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Home My WebLink About0021DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 1 -1 -21 BOX 1 00021 ` PUTNAM COUNTY DEPARTMENT OF HEALTH a � Division of Environmental Health Servkee. Carmel. N.Y. 10612 an CERTIFICATEr OFPeuvldo Permit N Permit N.. \ CONSTRU N PERMIT FOR SEWAGE DISPOSAL SYSTEM Patterson Located at Manor Road Town or Village Subdivision Name Fairview Manor Subd. Lot N 23 Tax Map 1 Block 1 t..t 19 Owm/APPU=t Name Homesite Associates Mining Address P.O. Box 285 Renewal_ ❑ Revislon ❑ Date of Prevlous Approval Town Thornwood ZIP 10594 Building Type Single Family Lot Area 2.926 Acres Fm sin Only Depth volume Number of Bedrooms 4. Design Flow G P D 800 1 PCHD Notification Is Required When Fill Is completed Separate Sewerage system to consist of 1250 Galion Septic Tank and 667 1f x 2411 Tile Fie 1 d s To be constructed by _ 0ekla Ads Mahopac, New York Water Supply: Public Supply From Address or: X_Pdvate Supply Drilled by Tor 1 i s h _Address Other Requirements 31 -011 fill was placed I represent that I am wholly and completely responsible for the design anqtkftkl &'16f;,fh proposed s �rstt�a); 1) that t p rate sewage dis oral system above described will be constructed as shown on the approved amend �11i or �LvLlrt�� cordance he star, I roles yu a ions o to u nom County Department of Health, and that on completion thereof a ��q�,Otte • of ,�o4ue4ion Co DI !��1Fisf><tC67� the mmissloner of Healthwill be submitted to the Department, and a written guarantee will }� �uin,srhftw �ylne►,tfj{{�uc seer hdli* or assigns t Du{ err that said builder will place in good operating condition. any part of said sewage diiD I,•i m duringFthe p�ri&d f tw (2) y lately. olio ing thedate of the Issu- ance of the approval of the Certificate of Construction ComiltACO of the original system oT ny epairs t at th dril well described above will be located as shown on the approved plan and that said well 2f"? Instill nAs ordan h t stand I 4n r ns of the Putnam County Department of Health. = ¢ , Ac r r^ Date si_gahD P.E._ Z /1 /ftR ;G.. - - -- = - ._• h 4-70 1 APPROVED FOR CONSTRUCTION: This approval expires two revocable for cause or may be amended or modified when cons) requires a new permit. Approved for disposal of domestic s Rev. 1/87 Date A IAA By Lmn" water Title is been undertaken and is alteration of construction PUTNAM COUNTY DEPARTMENT OF HEALTH V Division of Environmental Health Services, Carmel, N.Y. 10512 Engineft to Provide Permit N on CERTIFICATE OF COMLIAN ` CONSTRUCTION PIR"lar FOR SEWAGE DISPOSAL SYSTEM �` j permit N j, l Located at Manor Road Town or e sabdivlalon Name FAIRVIEW MANOR Sam. Lot N 23 Tax Map 1 Bklck 1 tot 19 ter /Appll=,t Naas, Homesite Associates Reaewai_❑ Revision ❑ Date of Previous Approval >babigAddreae P.O. Box 285 Town Thornwood, NY ZIP 10594 Biding Type Single Family Lt ,rya 2.93 Acres 11u Section only LXJ Depth 3 vow.. 910 c Number of Bedrooms 4 Design Flow G P D 800 PCHD Notification U Required When Fill Is completed separate sewerage system to consist of 1250 Gallon septic Took end 667 L.F. x 2411 Tile Fields To be constmeted by To be determined Address Water SuPPIy1 Public Supply From Address ors X Private supply Drilled by To be determin�a Other Requirements 1 represent that 1 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 a$ shown On the approved amendment there to and in accordance with the standards, rules an regulations or u nam 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 w=the dards, rules and regu sT tuns of the Putnam County Depa ant of Health. Date !/ 7 Signed Irnra Baron / �'L P.E. X R.A. Add.es :for Baldvin & Cornelius, P.C., RD 6,Rte. 22, Brewster,NY l_ice�N, 43791 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the building has been undertaken and is revocable for cause or ay be amended or modified when considered ecessa,y by the ommissioner of Health. Any change or alteration of construction requires a new petrol App ved f disposal of domestic saniti y ewe , and /or Dr t pl o y. Rev. Z l �- y, 1/87 Date. By Title R. • 1111 a u PUIVAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROMENTAL HEALTH SERVICES AFFIDAVIT- CORPORATE OWNER APPLICATION FOR PER14IT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTWM T0: Camnissioner of Health In the matter of application for: � : t fr • • 'rr represent that I am an officer or employee of the corporation and am authorized to act for Fairview Manor Development Group, Inc. (Name of Corporation) NOW KNOWN AS HOMESITE ASSOCIATES 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 10594 (Name and address) Secretary: t (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 subseaUent acts relating thereto. Sworn to before me this � /day Signed: of �o �� 19 �""" Title: X�Fa7 /t, '��A os-�( . BETTY L. ESPOSITO Notary Public, gln!e of New York No. 4-'33 "3 0:18iifled i.1 i utnam County p 2 m „ Con:ic cr: Dpires April 30, 19.0" Corporate Seal 20 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 Kings Way Town/Village/City Tax Patterson Grid Number WELL OWNER Name Mailing Address Homesite Associates P.O. Box 285 Thornwood NY JOPrivate 105940 Public USE OF WELL 1 - primary 2 - secondary O RESIDENTIAL ❑ BUSINESS ❑ INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT 5+ gpm /# PEOPLE SERVED /EST. OF DAILY USAGE 800 gal REASON FOR DRILLING MNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL O TEST /OBSERVATION DETAILED REASON FOR DRILLING Drilled well serving new single family residence WELL TYPE IDDRILLED DRIVEN ODUG ®GRAVEL []OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: FAIRVIEW MANOR Lot No. 23 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: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION ®ON SEPARATE SHEET� (date) (signature)Irma Baron, P.E. 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: 14 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 /vided by he Putna Coun y Health Department. i Date of Issue: / ?- 19 J Date of Expiration: ,Z 19� ermit Issuing 0 ficial Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller /ol IX, ef:v PUTNAM COUNTY DEPARTMENT OF HEALTH Rev. 3/86 Division of Envbronmental.Health Services, Carmel, N.Y. 10512 b' b Engineer Mast Provide' V. - . CERTIFIC OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Located at Mannr RnRd Owner /appllcantName Homesite Assoc. Formerly Marling Address P . 0 . Box 285 Zlp_ 10594 Patterson Town or Village Tax Map —1 Block. 1 Lot 19 Subdivision NameFairV1eU1�Ubdv. Lot # ?3 Date Permit Issued 12/28/87 Thnrnwrinrl Nalco Ynrl< Separate Sewerage System built. by Hekla Address Mahopac, New York Consisting of 1250 Gallon Septic Tank and 667 LF Fields. Water Supply: Public Supply From Address or: X Private Supply Drilled by Torlish Address _ Armonk, New York Building Type Single Family Has Erosion Control Been Completed? Number of Bedrooms 4 Has Garbage Grinder Been. Installed? Other Requirements 3' Fill — 910 Cy I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the lans of the completed work ( copies of which are attached), and in accordance with the standards, rules and re gu ns, in ce w the ed Jan, and the permit issued by the Putnam County ,tment Of Heal M� > / /'� Certified by d P.E. R.A. Date nAS M Any person occupying premises served by the above system(s) shall promptly such action as may be necessary to secure the correction of any unsanitary conditions resulting. from such usage. Approval of the .separate sewera syste shall become null and void as soon as a pub": sanitary sewer becomes available and the approval of the private water supply shall become nul nd o when a public water supply becomes available. Such approvals are subject to modifi ion o9change when, in the judgment of the Co ml f Health.su�rtion modification or change Is neeessa y. Date By ��y� %� Title PUTNAM COUNTY DEPART OF HEALTH DIVISION OF ENVIROlZMrAL HEALTH SERVICES Owner or Purchaser of Building CL7 P Building Constructed by o r --2,3 14•10woelL 9a Location - Street 1,41 07"1'CaLSOw4Al? L-/ Hunicipality �? Building Type Section Block Lot i�I 1ec, V1/U0 UZ. Subdivision Name 23 Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL 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 successors, 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 approval of the "Certificate of Construction Compliance" for the sewage disposal systan, 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 occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environinental Health Services of the Putnam County Department of Health as 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 9 day of 19,7 Signature A50c. J,U(, General Contractor (Owner) - Signature 51A---f Corporation Name (if Corp.) Address rev. 9/85 mk Title As. 4uie5/7f A56-. � Xx- Corporation Name (if Corp.) S l h L) e IV „11. L' 1Y( , I (/. I/c o s Address Yprttown Medical Laboratory, Inc. ' ,321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -2800 Director: Albert H. Padovani X1. T. (ASCP) r � TORLISH & SONS PO Box 271 Armonk, NY 10504 -0271 L J LAB _ _ _ , 00,3474 Date Taken: 57_ ime : 91; 3a K?^ Date Re'd: 2� cg,U_ Time: / /;oo ,fin, Date Reported: i990 _ Collected By: D. o� lr Tsh PO /Client i/ Referred By: ez Sampling Site: Cc 7- ��i°esv � Jt/y` �rni cocci D ev. Phone ( 914) 273 -3448 REPORT ON THE QUALITY OF WATER INORGANICS m L) MICROBIOLOGICAL ( T 'IOOmL) _ Alkalinity Chloride _ Coplier — Detergents, MBAS Hardness, Calcium Hardness, Total Iron .Lead — Manganese Mercury _ Nitrogen, Ammonia _ Nitrogen, Nitrate _ Nitrogen-; Nitrite Phosphate, Total _ Silver _ Sodium _ Sulfate Sulfide Sulfite Zinc Standard Plate Count (CFU /1 mL) Mem ane Filtration Method Total Coliform < t j Fecal Coliform Fecal Streptococcus Most Probable Number Method _ Total Coliform Fecal Coliform Fecal Streptococcus Pre sence /.Absense (P-) Total Coliform P A PHYSICAL MISCELLANEOUS KEY FOR TERMINOLOGY. pH (S.U.) CFU = Colony Forming Units Color (Units) IT = <' = Less Than _ Conductance (uhms /c) GT = > = Greater Than. i Odor (TON) NA = Not Applicable Turbidity (NTU) SA = See Attached TNTC = Too Numerous To Count REMARKS COMMENTS For Lab Use (For Lab Use) SAMPLE TYPE: (Check One) L" Potable _ Non- potable OUTGOING: (Check Each) HNO —_ HC13 — H2SO4 _ NaOH ZnOAc Na2S203 Other: INCOMING: (Che k Each) IrE 40C - GT 4 /1s 20"1"; GT 200C pH LE 2 — pH GE 12 Other: THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NA) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TH - YORK STATE PUBLIC DRINKING WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE DBC TION. THESE RESULTS INDICATE TIikT THE WATER SAMPLE (DID) (DID NOT) MEET TI_E SATISFACTORY CHEMICAL QUA Y ANDARDS OF THE NEW YORK STATE DRINK- ING WATER CODES, FOR THE A ERS TESTED, AT THE TIME OF SAMPLE COLLECTION. x 7 /87(Rvsdl /90)RWE Albert 11. Padovani, M.T. (ASC P , Director WELL COMPLETION REPORT DEPARTMENT OF HEALTH ..Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET AOORESS: wNIV ! IY W'GRIO NUMBER: D Gl /1 . 0�✓ . WELL OWNER NAME . ADDRESS: �' / ��,.t 14441 C ti CC Q PSIVATE . Q PUBLIC USE OF WELT: 1 - pJdmary 2 - secondary ESIDENTIAL O PURI ir sirm LY ❑ AIR /COND. /HEAT PUMP 0 ABANDONED p BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify) ❑ INpUSTRiAL ❑ INSTITUTIONAL • O STAND -BY p MOUNT OF USE YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR _DRILLING Nt9►NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION 0 REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA` ' WELL DEPTH ft. STATIC WATER LEVEL `,ft. PATE MEASURED DRILLING.: ..EQUIPMENT':'- '❑ ROTARY ""&COMPRESSED AIR PERCUSSION ❑ DUG `0 WELL POINT 0 CABLE PERCUSSION ❑ OTHER (specify): _WELL TYPE O SCREENED O OPEN END CASING. OPEN HOLE IN BEDROCK 0 OTHER TOTAL LENGTH ft. MATERIALS: b -tTEEL O PLASTIC O OTHER CASING DETAILS LENGTH.BELOW GRADE d ft. JOINTS: ❑ WELDED. LbgHREADED OTHER DIAMETER . in. SEAL: O CEMENT GROUT O BENTONITE WTHER WEIGHT PER FOOT lb./ft. DRIVE SHOE. -tKES .ONO LINER: O YES _ ONO SCREEN . DETAILS DIAMETER (in) SLOT SIZE LENGTH (1t) DEPTH TO SCREEN (ft). DEVELOPED? FIRST o YES. o NO HOURS SECOND GRAVEL PACK OYES. O NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH tL BOTTOM` DEPTH It. WELL YIELD TEST'..'. If detailed pumping METHOD: O PUMPED tests were done is in- � 19,COMPRESSED AIR !.formation attached? O BAILED O OTHER ' YES 0 NO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. DEPTH FROM SURFACE water Bear- g Well DIa- pete❑ r FORMATION DESCRIPTION CODE, . WELL DEPTH 1t. . DURATION hr. min. DRAWOOWN It. YIELD gpm. Surface t. . G WATE$ -� LEAR ..TEMP.`'_' ' QUALITY' O CLOUDY' ` HARDNESS -O COLORED ANALYZED?��YES ONO ANALYSIS ATTACH0'A7 YES ONO ...: STORAGE TANK: TYPE CAPACITY GAL PUMP INFORMATION TYPE U 1'S 'b1't CAPACITY MAKER �'YbifL�(L 1�5 DEPTH AD D MODEL VOLTAGO-30 H WELL R�1I ER N.A E 0 E ADD ss- 1� ® SIGs RE �A FaIAr, cl?*_ ' o C.NHi 12.t ;: Cp I .iv _ E.: c - •1c: 1 CC= _ L =: cCvrCvea pla=_s 4 _ P; 4 =_ Gv=-= Yes crCrc-_'r c_-CLt C =_' plCES f ":i w- in 1 SC PE5 cC_ _ e_ l ' ' rl G-_'_ 1"��= 1 ? acccrCi1 ^c t0 T.'lm r. to C. 1 =arca aWa S:�u =r^ DISrC��r. aura I ._ jCr_ _=r+ as FZT armorGv ea D! an s ✓ I Da L-3 cL placan— ✓ 2_1 wry; _- L= � I I E= c- - -�nr t��rl 15 f,CU E_ 1r0 f`_ f.c.. Ham_ T ; . -•r- D_:I S7 C` ? =• E: c 1,000 1,2f7 1E el a_ ice- goo r-, C. -ricut W_tnin 10 S. Ci Cco Cc_G I I I e_ ��L -T ._{ �X an L Lan WE —r -t-, C C .. c -C� c 1/1� - i /32 ac. � c . 10 2r r_= I Size C. c_ ,,ei 3/a 1 I 5 -7e C. Ta-' C1c I c.cle f I .iv _ E.: c - •1c: 1 CC= _ L =: cCvrCvea pla=_s 4 _ P; 4 =_ Gv=-= Yes crCrc-_'r c_-CLt C =_' plCES f ":i w- in 1 SC PE5 cC_ _ e_ l ' ' rl G-_'_ 1"��= 1 ? acccrCi1 ^c t0 T.'lm r. to C. 1 =arca aWa PDillM COUNTY DEPA22TA Elf1' OF KBALTH L x DNblw d 15etrke�wW Hoedb Seadeea. CaMML N.Y. 14612 Ertglaaer to Pnvtdo Fewi t / an CEnUWATZ OF COMPUAM PIS POIe =WAGS DIWOS" SY52M PON* . A� Leleefaiat 1"' T"Ill 41"Mo Namo 1 /�i 2y Gtl1/S, x SWIM Lost 0 Z3 Tao lap 1 Block ( lat i Deaewd_ o Dedele a ❑ Date of Piewbels Approval 10 -% 1 bb 'F(I MaWS Arioaa �vX IYa S� Teter• �C3'� � i� 1 Sl zip � U S 2 L� Date Subdivision Annroved Fee Enclosed ❑ Amnt,nt Deiiag Type GS I Dr 1 _T1 /_i✓ Lot Ana Z .c'7 •Z_- Fm Seale, Ody DepOi Voblme Number of B 4 Deaf Flow G P D �CJZ� PCHD Nelldotlon 4 Yeildred Wbeo FBI b oaaplefild SepraM SowaaSo Sylom q ewit d i Z5u GaBw Soptle Tank >'? U L . -E. u To be one4wctd by 7-6 15 D1?T (�u + tv AebLede Wager Soppy: Pl - no Soppy Fnm Addnm 011sw Rmphenesdil 1> 157 , 0 (r x -TI) S 0L'A-r L_cA._J 1 represent that I am wholly and completely responsible for the design and location of the proposed systam(s); 1) that the operate sew di sal slam above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ens nnn County Departfhant of NMlth, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of He lthwill be submitted to the DeWomtt, and a written guarantee will be furnished the owner, his succenors, heirs or assigns by the builder. that said builder will pNee in good ogwatklg condition any Part of said sewage disposal system during the period of two (2) rims Immediately following thedate of the isau- anCe of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto: 2) that the drilled wolf described as 0- wife be located see shown on the Apia a - plan and that said well will be Installed in CCOrdanCA with the stanoards. rules and ragu TIM of the Putnam County Depertmefst 1f gHNlth. Date 4 1 3 1 1 C) Signed f-7,7- 5-Z L"Ai a(&.. c' Address— No APPROVED FOR CONSTRUCTION: This approval expires two year from the date issued unless construction of the building .has been undertaken and is revocable far cause or may be antoAed or modified when can ed ry by the Commissioner of Health. Any Change Or alteration of construction "Quires a /new mitt* Approved for disposal of domestic it ace, nd Ivate water supply only. O SV • Oats 711 �� RY Title �• 10/88 !!! lio Vab PUTNAM COUNW DEPAHTMBN'P OF HEALTH d Environmental He dlit Services. Camel. N.Y. 10512 B aglneler to Ptt)vide Permit g on CEETMCATE OF CONSTEIICTION FOR SEWAGE DISPOSAL SYSTEM PSMU III `' ' NJ Located sit N1w.)oiz Ica �b Town or Vmage SubdMelon Name F- %&,Air_W IZ'Lawtoe ca id. Lot 0 23 Ter: Map � Block � Lot 19 Relsewai_ ❑ Revisim ❑ Owaier /Appllcaat Name "o ttic i'Ti✓ ,nMES Date of Prevlow Approve! MamngAddren Bo),. IRIS Town Ti4D&O\A/00►7- I.IY ZIP 1094 Blifi nB Type 12E51Dir.1Ga Lot Anew :Z-V?- Actacss M SecBon 0* LXLJ , Number d Bdeoo>sa 4 �Ptb � Volume i�l $ GY De s1p Flow G P D Boo PCHD Nodfindion is Required Wtteln Fm is compteted Separate Sewerage Syeltem to consist at i_GaBon Septic Tank and CP-10 L.F. Li6SotitPT► o IJ �RSNGi3 Te be C=5&wcted by Tb 13ea Addmu Water Supply: pul, SPPIY Fman Addeen or: `i( Peivate Sappily Drmd by -ro Bg � �Addnm Otber Regoiremento IS ; 118u-c:o►1 80 I represent that 1 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 a regu a ions o e u nam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Heahhwill be submitted to the Department, and a written guarantee will be furnished the owner, his wcosssors, 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 hereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be installed in ccords with the erds, rules and ►ego a� T ons of the Putnam County D/0�e`pyyartment of Heal'thl� Date f (►`' L�4� Signed P.E._ R.A. —��' Address IAi /d.SSOC:IATES 1ZT 5 EL NY ^ � License No i&oG 13 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the building has been undertaken and is revocable for cause Or may be amended or modified when considered necessary /by the Commissioner Of Health, Any change Or alteration of Construction requires a new p rmit. A pvad for disposal of domestic sanitary was an ivat Mi or p only. Date ' /pr By -i Title /�� ,p DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL Down tnnurm a 0- _<9'< Q WELL LOCATION Street Address Town/Village/City Tax Grid Number WELL OWNER Name Mailing Address ®.Private -rm F'o. o tes 4 Wooi�, 0 Public USE OF WELL. IN RESIDENTIAL ❑PUBLIC SUPPLY OAIR /COND /HEAT PUMP ❑ABANDONED 1 - primary 0 BUSINESS O FARM 0 TEST /OBSERVATION O OTHER (specify 2 - secondary ❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY 0 AMOUNT OF USE YIELD SOUGHT Mi►.t 5 gpm /# PFOPLE SERVED IL�/EST. OF DAILY USAGE goo gal REASON FOR EkNEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION DRILLING O REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE -ODRILLED 13 DRIVEN DDUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: rA1RJ1E % M,�+wlo� Lot No. ZS WATER WELL CONTRACTOR: Name to ICE 17�- reRM�t,►� 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: GReiAz-r-x!52 �ONAI EPA , LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION 0 AR1� A;; "HE E1� . (date) PERMIT N- E Sim oF� !o rN 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 C mpletion Report on a for;;viid b the Putnam County Health Departm nt. Date of Issue: 44 19 .Date of Expiration: (� 19 mt Issuing fficial White copy: H.D. File Permit is Non - Transferrable Yellow copy. Building Inspector 2/87 Pink COPY: Owner Orange copy: Well Driller A_PRI- VULL B F OTNA -" CrL�7I`! OF aA=M - DIVISIM OF EF -AL : SZizV -T(=_ s a- L 11-CiCnL WA=1 SUPPLY & SUES:iRF = Sr.Tv?C DISPCS.AL S'icTIE-d -S RE J--rTzTr, „rG- I' - CGNS=K=ICN PERMIT (i =T_ of C.,inar ) i I 1 _ rzc.ii _ a G Fa E-Ll =' " r n -C = 1002- i I I I I � I SYSTE `S 0f I I _iI i nct_s Y SCeC. c=z t-i c uc`s I I 1 I I I'? v--. 1 CCC e _V I i=_ r =_s ryci =, etc. AP i 1_v rte_ t_ig, li�•l =- � I I I I I i I 0 I =JL�TS Perr;ut Rnnlic =ticn Ccrxrate Riescluticn HY JE7 - (ij rZ3 pwv-`^ Plans - Thrae sets Engineers AL-- E- icri2nLicn D25ir Z DcL.� SiiE =t (S'� ) Dec Hole L,-a C=S_sta t Pe_ c RF ( 2 Parc Hole Depti Su�D' c -r� Pcr�O F11-1. C_ Fic,s P'_ari - - Two _ =_ t_ Ttie'_2. �G_r 1ERAL Lac-al S 7i.tdi v =S ion SiIC r_sicn ;�ccr'Cva'_ C e=_-R = We =- ar.- (Tow L-: /DEC Fe__: P.c -l-.r-_ Cn DCS P! Hr's & P:_::i? _ Ec__ REQui_= C_d PL tiS L.�.vc'C- Cam= �,='.1 CiVC'_"s'i1 ? C F= •CL- -= 1: = =_ "J _ � i - -- tillrF =Dille & D;--= r'_ =_cn -s - Vc_ :, - D or J S -7)t_c TGnk - Sizs, Ce_il We?' 1 re-i =__, Serv_cs Line if c%_= Ccns`-ucticn Vote_= (cr_ncer r __; CesIcn Dam: pert a ^.C. -Ceec TTNV Fcct C^ritcur= Existi nC & P ""' se DriveYa_v & Slopes Chat F^"Ot? n /Gatt=r, C?rrz ? n Dra L ns (`_= C_harg CK ) Pero & Deen Ecles Lc,- -a.=," L� Repr santative or pr_rvar ar= = xziansi cn at'...Gii°_icc Area= ; srLcw,1;crravit-! S L` P=ed Pit & D Box Shcwn, & Det -iled House - No_ of Eerccns S^!e?'_s & SOS's w /zn 200 =_. c: Proposed EV_ Proce_rt'T rtes & E�,ures HcuG` Set zc'.47- Necessary ('?'_cat lot) House Se: er - 1 /4 "/=t.- 4 "0; Jzy-, = pi_re No - ^'G; Max. Ee_rEs 4.5° w /cis �Lt SZD?R.A.TICN DTST'=tiCZS S?SC Cl Fr�N Fielcs 10' to P.L. , Driveway, L -r;e T=aS,TC_ cf 20' to Focr.= =tics Wails 100' to Wall; 200' in D.L.O'.D, 150' pit= 100' to Stream, WaitLercourse, TEa {s E•_ 15' },tc Dra T ^}s L t_iz, Lcsr, Footing 35'ta =tch LGClTi r�1�rG?_l1 1� (yGL =T �� 10' to Line (pits -20' ) 50 ' antarr itOe t =- z_I r =ee C`' Scant i c Tank—'= 10' f_cn Fcuncat_Cn; 50' to IeL L.,' Gvzl to rL John M. Simmons, M.D. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of ' INSPDCTION NAME D .�J — Orig. Routine L-rve Orig. Complain ADDRESS C-�-am-L, Orig. Request No. Street Town TK No. _ Cmpliance Complaint Camp MAILING ADDRESS Final P.O. Box Post Office Zip Code Group Illness Construction RN34"M"Ail i PERSON IN CHARGE OR INTERVIEWED Name and Title DATE 4 / /,?/ Ole TYPE FACILITY TIME ARRIVED /0 r' J'D . TIME LEFT /0 , 53-- FINDINGS: Reinspection Field, Sampling Only Field Conference Other - Explain INSPECTOR: tore and PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: TELEPHONE: . PUINAM COUNTY . DEPARM4ENr . CtP' BMTH • DIVISION OF REUM SERVICES DESIGN DATA SWMT-SUBSUFACE SEWAGE'DISPOISAL.SYSTEW:. FILE NO. Owner LpT 1l= c� �� "� f `"— = oc �H� �s Address P *o. Fok 1g5 l�beil.�lo 1 1SY �ob-�t<1 Located at (Street) ML�s R�e.� Sec: 1 Block Lot 19 (irulicate nearest --.. , cross street) �z ,�• z3 Fai ii.cipality -Watershed. ' 503m, PEROQ=CN ZEST DATA ,RDQ mm- To Be SUi iITI ) WITS APPLICATICNS Date of 1>4:e-Sqa g 8. S-A Be Date of Percolation Test 8. zs •86 HOLE �. . NUMBER CLOCK TIME PERODLA-TICIN PERCOLATICN .. Run Elapse Depth to Mater From Water. Level ; No. ''Time Ground Surface In Indies Soil Rate Start -Stop Min.. ' Start Strip Drop In Min/In Drop ' Inches Inches inches • 1 8:00 - 2 g:z� -9spo 33 Z� 2 1 3 1\ 3 oo Zq Z1 3 tz 2'7 3 I Z 5 �o;lz- to qa 3�' a,A 21 IZ 1,B; to - 8 40 30 ?_q 21 3 10 2 g :4o - 8 i 33 3,:13- `:j :49 3Cn Zy 2l 3 tZ Q o' S 3 - 5 io 25- 1 I.oI 3(0 24 ZI 3 I L Tests to be repeated' at same depth until. •approximately equal soil rates -- - are'obtained .at each percolation test hole. All data to* be .submitted TEST PIT DATA, REZZU D TO' BE 'SUBM'I M WITH APPLICATION . DESCRIPTION OF SOILS ENOOONTERBD IN TEST HC]ILFS DEPTH HOLE • ND. I HOLE NO. • 2 HC LE * N13. G.L. 1' TO F'SO l l_ 3' 4 ;. G.W. 51 6; .71 ' 9' ' 10, 11' 13' 14' INDICATE LEVEL AT WHICH GPMNDWATM IS ENOOUNT'E RE ' 7' INDICATE LEVEL M WHICH WATER LEVEL RISES AT= BEING ENUOUNTERED DEEP' HOLE OBSERVATIONS MADE BY: S Mme. DATES - -- DESIGN Soil Rate Used 'n-v5 Minti/I" Drop; S.D., Usable Area -Provided 9 No. of Bedrooms' •q Septic Tank .Capacity ,ZSO gals. Type Absorption Area Provided By com L.F. x 24" width -trench gther D r r'= Igu-ri of.7 F3ox� 3 1Z 0. 1=1 L.` C`17'3 C� �c�> Name , ��_:..H„a <_, �� . �. Signature Address OUTS 6Z i SEAL Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORI.TE aVNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY }[DILTH DEPARTMENT TO: Commissioner of Health - In the matter of application for I' 41 161-4 � l%- I-- cc -� - -- : — — — — — — - - — — - represent that I am an officer or employee of the..corporation and am authorized to act .for _ _ 1-,L0 � ts! T- C�550�iu1-71e , _ _ _ — — — — (name of corporation) _ — having offices at — /O ieG -mow -- --- - --- -------= —'_ --- - - - --- _Whose officers are President —%� ivy e . n., —ICA4C e4, _%D 40rK� _ c_v/Zo(_ _ (NWme and Address) V4.^ en t iv7 1,9,V �_ (e L4 e c r 3 &1,'ji3_etc t z,4 (t,),q Rye 0 . Secretary _ _ — — — — _ _ (Name and Address) _ Treasurer _ _ _ — — — — (Name and Address) — — and that Ham and will be individually responsible for any or, all acts of 'the corporation with respect to the approval requested and all siib- sequent acts relating thereto. _ Stvorn4toefore me this _day Signed of 19�Lj Title Nb farY/Publlc KELLY H. WILSON NOTARY PUBLIC, NEW YORK STATE No. 4862845 QUALIFIED COMMISS ON EX EXPIRES 7 21jU Corporate Seal I I r � x' �� w . -,..��.{ ; Y �.A' .bous.. +�n 1 � � "'G. 1, T . J. r+ 4 4`*' � ..s ? � ': , . i• � ea x �#, ' . ,f -i . . ea t� . � ..-. z+v4,^.cv- i'� s !3 `° t r . ^"`u'r,.a,, , .� ,. t 7tk , r k r �. _ 5 -.# II I HOOSE I F CLEANOUT r CLEANOUT f 6� ANOUT TS� GAL. SEP NK L } ; h i B j? A LO CAT.I ONS A to D- 118' B to D- 102' A to E- 1 17 B to E- 103' AtoF - 115 8 toF - 105' A to G- 1 1 3' 8 to G- 10 7' A t 0 H - 112 8 to H -- I10' A to I- I 11'. 8 to I- 113, AtoJ - III' 8toi- 116' A to K- 110' 8 to K- 1 1 9' A to L - 70' 8 to L - 56' A to M - 59' B to M - 79' A to N - 162' 8 to N - 165' A to 0- 1 64' 8 to 0- 1 52' E to K 56, S to T - 34' S toU - 46' WtoY - 66' W to Z - 85'