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NAM COUNTT DEPARTMENT OF:HEALTH
R v. 3/ 6 04; °°. Dlvlslon of Envlrom» ental Health Services, Carmel, W.Yi 10512 ' =
6 Engineer Mast Provide 4 g 7
Permit H
CERTIFIC :OF CONSTRUCTION. COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM �o t;�Y. S.6 rl.
Town or Village
Located stA / a'.a?t1
Tax' Map 1 Block J Lot, 1
1� soh t 5 �. f sse C • Formerly Subdivision Name `^ ..er Sabdv. Lot'q 2
Owner / applicant Name Y
Melling Address P.0 _ P Date Permit Issued
T'h lu V
Separate Sewerage-System built by 5 c: it rct r\ Address 40 Pe vv ti. I 7 CT J� .
Consisting of ' I Lam. Gallon Septic Tank and F t ! d S
Water Supply Public Supply From Address
` or. K Private Supply DrWed by fa r I i S' h Address A M on
r
Building Type '1 mdr Has Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?
Other ReWrementa
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'standards, rules and regulat ns, in accordance wit4 the filed plan, and the permit iss by the
Putnam County.Depakttment.Of Health. %
1Ll 3 ITT P.E. R.A.
Oats a- Certified by
Address l�Xr Aht; - h t [erne• / i v5 PG eoyk— LZ a � Licence No. ��
Any person occupying premises served by the above system(s)',shall promptly, take "such action as may, be naassary'to secure the correction of any unsanitary
conditions resulting from such usage.. Approval of the, separate sewerage system shalt become null and void as soomas . a puW?. unitary sewer becomes
available and the approval of the private.wetar 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 'CorrimissioneL.of Health, such revocation, modification or change Is necessary,
Date
CH
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wr.LL l"VlirLC 11V1V icr.rV�i
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use OnJ/y
1
WELL LOCATION
STREET AOURESS: WN /VIL / IiY TAX GRID NUM1iER:
Nnn '�T'f d�.�
WELL OWNER
ME. I N Cel ' W
ADDRESS:
0 �� d`» tJ
p PSIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC 9UPPLY O AIR/CAD./HEAT PUMP ❑ ABANDONED
O BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT J gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
NEW SUPPLY ❑.PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL JA I
DEPTH DATA
WELL DEPTH �� ft_'
STATIC WATER LEVEL ft.
DATE MEASURED 7Ab
DRILLING
EQUIPMENT
❑ROTARY %& COMPRESSED AIR PERCUSSION C1 DUG
❑ WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. __*SOPEN HOLE IN BEDROCK O OTHER
CASING
jFTAII C
TOTAL LENGTH __3 ft.
MATERIALS: �& STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE J ft.
JOINTS: O WELDED iS•THREADED O OTHER
DIAMETER in.
SEAL: El CEMENT GROUT O BENTONITE '&G-THE-
WEIGHT PER FOOT — Ib_ /ft_
I DRIVE SHOE O YES NO LINER: 0 YEs"sVo
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
SCREEN
DETAILS
FIRST
O YES ❑ NO
HOURS
SECOND
GRAVEL PACK
O YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST pumping
If detailed
METHOD: O PUMPED i tests were done is in-
COMPRESSED AIR , formation attached?
❑ BAILED ❑ OTHER ; O YES ONO
1�lELL LOG if more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
water
Bear-
in9
Well
Oia'
in
FORMATION DESCRIPTION
CODE
It.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
Land
OL A 1�
WAM N CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES. ❑ NO
ANALYSIS ATTACHED ?�S YES O NO
``
STORAGE TANK: TYPE" U*
CAPACITY W', L,)- j rOL ` GAL.
PUMP IH HMATION /
TYPE C ) r5 )� I � CAPACITY ��
MAKER �7 ,Q f5 DEPTH.�'L'�
MODEL { VOLTAGP L- HP
WELL DAI LER AME - OA E "
Ao0f�E5P � S�� '�`� SIGfJ3tTUR a
`l' ` N' N \ �C/l�i•( ��r
r
Yorktown Medical Laboratory, Inc.
321 Kcar Strcct
Yorktown Heights, N. Y. 10598
(914) 245 -3203
Director: Albert H. Padovani M. T. (ASCP)
F
TORLISH WELL DRILLING
PO Box 271
Armonk, NY
10504
L
° -
Sr:
s1-,
LAB NJ}`A�,s {
Date Taken: al Time, °;.
Date Rc'd: ab Time;. -
Date Reported: P• 2A 1m
Collected By: Duane Torlish ; 4
Referred By:
-1 Sample Location:
Phone N 273 -3448
Phone d
J Repeat Test? _
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /100mL)
_ Acidity
Alkalinity
Chloride
Detergents, MBAS
_ Hardness, Total
_ Nitrogen, Ammonia
Nitrogen, Nitrate
Phostihate,. Total
_ Sulfate
_ Sulfide
Sulfite
METALS (mg /L)
Copper
_ Iron
_ Lead
y Manganese
Mercury
_ Sod'ium
'Lint
141:1 CE1,1,ANE011!1
pll (unite)
Color (units)
Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA
-L�LE
fl_�Standard Plate Count
15
(CFU /1.OmL)
_ DH
- MEMBRANE FILTRATION TECHNIQUE
Total Coliform
C
_ Fecal Coliform
GE 12
_ Fecal Streptococcus
MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR TERMINOLOGY
N/A = Not Applicable
LT = Less Than (<)
GT = Greater Than ( >)
TNTC= Too Numerous To Count
CON = Confluent ( =TNTC)
NR = Non - reactive
REMARKS /COMMENTS (For Lab Use)
Sample Type:
(check one)
A""—Pot ab1e
_ Non- notable
_ STP INF
_ STP EFF
Other:
Sample Status:
(check each)
Outgoing
- HNO3
_ HC1
H2SO4
NaOH
ZnOAc
Na2S203
Other:
Incoming
-L�LE
4 °C
_ GT
4 °C
_ DH
LE 2
— pH
GE 9
_ pH
GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T E NY YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED, AT THE E OF COLLECT
THESE RESULTS INDICATE THAT THE WATER SAMPLE (DID) (DIDN'T) (N /A MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK STA D NKING WATER
CODES, FO T_HE AMETERS TESTED, AT THE TIME OF COLLECTION.
/x/ ` "Vim _ 2 /86(Rvsd7 /87)RWE
APPENDIX I
PUTNAM COUN'T'Y DEPARTMENT OF HEALTH
DIVISION OF ENVIRON ENTAL HEALTH SERVICES
Owner or Purchaser of Building
Building Constructed by '
M✓arjov2 E2,::Yk .
Location - Street
[)A —rest 50AJ
Municipality
Res.
Building Type
i l l9
Section Block Lot
Tax Map Number
Subdivision Name
Z5
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEMI GE 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 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 the Division of Environmental 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 day of 19 Signature
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Title A5 ,
Corporation Name (if Corp.)
Address
16
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BY:(C`_
Location) _
DOCMEMS C �
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log �` Perc p
Consistent Perc Results (3) 0 Fill --
Perc Hole Depth cd
House P1 Two sets
Well '=permit; PWS letter
Variance Request
1 Subdivision
S 'vision Approval Checked
Ex -a proval SSDS Adj. Lots Checked
Wet and (Town /DEC Permit R & D)
On DDS Plans & Permit Same
UIRED DETAILS ON PLANS
Sewage 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
I Well Detail, Service Line if over
Construction Notes (grinder rate)
Design Data: perc and deep results
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Foot.ing/Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area; shown; gravity flow,suff. size
If Pied Pit & D Box Shoran & Detailed
House -No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Serer - 1 /4 " /ft. 4 110; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains - Curtain, Leader, Footing
35'to etch basin,stormdrain, piped watercourse
(Name f er)
9UMM NM
(Street
YES
NO
V
�,
j
LF trench provided
required 7 2 z-°
60 ft. max.
Parellel to s
3: a @%-eX7.
t17 Al �-
FILL SYSTEMS
cla Barr'
10 f
fill nVes
new s
deptlY ga es
100 fl elev.
V
200 ft/ re ervoir, etc.
150 f t.ri ll /gall.
10' to Water Line (pits -20')
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL 9
1
.0mu u _:. - --. — _ Town or :Vgbtg - -
SubdhMm'Nime' FATRV'T,FW.MANOR 'Sum.icti 2.5
T" h up 1- t :1 Let -19
m —
Homes' .. ite Associates ��--o x� -❑
Owner /Applkwut Nae . - .� ,� .. .. .
Date of Previous Approved
i�,�gAaa sa P.0. Box 285: Town T brnwood, NY 10594.:
ZIP
Building Type,- Single Family rot Ares 3'.01 Acres
FM Section On1Y Depth volume '
Number of Bedrooms . 4 Design Flow G P D 800 PCBD NotlBcatlon is Required When Fig V completed
Separate Sewerage System to consist of 1250 GaOon Septic Taplt and 889 L . F x- _ 2411 Tile : F i R 1 ii s
To be coistrie ea:hy To be determined
thin-
Water SaPPb". *uc Supply v iom Address
err X. Pelvete Supply Drilled by To be detLrdmdiddrew - ...
Other Requirements
1 represent that 1 am wholly antl completely responsible for -the design and location of the proposed systems) 1) that the .separate iewaye disposal system
above described will be constructed as shown on the approved amendment thereto and 'in accordance with the standards, rules an regu a ions o e u nam
County Department of Health, antl,that on compiet ion thereof a ^Certificate .of Construction Compliance`' satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a' written guarantee wiil. be furnished the owner, his successors, heirs or assigns by the builder,.thatsaid builder will
P1040 in good 0' ' . inq condition. any �pbrt of said sewage disposal system during the period of two (2) years immediately following the date of the issu-
ante 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 shaiWn on file apOrovaei plan.and that said well will be installed in accordance IM the standards, rubs and regu a— T'iTons of the Putnam
County Dep rtmentt of Health.
Date Signed IlT18 l P.E.. X R.A.
Address for Baldwin & 80ITl 1'US,P.C., Rio.6, Rte .22,B'tWSter:,NY10509 Iconeb'No ' 43791.
APPROVED FOR CONSTRUCTION: This approval expires two years lrom the tlate issued unless construction of the building has been undertaken and is
revotaDle for-cau or may be amended or.moditied when :considered necessary -the ommissioner of Mellth.. Any change or alteration of construction
requires now ermit. pr ved for disposal of domestic sanitary way and /or a e a p onl .- C;���l '
1,187 Date v BY n %'
Title _//
AI 1W.
;� POTNAM C=M DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
AFFIDAVIT- CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO Pu`IRm mum HEALTH DEPARZMEur
TO: Camnissioner of Health
In the matter of application for:
I► Anthony J. Amirurri
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 HOMESITTE 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
(Nam 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 subsefftlent acts
relating thereto. `
Sworn to before me this ��I day Signed:
of ° 19 6 Title:
BETTY L. ESPOSITO
Notary Public, Stale of New York
No. 4--,':(33"13
oaalified la pwnam County p
Commie :;!= Expires April 30, 19.0
c
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 #1,11R-OD, /'III " OD,
WELL LOCATION
Street Address
Kings Way
Town/Village/City Tax
Patterson 1
Grid Number
1 19
WELL OWNER
Name Mailing Address )]Private
Homesite Associates, P.O. Box 285, Thornwood, NY10594 OPublic
USE OF WELL
1 - primary
2 - secondary
0 RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 FARM O TEST /OBSERVATION
O INSTITUTIONAL 0 STAND -BY
13 ABANDONED
O OTHER (specify
AMOUNT OF USE
I.
YIELD SOUGHT
5+ gpm /#
PEOPLE SERVED /EST. .OF DAILY USAGE 800 gal
REASON FOR
DRILLING
NEW SUPPLY
❑ REPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
0 DEEPEN EXISTING WELL
0 TEST OBSERVATION
'DETAILED
REASON FOR
DRILLING
Drilled well serving
new single family residence.
WELL TYPE
LX DRILLED
DRIVEN
0DUG
®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. 25
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:
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 pr vid d y the Putnam County
Health Department /
Date of Issue: �/ ~�! 19 I
Date of Expiration: =/19 f� c emit Issuing Office �
Permit is Non - Transferrable � �-� copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
fAIA -,ew Pt A-,.,e
�n
SURVEY, OF PPOP>EP7y
FRE POLL D �nR
Q
Li &10 50'40' W
® 1 -►Co2' 44'00" W
C R_ 25.00
p= GO '•Oc' -00"
L= 39.27'
® NJ 2--7- 1 G- CO' E
1295
10.45'
AS SHCUI\I Ct-�
FINLL SZDNISION RZT OF FLIRVIEI[J MdNOR FILED ML?`2234 FILM) 5 -I5 -87
TD JI J CF" P ®rrF- P?SoN PUNAM CO., N. Y
SC� I" = ICYJ' WOVE" &E.g 2911 tg8B-
Q��� -�R� U� QpO�TQU��iT �S� AC��'rnoN�EALTH �ANpP�'
"i -ITLE I1�4. GOM� FO ty "r l-t E�1Z PO LILY
c�nctc�not -K I�IC��� NE.�J st�,►.ltcY `7uA�
TZ,LI�i 6U��tE.Y klAh PP�Pd.PFS> It-1 sI�CL�2DA� -K-E 1:lCM
-WEE EXbSTILK -. COCIF-E C PeAC ICE Rb2 LAUD 5U>?VEYh
ADOPTED m4 -n4E L4E1c1 ` 09V- --- T A c;.4 �A-nmJ c)'
Pe�---,,-i OkAL. LAKID '71..)exe4n 7. *AID ce vn gC4T-tC W7
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SEAZ -TUE IMIPfzEhhED SEAL cC -7l4E
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B D
125. 5 �
A E'
- :'".71`c 5' `.:,:
B E'` ,
121:
A —F
74'
B —F
117'
A =G
76.5'
B —G
112.5'
A —H
79'
B —H
101'`
A —.I
82'
B —I
103'
A —J
85.5'
B —J
98.5'
A —K
89'
B —K
94'
A —L
93.5'
B —L
89'
A —M
145'
B —M
140'
A —N
130'
B —N
160'
A -0
29'
B— 0
92,'
A -P
69.5'
B -P
51'
Q—S
R —S
�L NO DATE REVISIONS
JOSEPH MERRITT $ CO
N