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PU NAM COUN'T'Y DEPARTMERr OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Municipality
Building Type
1 � 5 -z
Section Block Lot
Subdivision Lot #
GUARANM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
-1� 7 t--*
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.
19 90 Signat c
Dated this �_ day of
Corporation Name (if Corp.)
Address
rev. 9/85
mk .
Corporation Name (if Co .)
Address
A Cpl
N REPORT
*
%jVrLrTIO
WELL LE
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Off ice Use Only
t
WELL LOCATION
STREET ADDRESS: wNI I : TAX GRIO NUMBER: "
�. - n o e o - s- s -z
WELL OWNER
NAME: ADDRESS:
o
11 +�i43 4Md J�.��ae aft 401 PO l�oX �'i37 Pal :e 1,50 /Uy X15-63
P8IVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT_ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 6W- gal.
REASON FOR
DRILLING
VfNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH —1.6 02 ft.
STATIC WATER LEVEL ft.
DATE MEASURED A be
DRILLING
EQUIPMENT
0 ROTA RY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH ft.
MATERIALS: STEEL ❑ PLASTIC O OTHER
LENGTH.BELOW GRADE tL
JOINTS: ❑ WELDED THREADED O OTHER
DETAILS
DIAMETER — in. •
SEAL: O CEMENT GROUT ❑ BENTONITE OTHER`
WEIGHT
PER FOOT ____f� Ib. /ft.
DRIVE SHOE: YES ❑ NO
LINER: OYES . NO
SCREEN
DETAILS
DIAMETER (in) .
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
S S ONO
HOU
SECOND
GRAVEL PACK
Es
ONO
GRAVEL
SIZE
IAMETER
OF PACK in.
TOP
DEPTH fL
80TT M .
DEPTH It.
WELL YIELD TEST If detailed pumping',
P P 9
MEJH00: O PUMPED tests were done is in-
tp'COMPRESSED AIR ,formation attached?
O 8AILE0 'O OTHER i ❑ YES O NO
It more detailed formation, descriptions or-sieve analyses
WELL LO:G are available. please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
wen
�a"
meter
FORMATION DESCRIPTION
cone .
K.
it
WELL DEPTH
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
S --
^IL
[�
WATER irCLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ,ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK :. TYPE Cl/It°�%
CAPACITY GAL.
PUMPNF RMATION
TYP -
MAKERf -
MODEL
r Xle. i CAPACITY
DEPTH ()
VOLTAGE HP
WELL DRILLER NAME DaTE
Ahq &�T M. HYATT .I&., f ONS- INC.
a Well' Drill6$ stctrTtTITRE %Y���'"'' "
Rte. 311 R.R. 2• Box. 17TA
NEW YORW11,19563
Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(9 14) 245 -2800
Director: Albert H. Padovani M. T. (ASCP)
THOMAS HAUGHNEY
P.O. Box 537
PATTERSON.,NY. 12563.
L J
LABORATORY REPORT ON THE QUALITY OF WATER
. :-
LAB
Date Taken: 849Z20 Time: 111308m
Date Rc'd.: 0 Time: 12;40P m
Date Reported: 3- Y6,
Collected By: Thomas Haughne
Referred By:
Sample Location: Kitchen ap
South Street
Patterson .
Phone N _ 7 - 59-.
Phone if Sample Type:.
Repeat Test? _ ( check each)
Potable
Non- potable
INORGANIC NON- METALS mg /L MICROBIOLOGICAL CFU- /100mL` ST-P- INF
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 )
STP EFF
GENERAL BACTERIA Other:
_ Standard Plate Count
(CFU /1.OmL)
MEMBRANE FILTRATION TECHNIQUE
Total Coliform
Fecal Coliform .
—Fecal Streptococcus
MOST PROBABLE NUMBER TECHNIQUE
Total Coliform Index
Fecal Coliform Index
KEY FOR
TERMINOLOGY
CFU =
Colony Forming Units
CON =
Confluent (q.v. TNTC)
LT =
C = Less Than
GT =
> = Greater Than
N/A =
Not Applicable
S/A =
See Attached
TNTC=
Too Numerous To Count
REMARKS
/COMMENTS (For Lab Use)
Sample Status:
(check each)
Outgoing
HNO3
_ HC1
_. H2SO4
_ NaOH
_ ZnOAc
Na2S203
. Other :
Incomingo
LE
4 °C
GT
_4 °C,
pH
LE 2
pH
GE. 9
pH
GE 12
Other:
ELAP No . 10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WaJ)ORK (Wasn't) (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO TH E STATE PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLE TION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (Did) (Didn't) (N /A) MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK PUBLIC ING WATER
CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF SAMPLE COLLECTION.
/x/ C.>C�U�s %��J�C ,j 2 /86(Rvsd7 /87)RWE
Albert H. Padovani, M.T. (ASCP), Director
FTIPL SITE Cate.
s� by
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DEPARTMENT OF- HEALTH
Division of Environmental.Health Services
110 OLD ROUTE SIX CENTER, CARMEL,.N.Y. 10512 .(9i4) 225-0310
APPLICATION TO CONSTRUCT.A_WATER.WELL
PCHD PERMIT..•
WELL LOCATION
Street Address
PTown Village City
Tax Grid Number'°
17
WELL OWNER
Name
Mailing Address s
P f1 t4,L
riyate
Ny D'Public'
USE OF WELL
1 - primary
2- secondary'
GYRESIDENTIAL
D BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
Q AIR /COND /HEAT .PUMP O ABANDONED
O TEST /OBSERVATION' O OTHER ('specify
O STAND -BY O '.
AMOUNT OF USE
YIELD SOUGHT Onec S gpm /# PEOPLE SERVED_ /EST.
O REP SCE EXISTING SUPPLY O TEST /O.BSERVATION.
9-nW SUPPLY NEW DWEL I G []DEEPEN EXISTING WELL
OF DAILY ,USAGE_$Wp gal
12 ADDITIONAL SUPPLY
REASON FOR.
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
[]DUG
[]GRAVEL
[]
OTHER
IS WELL SITE.SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
M Zy�i Z- Lot Na.
WATER WELL CONTRACTOR:. Name �' D►'� -Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER.SUPPLY: !� �M- TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �-- -�
LOCATION SKETCH_ & S RCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(date (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
thirt3! (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.
During all well drilling operations, the applicant shall.take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such manner as not to,degrade or o e wise contaminate surface or groundwater.
Date of Issue: 19��
Date of Expiration 19� ermit Issuing Official 4-
Permit is Non- Transferr ble White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
/ •' • � /• 0' 1� V• '1 �• •ice
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE ND:,
Owner Address
Located at (Street) V -S Sec. l Block '� Lot
(indicate nearest cross street)
Municipality Watershed
Date of Pre- Soaking S ro
o Date of Percolation Test
S / /OIf0
2 1
15- Z� 2l
3
S_o
HOLE
NLEM C= TIME
PERCOLATION
3
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
1 1Z 27 3 _o
2 �°� Zy Z7 3 C -3
' 3 2$= 2 27 3 '1
1 4 3 C -1
5
2 1
15- Z� 2l
3
S_o
2 2
L 3
'''mac 2 ►¢ Z 7
3
�.`] ,
Z 4
V-f 77
5
1
2
3
4
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 sulmittOd
for review.
2. Depth news cements 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.
G.L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
i
HOLE NO. Z
HOLE NO.
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED N
DEEP HOLE OBSERVATIONS MADE BY: f"M DATE: Ay
DESIGN _Z
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided o
No. of Bedrooms Septic Tank Capacity gals. Type cep
Absorption Area Provided By _-3'150 L.F. x 24" width trench
Other
Name Signatu
Address 7 z t" \o-� - SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved
sq.ft /gal. Checked by
k •" N
No.43��
PROFF.` `
Date
o/
h
4
Gc C n Neii
� / J
A
ge disposal system was 4
plan and that the 5 z a
before it was . cover_ . t
istructed in accordance o:.
ns of the .- Putnam Courr
7 �.
0
o
i ys
S/
egg `920 `Y os'
oll
/ � Bhp• d��- -�_�'c .� h
�NO 2
�a4_?d
AS-BUILT SURVEY BY S. R. MILLER, L.S.
v�UT T
a
SEPARATION ' DISTANCES IN • FEET'.'.
OQUI
am
Cainei
®ummuci
n�
n
tmmmorrrrr
n
i
���
®m�
®�rrrrrrr■
a
SEPARATION ' DISTANCES IN • FEET'.'.
OQUI
®ummuci
tmmmorrrrr
���
®m�
®�rrrrrrr■
rr■
®r�rrr�rrr
■
®r
A S —BUILT SEPTIC. PLAN
°
prepare d for
° HAUGHNEY RES NC.
IDE E
SOUTH ST. SCALE:
TOWN OF PATTERSON 8/14/90
PUTNAM COUNTY, N.Y. M ' B 5 L 5.2'
Patna® County Department of Sealth
Division of Snviromental Health Servioes
Approved as noted for oonformanoe with