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00258
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PVTNAM
DIV/S%fNl OV En"ViI
CERTIFICA _ ; OF.. CQNSTRUCTION,CO•MPLIAN
l'7
° ;tlNb 1 +IVttlf 'I�IUJ
ERMIT
67 k 4,`
w
Town w
w ,.er- Vi11pe
- U 1�. AAI'E P i
� Taxi Ma r :t ¢ Block
'L'ocated at 1 1 ' V
c p
"' "� °6rBR�o.� D . ,SZoo►.IEY
Owns►
it Taxp rot 'i 3 }subs zpt a
Former
Separate Sewerage :System' built by i MAV£S • �r,�ST �,o , 1►.IC . Atldress i�O VUN Q V Awe 7 k tU 7
"" Conslitlnq of, ►ooC.' l3al.' Septic Tank andCiO L .V �►$SoRP'T4o►J' TEI.►CN►
iOthor,`requlrements h
Wale► Supply _ :P.ublic Supply From .
Ilk
y.
Private Suppty Orllled By
At_gHRT_ 1- 11/ATT SotJS� .ItJC v
e
Address ;:Qt�t:IT 3'.:.. (3e1� .':li I •:'A ps'3TLR5'O t.� �Ly,'. :'.1:25!03 >'.'.
2 �s��F c.E. w 3 £3 S +8ro
Building Type No of Bedrooms° Date Pum'ic. (vkud '
Nes Erofiun Contiol Been "Completed? Has garbage grinder been ynsta11ed7 t � o
k
h certify that th,a a ystati(s) ae listed se=wing the above premiseshwerefconstructed essentially as shown on the plane of the,'completed work ( copies
oP which,-are attn'ghed) ;arid in accordance -with ,the atandar3s rules and regulations in accordance with'the f11ed'plan;'and the permit issued by the
Putnam County Department Of Health °
r
Y
Date ✓' 0 T} r Certified by P E R.A.
Adgress 5► -411.1 O T S L�aR Y LJctnii No 1& B
A'ny person occupyirlq prisrnlzea served by thi above system(s), shall promptly tske }ueq action at;may be,neeewry to 'secure the eo►netlon ,of any unsanitary
eond(tions: resultiriy i►oni >wch :usage Agproval,of' the rsepprite seweroge� system shall become null and void i'Soon as a pub lic ianitaiy,awn becomes
available and the approval, of ther,private wets► supply shall Decome null and void :when a`putilic,wate = supply'ii !, la` available. , Such .`approvals are
sub)ecY_fii modallcatton,ok'change?when,.iri the judgment .oi the4Commissionerof Nsalth, such revocation, modiflufion or the ngg,it necesuiy,
itN
Y
1. ;
Rev. 6/85
}
_.. ... ..
-- ... .. ,r.^d�•.w �'� ._"4 _
4' *COQ WELL COMPLETION REPORT
y .G
*
�•
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only.
P-31-t
STREET ADDRESS: WNJVt 1 TAX 6TI10 NUMSE,i
&0712ef j QjC, &&=11 ice, 1 A" 7 �� �` % 3
WELL LOCATION
j
WELL OWNER
NAME: ADDRESS
q- J � 3(,
flIVATE
0-
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O- ABANDONED
O BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL 0 INSTITUTIONAL ❑ STAND -BY ❑
0
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED � EST. OF DAILY USAGEgal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL =ft.
DATE MEASURED ®�
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH ft. •
:MATERIALS: STEEL ❑ PLASTIC 0. OTHER
CASING
DETAILS
LENGTH.BELOW GRADE __-®._ n
JOINTS: O WELDED OfTHREADED O OTHER
DIAMETER in.
SEAL: CEMENT GROUT p BENTONITE ❑OTHER
WEIGHT PER FOOT. Ib. /ft.
DRIVE SHOE YES ONO
LINER: O YES 60
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE
DIAMETER
OF PACK _____` in.
TOP
DEPTH ft.
BOTTOM •
DEPTH It.
WELL YIELD TEST If detailed
' pumping
METHOD: O PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER ❑ YES O NO
1P1�LL LOU it more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
water
Bar.
ing
wen
Oia-
(meter
FORMATION DEScmirrioN
CODE.
ft.
fL
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Land
.r
p
a
`
®�
300.
K
WATEP ❑ CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE t Le CAPACITY
MAKER /0 � A DEPTH --�—
MODEL ��� VOLTAGE(HP -:L
WELL DRILLER NAME DATE
ALBERT M. HYATT &SONS; iivC. d P
ADDRESS StGil7i?UAE
Well Drilling
Rte. 311 R.R. 2 Box 171A
pATTERQN, NEW YORK 12563
i''orktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245.3203
Director: Albert H. Padovani M. T. (ASCP)
T- ROONEY, GERARD 71
VALLEY POND RD.''
KATONAH, NY,. 105 ?6
LAB / y CA.005615
Date Taken: 10/12/87 time: ?;20
Date Re'd: 1 12. Time: g; "15
Date, Reported: 51987
Collected By: 7 oo n ee,y
Referred By:
Sample Location: o e q.
Sonnet Lane
Patterson,
.
Phone ,N 2 .71
Phone N. Sample Type:
L J Repeat Test? _ (check one)
LABORATORY REPORT ON THE QUALITY OF WATER
INORGANIC NON- METALS (mg /L) MICROBIOLOGICAL (CFU /'100mL)
_ Acidity GENERAL BACTERIA
_ Alkalinity
Chloride- X. Sta4da.rd Plate . Count
Detergents, MBAS ' .(CFU'/'l ..OmL)
Hardness,
Total
_ Nitrogen,
Ammonia
MEMBRANE FILTRATION TECHNIQUE,
_ Nitrogen,
Nitrate
_ Phosphate,
Total
X Total Conform
Sulfate
_
Sulfide
Fecal Coliform
_
Sulfite
_
_
Fecal Streptococcus
METALS (mg /L).
_
MOST PROBABLE NUMBER TECHNIQUE
_ Copper
�.
Iron
_ Total Coli,foim Index
Lead
_ Manganese
_ Fecal Coliform Index
Mercury
_ Sodium
KEY FOR TERMINOLOGY
Zinc
_
N/A = Not Applicable
MISCELLANEOUS
LT Less Than (�)
GT ..Greater Than ('�)
pH (units)
TNTC= Too Numerous'To Count
_
Color (units)
CON = Confluent ( =TNT.C)
Odor (TON)
NR' = Non- reactive
_
Turbidity
(NTU)
REMARKS /COMMENTS (For Lab.Use)
X Potable
Non- potable
_ STP- INF
_ 'STP EFF .
Other:
Sample Status:
.(check each)
'Outgoing
HNO3
HC1
H2SO4
NaGH
ZnOAc
Na2S203
Other
Incoming
X_ LE 4 °C
GT •4 °C
pH LE 2
pH GE 9
pH- GE 1.2-
_ Other:
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WASN'T) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO T YORK STATE DRINKING WATER
STANDARDS, FOR THE PARAMETERS TESTED,.AT.THE TIME OF COLLECTION
THESE RESULTS INDICATE THAT THE WATER SAMPLE (D.,ID) (DIDN'T) (N /A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF.THE NEW•YORK STA DR KING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
Albert H. Padovani, M.T.. (ASCP
, Director
2 /86(Rvsd7 /87')RWE
PurNAm couafy DEPARu4wr OF HEALni.
DIVISION OF &NMOII TTAL HEALTH SERVICES
Owner or Purchaser of Building Settign Block Lot
7. IS
Buildihg Constructed by
GRA°JSRpAi>s.
Location Street ..Subdivision -Nare
A=116, r c) '�j
Municipality .;,-.4's.wSubdivi•s ion LQt #
Building Type
GUARANM OF SUBSURFACE, SEWAGE DISPOSAL SYSTEM
I represent that I am wholly :and.I completely. responsible for. the- location,
workmanship,, material, construction and drainage of the sewage disposal system
serving the. above described. property,: and that it had been Constructed 'as, shown on
the approved plan or approved ',amendment theretq, and in' icco"tdainde with the
standards, rules and regulations of the'-Pijtnam County Department of ' Health, and
hereby guarantee to the owner, his successors, heirs or. assigns, to,plaide in good
operating condition. any part of said I sy:�teM'-,constructed by -me ..which f a-ils -tio'
operate for a pekiod . of two-years, immed;ately,follcwing the date'•of spprovai of the
"Certificate of Construction Compliance" for the sewage dispbsal system, or any
repairs made by. me to such kart, except Where the failure to ope'ra'ti-- P roperly is
caused,•by the williul or negligent act. of tbp:bccupant of- the building utilizing
the system.
The undersigned further agrees- to accept .as conclusive the determination of'
the Director of the Division of Environ&ental Health, Serviclijs of'th6 Putnam' CoUnty
Department- of Health as to whether or riot oL the ' syt;tvni to -upe�.4te iiu�i
caused by the willful or negligent act of the occupant of the buil�iing,.titilizing
the system.
A
Dated this Zs�' day of Or_-T7 196*7
f.
General Contractor (owner) Signature
_Rl
Corporation Name (if Corp.)
S i g p a t1i r- —_ I
Title
ratio ry/Name,,(if Corp.
Addr s
Address
rev. 9/85
mk
PUTNAM COUNTY DEPARTMENT OF HEALTH','
DIVISION OF ENVIRONMENTAL HEALTH'SERVICES
C ER.A.�...y izoc�,..►�Y 1 `1 'l. 3
Owner or Purchaser of Building Section Block Lot
Building Constructed by
-t' -" .�.�... --e
Location - Street
�
Municipality'
►2ES� n E�c�.
Building Type
�Q.oSSroa.DS
Subdivision Name
Subdivision Lot #
GUARANM 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 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 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.
(SEE ATTACHED "LIMITATION OF GUARANTEE ")
Dated this IST day of seP,- 19 8- Signat
Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
��qorpor4:flon Name (if Cotp..)
_f�;�_
�.0 �i .
= II.
':a
IV.
V.
VI.
APPENDIX C
FINAL gTE INSPECTION Date �/
IM #OR
G �4-
ION LOT
Inspected by
in
CCMMENTS
SEWAGE DISPOSAL AREA
a. SDS area located as per approved plans
b. Fill section - Date of placement
2:1 barrier.. LGTH WID'T'H AVG. DPTH
c. Natural soil not strippe
d. Stone, brush, etc.,,4,r&at)# than 15' fran SDS area.
e. 100 ft. fran water /c urs / etlands.
SEWAGE DISPOSAL SYS
a. Septic tank size -\,I\, OOV 1,250
b. Septic tank install evel
C. 10' minimum fran foundation
d. No 90° bends, cleanout within 10 ft. of 45° bend
o
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
3. Minimum 2 ft. original soil between box and trenches
f. JUNCTION BOX - properly set
g. TRENCHES r
1'. Len r ired O U Length install
2. Distance to watercourse measured: ft.
3. Installed according to plan
4. Distance center to center
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
6. 10 feet from property line - 20 feet - foundations
7. Depth of trench < 30 inches fran surface
'�
8. Room allowed for expansion, 50%
9. Size of gravel 3/4 - 1 " diameter
10. Depth of gravel in trench 12" minimum
11. Pipe ends capped
h. PUMP.OR DOSE SYSTEMS
1. Size of. purrp chamber
2. Overflow tank
3. Alarm, visual /audio
4. P=p easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health Departrnent
estimated flaw per cycle
i
HOUSE
a. House located per approved plans.
b. Number of bedroans
-j
WELL
a, Well located as per approved plans
�✓1
b. Distance fran SDS area measured ft.
c. Casin 18" above grade.
d. Surface drainage around well acceptable.
OVERALL WORKMASHIP
ro 1 routed
a. Boxes properly-
m
b. All pipes partially backfilled
_
c. All pipes flush with inside of box
d. Backfill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain outfall protected & dir.to exist.watercours
g. To'oting drains discharge away fran SDS area
h. Surface water rotection adequate
i. Erosion control provided- on slopes greater than 15 %.
in
.,PUTNAM CO.UNSjYW DHPARTMENT OF HEATH' Perm =�f«
_
Y• CC
J
Division Enwronmenfal. 7Healfh 'Servsces ,Carmel N ; Y 105;12
CONSTRUCTION PERMIT 1FOR SEWAGE !DISPO$AL'SY$T1EM _PA'ITERSON
�+ T Tiovrn r nllage
Sonnet .:Lane. -, o t r ! iii %T Lot •,� "
Loeated at Y
~ rf e, , t r a `y Rev=s =on
SuDtlivision
Crossroads ❑
s f ,
?- a
ro,ownez /Addiesa� Gerard.. °Rooney,P -0: Box.�198,Mahopac; N Y ,v Date Ofy Previr�ue 7Approval�
_.
F a F
I Budding. Type - 1 'Family Residence fat Area. ' i `�F = =11 Sectors Only s r C
40 4
qq
`+NUmt)ef.�Of LBedfOOmS •J 'Design Rlow G /P /D` 600 GPD '�� y P C H D Notification„Requ=red " - --
1;000 5,00X 21� ide
SeparateSeweraga System to con`s�st of Gal Septic Tank and L: F,. W' trench
T,o; ,be cleternuned ,Add.ess '
a'_T'o 1be ieOnstrueted by _ + e
j } Z♦
F 3 Water ,Su "PPIY Public Supply F ►om a ''fix9 t
r
4 X Pgwate•,Supply 3o be dulled byZO £be 'deteT7 ilTledz�
7 77
x a Address ' r x z
* b- P .. ti 2 �` tom♦ f_ 4 �aY =' i a's h;•,� ' y je i t
I rEorner •gevuirements R C B. F111 7'4D Gtl: Yds o 4 c
s Y represent that P ram_ wholly antl, <completely. responsible for •the des gm andilocatwn of the proposed system(s),; 1) that ;tde separate sewage. disposal system
` rr - ^Y.
.above. described ,will ibe: constructed; as shown on,the?apDroved amendment there toand�nM1accordance with the stantlards, rules an !regu a, ions o _,e .u, nsm
Gounty.: De artment of" Health ` and' that; oncomplet�diiAhereofa :":C'ert�f�ca4e of'rConstruction Comp��ance ; sat{ sfactory' to _the;Commitsioner'of'Healthwill
y . P, +
r!be submitted ito the D'epertmerft; and, a''wntten._guaran'tee wlIlFbe:,furnished the OwrPer hissuccesso►s; rh`eirror auigris by the;.b "uiIder;Rhat said 'builder .vy 11
° - f she ,perio0 �of,`two (2) years imrtiediately.,followng ttieCate'of the issu
yr.,,place,4n::,ggod 'operating; cbnditidn1 any ,;part L1 said sewage disposal system during„
i ancel•.of: the a'pprovpl .of the .Certificate of Construction Compliance of th'e orjglpal: system.or any repaus thereto 2) =that the;diilled' well described yabove
. :wilq,be locatetl as:3hawnao� the agproved; plan and. that said`w;ell will be installed do acco `dance's -with thew standard rules* and vegu a Ions -of •the, iP,utnam
• �<
F'5� ned_,. y $
g _ P E. X_; pR A
AdCr @ss �•�_ ; _ _ _ a # x hr .� iLlcens8 NO 26000
u' `APPROVED,FO:ft' C,ONST.RUGTL:O'.N This approval. expire ,tone yyeairfrom the date l �u`riless coristructwn 'of tfif building`ihas, been ,unde►taken_ and ";is
S4 �ievocaD;le for 'cause o► imay ber`amended o "r,modified' when co dared =necessary by t " ' C missioner -;of Health:= Any change'o alterbtion of:,- onstructio_n
quires a n w,,permit . rApproyed for disposal of- (domest,i ry`s aga� and/ 3 ,rpr ate ,water supply�onlyq `�,
Date' a BY Titl
'Z h o+ Z5> �. <1 w -.yam ur:wy; ? .�Ya .ors •xit_r �, t t
�'
.,u7.�C . -o m� � ¢ ,5,,•_`�....,- sy^� F �i. ., ^A'Y d � y.�s •�_S<;mr.. �.Y , a. :..i'�7r.s4 _. ti1ti 7• s «r�E�„ � '+m `i"'.• a ry �.a�_.+" tt..+.',.�.... -'L?.: ..
n.
0
b a }: r ' ^ifiN t'1 }' !'j _u'r+ 6-a5% - Tlf- "'se1r^�{e -�` s+*�k +^t r �, 4.`..F. „'., F :• ! kF� v i
PUTNAM2COUNTY DEPARTMENT OF�IiEALTHfi ° r i . >. , . '
Rev 386 Divhdon of,Envlronmental Health'Servloee Carmel N Y 1051? Engineer tb Provide:Penmit N'
c< OR' .' xs �i F> on CERTIFICATE OF 1VSPLIANCE
x-a s s r
ON k
DUCTION P RM1T FO EWAGE DISPOSAL SYSTEM ” Y 9Permit N
,C
j�� T F 9
i.
Located 8t UA
} . 1 '. n `+. v*x Wnv t [ Y e i ''
E. rr z ! T0." i0 •..� F ti ii
r
P ^ K
N
Sabdivlelon Name �-� •� -`-= _,:1 e T Map �a, tl y t Bock ;
Sabd -Lot N a: S I k� Loth
Revision � s.
Owner / ,PPllcant Name a
Pxevloas Approval
Msillng Address T d M.� 4 AS A Zip
ns{wh,
r �p i
Balldhtg Type j�3r' R�` �i SF r Lot A[ea. t i ` r a woo
r' 1 S A FiII SectlOn�OOIY
Number of Bedrooms Design tFlow, G /P /D PCHD Notification Is`Regaheil When +Fill istcompleted .•
t S A
Separate Sewerage System to}coaelet +ofA` on Sepklc Tankan s a -� r 2,
To`be ¢onstiacted by� aC �rC-1� ddreee
+W" S } ww f rL x S ,.
Water SapPIJ ' ' PablicsSaPP Y "Flom 1 r 21, Ya��� t d s 1 V nd:M1 r¢s
nor G. �{ > PrlvateSapplyrDrWed by �T�rAddiess r
Other Regairements -:� .° '--_.. � , : ��b • =� .. .-+: � . _ r u:w .,rs_�s .N _ a_: k ��
z
' ;' ; I represent that,l am wholly and completely respons bile forkthe desryn and locet�on of the proposed systems) 1) that the separ atedsewage;'disposal'system;' ".
i a f
aboveGescnbed will be constructed as shown on theapprovetl.amentlment'there,to , antl rm accortlance wdhthe stanAartls rules;an lregu a ions o,� e.= u nam,�..'
14.,,. Y4� J .i itfa Kba'W..� N..vyw t, t... i.,,,, 'k,•K@',F.� r�.'t -?:t .4•w. .':la i` 'r .. _ ,.....e.� i.. ^; ?,3rTw� , {'... �tt .i',n ..:.5 -. i s s.c.. 1,..• e.i c;�' -f� ta..` •�l.'rf:. "; t'., .
County Department of,yHMljh and that on completion thereof a C_ erUfficate of ConstructionaComphsnce .- satisfactory to the Commissioners .of- Healthwill!r.
be submitted -to the Department -antl a wntten guarantee wi11,De furn�shedt! o owneriliss Successors heirs or`ais' ns'D :the build4 ie'that said`.builder evitlk'':
s a r t ' r.: •r • ;ax..:.. s <. s.:S.a. �. 3 ..,.. ..n a -v. ,_:„, . a..y's .!�a, ..Y, .J .: u; -zy
place �in� good` "gperating`,eonbition any part ofusaid` sewage tlisposalsystemY .`•du►inyth'e'per�od, of two (2).�yeers immediately follovr�ny thetlate. of the assu;
sneeof rthe approval ofd the aCertdieatetrof ,ZConstr,uctionComplia a o(nthe ongmal system ocany repairs thereto ,2)ethat ¢he�drillstlwetl pe'scriDeG,,abovb' -.
`: will�be located as shown ?onthe approved plan and that se id welhur I� Ir`be (nstallediriYaccordance wlLh the �ftadartl '�iu18s a egu a�'ona of ;,th0 Putnam
County Department of Flealth
25 !
Date �� a r Signetl ti 'k: P EE))y�, R Av
S2�
,z � AdCress z • jl�� � ;t."�i�' a ♦M�.Y+, #�tl 1
,� a "- r--..- „� * ...ro '' .; ..!'U' s'.irrt.y."` • }:�jrs -+'�. ��'s='x. a��vznrr "". a "'`..` 2 x' ,r ' :• sue`` ;..;,.....t..a
APPROVED FOR CONSTRUCTION This approval expire ne year�f►�omathe d a issu' unles,; onstrucbon ,otYfie builtling has been undertaken; and r9'"
w 7 5 r 3 saf a- 6 7n =t a fi. �k s y w
revocable Io wu; or maybe amended roc modified when, idere ace rye y the CO miss�oner of Health A`ny change or ager'ation of construction ;.:
repuires' a n w ;p mit Approved for disposal of dome i samta Tse pe ' n z.puv er wet r sYpply only
1r , rr + r d S'� � '� � Ar�rl .if.° ! s t. yl •+y - s .
Date = r ey ' ? r , i Title
red 1 F z 1 f hs,•- ,�. tt :r,.t ,�. t r +
l
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - .CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A.WATER WELL `� C
PCHD PERMIT # ✓��`�
WELL LOCATION
eet Address] Town
L
ge Cit Tax
Gr d .Number
WELL OWNER
Name
Mailing ' Address
OPrivate
D Public
USE OF. WELL
1'- primary
2 - secondary
SIDENTIAL
Q BUSINESS
'O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O.INSTITUTIONAL ❑ STAND -BY
O ABANDONED
❑ OTHER (specify
O
AMOUNT�� OF USE
.,YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON- FOR
DRILLING
SUPPLY' ❑PROVIDE ADDITIONAL SUPPLY
❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
❑TEST OBSERVATION
DETAILED
REASON' FOR
DRILLING
rig
WELL TYPE
DRILLED
DRIVEN
aDUG.
GRAVEL
0
OTHER
IS`WELL SITE,SUBJECT TO FLOODING? YES. NO
IF WELL IS'LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES O
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 SEP ISHEE
(date (sign ture)
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 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 Department. �.
Date of Issue: r,
1 l 19 q 7
Date of Expiration: � /;1q � �j ermit ssuing ic�a -
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 ,� Pink Copy: Owner
Orange copy: Well Driller
. I.- ���"J:A•.::�ri:- rv:u�asa 1 •:satiW#Y'aYSx:.•R- ::�: -t - w�•.h....1i43 w.•.+�:FA[:vaA ••.Sia '.. .i.1trX +_:• .?'- i %:+f..:�i•u::�y�..s�!.'��rwF•YM YiMl..'Y v..N
r�.w - r+�.�_ •.•..�... '-' ••� ` • -SiC:ai�tn:r.S.C�Mt'iu'<e� �� .+.�i4•.M..�es- �'.�`3J4YiQrJX' .4.+�iweA �wV.[..+�ti� - -
_ .Y.eCwY AsCCdI
' ..... - Ws•• �'•.�..�:tas••�rr:`.a' � aps�:s - -Mnbu -- r.nw..�,.,,•��r•+.
r u n r r• �+• r 4 a r• p ••. Y�
%IDPW
(Name of Owner)
Cm em
(Street Location)
YES .NO DOCIF=
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization'
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
30" Perc Hole
Other
Dose Mans =Two se`s`
If PWS - Letter �-
Variance Request
REQUIRED DETAILS ON PLANS
Sewage System, Plan.
(3)
Sewage System Hydraulic Profile - Gravity Flora
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
e11,Detail, Service Line if over
Construction Notes
Design Data
Tram -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter Curtain Drains
Perc &-Deep Holes Located
Representative of Sewage & Expansion Area
Expansion Area;shown;gravity ' flow,suff. size
If:Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe
No Bends; Max. B6ds 45° w /cleanout
SEPARATION DISTANCES PECIFiED ON .PLAN
Fields
10' to P.L., Driveway, Large Trees
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 - artain,Stonn,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' fran Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGEDISPOSAL SYSTEM FILE NO..
Owner. i l'E Address P.o, 4E�OX 138 Mi, 46;' A �j
Located at ( Street �y4wE"r LaKi� Sec . Brock `7 Lot: "T 3
�lndica e neares `cross street)
Municipality Tcg -So t-1 Watershed G °row
SOIL PERCOLATION TEST DATA REQUIRED TO BE.SUBMITTED WITH APPL3CATIONS
Hole
Number CLOCK TIME
PERCOLATION
:....._...
....: .
PERCOLATION
Run
No:
Start -Stop
Elapse
Time
Min.
Depth to Water
From, Ground Surface
Start Stop
Inches Inches
Water. . ve .............
in'Inches.,
Drop in:'
Inches
..
Soil Rate
'Min. /in drop
2 /0:2 3
5-7
3 11;39
`iS
Idj
ZS
lJ 33 12 59
8 !
I°J
2�-
3
27
5
.:
z 18 ;5,x-~9:4+',4
G
2 9.44 - /o:
C
20
2
3'
20
3 ib'44 - ll'�Sc�. �z
20
2�
3 .
?ri'
5 ...
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 submitted
for review.
2) Depth measurements to be made from top of hole.
DEPTH
G. L.
6"
t4
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO.� HOLE NO. HOLE NO.
4
72"
18"
24"
3011
36••
42'►
48"
5411
60,.
72..
84"
INDICATE IML.A WHIIICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH.WATER LEVEL.RISES AFTER BEING ENCOUNTERED,
TESTS .MADE 'BY'3 d Date ' .
DESIGN
Soil Rate Used,21-3�>Min/l "Drop : S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity � � Gal e iY�A e-
Absorption Area.Pro 'Provided By L.F.x24" f- SAN c - ench.
7 `
Name P z lgna ur t
Address �a2R 1e :. SF,A o
C42�vlEt_� 11•�
o do 2AOO s
hf sTAWE
THIS SPACE FOR USE BY HEAITH 'DEPARTP T ONLY:
Soil Rate Approved Sq. Ft /Cal: Checked by Late