NY -
Par-r�E�s��ir
Town or.Vtllage . , n
Tax Map Block Lot I
FanihvuR �
Subdivision Name �, / Sabdv. Lot N D
Date Permit Issued ! z-/ hp !S-7
Separate Sewerage System built by H r KL A Address M A Ito P r:G N
Consisting of ) S Gallon Septic Tank and SIN L F F r EC b S
Water Supply: Public Supply From Address
or: Private Supply Drilled by 7U (L i_ 15 H Address f! Q M e IV K f N y
Building Type S,,v 6 t l: F Am I L a Has Erosion Control Been.Completed?
Number of Bedrooms Has-Garbage G*der Been Installed?
Other Requirements 'y 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 standiiiid,.rules and regulations, in accordance with the filed plan, and the permit issued by the
Putnam County De/partjme� /}t of Health. F i
17 I P.E. `� R.A.
Date _ -r c r C'ertitled'by l - ? 2
AddresslQ'r�J eZD S, `(�eJ7r Z2- i3(LCwS fGt° N 7 �/ License No.
Any person occupying premises served by the above systems) 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 hull and void as soon as a pub+': 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 �modification or change when, in the judgment of the Commissioner Of Meal s, such revocation, modification or change Is necessary.
Q / / b By /"�'- �_ Title
Oats __��
�
-�
* , r
Wr,LL UL)rirLLtlUV BlzrVAi
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STAEET ADDRESS: WNIVIL 1 1 Y TAX GRID NUMBER:
M 1
i
WELL OWNER
N E: AGGRESS:
YI I
PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL O PUBLIC SO PLY ❑ AIR /COND. /H T PUMP ❑ ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT � gpm. /NO. PEOPLE SERVED / EST. OF GAILY USAGE gal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH '32-5' ft.
STATIC WATER LEVEL rift.
DATE MEASURED , f
DRILLING
EQUIPMENT
O ROTARY .COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH -3 ft.
MATERIALS: STEEL ❑ PLASTIC O OTHER
CASING
DETAILS
LENGTH.BELOW GRADE =-24) ft.
JOINTS: ❑ WELDED THREADED ' O OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT ❑ BENTONITE IS OTHER
WEIGHT
PER FOOT l lb./It.
I DRIVE SHOE O YES X5410
I LINER: O YES ❑ NO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (f t)
DEVELOPED?
DETAILS
FIRST
❑ YES ❑ NO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH it.
WELL YIELD TEST If detailed pumping
METHOD: D PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
D BAILED ❑ OTHER ' O YES ONO
If more detailed formation descriptions or sieve analyses
��/ELL LOG
lltf are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
Well
Dia-
meter
FORMATION OESCRIPTION
cone.
tt.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
9Cm
Land
Surface
da
305*�
&
WATE)l _-B.CLEAR TEMP.
QUALITY D CLOUDY HARDNESS
D COLORED ANALYZED? 'WES ❑ NO
ANALYSIS ATTACHED?--q YES D NO
STORAGE TANK: TYPE LL.,C °t 0L
CAPACITY UK U,'ll, fCYL1 GAL. 44
PUMP INFORMATION ., �
TYPE -SV9 WP rS J b 1f) CAPACITY —_
MAKER ��'� 1 � DEPTHS.
MODEL VOLTA6 Hi
WELL DRILL f N !E , 0;
U 11Sh 4-S0NS
�� RE ✓�
Yy 2
-116 Nk
'Yoiktow' n Medical Laboratory, Inc.
321 Kezr Street
Yorktown Heights, N. Y. 10598
(914) 245.3203
Director: Albert H. Padovani M. T. (ASCP)
F I
TORLISH WELL DRILLING
PO Box 271
Armonk, NY
10504
L J
RE ?OP.T ON THE QUALITY OF 'MATER
32-01521.4.
LAB #
Date Taken: 6 -G Time:
Date Rc'd: /, ( i{ j% Time:
Date Reported: JUN. 0 1908
Collected By: Duane Torlish
Referred By:
Sample Location:
cc[
!
Phone 1 273 -3h48
Phone I Sar..ple Tv-.e:
Repeat Test? _ I (check one)
I`iORG -'.3IC `i0'J- 5!ETALS (mR /L) MICROBIOLOGICAL (CFU /100ytL)
Ac,.city.
Alkalinity
C::loride ,.
De.-terge.nts, MBAS
Hardri -ess-; Total
:iitrogen, Ammonia
Nitrogen, :citrate
Phosphate, Tctal
_ Sulfate
_ Sulfide
Sulfite
MI
_ Co ^per
_
I r 0 n
_ Lead
Manganese
Mercury
_
Sodium
Zinc
.,!ISC :IT -A N EOUS
PH (units)
_ Color (units)
_Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA -
/Standard Plate Count
(CFU /1.OmL)
.1IE`QBRAiJE FILTRATION TECF.?JIAUE
Total Coliform
_ Fecal Coliform
Fecal Streptococcus
HOST PROBABLE 'NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
T
KEY FOR TERMINOLOGY
N/A = Not Aoolicable
LT = Less Than ( <)
GT = Greater Than (>)
TJJTC= Too numerous To Count
CON = Confluent ( =TNTC)
NR = :Jon- reactive
REMARKS /COMMENTS (For Lab Use)
_✓ Potable
_ :lor. -oo p vie
_ ST T'
STP ..FF
Other. .
Sample Status
(check: each)
_ HC1J
H 2SOL
_ NaO=
ZnOAc
`Ja2S203
Other:
Incomi. ^.e
LE LOC.
�_
GT L °C
_ DH L- 2
— pH JC 9
_ n G3 12
Other.
THESE RESULTS INDICATE THAT THE WATER SAMPL (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO E YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) N /A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA DR KING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
/x/ "�' l� % -;f� „ /C>>!�G,�!��t I� r 2 /86(Rvsd7 /87)RWE
Albert H. Padovani, M.T. (ASCP), Director
O) rig a - or `F'urcIia -ser of 1311 i I l i.ii };
13ui.1-ding Constructed by
rL, f
Location - Street
177eR'..Sj/ l
Municipality
Building Type
Sr.(' t. i <'>II
131ock
Lot /
Subdivision Name
2 C)
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 willf oP"' egligent act
of the occupant of the building utilizing the systerc�% `\
Dated this day of 19 Signature
t.
Title
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
II.
IV.
V.
vi.
l
8iy
7
i
a
FINAL SITE INSP=ION Date 6 a
_ InsFecte1 bJa —
'., AT. ;ON CSvTIER p
r 'IM e np Si7EDTVTSION LOI' n 5 1 I C/
��° p /°? 5/Gr/f
YE5
NO
S c NPG. DISPOSAL AREA
a. S-DS area located as r approved plans
b. Fill section - Date of placement
2:1 barrier_ LGTH WIDTH AVG.DPTH
c. Natural soil not strinued
d. Stane, brush, etc., greater than 15' from SDS area_
e. 100 ft_ fran water ccurse /wetlands_
SAC DISPOSAL SYST24
a. Septic tank size - 1,000 1,250
b. Septic tank installed level
c. 10' minimum frcm fcundation
Igo 90" bends, clearcut within 10 ft. of 45" bend
0cal u
e. DISTRIBUTION BOX
1. All outlets at same elevation - watei" tested
2. Protected belcw frost
3. Minimum 2 ft, oricin-al soil between box and trenches
f. JUNC 1ON BOX -- properly set
g. E--Ja =
1. Lencth retired - g j L-mcth ins taller Q K 3
I
2. Distance to water-ccursc measured ft.
3. Ins' —L1e - according to plan
4. Distance cents'" to cant-
5. Slc e of trench acceptable 1/16 - 1/32 " /foot.
I I
6. 10 feet from prcpe_''ty line - 20 feat - four_caticns
%. Dent. of tench < 30 LnChes frcm surface
ITy
S. Rcan allcwed for excansion, 50%
I
°. Size of cravel 3/4 - 1�" diameter
10. Death of gravel in trench 12" min;
Il. Ps.re ends crcea (
'
h. PUNT OR DOSE SYSTEM I
1. Size of pum cnGnicer
2. Overflcw tank
3. Ala=, vi saal /audio
4. Pump easily accessi e manhole to grade
5. First box baffled
6. Cvcle witne_ssz v H°. th Deparument I
I
estimated flF .- cycle
HC -SE
a _ Ecuse located per an-orovea plans..
b _ M-nber of bedroom
'
KEL
a_ Well located as per approved plans
b_ Distance from SDS area measured ft.
c- Casing 18" move grade. I
d_ Surface drainace around well acceptable.
OV- -,RA1L WORKMASHI.P
a_ Bcxes roperly grouter
✓
I
b- A> >> pirzs partially backfilled .
c- Ail piE�es flus.`i with inside of box
d- Ba6 -fill material contains stones < 4" in diameter
e- Curtain drain installed according to Plan
_ Certain drain cutfall protected & dir.to exist.watercour
g Fcotinq drains discharc'e away from SDS area
I
N Sp
_ Scrface water rotecticn adequate
4
E_=os.ion control provide~ on slores are?ter than 15 %.
��° p /°? 5/Gr/f
1 .�
���
r
�1
i�
i
j�.. PUTNAM COUNTY DEPARTMENT OF HEALTH f
Dlvislend Euvhunmentsl Health Servbes. Cliemel, N.Y. 10512 r to CO Permit AL
`\ on CERTIFICATE 0i :C0 LL�NCE `
CONSTRIICrON PnMlT FOR SEWAGE DISPOSAL SYSTEM Fermlt N = =
Located at MAhI Cdr— Town or vipage
Subdlvlalon Name rA1F- Jr=" MWJO — 'Salad. Lot N Z C> T= Map Biodc Lot 10)
Renewal-0 aRevwon ❑
Owner /AppReent Name �ESiTI✓ �S`�c�GADa'j1:5 , i1 .. '
p Date o[ Previous Approval
ress_
ManingAdd TownT429.. 1\Jco3 h� 7Jp.- 1V' --01 ! -
Building Type V 3 Lot Area . �' p'�" [FBI Secdon Only De P th volume
Number of Bedrooms Design Flow G P D O PCHD Notification Is Required When Flit is completed
Separate Sowerage SYstem to consist d I o Gallon Septic Tanit and ��� L :�, v` Zit.:, TiLE Fiei-M,
To be constmMed by �'` E -d Address M W OMic-
Water Supply: , . PubUc Supply From Address
or: _Private Supply Drilled by address
Other Reoulremente
I'represent that. 14m wholly and completely responsible for the design and location of the proposed systarn(s); 1) that the separate sewage . disposal system
above described will be constructed ai shown-on the approved:amendment there to and in accordance with the standards, rules and regulations of e u nam
county Department of .'Health, anti that On Completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Health will
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 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 wit the. standards, rules and regu ail ons of the Putnam
County Department of Health. _ 'w�,a
pate /,g_ Sign" NA.�►1� P.E. R.A.-
Address License No
APPROVED FOR CONSTRUCTION: This approval expires two years from the dal issu unless construction of the building has been undertaken and is
revocable for cause or may be amended or Modified when considered n ssary the � mmissioner of 1 . Any change or alteration of construction
requires 2new p rpiy ppr vetl }or disposal of domestic sanitary age rW /or a at su lRev. - (/ {((/' 1/87 Dat By Title _
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 0 P-11'-) � � I
WELL LOCATION
Street .Addre
s Town/Village/City Tax
Grid Number
WELL OWNER
Name
Mailing Address
m ING, 11.6zj%japo iv.,
BPrivate
13 Public
USE OF WELL
1 - primary
2 - secondary
.®'RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
11 FARM Q TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
❑ OTHER (specify
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE8ppC- gal
REASON FOR
DRILLING
0 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
D
DRIVEN
ODUG
®
GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES '1( NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
H�4r_iPiErw "Wc:,v-- Lot No.
WATER WELL CONTRACTOR: Name _-rc> 16 TL- i��^iFD 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:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION BON YEPARATE SIMET
dhgk-7 — !,=, L4p A- lad
(d te) (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 Completion Report on a form rovi ed b the Putnam County
Health Dep rtm n .
Date of Issue: �Z, �� 19 ,( 1
Date of Expiration: 19 ermit IssTjing Dffic7la
Permit is Non - Transferrable White copy; H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
C�
G
APPENDIX B
PUINAM CCUNTY DEP_AR24MP OF HEALTH - DIVISICN OF ENVIRONMENTAL HEALTH SERVICE
INDIVIDUAL WATER SUPPLY & SUBSDRFP.CH SE QM DISPOSAL SYSTEMS
REVIEW SHEET - CONSTRUCTION PERMIT /
�s e DATE REVIEWED: °-
'�� BY:�2 / (Street Location)
COMMENTS of Owner) i YFS L NO I DOaMMS
LF trench provide
re;ruired fPG
60 ft. max..
Parallel to
new
100
Permit Application
Corporate Resolution
ans - Three sets
Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
SUBDIVISION
Perc �-
(3) Fill
ca ®"
House Plans - Two sets
Well _ •- permit; P4vS letter
Variance Request
C AL
Lead Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj_ Lots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
RFjQUIMD DETAILS ON PLANS
Se.vage System Plan - (north arrow)
Sewage 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 notes)
Design Data: perc and deep results
Two -.Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)..
Perc & Deer) Holes Located
Representative of primary and expansion
Expansion Area; shcwn; gravity flow,suff. size
If Pu ped Pit & D Box Shown & Detailed
House- No. of Bedroans
Wells & SSDS's Win 200 ft. of Proposed System.
Property Metes & Bounds .
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPMATION DISTANCES SPECIFgD ON PL-a-N
Fields
10' to P.L., Driveway, Large Trees,Top of fil
20' to Foundation Walls
100', to Well; 200' in D.L.O.D, 1501 pits
100' to Stream, Watercourse, Lake (inc. ear
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stormdrain,piped watercour:
10' to Water Line (pits -201)
50' intermitte. ,it drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
9
e21IB210 6-41-811
` PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
AFFIDAVIT- CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT
TO: Camnissioner of Health
In the matter of application for:
FMA� 1 R u P-,,J M �}- 1�,1oR- - S S P5 P L07-
'La
represent that I am an officer or employee of the corporation and am authorized
��S� r`� ''Uc� /A,5 -S'
to act for F r 1 P IN M a r o r^ — m �raa+ �n�T n
(Name of Corporation)
having offices at P.O. Box 285
Thornwood, New York 10594
Whose officers are:
President: Daniel A. Amicucci, P.O. Box 185, Thornwood, NY 10594
(Name and address)
Vice - President: Anthony J. Amicucci, •P.O. Box 185, Thornwood, NY 1.0594
(Name and address)
Secretary:
(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 �4' day Signed:
Of �° �� 19 Title: 5pc
BETTY L. ESPOSITO
Notary Public, State of New York
Pao. P3L3
Quaiifiecl in ?ufnsrl County pp
Contr:ic3ic;; E,;Pires April 80, 19.0
Corporate Seal
20
d
0
0
Q
o_
T:-A, 117 \/I F I AI
LOCATIUN
C.HAKT
AC= 52'
BC= 45.5'
AD= 87'
BD= 90'
AE= 91'
BE= 95'
AF= 96.5'
BF= 99.5'
AG= 103.5'
BG =105'
N OTC-: ME,�.SVrr
AH =108'
BH =110'
TO Hoc,-$,S
AI= 113.5'
BI= 115.5'
50v -Nlv-'f, f
AJ =119'
BJ= 120.5'
HovSE
AK =125'
BK =127'
AL =131'
BL =132'
AM =137'
BM =137'
AU =132'
BU=
AT =126'
BT =123'
AS =120'
BS =118'
AR= 114.5'
BR =113'
AQ= 109.5'
BQ =108'
AP= 103.5'
BP =103'
A0= 97.5'
B0= 97'
AN= 92'
BN= 92'
AV= 96'
BV= 137.5'
AW =138'
BW =168'
AX= 120.5'
BX= 77'
AY =157'
BY =123'
WELL to Z
54'
WELL to B
78'
WELL to .Y
139'
to Y
44'