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Home My WebLink About0178DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 4.10 -1 -16 BOX 3 r `0 , �0 �. -' ,L L P, 00178 Water Supply: Public Supply From Address do or: Private Supply Drilled by Address. Building Type t ~�� Has Erosion Control Been Completed? ,Y �^ Number of Bedrooms Has Garbage Grhider Been Installed? N17 Other Requirements I certify that the system(s)"as listed serving the above premises were of•which are attached), and in accordance with the standards, rules and Putnam County De artilel[ernt Of Health. Date l Q� C Mied by Address z I Z as shown the plans of the completed work.( copies nce ith filed plan, and the permit issued by the P.E. R.A. 4s'►viN!( NJ License No. ' 3 73 6 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary s ,,conditions resulting from such usage. .Approval of the separate sewerage system- shall.become null and void is-soon as'. a pub(': sanitary sower 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 Commission rr of Health.. such evocation, modification or change is necessary. Date! %! v, M" rT . 4. vi - .. r_ `CN 4H rim a C�rz sut-Dr7islcm rar 9 iA- DISPOSAL P = - =_ a- �'*z: area lc=- t=--4 as Fir a=- r; --ye: I..1ans I b. f_ 1 y�acCLic-n - Eat-= of �].� acan. =_*1L 2: ? •r ri? �r Ll xic- DPTH I '� C_ 11c- ':Lr�� SC L_ P_CL. c- �1?✓C�. I �' d bra_ e C± tar t�Z 13' t =an SDS E_ ,��_- �►- e- 100 ft_ cCUrs =_icYe =a* C_ I,�f— F..eLtiC i _ =k S: -_ - 1 / 000 La. c_ lr' =' iiL'u __ C. 40u I✓�an�_, C_-= Ct L Wl_rl? 113 Z__ CL Cc, hend 1 `L11 c,, c-= at i=CSz — 3 - �c_.ve = ^_ CC i ar- _ C r rf-_ - ^ c L' : C_:1 =_ SIC-1Z cf 20 �< i D=C=: C t--=—=H 30 i,c eS ME= s" =aC - v -r ° SiZe Cf c a e l 3/' - :� Cia ---- 1'i _ F _ ^•• OR EC:S ^_ J 2. I I e- 5'i cC"-- =.D1 °_ IM ! - t-0 hcx 6. C:c1= w_= = =__= cc Gc__i th e �iTic�c = C'ti Ce_r CrC_E rl I I G_ G��C� 1c%.. =:.�' C� G_C'r•CC�ri1G:S I �, WELL. .-• c_ GYM: 1C=—L=- c- 1'_r cC^.rC'vc= D i _nS C- C_S_nc 13" CCcGc_ a_ C_ < e_ r1 =a aCCCr� c �� r. L= T? Qi�_ 1 C.r:t�= & d_ -to c :- C c-:-SC^_- T•ce aSgai t :r= S2. S a--- h_ S - --c= C_- -1c_ Cn S cces cr- - -`-•r t:t t -- - n.nn n n 0/ noYAA I1aI%f% O nnnJI..,11.1 _ I Irs� ov j QL614�', Cli& U-1/ f PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEMAL HEALTH SERVICES Owner or Purchaser Building 5&D w yvQ r Building Constructed by ,5 C� J� Location - Street `�pp �ctyCrz, �J Municipality Building Type. IL j .2 Section Block Lot ? i 's Subdivision Name a• Subdivision Lot # GUARAN= 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 cood 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 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 occupant of -the building utilizing the.system. The undersigned further agrees to accept as conclusive the determination of the Director of {;:he Division of Envirorurental 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 is ) day of c�1a�c� h 19eL �� _ Geri al r (Own - ignature Corporation Name (if Corp.) Address 4:4. rev. 9/85 mk ` P27,7 Signature i Title Corporation Name (if Corp.) KI-t R�cx, (3,7 Address wce*�y5cm I AW a .e WELL CUE1rLbT1UA rcr•rUAI DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION._ STREET ADDRESS: WNIYIL l IT TAX GRIO NUMBER: 3 WELL OWNER ME: AO 5S: , /oS�d��3 ❑ PUBLICS USE OF WELL 1 - primary 2 - secondary ® SIDENTI ❑ PUBLIC UPPLY ❑ AIR/ CONDAEAT PUMP ABANDONED ❑ USINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT -5 gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE _:c0 gal. REASON FOR DRILLING CR NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH �O ft. STATIC WATER LEVEL -�S ft. DATE MEASURED 3 DRILLING EQUIPMENT fa ROTARY ❑ COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. JO OPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH ft. MATERIALS: STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 3 '� ft. JOINTS: ❑ WELDED .9THREADED ❑ OTHER DETAILS DIAMETER in. SEAL: ❑ CEMENT GROUT ❑ BENTONITE .® OTHER WEIGHT PER FOOT 1.7 lb.,/ft. I DRIVE SHOE: EYES ❑ NQ I LINER: ❑YES JRNO DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (f t) DEVELOPED? SCREEN 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: ❑ PUMPED i tests were done is in- ® . COMPRESSED AIR , formation attached? BAILED ❑ OTHER ; ❑ YES ❑ NO It more detailed formation descriptions or sieve analyses WELL LOG are available, please attach. ROM CE water Bear- ing welt Ola- meter FORMATION DESCRIPTION CODE❑ it. WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD BCm. Lana SuA ace l l� /„ At WATEP ❑ CLEAR TEMP.. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES 0 NO ANALYSIS ATTACHED? ❑ YES e ONO STORAGE TANK: TYPE k4zx CAPACITY / 'YO GAL. PUMP IMF RMATION ,. TYPE/ '� '�� CAPACITY MA EA DEPTH MODEI L1.1Q 7` ,, VOLTAGE ZIL HP =f, WELL DRILLER NAM s �, / ��rr— OAT O Q AOORESp iIkTURE /�S ✓, Yorktown Medical Laboratory, Inc. 321 Kear Street Yorktown Heights, N. Y. 10598 (914) 245 -3203 Director: Albert H. Padovani M. T. (ASCP) r 50 ..-I S' i�41 Cf7 LAB [CW N ,HerJe'] Date Taken: �n Date Received: 2 LC �• ^ Date Reported:_ Z Collected By: Referred•By: Sample Source:_ LABORAtOR1 xzrvxt ON THE QUALITY OF WATER INORGANIC NONMETALS (In mg /L) MICROBIOLOGICAL (per 100 ml) Acidity: To pH GENERAL BACTERIA — _ Alkalinity: To pH 5• Chloride _ Standard Plate Count per ml _ _ Detergents, Anionic (Agar plate 235 °C) Hardness, Total _ _ 'Nitrogen, Ammonia MEMBRANE FILTRATION TECHNIQUE _ Nitrogen, Nitrate / (I _ Phosphate, Total. Total Coliform Sulfate _ Sulfide Fecal Coliform _ Sulfite _ t _ Fecal Streptococcus METALS (In mg /L) MOST PROBABLE NUMBER TECHNIQUE _ Co per _ Total Coliform Iron _ _ Lead Fecal Coliform _ Manganese Mercury Sodium REMARKS (For Laboratory Use Only) Zinc MISCELLANEOUS ANALYSES _ pH (units) _ Color (units) _ Odor (TON) REMARKS (For Collector's Use) _ Turbidity (NTU) a, c leas than / TNTC = Too Numerous To Count / CON = Confluent THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO TRf_NV YORK STATE DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE T7(NI COLLECTION. THESE RESULTS INDICATE THAT THE WATER (DID) (DIDN!T) A)' E ET THE SAT- ISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK DRINKING WATER STANDARDS, FOR T,.HHE� PARAMETERS TESTED, AT THE-TIME OF COLLECTION. / N/A �z not applicable I. R w. , PAFtA 'li7N ISTANCE,S IN FEk , r M IS /6 . li .. is Fl,.. Xo , 2f 7 56 fs5 'fit 4b` ss 54 6 72 yq . 3 S7 'f,L 'l! 78 • 6 't�3 54� o.. 44 71 IV 41 70, . Y•, _ , r PUTNAM COUNTY DEPARTMENT OF HEALTH NOO o l 9 0 -19 COMPLAINT OR SERVICE REQUEST RECORD TOWN pATTEg ON DATE January 2, 1990 REFERRED TO Bill Hedges TAKEN BY Bill Hedges TELEPHONE CALL IN PERSON LETTER CONFIDENTIAL REQUEST FROM Ken Dixon TELEPHONE 8 78-385 2 ADDRESS South Quaker Road, Patterson, NY ENVIRONMENTAL HEALTH: Home Sewage Rodents Refuse Public Water Food Service Migrant Camp Other COMPLAINT OR REQUEST New House ( 2 years old - P -43 -88 - built by G. Megline Sewage disposal system failing.. DIRECTIONS: Rte 22 to 'wSouth Quaker Road. Approximately 1/4 mile on left. ACTION TAKEN BY �.ac� DATE FINDINGS FOLLOW UP INSPECTION (s) DATE FINDINGS DATE FINDINGS PROBLEM ABATED DATE PERSON NOTIFIED ESTIMATED TOTAL MAN HOURS SPENT `Z 77 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF'ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of 1N�rrx:riun Orig. Routine Orig Canplain ADDRESS �� fl �� cT ��'." v �� Orig. Request No. Street Town TM No. _ Cmpliance MAILING ADDRESS � "'" - 5 _ Final nain t Carp P.O. Box Post Office Zip Code Group Illness TELEPHONE .PERSON IN CHARGE �- �. OR INTERVIEWED Name and Title DATE l 3 C TYPE FACILITY TIME ARRIVED //TIME LEFT /11 INSPECTOR: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: Construction Reinspection Field, Sampling Only Field Conference Other 74,—x, � TELEPHONE: c Explain PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Cc missioner of Health - FIELD ACTIVITY REPORT - Sheet 4— of ADDR MAILING ADDRESS P.O. Box Post Office Zip Code Orig. Routine Orig. Canplain Orig. Request Canpliance Canplaint Camp _ Final Group Illness Construction TELEPHONE R:einspection PERSON IN CHARGE Field, Sampling Only OR INTERVIEWED Field Conference Name and Title Other DATE 3 �� TYPE FACILITY /-L",,( TIME ARRIVED TIME LEFT ) `. z% Explain FINDINGS: INSPECTOR: TELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: PETER C. ALEXANDERSON r County Executive - I DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route . Six Center, Carmel, New York 10512 (914) 225 -0310 CERTIFIED RETURN RECEIPT REQUESTED --- - - - - -- - - - - -- - - - - - -- --- - - - - -- Kenneth Dixon PLEASE REFER CORRESPONDENCE TO: Quaker Hill Road MANE: William Hedges Patterson, NY 12563 TITLE: Public Health Sanitarian PHONE: (914) 225 -0310 ext. 319 DATE: February 2, 1990 JOHN KARELL Jr., P.E. Director OFFICIAL NOTICE OF NOR COMPLIANCE YOU ARE HEREBY NOTIFIED that non - compliance with Article III Section 3 of the Putnam County Sanitary Code where evidence of sewage, discharged from the vent pipe onto the surface of the ground was found at your residence, South Quaker Hill Rd., by a representative of this Department on February 1, 1990. Your sewage disposal system is protected by a Guarantee of Subsurface Sewage Disposal System' signed by Gary Neglino and Alan Smith on Harch 1, 1989. Copy Enclosed. Please be advised that appropriate steps must be taken immediately in order that the sewage overflow .cease by.arranging for the septic tank to be pumped out and maintained pumped until the proper repairs are ,made to the system. " = Approval of proposed repairs must be obtained from.this Department.prior to any .alteration of rebuilding of existing disposal systems. An application is enclosed.. Failure to pump the septic._ank by February.9, 1990 and further, to correct this condition by February 23, 1990 will make you liable for additional penalties provided by lad, including prosecution'on a charge of committing a violation punishable by a fine or imprisonment, or both such fine and imprisonment, as prescribed by law in addition to such other action as may be prescribed. A reinspection will be made. It *s sincerely hoped that the above- mentioned further action will not be necessary and that you vill. cOOperate'by securing -the correction Of this condition: For The Public Health Director Very truly yours, Johrr C3 Di 4ctor, En ronmental H Yt h Services IK/WH/jp By: William Hedges mc: Permit Application Public Health Sanitarian Guarantee of SSDS :c:,BI (T) Patterson -Gary Heglino, 73 Spring Road, Scarsdale, NY 10583 Alan Smith, RR 04 Box 137, Birch Hill Road, Patterson, NY 12563 PETER C. ALEXANDERSON County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 CERTIFIED RETURN RECEIPT REQUESTED PLEASE REFER CORRESPONDENCE TO: Kenneth Dixon MANE: Uilliao Hedges Quaker Hill Road. TITLE: Public Health Sanitarian Patterson, NY 12563 PHONE: (914) 225 -0310 ext. 319 DATE: March 21,, 1990 a JOHN KARELL Jr., P.E., M.S. Public Health Director OFFICIAL NOTICE OF ICON COMPLIANCE -- - - - - -- - - - - -- -- - -- --- - - - - -- 'YOU ARE HEREBY NOTIFIED that non - compliance pith Article III Section 3 of the Putnam County Sanitary Code where evidence of menage, discharged from the vent pipe onto the surface of the ground pas found -at your residence, on Quaker Hill Road, by a representative of this Department ,on March 19, 1990. !It is believed that you are responsible for correction of this condition. If you are not responsible, you are requested to notify immediately the inspector above indicated.. Please be advised that appropriate steps must be taken immediately in order that the sevage overfloa cease by arranging for,t.he septic tank to be pumped out and maintained pumped until the proper repairs are made to the system. Approval of proposed repairs must be obtained from this Department prior to any alteration. of rebuilding of existing disposal systems. An application is enclosed. Failure to pump the septic tank by March 30, 1990 and further, to correct this condition by April 17, 1990 mill make you liable for additional penalties provided,by lan, including prosecution on a charge of committing a violation punishable by a fine or imprisonment, or both such fine and imprisonment, as prescribed by law in addition to such other action as may be prescribed. A reinspection hill be made. It is sincerely hoped that the above - mentioned further action hill not be necessary and that you bill cooperate by securing the correction of this condition. For The Public Health Director Veyy tr y y rap 0 ohn Kare , Jr. p P. E. . Director, Environmental Health Services JK /WH /jp By: William Hedges enc: Permit Applicaton Public Health Sanitarian cc: BI (T) Patterson Gary Meglino, 73 Spring Rd., Scarsdale, NY 10583 Alan Smith, RR 34 Box 137, Birch Hill Rd., Patterson, NY 12563 1 1�Li1N ,S�DFPFitDEPARTMEW OF . Paovld® ` - bo Peemdt d' r g ? " os CE�1ICAR� OF COANCE kl .,• �RISdi� ®Pd ,�.. _, . �ID� $_�®YA�'�Li7P��, $�'. ., _ �...: ... , m ?.� A • .. APPENDIX B ' Pr I4 CCTRgP` ' - DEP-AM= OF HEALTH - DIVISION OF RZ=ONM 2ML HEALTH SERVICES R IhD' I4r -DC1AL 4yATER SUPPLY & S'JBSuTF?CE SSZAAAGE DISFCSIL SISTLMS REVT—FTX S'riEL'I' - CONST=ION PERMIT BY: (Street Lccsticn) ;= -- CC. fS ( YES NO DCaN& RU'S Per-ait A-ppli.caticn Corporate Resoluticn%� ' Plans - Three sets s/s I --- Engineers Authorization I Design Late Sheet (:,)CS) SurDIVISICN, I �--1-- I Deep Hole L- Pzrc 7 C I I—� C--nsiste_nt Perc REs;:ltc (3) Fill s, i I Pe_rc Hole Depth C -7 P.1 ans - T �o S=4-- per i Variance Recruest I. I Le--al S,divisicn Sai-di Asion A - p p r c v a , ae=sed .-- i —r--°- I Es- acprcval SSDS Pte;. Lots Che--ce� .f . -- I �. - {--- -- We -i and (Tcw-n/DEC Ps i = R & D) -y �. I I a - D . On DDS Plans & Pe�-ai= Same i=' �-ch pr: v_c I I I REQL?RD DETA c CN FLANS Se.Tage Systsn Plan (or `z ar_ zw) ,..- 60 ft. Cc.r -ge SJS t a-n ^VC -till is Profile - Cr v-* =i F'c F� X1_1 to ccn ours I f%'I` I Fill "i le &1 DiT�ensicns - Voit = - r"%' / 100 � emp I ^ I D ot� %Tr nch /Ca11 pry; Pump pit ceta_ls Septic Tank - Size, Dr` i1 We11 Detail, Service Line if over Ccnst_ructicn Notes (grinder rte) 0 1-7 Data: pert and deep ressl __ ¢.--. Twc -Foot Contours Existing & Pr;:ccsw G{- — Driveway & Sloes Cut I <' — Foot?ng/Gatt`r,0.s-L,---in Drains (discharge OK) Perc & Deep Holes Lacated FT SYSTEMS ,� I Representative of prima--y and e- <- -ansicn ' c barrier I i°"" I Exp nsim Area'; shown; gravity flt-w, saf . size s. 10 ft. not =s ' I Pitt &,—D 4Box -xS:zcvn & Detail—A. Hous2�No or P.iroaris . _ _ �. neY ( . ehle "S S in 2 f Hof Prcccs i Svst� ' s w/ v00 . der t'1 c uceS *' I Prcoe._ ty M_°_tes & Sour_ds Hour` Setback Necessary (Tight let) House Seger - 1 /4" /ft. 4 "0; Type pipe 100 vr. fi elev. I �f " No Bends; Max. Bends 45° w /cleanout SEPARATION DISTP�NN=- SPECIF= CN PL•ati Fields 10' to P.L., Driveway, Large Treez-joo of f -- 20' to Foundation Walls 200 ft. reservoir, e 100' to Well; 200' in D.L.O.D, 150' pig ,. 100' to Streann, Watercourse, Lake (inc. ec-- 150 ft. tricall /gall.' �j J 15' to Drains1%rtain, Leader, Footing 35'to catch basin,stor:ndrain,yiced waterccL 10' to Water Line (pits -20 ` ) 50' intermittent drainage ccurse Septtc 'hanks Y 10' fran Foundation; 50' to will �°I 15' Well to PL 9 'I I� APPENDIX B PIjiUPu CCUNT"_' DEPARM= OF EEAL,H - DIVISICN OF EN=Zff • HEPLTIi SERVIC"S D017 11D AL WATER SUPPLY & SJPSb -RF3(r DISrCEAL SISTEZAS R=9 S= - CONSTFCC'PION PEPMTT DATE RAJ_ OD: Lcc.ticn) ( CCC'.I^�7I5 I Pe-rmi t PmDL i cat i cn Corporate�Resoluticn Plans - Three s`_s E::gLrie rs puthor? z =ticn i Design Data sieet (ACS) Su�D1t7IS�C'ti Dr=r Hole Log C_^nslsr?nc Perc. Res. __ I Pe_rc Hole Cepth c.7 ans — T6.vo se _= I variance Re.._uest Si?tvi sicn ., I Suci.�risicn Pypro�a= C-_�.c�,e� I E s -az_ rcval S SDS P-- Lots C' .eC Stiet2 � " -d (Tcry - /DE: Fa=it R & D) Data Cil DC'S Plans & Fe_: �i = Same CN S:F vace Svstam Plan I Se.��c2 S st_z =lrcre �� is P-cf i l _ - G =_V I Fill Wile e &L D= :ce 1� =CnS - Vol = - I D o�,':'r�nCZ /C�llE =�; Per+ p' e de--,,, i Septic Tank - size, ce=ii cve_ `�%2 -% v I We l! Derail, -e_-Ac= Line if _ 1 Crnst_ructicn Notes (crinder rte) D =sicn Data: z:---c and deep 1 TtvG�Foot Contours Existing & Prc_resaa Drive.Yav & Sloces Out FootL n�Gatter, C� main Drains (discZar a CK ) Perc & Deep 'Holes L.^cat Representative of and Er.�zsica Expa-ansicii Pse? ; s hcw-n; c r i . size GV1tY flc .V, s - i - & D--+-= ile _ or Eedroan - ':.._. Eousa No s s• w iii 200 f'�of r_,.ccsed Svst= Prc�* .Y �teS & Bounds House SEt. ack Necessary (Tight lot) House Suer - 1/411/ft. 4 "0; Tyge pipe No Be_*-.Lis; Ma.Y. Bends 45° w /cleanout SEDMRP.TICN DISTP \C—Eq SPEC?'= CN P=N Fields 10' to P.L., Drive°Navr large T? a=--s,TC_o of i 20' to Foundaticn Walls 100' to Well; 200' in D.L.O.D, 150' Pit 100' to Str -an, wat= rccurse, IZ<a (inc. 15' to Drains -Oirt -a n, Leader, Footing 35'to catch r basin, sto tr'_rain,oi ced wat arc=: 10' to water Line (pits -20') 50' tt=T:t drci 1ZCEi CCL:r =c SenLC T-rik5 10' fran Founda- ticn; 50' to will 15' well to PL (Street CCi�IS I YES I NO I °ter �}-- I I GL i �t'�- I --- /... EO = t. era:;. I LO ccatoL'ir s.i' I f^' - 100 = Et I I LL^ !'{` lam-• of I 1 4, G}-- t I I T � C' C?'w!,1C F I- - IS I C -vcarriar I !-f —' I 10 f z. I -I . --1,714 - ..riot =s --V _ , `' r ' I it, R�, t5 yY �- - y f` _..i I depth cauces I n - 100 vr. fl elev. I '` "- r, 200 ft. re._a -voi_ e_c. .�E 130 ft. t_ical l /call. _ ter. I 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 Stree Ad re s � T %1 aU 1 141 Town Vi g$e City Tax Grid Number . 4 t- WELL OWNER Name p y mailing AddressL 4 Gprlvate i1 �`�- ❑ Public USE OF WELL 1 - primary '2 - secondary EM19SIDENTIAL ® BUSINESS ® INDUSTRIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP 0 ABANDONED ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify O INSTITUTIONAL ❑ STAND -BY_ AMOUNT OF USE YIELD SOUGHT io %i0% i3, gpm /1/ PEOPLE SERVED -' /EST. OF DAILY USAGE ;;CICi gal REASON FOR DRILLING Uqm SUPPLY ❑REPLACE EXISTING SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY (3 TEST /OBSERVATION ❑DEEPEN EXISTING WELL .DETAILED REASON FOR DRILLING WELL TYPE RILLED DRIVEN ®DUG ®GRAVEL ® OTHER IS WELL SITE SUBJECT-TO FLOODING? YES ---'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION.: � ;� t:., tr:• Lot No. WATER WELL CONTRACTOR: Name Address IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES :/ NO NAME OF PUBLIC WATER SUPPLY: �% ��} TOWN /VIL /CITY A DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION SEP TE S 1, i i zi�'l h (date (signature PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well asset 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 provided by the Putnam County Health De artment. Date of Issue: 19 195 Permit Issuing ffici Date of Expiration-e-" Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller ;% PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF EVVIRCNMENTAL HEALTH SERVICES DESIGN DATA SHEET-SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Address Located at' (Street) A4 t� Sec. G Block. 2- Lot (indicate nearest ,*cross .street) Municipality 15a,, Watershed SOIL PERCOLATION TEST `DATA REQUIRED TO BE SUBMITTED 4= APPLICATIONS Date of Date of Percolation Test 42Z- HOLE NUMBER CI= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches 3 1 2 77 1 3 Zci 27 3 t 4 2 -Z 7 3 5 1 2 Z7 3 13 3 % 2y. 2-7 4 13- 5 2 vlz= 10 NOTES: 10-- 'Tests.:-to be repeated at same depth until approximately equal soil rates are obtainedat each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. _ HOLE NO. G.L. 2' 3' S��-t 6' 7° 8' 9' 10' 12' t 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED 01A DEEP -HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used if -IS Min /l " S Z :Drop: S.D. Usable Area.Provided ,opo ~ No. of Bedrooms ; 3 `� ` Septic Tank Capacity gals. Type cd-.ty Absorption Area Provided By `r37�' L.F. x 24" width trench Other Name Signature' AN- Address SEAL loe_\5o� -411 No. 4 31''6 sTF�F THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date C GSDS Ms i I ex PER-001 tr 7— < DEEP I G) WELL 0 0 0 SEPTIC JUNCT %0 proposed l bad,00m esidence ff r-30, propose S Zi- 09-33 w SOUTH QUAKER HILL ROAD