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00574
ev.` 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH
g Division of Environmental Health Services, Ctimel, N.Y. 10512.
Engineer Mast Provide
l' l`
CATE OF CONSTRUCTION:COMIKIANCE FOR SEWAGE DISPOSAL SYSTEM;
V - Town or Village •
Located .t s ,� 2:3 lock , Lot 3
�-1 PubdMap ' Owner/ -_ V Name S / ornlerl on ame Sabdv: ot'M app
Malllng. Address _ , 1 zip — Date Permit Issued
AIL
f.
Separate Sewerage System . t by „- Address
..;.. ,
Conelstlt g of 62 40'6 Gallon Septic,Tank and � 1-
Water Sapplys public Supply From . Address
Private Supply Drilled by Address
Baildiog :Type� His Erosion Control Been Completed?
Number of Bedrooms / Has a Grinder Been installed? �%
Garbag ”
OtberRegalremeuts
I certify that ,the systems} as listed serving the- :above premises were constructed essentially ae shown'o 'the plans of the completed work ( copies
of which'ara attached), ,.and in accordance with the standards; rule's and ieq a ions, in accordance'with feel- p an, and the permit issued by the I. iiutnam- dounty Department of Health
Date 42 / Certifleri by P.E. P.A.
Address' ' 'v( y .. L . �, a l.fcsnfe No:
S.
Any person, occupying Prerni"s:seryed.by the above_system(s) shall p►omptlytake such action as may be necessary to secure the correction. of any unsanitary 1.
conditions resulting *6ni such.. •usage Approval ,of the separate sewerage system shall become null and void as soon as a pubt'c sanitary sewer becomes
available: and the 'ippioval of `the ,private water supply shall `become null and void "when 'a public water supply .becomes available. Such approvals are
sublect to modification or change when in the Judgment of the ComrwFssiorm of Health, such revocation, modification or change Is necessary,
Date
Title
i
Ir.�.r�
_ _. _ 1_. .... ,d _.. _.._... .. .___
— - - �la
PUnIAM COMM DEPAFTME7r OF J�111
DJ,VXSZOc1 OF f1EALTH SFRVIM
(�.nex aw :ch�se�' of Zui.Idzng
ding C,orlstrt OUA by
S 'C-a i
,zr�cation -- Street
ia= ding TA4
{ f
,. tip
23
sect! Lot
st�ivisinn tiara
cL
)ayl vision I�ot {�
CUt'1WM'42 OF SLMSUR,'AC2 SF.WAGS DI PO& &AL. SYST;M
I represent that i run wholly and ccnpletely responsible for the ICKMI corn,
%vri,T,w,ship, t ].al.r construction and drainage of the sewage ai�pc»a]..system
s, -wing the above desc:cibC3 proparty, anu that xL has •b-eri constructed as sha'M on
the approved plaiX or appxov,-=d anendmcnt thereto, and in acCordanca with tho
s ndaa ds r Rules and regulat .nas of t.7,e putt-.10.m County rap:LL o i. of: P;eal.th,, ana
,;exct'.t :ar�rltes4to.tila o�nex, his successoz�r t�eire v ►_' as:�3.gn-r to place in goad
opara ping conditi6h any part of s rra said sys -te constzuc ted by me which fails to
c ite £br a p rod Qi two yeaxG avtn iiataly follcwing ec dq e of approval. of_ the
"Certifica.te vt CousLracL"ion. Compliance" ,for the wedge disposal system, or any
A�epaiss ;ride by r tb stYC�i syate'a, except where the &Uure to opexaLe. properly is
caused by the w1,11ful or negligent act of the.ocxvpajit.of the b%aUaing utilizing tt-
the system.
The undersiyne-cl .further agrees to racc ,pt as cvncl.usive the cleti?j-�ni.nation o£
the I')irect r uE the Vivizion o£ E1lY ton.'Y mtal Health Sexvi oes of the L'LIUlam County
Department o:C wealth as to whethex or not t-,e failure of tho E} ,nt= to opa.Zate was
caused by the wi?ltul oz negligent act o: the occ:upauit vt buiMi utxX i.ai.rlg
the system.
rat thi -.� day of A10L) . l9 9Z- Si.gnatun- 7�...
al ac r (Ownor) Si.gratuz:e /U •
eorppLa oil Name (if Corp. )
corpmt $ on Nam CxUl Corp. )
r,
rev. 9185
m1C
CAMO LABORATORIES, INC.
367 VIOLET AVENUE
POUGHKEEPSIE, NEW YORK 12601
`DOH #10310 Tel. (914) 473.9200
Con.: PH-0593 Fax (914) 473-1962
BACTERIOLOGICAL EXAMINATION OF WA
.pill To:
b
VA 1. _ --- ....... !� � • � _.... .
t�
:rattle No...n ,�. 221 Date Coll'd
Mh N. / ^ r */ it _ rAM0 (ne Nn.
rAStA RaqueAtad C+,�.i �0,� ✓%1
'nl I'd by: -6, 1,
dentificat ?on Of Source:
piing Point:
Point:
supply Chlorinated When Sampled: Yes ❑
l
Time �.' S� Time Submitted
.�. 1
G� rility Typo
Refrigerated?
_ Agency Coli'd for:
Tetephnne #'
No Free __. -_ Comb. ,., pH ...
15SULTS OF EXAMINATION OF WATER:
'RN ?100 ml
Goliforrn Group _....
Fecal Coliform
MEMBRANE FILTER METHOD /100 ml.
Total OOliform; 'FI PPlvuw
Total Coliform: Present (
MEMBRANE FILTER METH001100 rnI '
Fecal Coliform
STANDARD PLATE COUNT
Fanal Conform Indicated! Bacteria per ml,
Yes ( ) No ( )
These results Indicate sample(6"�as not) of satisfactory sanitary quality.
,rate Reported:
deported By:
silent Notified:
Amount Paid:
Amount Due:
r�
Check Number:.
-OMMENTS: ,.,� 1 _
C 0__ -<D a
OF
t
FP:-I,'`i : PRESE;DENTDAL HOrIES 229 -0117 PHONE NO. : 229 0117 P02
0u/Avl j'W-
Wr•` r N►m�l��.r
NW& A O%r% R D my-r% vati -i a mrsit i 1w1^
n Dtl 1 IAIr 1 0MTAArT(lRC
1_ock Time
- Elapsed
Time
---
GPM
Drawdown
Feet
-- -
Remarks
AS
75-
i I '30
q P,
� � ►qs
i
`, d
3os '
ZIA
9.9
330
WAY
CV
IS
.r
361LIR
3117,
a►A e-
s
1
s
___
-3 . _16 �_...
30
3-99 ,
T--
D AF
c_ rj ZE-= 1,r - -_, as F =r car vc-- G� --
�_ E= 11i sue, mac:. -"Da". cf pi
L:1 L
C_ ITG „-_ � sci I_c-
E_ ?:I0 ft-
a_
C_
c_
E.
J
S =-mac 1=�= s = - 1,000 1 , 56
-C-_D
All
CN
-- - - L'_ L -_
F . RccL_ =cam E::-= -=icr_, 50
u _ DST c c 1 i- t _ch L"
?. Fi"C;e EEC
=c_ =-
_ R.r0 OR ECS c%, :c
2- Cti C-W ►__'
� F'�:� E.. '% cC-. =� _�! - u„''rC! = L': C ter'= •
F Ice = r: - a rc-va pi
C_ 1 -i L i Ccc f �•c:; 4+_`Z l CL EC:•;
C_ �zR-f 1 1 I -,a t = "c_' CcI ?:l= SzC^ES < ��' 1_''- L�T=
C-.=? ^ `_ : C:i =l? C:CL -' _r
C.'1 SIC—cc-
I I I
I I I
I I I
I I
WO
AW v
1 rapresent:that 1 am wholly and completely responsible for tha design and location of., the proposed system(s).. 1) that the separate, sews disposal slam
above described will be constructed as shown on Me approved amendment then to and in accordance with the standards, rules a rpu . sus o ham
County, t�pertmant of. Maetth, ,and tA_at on completion their a "Certificate of Construction Compliance" satisfactory to the Comtniationer of Hwtthwill
be submitted ,tithe Department, aid .a written guarantee wlll'be furnished the owner, his successors. hairs or assign} by the builder, that said bulkier will
plb" :in good,_oparalke :eondition'`iny Oat of .said :sewage disposal system during tits period of two (2) years immediately foilowini,: the date of the tau-
~' of thi: apps 6.41 of i1i Certificate of Consirullon'Comp I original system or any repairs thereto; 2) that the drilled ;well described above
wo lag ult -tad as shoairn on the approved plan and thetskl well wit instal in a Meng w the ros, rules and rpu ns of tits Putnam
C.01111:Y eoaKl6elle' of'MMlth:
Date ± � Sign P. MA.
Adds License No ��7 T•
APPROVED FOR CONSTRUCTION- This ♦xpN' et two years from the date issued unless construction oft a building has been undertaken and is
revocable for Cause or may be'7imnded, or modified when considered necessary by the .Commissioner of Health. Any change or alteration of construction
D,., requires a w per mit. Approved for disposal of dOmenk: sanitary sewage. arwor priv a water supply only.
'L1cV. �E�' Title
!0/88 sub
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL Q
PCHD PERMIT #�L_I� /__)'
WELL LOCATION
< Street Address
vP,
y- Tax Grid Number
W r
WELL OWNER
Name
Mailing Address
2s
g/�
8l ��' �G4
OPrivate
Public
USE OF WELL
0 - primary
2- secondary
RESIDENTIAL
� BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
b INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED '3 :� /EST. OF DAILY USAGE gal
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION M ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING)- ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
e
WELL TYPE
®DRILLED
DRIVEN
ODUG O GRAVEL
a OTHER
IS WELL SITE SUBJECT TO FLOODING? YES A NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name P D, Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: A) IA TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: c) Y`e%L A VVN i fe
LOCATION SKETCH& SOURCES OF CONTAMINATION PR )f�
ON SEPARATE SHEET
s�--�
(d te) (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
thirt}, (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 a manner as not to degrade or otherwise contaminate surface or groundwater.
no
Date of Issue: U C �" �� 19_ -7G
Date of Expiration 19 4 PermitIssuing Officia
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH - DMSION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
-/ REVIEW SHEET for CONSTRUCTION PERMIT
\ME OF OWNER / J� �S / T c %c --- ,,_,� LOCATION
DATE TAX MAP # 2
DOCUMENTS.
RMIT APPLICATION DISCHARGE (OK)
PERC & DEEP HOLES LOCATED
rEIdNEERS L PERMIT; PWS LETTER REPRESENTA IVh OF PRIMARY' AND EXPANSION
� AUTHORIZATION EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
.d DESIGN DATA SHEET(DDS) IF PUMPED PIT & D BOX SHOWN & DETAILED
LOG
T PERC RESULTS (3)
DEPTH
RESOLUTION
S THREE SETS
V OUSE PLANS - TWO SETS
ARIANCE REQUEST
GENERAL
LE AL SUBDIVISION �c 4P
DIVISION APPROVAL CHECKED �
d PERC RATE
REQUIRED
CURTAIN DRAIN REQUIRED mSTANDPIPES
EX- APPROVAL SSDS ADJ. LOTS
WETLAND (TOWN/DEC PERMIT R & D)
DATA ON DDS PLANS & PERMIT SAME
PRE -1969 - NEIGHBOR NOTIFIFICATION
3 LETTER BI/ZBA
100 YR. FLOOD ELEVATION
QUIRED DETAILS ON PLANS
SEWAGE SYSTEM PLAN - (NORTH ARROW)
SSDS HYDRAULIC PROFILE m GRAVITY FLOW
D/ J BOX m TRENCH/GALLEY m P- PIT DETAILS
SEPTIC TANK - SIZE, DETAIL
WELL DETAIL, SERVICE LINE IF OVER
CONSTRUCTION NOTES (GRINDER RATE)
DESIGN DATA: PERC AND DEEP RESULTS
TWO -FOOT CONTOURS EXISTING & PROPOSED
DRIVEWAY & SLOPES CUT
FOOTING /GUTTER/CURTAIN DRAINS
)MMENTS:
HOUSE - NO. OF BEDROOMS
WELLS & SSDS'S W/IN 200 FT. OF PROPOSED SYSTEM
PROPERTY METES & BOUNDS
HOUSE SETBACK NECESSARY (TIGHT LOT)
)HOUSE SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE
NO BENDS; MAX. BENDS 45 W /CLEANOUT
FILL SYSTEMS
CLAYBARRIER
10 FT HORIZONTAL: SLOPE 3:1 TO GRADE
FILL SPECS a
DEPTH GAUGES
FILL PROFILE & DIMENSIONS
VOLUME
TRENCH
TRENCH PROVIDED
60 FT MAX
PARALLEL TO CONTOURS
1100% EXPANSION PROVIDED
�U 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)
50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
10' TO WATER LINE (PITS -20)
50' INTERMITTENT DRAINAGE COURSE
200 FT. RESERVOIR, ETC.' ED 150 FT. GALLEY SYSTEMS
SEPTIC TANKS
' FROM FOUNDATION; 50' TO WELL
WELLS
QJ 15' WELL TO P.L.
LAURENT ENGINEERING
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
RANDOLPH W. LAURENT, PE. ( 914) 278-6108-(FAX) 278.2658
HARRY W NICHOLS, JR., PE. CONSULTING SITE ENGINEERS
August 18, 1992
Mr. William Hedges
Putnam County Health Department
Route 312, Geneva Road
Brewster, NY 10509
Re: Individual SSDS
Lot #18 Cornwall Ridge
Somerset Drive'
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing SS -18 "Proposed SSDS ", dated
8- 14 -92.
2. "Application For Approval of Plans For A Wastewater Disposal
System ".
3. "Construction Permit for Sewage Disposal System ", dated
8 -4 -92.
4. "Application to Construct a Water Well ", dated 8 -4 -92.
5. "Design Data Sheet ".
6. "Letter of Authorization ", dated 8- 14 -92.
7. "Corporate Affidavit ", dated 7- 30 -92.
8. Two (2) copies of Residence Floor Plan(s), for "Bedroom
Count Only ".
9. Money order in the amount.of $300.00, review fee.
We would appreciate your review, approval and issuance of the
Construction Permit at your earliest convenience.
Sincerely,
LA NT ENGINEERING ASSOCIATES, P.C.
Randolph W. Zurent, P.E.
RWL:bd
92056
cc: Mr. G. Angelo w /enc.
PUTNAM C OUNTY D E PARTMENT O F H EAL TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant:
-72-o bt,0 ! mil' ,4vc,
17 a� 7S`3�
2. Name of Project: �o d S 3.._, Location(T,yV /C:
4. Project Engineer: )o),24
1 /, ,4 5. Address:
/ `/Y
License Number: Phone:
6. Type of Project:
i�rivate /Residential Food-Service ....Commercial ,
Apartments Institutional Mobile Home'Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject•.to State Environmental Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt 1'-
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? .............
9. Has DEIS been completed and found acceptable by Lead Agency? ...........
10. Name of Lead Agency
11. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ......... ...............................
12. If so, have plans been..submitted to such:. author .sties..: ...................
13. Has preliminary approval been granted by such authorities ?,,�f'/A- Date Granted:
14. Type of Sewage Disposal_ System^ Discharge...... Surface Water L: Ground Waters
15. If surface water discharge, what is the stream class designation? ........ i-
6. Waters index number (surface) ......... ............................... J14-
17. Is project located near a public water supply system? ..................0
�8. If yes, name of water supply Distance to water supply
9. Is project site near a public sewage col lection or disposal system ?..... A
'0. Name of sewage system /11 A Distance to sewage system
A. Date observed: 23. Name of Health Inspector: /i/t ,,- /ua
.4. Project design flow (gallons per day) ...... ............................... Lz06
a
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?..
26. Has SPDES Application been submitted to local DEC. Office? ..a............ _.
27. Is any portion of this project located within a designated Town or State
wetland ?...... .......................... ...............................
28. Wetland ID Number .
29. -Is Wetland Permit, required ?• ..................... ...................... �O
Has application been made to Town or Local DEC Office?....................
1
30. Does project require'a DEC Stream Disturbance Permit? ...................
31. Is or was project site used for agricultural activity involving application
of pesticides to orchards or other crops, solid or hazardous waste disposal;R'`' 'j
landfilling,"sludge application or industrial activity ?......... YES or NO ,//VV
32. Is project located within 1;000-feet of existence.of abandoned landfill,
hazardous waste site, salt stockpile,. landfill, sludge disposal site or /1
any other potential known - source of contamination? ..............YES or NO .. �.
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ...........
34. Are community water, sewer facilities planned to be developed within 15 years? lea
35. Are any sewage disposal areas. in excess of 15% slope? iV Q.
3
36. Tax Map ID Number ........................................................
37. Approved Plans are to-be: returned to: ................ Applicant Engineer
If the application is signed by a person other than the applicant shown in Item.1, the.
application must be-accompanied by y-a Letter of Authorization: Failure to comply with this
provision may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury;- that information provided on this
form is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of
the Pena 1 Law.
IIGNATURES & OFFICIAL TITLES
1AILING ADDRESS: ffil
SOA,8S
xnlnoo
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Address JZ? VIp AV f NYD� f�12K -� ICIY
�01Jl r`T PIZ►�
Located at (street) & � pw r,> Sec. Block i Lot 0
(indicate nPA est cross street)
Famicirality 'r}4� �V Kj Watershed U'Zb°rof�l
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBNB= WITH APPLICATICNS
Date of Pre - Soaking Date of Percolation Test
_T
HOLE
NUMBER CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water Fran Water Level
No. Time Ground Surface In Inches Soil Rate
Start-Stop Min. Start Stop Drop In Min /In Drop
Inches Inches Inches
2 11: 0 : ?S ZO 22 3�
311:26 _ I I : q (0 20 2Z 257 3" I
4
5
1
2
3
4
5
1 IDgG, II:Oa (d- 2Z 2,5
3
P._.
J
f 57 ✓
x.
NOTES: 1. Tests... to' be` repeated
are obtained at each
for review.
2. Depth measurements b
rev. 9/85
at same depth until approximately
percolation test.hole.. All data
be made; frcin top of hole.
i
'
equal soil rates
o• be suimitted
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE N0. HOLE NO.
G.L.
2'
3'
4' LVAO
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUN'T'ERED
DEEP HOLE OBSERVATIONS MADE BY: M 12U bZ1 DATE: 85
DESIGN
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided Q Ob s.�•
No. of Bedrooms Septic Tank Capacity We) gals. Type :�npOe-,
Absorption Area Provided By 5�1
.90 L.F. x 24" width trench
Other
Name a) p0 J�,rJ I IA) . VA 0 rr-E Signature `
Address I, SEAL
2G✓D1a 1.1 � � {1l� -z�bi �$��® f�o.045781 ���
THIS SPACE FOR USE BY HEALTH
Soil Rate Approved
:- Checked by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date R- I j –� 7'
Re: Property of
Located at sG�- .,zrt -� �YI i., -C-
(T)F(We4 S ection 7-3 Block *-�- Lot
Subdivision of Kti L4-,c. I. x"IC-1 -rff-
Subdv. Lot # iA Filed Map # x1L �+ Date
Gentlemen:
This letter is to authoriz\ � �.O
a duly licensed professional engineerXor registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary
Count
P.E.,
Telephone
Y truly_ y
aed
E
1•
of property
`7 oZ? v to
te:T 14J z
- Address
Oe ( P-k
Town
Telephone
rurnam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE CWNER APPLICATION
FOR PERMIT-APPLICATION SUBMITTED-TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health - In the matter of application for
I' -- �C.S __ _�...�- 0-- _— .— _-- _--- - -_.__ • represent.
that.I am an officer or employee of the corporation and am; authorized'
to act for _ 1 �Q e %A CY V_, j .(+ L_ `'�-%� FCC_
(name of corporation)
having offices at "') f p �� _ U _ �} e�
�. Whose officers -are
President
ame and Address)
Vice- 'Presic qnt � �i Cl L > o
_ A
• (N me and Address) -
Secre =tar
y
." .
(Name and Address)
Treasurer" _ _ _ _ _ _ _ _
(Name and Address) �- — — '- '— — —
and that Ilam-and will be individually responsible fon any' r all aptp
of. the- corporation with respect to the approval request an —all .sub-
't t 1 '
sequen acs re ating thereto.
Sworn: to be fore ine this ,3O day Signed _ _
of 199 Title
oN -'tary R.il;lic
- BONNIE J. DAMS F max:
x0nW =VV=
MrCOWq S�
MMi
Corporate Seal
t .
�11.
:THE NEW PIUNDLAND ,- 8- ,x40', 1120
16' X 40' Unfinished Second Floor . 640 Sq.
Second Floor
BEDROOM
Id'- !' x IB' - 0'
PUTNAM "01
BEDROOM 2
ir' -3'x ie' -o'
3E PLAN S Al
100M COU T
r
I 40'
First Floor
)E ' RTi-'?FjTf 0 HEALTH
ED FOR
i 40'
I
- i
!7'8„
STANDARD NEWFOUNDLAND FEATURES
• Luxurious First Floor Master Suite
• Compartmentalized First Floor Bath with
Two Separate Vanities
• Formal Entry Foyer
• Formal Dining Room
• Formal Living Room
• Spacious Eat -in Kitchen
• Fireplace Options Available
• Consult an Authorized Westchester Builder
for a Complete List of Options
• Artist's renderings and Floor Plan Dimensions are
approximate. All specifications must be Written in the
contract No oral conditions.
_.
MN
ESTCHESTER ODULAR OMES, INC.
Reagan's Mill Road . Wingdale, NY 12594
(914) 832 -9400 • (800 ) 832 -3888
i
W Y�
WALL UUr1rLL' iiUA A�,rUA.1
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
ST 59q AOORESS. A TOWN/YILLAUILICIFY TAx GRIo NUMeEd•
WELL OWNER
NA ADDRESS
him n ,
"IVATE
O PUBLIC
E OF WELL
1 primary
- secondary
RESIDENTIAL O PUBLIC SUPPLY ❑AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT_ gpm. /N0. PEOPLE SERVED =/ EST. OF DAILY USAGE 22CL gal.
REASON FOR
DRILLING
❑ PLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
ONEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL 161D it.
DATE MEASURED 9
DRILLING
EQUIPMENT
O ROTARY eCOMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
��//��
O SCREENED O OPEN END CASING (13"OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH _ tL
MATERIALS: OISTEEL ❑ PLASTIC D OTHER
CASING
DETAILS
LENGTH BELOW GRADE �9— ft.
JOINTS: ❑ WELDED 116HREADED ❑ OTHER
DIAMETER 6 —in.
SEAL: ❑ CEMENT GROUT PfENTONITE ❑OTHER
WEIGHT
PER FOOT ¢� �' Ib. /ft.
DRIVE SHOE YES ❑ NO
LINER: 0 YES. OKO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (It)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
o Nos
GRAVEL
SIZE:
DIAMETER
OF PACK In.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST It detailed pumping
METHOD: O PUMPED t tests were done is in-
t
GKOMPRESSED AIR , formation attached?
O BAILED O OTHER : O YES ONO
It more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Oi3-
meter
FORMATION DESCRIPTION
p0E
tt
It
WELL DEPTH
tt.
DURATION
hr. min.
DRAWOOWN
It.
YIELD .
9 •
Lund
,
W- Coo,
e
O CLOUDY HARDNESS
O COLORED ANALYZED? O YES ONO
NALYSIS ATTACHED? O YES O NO
rAKFR O CLEAR TEMP.
STORAGE TANK: TYPE
CAPACITY GAS.
NFORMATION
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAM Q, DATE®
AOORESS R 0' t
6♦�-�'d
J/ ov
s M .-w
J/ 07
wl:,LL UVrLrLG11 t V" aNXIrVn
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
Si ADDRESS: wNr I Y TAX GRID NUMBER:
V
NAM • ADDRESS: "IVATE
LAW,f if O PUBLIC
WELL OWNER
E OF WELL
1 primary
- secondary
RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
0 INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY O
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE -9-90- gal.
REASON FOR
DRILLING
.O PLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
ONEW SUPPLY (NEW DWELLING) O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 41A0 — ft.
STATIC WATER LEVEL _! 5A ft.
DATE MEASURED 9
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
0 SCREENED O OPEN END CASING VOPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH ft.
MATERIALS: STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE ft.
JOINTS: ❑ WELDED grfHREADED ❑ OTHER
DIAMETER in.
SEAL: O CEMENT GROUT 04-ENTONITE OOTHER
WEIGHT
PER FOOT %7 lb./It.
DRIVE SHOE OYES 0 NO
LINER: DYES 046
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (1t)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ NOS
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH K.
WELL YIELD TEST It detailed pumping
METHOD: O PUMPED tests were done is in-
�,/ I
t� I.OMPRESSED AIR formation attached?
O BAILED ❑ OTHER ❑ YES O NO
1�IELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Ola-
meter
In
FORMATION DESCRIPTION
CON
It.
ft.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
it,
YIELD .
g
Land
� 070o
In
WATER O CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ❑ NO
low!
ELI
STORAGE TANK: TYPE
CAPACITY
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAM '
ADDRESS t t 1 `� 8V St
O Ia Pi
J/ 07
+t
WLLL UVP1rLL11V1V ar;run
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use-only
WELL LOCATION,
S 'T AOURESS: NI I ! TAX GRID NUMBER'.
I R3-1 —
WELL OWNER
Na E: A RESS.
BIVATE
o PUBLIC
U E OF WELL
1 primary
- secondary
RESIDENTIAL ❑ -I Wr SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDO ED
❑ BUSINESS 0 FARM 0 TEST /OBSERVATION 0 OTHER (specify)
❑ INDUSTRIAL 0 INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE.SERVED --3-1 EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
❑W LACE EXISTING SUPPLY OTEST /OBSERVATION []ADDITIONAL SUPPLY
—
SUPPLY. (NEW DWELLING) DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH `4� ft.
STATIC WATER LEVEL
DATE MEASURED Q 17 Q
DRILLING
EQUIPMENT
❑ ROTARY M COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT 0 CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING ®`OPEN HOLE IN BEDROCK ❑ OTHER
'CASING
DETAILS
TOTAL LENGTH tL
MATERIALS: 2tTEEL 0 PLASTIC ❑ OTHER
LENGTH BELOW GRADE _ 9 ft.
JOINTS: ❑ WELDED t6THREADED ❑ OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT BENTONITE 0OTHER
WEIGHT
PER FOOT �7 lb./ft.
DRIVE SHOE ES ❑ NO
LINER: DYES O
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE .
LENGTH (11)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
❑ YES ONO
HOURS
SECOND
GRAVEL PACK
0 NO YES
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH ff.
BOTT061
DEPTH ft.
WELL YIELD TEST It detailed pumping
M 0: O PUMPED t tests were done is an-
t
PofOMPRESSED AIR , formation attached?
O BAILED ❑ OTHER ; ❑ YES O NO
TELL LOG
it more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
Water
Bear-
Ing
Well
Dia-
meter
In
FORMATION DESCRIPTION
pat
tt.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD .
gpm.
Surface
°
.®-
! i
6P M
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAI,.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAM W DATE //
ADDRESS �} � � sl M11TURE
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