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631- 589 -8100
13.332
BOX 5
J
■ 1 J6
Wil
00204
IN-
y,
sl� "Y'
Rev 3/."86 PU Tq
C U Nn E
RTMiE`NT OF HEA; LTH
:
Division blmental Hesdth Semies, -C"A NY 10512
Mnet n&
P.QHD`P&J
-.
e
.CERTMCATE XONSTIRVICTION,COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
jT2oVp1` -6r -114
Located at �' u (+ i�� `Block Zo
erly Subdivaoi-Maii-
udy. Lot # ame
Date 'Permit Issiie
414-
Melling Ad.---
IR: 0,6749-gm eq,
Sep Sewtgage':S, teinhiliii,b Addie,,��
P. System -y
'.
Consisting .. I 1 of Gallon. Septic Tk -.-i -I- r1,qi!;WV-1W
Water Supply: Pii U'Spoi ply From Address
or Private sipplibrtu MPL,14P -k -K—Addre" 60.k 3r5
pd 4y
'Has Erosion Control lleen Coin p leted?
----,H" Garbage Grinder Been
Number of Bedrooms Instal][,ed?
O
Other Reqidrements
i certify that the system(s).,as iis:ted,,sery#iqthe,-,above premises were constructed essentially as shown'on plans of the completed work copies
of which are attiched);-and in-4ccordance" with the' standards rule's and re ulations, in a ccordance with, th ed plan, and the permit issued by the
Putnam County De rtme t bf Health.
P E. R.A.
1. Date
'Address :73 License No. fd:�]
Any ,person occupying premiseiiss6red by the above systqm(s) shall promptly take -such Saldil as may De necessary to secure the correction of any: unsanitary
e'se era'96 system ihall. become null an
conditions resulting fiom,silchl --Ugiiilsl.17"Ab a I of the .'sop i aiit w dv6Id,asa*6n.as A puW% sanitary sewer becomes
prpy "d void 1�66*n a public water 'supply becomes available. Such approvals are
available and the appioval of, t6e•priyate vvister,. supply. Shalt becqme/'M.T11l*1V
subject to modifi o
ti' ' -r1:chjngs",wnen*, An the'�judjment of'the tormNsI01nar,;oi kealHealth such revocation, modification or change Is necessary.
Date BY ot&t Title
I
AJ \` - o1.
/��`" �✓f,�
y , t
�
WELL GUMYLh"11UN KLrUml
DEPARTMENT OF : HEALTH
Division Of Environmental Health Services'
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
STREET AOURESS: IM IT Y TAX GRID NUM148ER:
a II . lQ
N ME: AD ESS: Q rcc� Z PRIVATE
�ah� - t', Alb- Oktjoofl, 279,y(,�•t�rfse �,I) ❑ PUBLIC
WELL LOCATION
WELL OWNER
USE OF WELL
.1 - prim ,ary
2 - secondary
qX61.10ENTIAL ❑ PUBLIC SUPPLY ❑ Al'R /CONDJHEAT PUMP O ABANDONED
❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FORCSUPPLY
DRILLING
❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
O'REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH —�ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY ❑ COW..RESSED AIR PERCUSSION ❑ DUG
O WELL POINT ABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED PEN END CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH ft.
MATERIALS: e<EEL O PLASTIC O OTHER
LENGTH.BELOW GRADE .� ft:
JOINTS: ❑ WELDED 04HREADED ❑ OTHER
DETAILS
DIAMETER ___ in.
SEAL: VVRMrNT GROUT O BENTONITE ❑OTHER
WEIGHT PER FOOT /7 lb./ft.
DRIVE SHOE UAT9 El NO
I LINER: ❑ YES 0
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
ONO
HOURS
S 0
GRAVEL P
❑
O NO
GR
SIZE_
OF PACK 1 ,
TOP
ft.
t
DEPTH It.
WELL YIELD $T' If detailed pumping
METHOD:' PED 1 tests were done is in-
O COMPRESSED AIR ;formation attached?
O BAIIED O OTHER i 0 YES O NO
WELL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
gea�f
ing
well
Di,-
meter
FORMATION DESCRIPTION
G70E,
tt.
fi,
WELL DEPTH
It.
DURATION
hr, min.
DRAWDO`,WN
ft,
YIELD
gpm.
Surface
D S�
/ ^/
e
WATEA JrCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? CUES ONO
ANALYSIS ATTACHED? UX 0 NO
STORAGE TANK: TYPE ft&-j - p� S
CAPACITY rPC1 GAL.
PUMP INFORMATION
TYPE -5 y2 CAPACITY 7
MAKER G_ d ALL n S DEPTH
MODEL _- _ VOLTAG @-la HP Z
WELL.DRILLER NAME v �.� C (/ DATEI a �.
ADDRESS d �l � 1� SVikTURE
C 0 rd /I/
L/
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
of��}�2 J2 b'n d_ l 1!L2 r f
Owner or Purchaser of Building
Building Constructed y
!')I(�
Location - Street
Municipality
Building
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
worMmanship, 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 imnediately 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.
Datied this day of V0 ,-,J 19
2 —/
eral Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Signature ?-
Title
Corporation Name (if Corp.)
ell
Address
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245 -3203
Director: Albert H. Padovani M. T. (ASCP)
F
Dennis Malanchuk
PO Box 313
Croton Falls, NY 10519
L
1
J
i
LAB /!
Date Taken: — �� "�a Time: q A r
Date Rc' d : Time:
Date Reported: JAN. 22 9990
Collected By: Dennis Malanchuk
Referred By:
S, m le Location: UlCtl
�y r1 CPrry LL
Phone #
Phone # — I Sample Type:
Repeat Test? (check one)
LABORATORY REPORT ON THE QUALITY OF WATER
INORGAiIC NON - METALS (mg /L) MICROBIOLOGICAL .(CFU /100mL) w
Acidity
Alkalinity
_ Chloride
Detergents, MBAS
Hardness, Total
Nitrogen,.Ammonia
—.Nitrogen, Nitrate
_ Phosphate, Total
Sulfate
Sulfide
Sulfite
METALS (mg /L)
Copper
_ Iron
_ Lead
Manganese
_ ;Mercury
_ Sodium
Zinc
MISCELLANEOUS
pH (units)
Color (units)
Odor (TON)
Turbidity (NTU)
GENERAL BACTERIA
_ Standard Plate Count
(CFU /l.OmL)
MEMBRANE FILTRATION TECHNIQUfE
Total Coliform t
Fecal Coliform
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 = :ion- reactive
REMARKS /COMMENTS (For Lab Use)
Potable
Non- potable
STP INF
STP EFF
Other:
Sample Status:
(check each)
Outgoing
3
_ HC1
H2SO4
NaOH
ZnOAc
Na2S203
Other:
Incoming
LE 4 °C
_ GT 4 °C
_ �H LE 2
pH GE 9
DH GE 12
Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE WAS M WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS. TESTED, AT THE TIME OF COLLECTIO .
THESE RESULTS INDICATE THAT THE WATER SAMPLE ( -DID) (DIDN'T) Q(N/-� MEET THE
SATISFACTORY CHEMIrMETENP
TY STANDARDS OF THE NEW YORK STA NKING WATER
CODES; FOR, THE PAR TESTED , AT THE TIME OF'COLLECTION.
/X/ I N-.-V
Albert H. Padovani, M.T. (ASCP), Director
2 /86(Rvsd7 /87)RWE
6 -4'�3 ` 0°2"6
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Camnissioner of Health - FIELD ACTIVITY REPORT - Sheet .I of
INSPECTION
NAME J ^0 9 CA Q —
ADDRESS C0 (z{j WA'(- C- W l L C-_
MAILING ADDRESS
P.O. Box Post Office Zip.Code
TELEPHONE VJ " _ C% 2-6
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
Orig: Routine
Orig. Complain
_ Orig. Request
Compliance
Complaint Carp
_ Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
_ _ Other
DATE 5 TYPE FACILITY 4ou 5,E
TIME ARRIVED ' -�� TIME LEFT 3.1 S Explain
FINDINGS:
ME- A (2 0 L C.Dn>1 ilk t ti r'
C'i Fes.r� IC) wA-5 eACP-u-tlUt'^ 4SEDiMEE&Z
WELL WAS LefF
fL -
i 2 A A5 TojG 0o A6AItJ
{ , IAIV.4 I. , to L I h f ai 1 n 1 / V,) iJ ko U e S
L AIX4 tJA-� t„jJ 1- '11m 0e,Tt 7
INSPEC'T'OR: _ Ivy !el-/( 1i
Signature and Title
PERSON IN CHARGE OR INTERVIEWED: '
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE:
9�
r_ivr -u .rte._:... ti•�.i_w___�.i. Lct.� / l��
Sm'= -T %CCyTION C'2 LLA:i I of ���� /'G�'c -a l�Y/ ON -ER
P�MST z / y 7 ` �1 a OR Sua7IVISieN for
I
L
IV.
V:
CI_ z:ur=ace CLr2.? r =ce a rcunt wZl accentabi °_.
VI. 04-=--.ZILL wGpjmAcn i D .
a. Boxes vropzly crcut =a
b. a_1 pines oar`�a11y L-ac=H 1 ed
c. AU pipes fI =z with inside of bex
d. ;�=cldill rraterial contains stones < 4" in diameter
e. C-1-`fain drain irL tilled according to plan
f- Cr`,ai n drain cut =e? I protytea & dir. to ex? st_wat =rcour
g. Fcoting drat Ls d l scharce awav from SDS area
h_ Surface water Drot- e'�ien adecuate
i_ =-os� cn comp provided cn sloces Cra =t_r than 15-%-
YES No
SD&C -E DISPOSAL. Pk.3
a. SI?S area lqc:at=--2 as per anoroved plans
-
b. Fill section - Date of placaient
2:1 barrier _ 1= WZrIITi AVG_DPIE
c. Natural soil not strirce-A
�- I
d. Stone, brush, etc-, ar_tar Lhan 15' f on SDS area
I i
e. 100 rL._ fran war-- course/wetlands-
I I I
_ St A DISC OSPL S�'S�1
a. Seotic tank size - 1,000 1 2 0
I =--I-
b. Sentic tarts install-led level
I I
C. 10' Minim= from fcuncat?cn
d. No 90' beds, cle= nout w i gain 10 f =_ of 45* bend
I 'I-
e. DIS=l Tj -TION BOX
1. p� l outlets at sale e?evation - Water test-=E
2 _ Prote c•tt�- be—1 cw fres
I-
3. M— niiLT1i 2 f= onCi n`1 coil be:ria =n bcx and
f. JUNCTION BOX - nronerly se.
-
Q MEN J7�
1. La*2q 'L Ie_na -�*j ins - %11 ed
I`TI
2. DissL---rice to ms s --a
3. ac — ro --iQ to D? =n
I �t
4. Di stance to C.- °'7te'-
5. Sloe of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet- rrm Drcz"r line - 20 f=:t - four a-'" C s I
`- --I- -I
7. DepdEri of 4--re_ncn < 30 inches from surfa ee I
�--1-
8. Roan a1lawed for e- m- mr-sion, 50% I
�—I--
9 Size or Ci✓"vZ 3/4 - 12 " di �Zlet`r
10_ D<ot:�r of cr ave in t=ench 12" minim
11. • Pine ends C =*:,'r.,c� I
�I^
h. " � oR DOSE sys° --s
1. Size of a=- ch-a-mbar
2. Cver_lcw tank I
I
3. Alarm, visa:? /a=d i o
g Punm easily ac=essible manhole to c*aae
5. First bcx bar-flea I
I
6. Cvcle by fi= =11 to Dew u :=rat
esti mat- flow r"E-=- cvcle
2. &. -a located pe_r a:=rcved plans.
b. Nunhf r of bedraas
a. ��. 1=t---; as 2---DrC4 "cd p12r5
b. Distance from SD-S area rr --surad 6y)-,-ft-
c- Casing 18" above c --ade-
CI_ z:ur=ace CLr2.? r =ce a rcunt wZl accentabi °_.
VI. 04-=--.ZILL wGpjmAcn i D .
a. Boxes vropzly crcut =a
b. a_1 pines oar`�a11y L-ac=H 1 ed
c. AU pipes fI =z with inside of bex
d. ;�=cldill rraterial contains stones < 4" in diameter
e. C-1-`fain drain irL tilled according to plan
f- Cr`,ai n drain cut =e? I protytea & dir. to ex? st_wat =rcour
g. Fcoting drat Ls d l scharce awav from SDS area
h_ Surface water Drot- e'�ien adecuate
i_ =-os� cn comp provided cn sloces Cra =t_r than 15-%-
-no
Uv.
./87
Other Req r C-4.4& 1-'OC44o;, 4A Cl�'
I fOPrOsirit'that 11.'am wholly ! anq th�i desigman�dd locatio n of
proposed . o -Syst&n(s); 1) that the separate sewage disposal system
f
aboie described will be'co_nstrucie6 is'sh6wh on theappfoved in�indiimint'thire foand'in laccordancewith the itindards, rulesand regulations 0 I!uxnam
County Department - •Of :'H'eaqh.;.:and "that on 66r6pietiori ovCdnstiuctlon C60ripliinjo" sifislactoiy, to the i�ommisslonor of Healthwill
. . ... f . "
'brniiiii.* to t'
be' SU he 0 and 'a ,written quaran ell.,will be.' urni Il.Owner, S successors, heirs of a
"hi 'Ir' gins by the bulklei. that said builder will
place in
flood
oper"SH4 iOnwiiiion, any part '' i during the period IF
0 said sawage, _o Alwo (2) years immediately, following the date of-the issu-
Once of the approval, of the Certificate Of Construction compusfici_of thli original. , s the or . any repo epom therelp; 2) that the dril
led Well described above
will be located os-shoWn On''i6e.approved plan and ,thatssid,wsil.iwil a, k4ii6rdince with th ards..rulas nd.reoulations 3i the Putnam
courty
itmon't of ""lih`.,,,,,.
C)"
Data 50 P.
E. R.A.
-License N
Address -
W
APPROVED F " OR CONSTRUCTION This approval expires two yarn ,from:the, date', issued construction of the building has been undertaken and is
o Health. Any change or alteration.of construction
revocable f6r,ciulsll Of ...4�d ;unless cohstru
require A0pjO�jj,'j6r di sii Ii diomiibc�
s a now permit. spq 0 Sanitary IS water supply only:
Title
-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 # —
WELL LOCATION.
Street Address
KILL `DRJ
Town/ y Tax Grid Number
J� - - d2 , I /)
WELL OWNER
Name
JO Nj7H
Mailing Address AA''
LL Sit 915e tL L' /1/00ft4 C7 j bO51
rivate
-O Public
SE OF WELL
- primary
2 - secondary
QrRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
0 ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT
5 gpm /11 PEOPLE .SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
eNEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
�GU �PaV lig /zG[G u2[�
WELL TYPE
EIMILLED
DRIVEN ®DUG OGRAVEL
D OTHER
IS WELL SITE SUBJECT TO FLOODING? YES V NO
IF WELL IS LOCATPD IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
�p2NG� G f�il� Lot No.
WATER WELL CONTRACTOR: Name yo 6z 7;eTeeMiAJr_D Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: AIM TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON REAR OF THIS APPLICATION �Oz=l E SHEET
(ga 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 provided by the Putnam County
Health Department.
Date of Issue: 19
t �'----- •_ —• -• --- '��_19 Permit tt Is—suing ffi c a �
White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
I represent`.that I am- wholly antl' completely responsible for the des�gn�antl location of'the proposed system(s); -1). that. the separate. sewage disposal system
above describetl will be constructed as shown on the approved amendment there t0 arid-in 'aCCOrdarlce With the standertls, rule an IegU a FORS or e U nam
County Department of Health,-and that'on completion thereof a Certificate of Construction Compliahce' satisfactory fo.,the'Commissionor of Health will
be submitted` to the Department and, ariwntten, guarantee will .be furnished dhe' owner, his wc`cessors, heirs or assigns by thebuilder,.that said builder Will
place in good!operating'lcondition any part'of ,said, "sewage disposal system. durmy. the period of.two (2) years immediately following the date of the issu-
ance of the approval of the Geiwi:cate'•of .Construction Compliance of t e ongmal.system or any repairs thereto; 2) that the drilled well described above
wilt be located as shown on the approved plan and that said well will be Inst '�n `accordance with, the stsndar s, , ru 3 and regu a ions of the Putnam
County Oep rtment of:;Health > f t
j%�(} �1 P.E. - R.A.
Data X377 i ' f Sognad
Adtlrett license NO
Z
APPROVED FOR. CONSTRUCTION :ThisappiovalexpirestwoYears =.from the date.�issued unless - construction -of the building has. been undertaken and is
revocable for. cause or May be amended or modified when considere6 necessary by the'COmmissioner of Health.:Any - change or alteration ot, construction
requiies a. new permit:` 'Approved for. disposal of domestic samtaryrSewage,- and /or pri, to water, supply -Only. ,
87 Date ¢j/ BY ^� rr Title
H.
DEPARTMENT OF HEALTH
_Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL /11) /
PCHD PERMIT # D 6
WELL LOCATION
Street Address
Gzhmu 1ILL
— Village City Tax Grid Number
°c r t5— Cb �— d
:ivate
WELL OWNER
Name
CO
Mailing
Address
O _MKM
K(Y O Public
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL
® BUSINESS
0 INDUSTRIAL
0 PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
❑ OTHER (specify
D
AMOUNT OF USE
YI LD SOUGHT
gpm /#
PEOPLE SERVEDS--rj /EST. OF DAILY USAGE5C> gal
REASON FOR
DRILLING
MNEW SUPPLY
❑REPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
ODEEPEN EXISTING WELL
0 TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
1n�
WELL TYPE
DRILLED
DRIVEN
®DUG
C3
GRAVEL
El
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: (ZbZN4"L_!` _
f`7'C�S Lot No.
WATER WELL CONTRACTOR: Name 'Lo fj:, ,/!A[ � 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:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON REAR OF THIS APPLICATION DION SEPA E SH
� 7 42 �'° jj
(date) s gnature)
PERMIT
T0.'- 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 provided by the Putnam County
Health Department.
Date of Issue: �'lcry 4�' 19 Date of of Expiration :mss 19 5;1 7 Permit Is g f i
Permit is Non - Transferrable White copy: H. D. File
Yellow copy: Buwilcling Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
G
T'UTNAM COUNTY Dt;PARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DhZ10 DA'PA 31047P- SEPARATE- SEWAGE DISPOSAL SYSTEM FILE NO. _
(hittarC��tmnt_�, t���t E-st'� T%
_s)4<- 'Address :ZZ3 k/tMNAl-1 Avg} LCA T -Wrih 14Y l
t.�wJV.c_ µices Q"O. .
Located at (street Indicate l(o Sec. Block _G
Tnc ca a nearer cross s ree 3
Mwticipality "['TQ.S_ Watershed-
301L PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Tiu7 "�
NtU111( •
CLACK TIME'
PERCOLATION
-PERCOLATION
—RW1
huapse
Depth
to Water
Water Level
Nu.
Time
From Ground
Surface
in Inches
Soil Rate
Start -Stop
Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
L
: n -
r3
CQ
22
25'�'
2q
� • 3Cv
- 1.1 OBI
�8
•22
2;'
3+�
30 .
-s
2-
2<
-4
,
. 1
4
Note:►: 1) Te::st3 ,to be repeated at same depth until aff� �roxiinatelyy equal soil
gates ave obtained at each percolAtton test hole. Aly data to be submitted
for• rev i ow .
', •r,th mea3urerry�,nt:i to be nvide, from ton of, 11ol e.
Dt M
G.L.
6"
12"
18"
c
42#4
48'1
,>4 �r
6011
'(2
t34"
TEST PTT DATA I=UIRED TO BE SUBMITT1?DD WITH APPLICATION
DE:3CRIP'1'ION- OF SOILS ENCOUNTERED IN TEST HOLES
IME NO. ��_ HOLE NO. HOLE NO.
-p 54 �
•C 1rim-
INDICATE MVEL AT WHICH GROUND WATER IS ENCOUN'T'ERED
INDICATE LEVI -:L 1110 WffICH WA'T'ER .LEVEL RISE'S AFTER BEING ENCOUNTERED
Th;3 T'S MADE BY R. W . Le . Date
SIGN
Soil Rate -, U4.ed ' -a- O MirVi "Drop: S.D. Usable Area Provided
No. 'of Uc:drubrn3 4. Septic Tank Capacity 125a ra .�;Ety �'�pe
AbsorpLion Ama Provided By L.F. x24" - ���'�; i }�, renc .
=;� r
�1 Z88 L.F. TTZ.e• GAL.LSIZIES
Nail ;51g1)aT.tt f1 J
Addrwsis 7
<5 All
V, � -yy�:. !•:..: ' .tom
11113 3PAcE ) O1t USE BY HEALTH DEPARTMENT ONLY:
Soil $e Approved Sq. Ft/Cal. Checked by Date
Sk-P ,
PU �4J
D�pT AO rou , -
F HE44 T
PUTNAM- COUNTY DEPARTMENT OF HEALTH
Rev.. 3186 V �� Division of Environmental Health Services. Ceimel, KY. 10512' Engineer to Provide Permit N
on CERTIFICATE OF COMPLIANCE„
CON Urn — N PERMIT. F SEWAGE DISPOSAL SYSTEM Permit �
Located at C_ O PoW ftAL(L. WILL R n A'® Town to
Subdivision Name Gc1Rf�iWAi.L �i lC
. Sabd. Lot A Tax Map Block ��Lot e., j
Renewal ❑ Revislon ❑
Owner /AppllcantName ZA E -'r' F Nr_
Date of Previous Approval
—
Mailing Address K V E • . Town - , AZ O W A K, _ Zip ! A 310
Bdilding Type Let Aiea r 70 / C ' Fill Section OdY Lj Depth - Volmue
Nnmber of Bedrooms Design Flow G /P /D �y ®q� PCHD Notification is Required When FM Is rnmpletod
Separate Sewerage System. to consist of `Gallon Septic Tank and + 1 G A LL E 7Z 1
To be constructed•by` BL Address
Water Supply: Public Supply From Address .
Pit Private Supply, Drilled 'by T 3 $ f _Address
I represent that 1 am wholly and completely responsible for the designpn
above described will.be constructed as shown on the approved.amendmenl
County Department of Health,. andthat�on completion'thereofa "Cart
be• submitted to the Department, and a• written guarantee will be Jun
place in good operating 'condition any part .of- said sewage disposal
ante of the approval of, he Certificate of Construction CompIlance-
will be located as shown "on the approved plan and that aid well will be ink
County Department of Health
Date
APPROVED FOR CONSTR
revocable for cause or may i
requires a nSg"er4. AI
ded or modified when conside
for disposal of domestic san
9m(s); 1) that the separate sewage disposal'system
ihe, standards, rules and regulations o -e u nam
ice' satisfactory to the'Commissioner of Healtttwill
heirs or assigns by the builder, that said builder will
;2) years immediately following the date of the, issu-
stirs reto; 2) that the drilled well described above
as d ds, 'rules and regu a sons of the Putnam
P,E.-K R.A.
License No --j � 1 is �
uction of the building has been undertaken and is
H Ith. Any change-or alteration of construction
3 , onlY•
Title b /Q
`� e
Aol
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
AFFIDAVIT — CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
Cornwall Hill Estates, Inc.
I� Kenneth Emerson
represent that I am an officer or employee of the corporation and am authorized
to act for Cornwall Hill Estates, Inc.
(Name of Corporation)
having offices at 223 Katonah .Avenu=e
Katonah, N.Y. 10536
Whose officers are:
President: Edward H. Emerson, 223 Katonah Ave., Katonah, N.Y. 10536
(Name and Address)
Vice - President: Kenneth Emerson & Martin Diano, 223 Katonah Ave., Katonah,N.Y.
(Name and Address)
Secretary: Janet G. Mastropietro, 223,Katonah Ave., Katonah, N.Y. 10536
(Name and Address)
Treasurer: Lynne Diano, 223 Katonah Ave., Katonah, N.Y. 10536
'(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 subsequent acts relating
thereto. 1"44
Sworn to.before me this % day Signed:
of Ca)mu . 19 y
Notary Public
LIONEL WEINSTEIN
Notary Public, S`nto of New Y6rR
No. 60.4 199160
Quaified in b'UWl Mitt: C40-WitV
(3bRU ► Ion EApiras ii9fC8 30. ig
8/84
Title:
Vice President
Corporate Seal
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O/JO
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DE:31GN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
owner ED Q b.�PLE C .. Addres346T C�1�1(�(� AVE ,Sc40iM AI.V. 106
Qn 4WAAA_ µ IL$, Q0. I
Located at *( Street�Indlcate 9--r, t(o Sec. )AS" Lot2.d
cross s ree 0)
Municipality '"j'TEQ.S' i, Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK
TIME
PERCOLATION
PERCOLATION
Faun
Eiapse
Depth to Water
Water Level
No.
Time
From Ground Surface
in Inches
Soil Rate
Start -Stop
Min.
Start Stop
Drop in
Min. /in drop
Inches Inches
Inches
� 1 � • Qc� °'
� : �`�
�� Z2 25�
'"?�' �
Zit
_ 2 3 11 ' OBI 22 z 3' �O
4
Notes: 1) Tests to tie repeated at same depth until approximately equal soil
rtites are obtained at each percolation test hole. All data to be st,bm.i.tted
for revs f -w .
• ; ',-pth measurements to he made from top of hole.
DEPTH
G.L.
6"
12"
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO.'_ /} MOLE NO. HOLE NO.
18"
24"
Jv"
CD
i..
48"
54
60"
66"
72
78
8411
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDMA`I'E LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY jZ, W , d.. Date (miss-
-DESIGN
Soil Rate Used 345 Min/1 "Drop : S.D. Usable Area Provided SO**
5.�.
No. of Bedrooms 3 Septic Tank Capacity 142160 .;�; ` �•��
Absorption Area Provided By O o L. F. x24" , ;4, i trench.
r
Address 3 1:A�t-1^ 161 t°.
J' �•'i. r 1 1 V
THIS SPACE FOR USE BY HEALTH. DEPARTMENT ONLY:, _ )
Soil Rate Approved
Sq. Ft /Gal.
Checked by
Date
DEPARTMENT OF HEALTH
DI'VISION OF I' •' ' M Y• L HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE S3gAGE DISPOSAL SYSTEM FILE NO.
Owner J0 f w 5 l 44a J L?I��,eoLG Address
Located: at (Street)6, 1j(,k9tt Wja Pb 6196/ 40. Sec: /5 Block Lot 2.
(indicate nearest cross street)
Municipality �T�SOtCl Watershed 61ZO%ON
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMI= WITH APPLICATIONS
Date of Pre- Soaking /d Date of Percolation Test 102
HOLE
NL24BER CLOCK 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
7
3 alp
4
5
1 m 35
-4 �. � 2
0
3 /a: a7 -Ja:57 30 a� l
4
5
1
2
3
4
.5
7
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be surmi.ttod
fore review.
2. Depth measurements to be made fran 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 N0.
® f&
if
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
A
HOLE NO.
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED N•ONe
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED /'(1015
DEEP HOLE OBSERVATIONS MADE BY: �GUG- DATE:
DESIGN
Soil. Rate Used 92 Min /1" Drop: �,' /�' S.D. Usable Area Provided
No. of Bedrocns Septic Tank Capacity gals. Type 64A)6.
Absorption Area Provided By �,15 G L.F. x 24" width trench
Other �' 01�iw &4emmi DJ '*A) - F N E W �.
Name �TNGi,i /Jf� /�, C. Signatur '
Address 7 r&le r"i�L(�
(/
e SEAL n r -+
r
U, r
/V `/ 6/p No. 0451811 -h�
THIS SPACE FOR USE BY HEALTH DEPARTME ONLY: � (1
NT'
Soil Rate Approved sq.ft /gal. Checked by Date
1
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