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HomeMy WebLinkAbout0020DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3. -1 -20 BOX 1 , ;; IJL or I ' r ti L [Val L 1 6 r ■ - .�t :., Rev. 3/86 ' PUTNAM COUNTY DEPARTMENT OF Iii Division of Environmental Health Services, Carini �.s Jk"7P !P ♦WYE 9 Located at A &AJ O R KdA D Tax Map Block 14cmE-SiTE As oG. Formed Subdivision Name fie' +y1rw ptubdv:Lotp Z2 Owner /appllcan4 Name Y MaWng Address 0 w,x Z 8 5 zip ) c� Date Permit Issued � ' No nic+�na by Separate Sewerage System built by i a J< In Address mA N o p,4 G Al. y Consisting.of - ZSf� Gallon Septic Tank and $ 9 C �r Water Supply: Public Supply From Address or: Ilc Private Supply Drilled by T o L 1 Address A- rz.rrlo,yR /V y Building Type SfN G b.E Has Erosion Control Been Completed? Number of Bedrooms Has Garbage Grinder Been Installed? . Other Regnirementa 3-5 F I certify that the system(s) as listed serving ihe, 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 regulati s, in accordance with the filed plan, and the permit issued by the Putnam county Department Of Health. O / Certified by R.A. Date r% 6l -/ A� Address License No. IX Any person occupying premises served by the above system() s shall promptly take such action as may be necessary to sscu►s the correction of any unsanitary conditions resulting from such usage Approval of the separate sewerage system shall become null and void 'as soon as a pub ': sanitary sower becomes. available and the- approval`'of the, private. water supply shalYDecome'null and `void "when a public water supply becomes available. Such approvals are subject to modification or change when,' in ".tile" 11 judgmOmt Of the .Commissioner` of Health, wch revocation, modification or change is necessary, Date Title '� W1;LL liUr rLLi iun 1<G i rUA �; ►� DEPARTMENT OF HEALTH Division Of Environmental Health Services I[l tij PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL STREET ADDRESS: WNIVII alClIr W GRID NUh18Ed: yyll�wofz WELL OWNER AME. ADD Ss V a z rif ❑ pgIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary ESIDENTIAL ❑ PUBLIC SUPPLY 171 A,R/COND. /HEAT PUMP ❑ BANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm.lNO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING NEW SUPPLY '- ❑ PROVIDE ADDITIONAL SUPPt Y ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH ft. STATIC WATER LEVEL ft. ° DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT O' CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING, ,OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH ft. MATERIALS: '4 STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE LIQ fL JOINTS: ❑ WELDED t5THREADED ❑ OTHER DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE )SOTHER WEIGHT PER FOOT 1b./ft. DRIVE SHOE ❑ YES )S.NO LINER. OYES ❑ NO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH if t) DEPTH TO SCREEN (it) DEVELOPED? FIRST O YES ONO HOURS SECOND GRAVEL PACK ° YES 0 NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH -ft. f row DEPTH it. WELL YIELD TEST If detailed pumping METHOD:. O PUMPED tests were done is in- O COMPRESSED AIR , formation attached? 0 BAILED 0 OTHER ; ❑ YES ❑ NO WELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- ing well Dia- meter FORIAATION DESCRIPTION cooe. ft. ft. WELL DEPTH It. DURATION hr. min. DRAWOOWN It. YIELD gFm. Surface WATEP 'g6LCLEAR TEMP. QUALITY O CLOUDY HARDNESS D COLORED ANALYZED? '*SjfES ❑ NO ANALYSIS ATTACHED? YES O NO STORAGE TANK: TYPEWQ. L"_rVjU CAPACIT _,d.(�i_T(bL a GAL. 4�, wEl ()RI ERN E DATE Ad0© It F1 ,�so�f 5 t 1r' w o 1�. N: Fez c,� PUMP IHFIO�RMATION. ,. TYPE iubrnQ i�- i k CAPACITY MAKER iorrf'y DEPTH �`Uj �% � MODEL '� VOLTAWP HP orktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -3203 Director: Albert H. Padovani M. T. (ASCP) 1r TORLISH WELL DRILLING PO Box 271 Armonk, NY 10504 -1 L -� TABOF.._1F: RE ?OPT ON THE QUALITY OF +A TER LAB f1 32. 015210 Date Taken: - -Time: Date Rc'd: Time: Date Reported: JUN. 00 1988 Collected By: Duane Torlish R,e ferred By: Sample Location: 71AP0, 4 L3% Phone d 273 -3 48 Phone N Sample Type: Repeat Test? (check one) J. p +abl a NO d- VETALS (ma/0 MICROBIOLOGICAL (CFU /10.0--iL) Conner —_ Iron Lead _ Manganese _ dercury _ Sodium Zinc (units) _ Color (units) _ Odor (TON) Turbidity (NTU) GENERAL BACTERIA _Standard Plate Count :2. (CFU /1.OmL) +. .MBRANE FILTR`FON TE'C" :IQUE Total Coliform Fecal Coliform Fecal Streptococcus MOST PROBABLE :.U'43ER TECHNIIQUE Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY i +/A = �1ot APpli cable LT = Less Than ( <) GT = Greater Than (>) TNTC= Too iiu,. erous To Cou. ^.t CON = Confluent ( =TNTC) NR = ,ion - reactive REMARKS /COMMENTS (For Lab Use) +o::- potable ST? I:iF STP �pF Other Samnle Status. (check °ac: ^.) O ,taoi r._.. HC!' H 2 SO4 _ 'lao:. ZnO ;c _. Na2S.203 Other: Incoming LE 4 °C — ^._falinit;j 4 °C C l'oriae LE 2 _ _ Detergents, M3AS -ness, Total Nitrogen, Ammonia _ _ .1itro er., Nitrate Posphate, Total _ _ S (fate Sulfide _ — Sulfite METALS ( ^v, /L) Conner —_ Iron Lead _ Manganese _ dercury _ Sodium Zinc (units) _ Color (units) _ Odor (TON) Turbidity (NTU) GENERAL BACTERIA _Standard Plate Count :2. (CFU /1.OmL) +. .MBRANE FILTR`FON TE'C" :IQUE Total Coliform Fecal Coliform Fecal Streptococcus MOST PROBABLE :.U'43ER TECHNIIQUE Total Coliform Index Fecal Coliform Index KEY FOR TERMINOLOGY i +/A = �1ot APpli cable LT = Less Than ( <) GT = Greater Than (>) TNTC= Too iiu,. erous To Cou. ^.t CON = Confluent ( =TNTC) NR = ,ion - reactive REMARKS /COMMENTS (For Lab Use) +o::- potable ST? I:iF STP �pF Other Samnle Status. (check °ac: ^.) O ,taoi r._.. HC!' H 2 SO4 _ 'lao:. ZnO ;c _. Na2S.203 Other: Incoming LE 4 °C _ SGT 4 °C DH LE 2 _ DH E Q nH GE 12 _ Ot:^.er. THESE RESULTS INDICATE THAT THE WATER SAMPI, (WA§ (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO Tj HE NV YORK STATE DRINKING-WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE E OF COLLECTIDDR THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (NIA) MEET THE SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK ST TE KING WA TER CODES, FOR THE PARAMETERS TESTED, AT. THE TIME OF COLLECTION. x �lL EJ� �_�i -� j�. 2/86 (Rvsd7 /87 )RWE Albert H. Padovarii, M.T. (ASCP), Director Ne.i:1FS 7 50c1 V4, n= S -1I-kjc . Owner or Purchaser of Building domeS /TP Bfilding Constructed by /tiiNN 0 2 %� crl . Location - Street MI III i.ci:prality S MAC, !e F14011 1 /11 Building Type Section Block Lot nn VIc' ors . 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 or egligent act of the occupant of the building utilizing the syste / 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 6 0 FLAN- fjouea L-ce-ATIaN I-- APNZO�IMATr. CH,,NF-l- A,Z 23-6'- V-Z 37' - i l � i l l l I III I j � l l � j F. O WEL-U a 5.5. b. 5. PLAN 1111l111"ll 0 R s HDvSe LC>C-ATION I-'- AFPKa>-�d MATr- CN�fzT A-Z 23.5' , D•Z 37' A -E . 6r- ' F- E 631 A•F 227' P.F ZOC' F-G' 56' F r' 67' F.H' 55' F'Q' 58' F.I' 57' F-r-' 5;9' F .T Sq' F s' ' A ".!' I� Q O WEL-U a 5.5. b. 5. PLAN 1111l111"ll 0 R s HDvSe LC>C-ATION I-'- AFPKa>-�d MATr- CN�fzT A-Z 23.5' , D•Z 37' A -E . 6r- ' F- E 631 A•F 227' P.F ZOC' F-G' 56' F r' 67' F.H' 55' F'Q' 58' F.I' 57' F-r-' 5;9' F .T Sq' F s' 61' F.K' ".!' F-T' GS' F-L' c5' F- • u' 61' F-M' 67' F-Y' 7f' F -N'. 73' F W' 77' F-O' 77 F- X $d, P• X' 6,1 ' G-o' G9' F. X 46' G• o 4C' �\ PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services. Carmel, N.Y. 10512 Engineer to PnVide Permit q on CERTIFICATE OF COMPLIANCE CON CTION PER FOR SEWAGE DISPOSAL SYSTEM permit ®� / r MR' t J Located at td NN Oe- eX >41L7 '8. own or Village i Subdivision Name Subd. Lot N LZ Tax Map t Block 1 I Lot _L— Owner /Applieant Nalme FNt- iE;StijE�j / t't7C i1� 5 Renewal_❑ Revision o Date of Previous Approval �p MWMg Address RR , MFA _Kle �s Town 1 t-1�EA�SVii , 1J 7 Zip 104 ") 4- Building Typet',A lZ 'rnl.Alsm -' f Lot Area Z-21 XCi Number of Bedrooms !!� Design Flow G P D 0 Separate Sewerage System to consist of t' Z 'iice' ' Gallon Septic Tank and U t-t To be constructed by Address Water Sapph': Public Supply Flom Address or: Private Supply Drilled by — Address Fla Section Only Depth S,5 Vobrme 0 PCHD Nodfication Is Repaired When Fill Is completed i;. 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 approved amendment there to and in accordance with the standards, rules an regulations o 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 i accordance with the andards, rules and regu aTi%ns of tfys Putnam" County Depart ent of Health, V/ Date P,E R.A. Address &1d w i n 3 fZ icenN. ? APPROVED - FOR C STR TION: This approval expires two years from the da a issuetl unless construction of the building has been undertaken and is revocabl77���90&ye, calla amended o di ed when considered nee awry by the Commissioner of Health. Any change or teration of,construetion requires w o of domest ic sanitary Z. and /or ►.vats water supply only, Rev. Date Title 1/87 '� PUTNAM COUNTY DEPARTMENT OF HEALTH ,1� Divlebu of Envi onmental Health Services. Carmel. N.Y. 10512 Eegtoser to Peovlde Permit N on CERTIFICATE OF CLIANC� CONSTRUCT! PERMIT FOR SEWAGE DISPOSAL SYSTEM pin iY A Patterson Located Manor Road Town or VUhoge Subdivision Name Fairview Manor UM. Lot x 22 Tax Map 1 Block 1 . Lot 19 pwner/Applicul1Name Homesite Associates Renewal— o Revision p Date of Previous Approval M-1111naAddress P.O. Box 285 Town Thornwood, New York 7Ap 10594 Building Type Single Family Lot Area 2- 771 A r r a s Fill Section Only Depth Volume Number of Bedrooms 4 Design Flow G P D 800 PCHD Nodfl ation is Required When FM Is completed Separate Sewerage System to consist of 175n Gallon Septic Tank and RR9 1b X 94" tile f2,elds To be constructed by Hekla Address Mahopac, New York Water SuPPh': Polblle Supply From Address or: X Private Supply Drilled by Torlish _Addrara Armonk, New York Other Requirements 3' -6" fill was placed I represent that I am wholly and completely responsible for the design and IofAtiP91 %! the proposed sys� (E)F 1� itki 1t�he separate sewage disposal system above described will be constructed as shown on the approved amendment.0 re p(grp�4 ti,%cordance Ipl the standards, / an regulations o e Putnam County Department of Health, and that on completion thereof a "C�iY ' i 1dNN�D on Con`ianeQ "� fat ®jrjor1yjths Commissioner of Health will be submitted to the Department, and a written guarantee will ba` Rsd��l� ,,QQcone ,�'SU certhe \R8 o; or assist b )reg e uilder, that said builder will place in good operating condition any part of said sewage dfsga sytfia•91Md1)t4t19".0it of (2) y m lo fo owing thedate of the issu- ance of the approval of the Certificate of Construction CompjaQ9 of t'`ji,ra origlnaI%s%9 ran pair 2) thhe illed well described above will be located as shown On the approved plan and that said well w21Wp installed in aeeordants' ith stn a ions of the Putnam County Department Of Health. Q: R� A i _ J I A Date 74L1." sign" Address RU 6. Raite 22, APPROVED FOR CONSTRUCTION: This approval expires two y revocable for cause or may be amended or modified when considered requires a new permit. Approved for disposal of domestic sanitar 1/87 Date By priy#te water Title i1 PL P.E._ Rt4• itVJ�e�No��� f has been undertaken and is or :iteration of construction .I,A5��C,Z Y I/(/7 Y �/11.f(/ T u c Tc� ;D S?CO T S UO D=DT 7^ za TO U ;D L�JTS0�3 ' T c1raD�? UDT' r BOZO :Z=-2?M 'cDz =^j bUTg0.� -I3 SCE 1JJ � 1??mz O� "rTTJ j �r 2�v i� L L = 71. :?-Tp U–,-TCI 04 nU -CT)TC D-2 C TT= SUT a - UT? :::70 -a �c1T?TD UT nV i SaiIO2S SUTt UCJ TzT -cLlI rLT=�,i- D SO aDTSUT LT'1TM UST17 SaOia LTTT'NP J AT T?�= ST_ T" -1 aa -q S ii -Ndcm nJ A -aT,- �� �aaoz TTaM ? rRa1z ao= -- z�oTao�zT-- -; -p1 ' 9: `` ZT?j �c lI 21? S`S = :g cDUz =SiQ -q SuzTd zaa2 spa s? _ -� T T7 -- -2 --l—zM 'A sq go tea: -:1 -q '�Ti1 -�T� �nl7�i�1�L 1v� _ ✓�. �. 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I suo L _= :Lnoz - _--1 OZr- au LT , L�ua:� �_� - -�5 OT '9 .=) -r/n ZE /T - °T /T aTq oTS S Cq ic=o -Du=- STQ ' - I u u-=La cT nu-, -7=Z)? _ =T; c su-I -Z ?M - L'- a 1 T: L .2 a ,�u� -j ' L vo: llszpqaq TTOS T- -Lr TDTZD -- Z UMU : uTy1 - ;7 a Sozj P�DT--q -7 I I I -'_a° °q 1_T�M - lio ,�1�sTs o!i _? � ono LTV L Y:-73 !�DI� -ri—HI LLSTQ - D:.?q p5V 10 = OT TiTL�TM '1i1Cu =vTO 'SCu�q L,06 �� '� Imo, ( ( *IOTT� ✓mod L`:�- -uli�uTtu , OT 'o i r I b / -I - z lU✓.L QV n V.&U ` c- -& -f -r II rowpxrl a/ I f- �3t1N�0 l' ND} VOe A;;.ncq TI 0(c J7. IV. V. FELaL SITE L`1SP=CTICN Date ml .:G'T- CpN m Cot -1 rj Ul n CR SUEDIVISICN LCT 1 Ins- bv�f Cr,v-NER&OjIWb CZ�✓�C t� b. Distance f_= SDS area measured ft. c. Casiria• 1,8 "" &� cve crate . a- S.77ace drG-L =ca arcur-E well accE.Ctable. a_ ^ c e s prCCGr_J CrCUtea b. AL! ' pires baccf i 11ed c_ A picos f with inside of bcti d. D✓c'cfill m=t_iall contain= stones < a ". in dia*r�t e. C- 2--tain drain in_ zalled accordinc to plan f- `- -ta-in drail n cute—all pr•ctact— & d1--.to e !1St.wc:arccur Q. F- toting Cl"a' - C' s= -arce away f-! c n SDS area l_`C_ water crctecticn aQeSLa t E 1. _csion ccn c-L crcviCcd on Sl JL es cri :: --ter t..- -: 153S. YES ccr Errs SL •it?L DISPOSAL A -RE? a_ LS area to t as per acoroved plans I �NIC I ✓( b. F_ll seC-ticn - Day._ or placQra-'7t 2:1 barrio~ _ L=- Tv= AVC.DFJI�i I �I c_ Natural soil not stricter d. Stone, brush:, etc., greater L= 15' fran SDS area. I �- e_ 100 tt_ tren water ccurSe /wetiand--. I -'I I SL Z-'- =-- D1SrC -SAL S?ST E. iml a. Sec�c tan••t s_�- - 1,000 1,250 I b. Sent? c t nK , ^_tall! — le -,el I I c. 10' minimum = fcur_cation d. >1C 900 hen c , c'_'=—:zr,_Cut within 10 2! of ¢5 c jrc ^. r e' DIST�UTIC�i =E X 1. All cuti e_ ate ele =rticn - water test =�--, I fox /Yrnootil �� 2. PrCte ce! cw frost I I I 3. Mlin .`nL'•il 2 '- Cr1C1 '? � soil b=L- ve_n box and t'_'E ncnes I I I f_ J[:,\-,C_PTCN B-D K Se- I I 1 LencL-n ra=- _ 2_ Distance tc wat =r-C=. .., �. I+�C �� �• ac_crcinc tc ulan - Di =t=ncs c__tar to 5. S C)ne C cb acc actable 1/16 - 1/32 "/foot. I 6. 10 fat =ir1 more -ti line - 20 Tom- - % Der--Cmt_h c t'v < 30 ? -ches aca I ✓�. 8. RCCIiI cl ! C';ad Cr ex- ca- n51cT, 50% I L I 9. Size of _-vim 3/3 - 1 d; a: e. =r 10. De =th of cwell in trench 12" min - u-n i Pirx Ze h. R, SD CIR SYS��E 1. Size c z�-� cam: ter ) I 2. O ierflC,v tam:-, 3. Al��, visual!a -odic I I I d P=-o eas_ 1'i acces=sible manhole to crate I ( I 5. First. bcx 6. Cvcle w_-=_ s by L=. =i th pep —=�qq I I I es ti That =� =1c-N ce c-,i cle HCUS? a. Ecuse rer accrovea lams. b. JNCrLeY of beE:=, s a. Well 1=—Lea as c r atDrcvE-d. Plans b. Distance f_= SDS area measured ft. c. Casiria• 1,8 "" &� cve crate . a- S.77ace drG-L =ca arcur-E well accE.Ctable. a_ ^ c e s prCCGr_J CrCUtea b. AL! ' pires baccf i 11ed c_ A picos f with inside of bcti d. D✓c'cfill m=t_iall contain= stones < a ". in dia*r�t e. C- 2--tain drain in_ zalled accordinc to plan f- `- -ta-in drail n cute—all pr•ctact— & d1--.to e !1St.wc:arccur Q. F- toting Cl"a' - C' s= -arce away f-! c n SDS area l_`C_ water crctecticn aQeSLa t E 1. _csion ccn c-L crcviCcd on Sl JL es cri :: --ter t..- -: 153S. A U .', . I�� oar -z.e� ..�,.�..�. (� � ��;� .�ml� -� .,� --e- ,�-� .a�� ✓�e�%�,,C `�- �rL�2- `�% �1,���� �a Q o°m Ce�m �a'n cf -Y\D 0 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simnons, M.D. Deputy Conmii.ssioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME )(,4-11 Q Q Orig. Routine ADDRESS No. Street Town 24 No. MAILING ADDRESS P.O. Box Post Office Zip Code Oyu MO Name and `4- DATE 3/� TYPE FACILITY TIME ARRIVED /0:00 TIME LEFT FINDINGS: nn Orig. Ccmplain Orig. Request Campl iance Camplaint Canp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other Explain INSPECTOR: AA ' 2bb Q �o TELEPHONE: ,y2),/Cna,tprU�d Title E.N-j_ PERSON IN CHARGE OR INTERVIEWED: (I I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES P- N 1 - ,9`7 1 x vr,ay-# I- /- / 9 a John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet / of TW701DLYYTTnK'1 MAILING ADDRESS P.O. Box Post Office Zip Code 0y DI IF Dl! . PERSON IN CHARGE OR INTERVIEWED ���►rnc,(a, iJ 1 �,(j,U Q- I �LtuQ �M 1 Name cYKd Title Other DATE 2 1 y k TYPE FACILITY dol TIME ARRIVED TIME LEFT ', �i� CL rYN FINDINGS: Orig. Routine Orig. Canplain Orig. Request Canpl iance Canplaint Camp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Explain INSPECTOR: Y vlff 7/2(,(- - (IY^ C /-, /-, X/ / TELEPHONE: Signature and PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: F� * *• 1►, INDIVIDUAL VPMM SUPPLY & SUBSURFPM MU M DISPOSAL SYSI REVIEW SHEET - CONSTR=GN PERMIT DATE BY: (Name of Owner) (Street Location) COM ENS YES NO DOMEM Permit Application Corporate Resolution �% ✓ Tans - Three sets----' -- -' ". Ugineers Authorization i Design. Data Sheet (DDS) LF trench required 60 ft. max. Par;-' lel to fill notes nea saec . death Qauces 100 s/s Deep Hole Log Consistent Perc Results (3) Perc Hole Depth SUBDIVISION P°_rc Fill 3' cd -� i- :..✓ House Plans - Two sets r .. Well errmit; PIS letter Variance Request Q�RAL . Legal Subdivision Subdivision Approval Chewked Ex- approval SSDS Adj. Lots Checked Wet and (Tcw-n/DEC Pe ,nit R & D) Data On DDS Plans & Permit Same REQUEM DETAIIS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flcw contours i 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 Fcoting/Gutter,Curtain Drains (discharge OK) Perc & Deeo Holes Located Representative of primary and expansion Expansion Area; shown; gravity flow,suff. size I If Pmaped Pit. & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /i.n 200 ft. of Proposed System: ! Property Metes & Bounds House Setback Necessary (Tight lot) House Seder - 1 /4" /ft. 4 "0; Type pipe No Bends; Max. Bends 45" w /cleanout SEP- MATION DISTANCES SPECIFIED ON PI-21.N Fields 10' to P.L., Driveway, Large Trees,Top of fi: 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. ems: 15' to Drains - Curtain, Leader, Footing 351to catch basin, stormdrain, pined watercour: 10' to Water Line (pits -201) 50' intermitte_*it drainage course Septic Tanks 10' from Foundation; 50' to well 15' Well 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 Add ess iJtosl. IA Town Village City Tax Grid Number iZ� i i i WELL OWNER Name r-L � Mailing Address CICA . C. ,,,Z, Qj 10c,-- JUPrivate O Public USE OF WELL 1 - primary 2- secondary 'SRESIDENTIAL ❑ BUSINESS 0 INDUSTRIAL ❑PUBLIC SUPPLY OAIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY OABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT t gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 800 gal REASON FOR DRILLING 0 NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST/ OBSERVATION OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN ®DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: vs-Agy I ee j Lot No. ZZ WATER WELL CONTRACTOR: Name '�� ICS i>45rmp -Y9 aen Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 'j-C 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 SON SEPARATE SHE (da e) (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 provid by phe, utnam County Health Department D 10--�11hZ " ate of Issue: Z- ' 19 Date of Expiration: 19 mit Issuing ffic�al ` Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 287 Orange copy: Well Driller First Floor L 15P ARY LIVING RO01.Y1 FA/^ILY Roor FOYER c tas. BREAK FP,5T lO'X IV -4' VIN I NG ROO^ 13' x IS' -'!' WOOD DECK KITCHEN 14 X 13' 00 0 GARAGE 21'-2x 21' . ill rl DEPARTM- YEAS. �f HOUSE PLANS APPIMED F?R. All room dimensions are approximate. Developer reserves the right to substitute materials of similar quality without notice. Fairview Manor • Monev Hill 11d.. RR 2. Box 348A • Patterson • N.Y. • 12563 .914- 878.4480 APPENDIX M PU NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROR4ENT-AL HEALTH SERVICES AFFIDAVIT- CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUMAM COUNTY HEALTH DEPARTMENT TO: Crmntissioner of Health In the matter of application for: I� _Anthony J. Amirfrrri represent that I am an officer or eaploy of the corporati n and am authorized to act for (Name of Corporation) having offices at P.O. Box 285 Thornwood, New York 10594 (dose officers are: Presider.-: Daniel A. Amicucci, P.O. Box 185, Thornwood, NY 10594 (Name and address) Vice - President: Anthony J. Amicucci, .P.O. Box 185, Thornwood, NY 10594 (Name and address) Secretary: (Name and address) Treasum: (Name and address) and this. I am and will be individually responsible for any and all acts of the corporreion with respect to the approval requested and all subs ent acts relatug thereto. ` Sworn o before me this �/,�- day Signed: of (,�Y �� �� 19 Title: s BETTY L ESPOSITO Notary Public, Stale of New York No. = 3t 3 r, OuaNtied i aMUm County S! Contn:!c.. ,. E ;:Pir2sApril 30, 79. 1 5 Seal 20 ' APPENDIX L PUT'NAM COUN 'Y DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DATE: D X- 3 Lp RE: Property of 6517-E /35s.c. Located at (T) Section i Block �_ Lot / 9 Subdivision of iF 14VI;ehl M'l3AlOr- Subdv. Lot Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professional engineer ✓ or registered architect (indicate) 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 Carenissioner 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 Sanitary Code. Countersigned: P.E.. �. 1,3 A.U_ �E Address ioa 50 ( �i4) a79 - -///s Telephone Very truly yours, Signed: )OvYner of Property Address Telephone 19