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23. -1 -56
BOX 7
00592
ii
Krjr
oim6
00592
PUTNAM COUNTY DEPARTNUMOPH
S
105121 2
Mlud'-Provme�.�
C Gaffon, Septic Twk:and -
,�ojjgjsij" Of 4—
W.awlwo: PubDe-Supply F'r= —Aiddre"
4?^&A 1�,Kem j5iz-
art Prwaw $. UPOY DMW byEtf_ 0 `: AL 9X
X . I . Widmg Tyj, I t (AL,16t Size ath `j
e
C-., Has Erosi6n Ci4-i-ell d?,
OOP 17'
Number of Bedrooms 'Garb 890
Grinder Been Installed?
Other` Regaliemeats L
I certify that the systtim(s) as listed serving the above.premil-es were constructed essentially as shown on the,plans of the completed, work l copies
of which are attached), s:nd,,in,aq_co'Fdance with the -standards, rules ands qpuptions,i. accord *i",. and the permit issued by the
Putnam Co"ty.liepaii6drit alth.
,7
oats I NO. --- P.E.— R.A.
ACdross :Csitifled by
A�
License 'M
unanKary
Any - person occupying premises served' b* systems) shall promptly take such action as msybe�nacallsary to secure the correction of any
conditions resulting from 11 -such' tinge. ^Ppro4al, of the j6parste -sair4rage,systern shall. become null and void 46:90" si i"pubV: military sr~' "M
null and id supply1 - , 11"lico .
available and the approval of tile p, rjjafs'%vst6r supply chili become wo witil!" a -public water - mas available. Such approvals we
subject to modification or, couin •when, in, the A'dignisrit' of the commlili6in or d, f, Wealth such revocation. modificiItIon or change Is no . cessary.
Cate :2, By
�/89
21
1I1 \
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i
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WLLL LU1virLL11UV rcDrUAI
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET AOURESS: TOWNIVIEDICLIC1119 TAi GRIO NUMBER:
Cornwall Hill Patterson, NY Lot #4
WELL OWNER
NAME: ADDRESS:
Cornwall Home Builders, 155 E,-Main St., Brewster,NY
❑ PBIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
II RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
0 BUSINESS ❑ FARM ❑ TEST / OBSERVATION ❑ OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) [:]DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 60.5 ft. I
STATIC WATER LEVEL -.._3o ft.
DATE MEASURED 94
DRILLING
EQUIPMENT
a. ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT O CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING ZI OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 153 _ tL
MATERIALS: ® STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE 152 ft.
JOINTS: O WELDED f3 THREADED .❑ OTHER
DIAMETER 6 in.
SEAL: LFCEMENT GROUT O BENTONITE ❑ OTHER
WEIGHT
PER FOOT 9 1b./ft.
I DRIVE SHOE. ® YES ❑ NO
LINER: O YES ®NO
SCREEN
DETAILS
DIAMETER (in)
-SLOT SIZE
LENGTH (11)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK JTDOEPTH
P
ft.
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: ❑ PUMPED tests were done is in-
i �
1QcCOMPRESSED AIR , . ormation attached?
BAILED ❑ OTHER :OYES ONO
WELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
mq
Well
Dia'
Inecer
FoRh1ATtON DESCRIPTION
can
ft.
tt.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm.
surtia
4
Drilling
in overburden clay & bould
rs
ro
k at 411
60
6
585
5
4
53
r57-94
li
g in rock, se casing, grout
d
15
605
li
g in rock granite.
Hydrofracturing Procedure
WATER O CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAT,,.
I PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DAIUER NAME .17.17.1155.L Ori , C . OAT
ADDRESS 4 Putnam Ave . 7/94
Brewster, NY ld'j"
J /by
\' I I
PUI'NAM ODUM DEPARn4EY2 OF HEALIH
DIVISION OF ENVIRO,iIQTAL REALTH SERVICES
Owner or Purchaser of Building.
Building Constructed by
��M���r 'I�12►V�
Location - Street
Municipality
Building Type
Section
Block Lot
Subdivision Name
Subdivision Lot #1
GUAR -711 .E OF SUBSURFACE SE PU GE DISPOSAL SYSM
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 Envi.ronin?ntal Health Services of the Putnam County
Department of-He ' alth as to whether or not the failure of the system to operate was
s
caued by the wilful or negligent act of the occupant of the building utilizing _
the system. -
Dated this day of/I__76 194 Signature
Title ,
eral r ( - tune
Corporation Namd (if Corp.)
Corporation Name (if Corp.) l .5 Sv M
e5srr
ser /fie
Address � n .
rev. 9/85
mk
ANALYSIS DATA SHEET
TYPE: PW
LOCATION: Lot 4, Devon Rd.
REPORT TO: Cornwall Homebuilders Inc.
ADDRESS: 155 E. Main St.
CITY, STATE, ZIP: Brewster, NY 10509
DATE COLLECTED: 01 -26 -94
TIME COLLECTED: 11:20
COLLECTED BY: Sylvester J. Pecora Jr.
REPORT DATE: 01 -31 -94
SAMPLE: 94 -0454
SAMPLE SOURCE: Water tank
DATE
ANALYSIS RESULT UNITS METHOD ANALYZED
Total Coliform Absent COLILERT 01 -26 -94
THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET
THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS.
Laboratory Director
NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914 - 278 -7600 / FAX 914- 278 -7754
Lot Acv.
N=bw d . .. Deter I%w G P D �� PCED tibd Moa is RegWmd Wben F61 i ea ipww
Sepaeobs Sewee e, S 0 to as+" of top" 51109 Teeth God � Z�D 0
To 6-ommkoded.by e Addreae
Watss Sam; @oa me S,"Ii,Fe
an I/ Pdwn" Suptib DsIBed bt . A&dN=
Olive eeta
1 iepiesant "that.) am wholly a'' -' pNtaly nspogsiblofoithe "ilgbandaoeatioil of tM proposed systorn(s)l 1) that the saparate' few.. .di sN f stem
above described will bo constructed a's drown on the approved ainentirn m th®►o to and in accordance with the standards,' rules ii rpumpons of nam
be fubmllted -to tM Oeperinlenl and a 'wr.i'
ptKe 'in fiMq' -'at' condtiloh snji'slart:
ahCe of the appmal.of the iwtifkats'of t
will be WrAted as, -I- W, 6 on threpproved Pion I
County Oaparuf a of I A"Ith.
oat®
ndd.ea...
APPROVED FOR CONSTRUCTION Thii app
revoeabso for cause or r w.amondoe oi.mo
requires a na mif%�pproved for dispoi
Rev.
10/88 ace
tNion fhMeof a 'Certifweto -of Constiuction_Compliante' satisfactory.to tM:Cominisslonor of McNlhwill
I,yarantim :will bi',sumisn� :;the;ownar his fuco_ es**,,MMs oi'aiiigni- by'the bulidei, that said builder will
ifd apwape disposal 'systoin duriiq.tlle,psiioe 04 two (2?)'yeais bnmodiaNlY follawirp tMdete of the iseu-
iuction; Complknq 'of., t¢o original, system; or any repair therNO: 2) that the drilled well deseribe0 above
let said well will be.lnstVi" in aocordanoo' with the s)badarpt. yt W and. ►in -U-6 oE1Ms of . the Putnam
MMZ Eli
i IM �
'exp ires two yeah fro'rn.the daidlssued unless construction of fM building has been ulWwtaken and is
I whop cDnsidere rieces00ry by-the Commissioner of Heal h. Any change or alteration of construction
domestic sanitary sewag% andlpriivmte water supply only. �/'
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL 99
PCHD PERMIT # ' /V /�
WELL LOCATION
Street Address Town Village City Tax Grid Number.
F�,L� fL3. _ I _
WELL OWNER
Name
p
Mailing Address
j z)JL Ef ty eq U
¢Private
O Public
USE OF WELL
- primary
2- secondary
13 RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
b INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (spec ifq
O
AMOUNT OF USE
YIELD SOUGHT 5 gpm /# PEOPLE SERVED �5 /EST. OF DAILY USAGE _6,:9nn Sal
❑ REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION GIADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
ODRIVEN
DDUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 1/ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �pU�,e�w }2fRF
Lot Mo. iJ.
WATER WELL CONTRACTOR: Name (J Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES V-/ NO
NAME OF PUBLIC WATER SUPPLY: W IA TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON SEPARATE SHEET
(date) nature
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.
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 mannX as not to degrade or otherwise cont i surface or groundwater.
Date of Issue: 19
Date of Expirati en 1_ Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
rLJililx'♦ �ll�il LLCly lJ11L...�t V4 11Lt11JiL _ _ ...
DIVISION OF RFALTH- SERViCFS
DESIGN DATA SaEh,T- SUBSUFACE SERI I.GE DLSPOSSAL SYSTEM FILE 'NO.
Owne -- P.ddress Zf
Located at (Street) 'p0-7 U,:O K) 1� Sec. Block Lot <o
(indicate neirest, cross.street)
Mvnicigality. �C'rh4 N Watershed �ifzaTo�
sorL PE` MLASIC�I TFST DATA RE�rUIl2F7D TO BE suFi'rirrrED w PPPLIC ICNS
Date of Pre- Soaking Date of Percolation. Test /fe
HOLE
NU-4BM P= RCflLA CN PERCOLATION
Run Elapse Depth to Water Fran Water Level '
No. Tune Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop _ Drop In Min /In Drop
Inches Inches Inches
1
Ind v- _ -. ,1; 1 r2
�1 2 v _ D
3
4
5
• .... 1
�G 2 .2- is
3 j : 2.
4
5
1 •
2
3
4
5
NOTES: 1.' Tests to be repeated' at. same depth until appradmately elLm1: soil rates
are' obtained at each percolation test hole... All data to' be sdbmitted .
for review.
2., .Depth measure Tents to be made fran top of hole.
rev. 9/85.
L�LJ.uv......+ tv Lazo ouzx: L11L11 rr1Al1 Mzrj�L. 11VN
DESCRII?TION OF SOILS ENCOUZ41ERED IN TEST HOLES
DEPTH HOLE NO. i HOLE N0. HOLE NO..
G. L.
l'
2'
3'
4'
5'
6'
7; I/
g'
9!- .
10'
13 ...
14'
INDICATE LEVEL AT W'diiCH GROUND;rZATER IS E 900UNTERED
INDICATE 10-M TO WaICa KATER LEVEL RISES A.F= BEING ENCOUNIE M
DEEP HOLE OBSERVATIONS t2 -.DE BY: DATE:.
DESIGN
Soil Rate Used Min/l" Drop: S.D. Usable Area Provided -5
No. of Bedroans Septic Tank Capacity gals.' Type
Absomtiob Area Provided By erV L.F. x 24" width trench
Other
Nary �c�I�2� W • 'i l,v ��: Signature.
Address _T?2 MI � j �D DI �I �!E SEAL
TT _
THIS SPACE FOR USE BY 'HEALTH DF.PARTMEN P ONLY:
S
i
b�s-is_r SM04i
Fri�
oil Rate Approved sq.ft /gal. Checked by
AROFESSXO
Date
pL77CNAM COUNTY DEJPARTMENT OF HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant:
2. Name of Project: Location d�V /C:
4. Project Engineer:��f 5. Address:
License Number: Phone: _=_610
6. Type of Project:
I/ — Private /Residential Food.Service ..•.Commercia•1
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 t/
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required?
9. HaSDEIS been completed and found acceptable by Lead Agency ?:...........
10. Name .of Lead Agency -I'J /A
11. Is this project in an area under the.control of -local planning, zoning,
or other officials, ordinances? ......... ............................... Q.7U
12. If so, have plans been..submitted to such author .sties ?....._...............
13. Has preliminary approval been granted by such authorities? N4A- Date Granted:
14. Type -of Sewage Disposal: System Discharge,...... Surface Water ✓ Ground Waters
15. If surface water discharge, what is the stream class designation ?........
i6. Waters index number (surface) ....... ............................... ..
17. Is project located near a public water supply system? .................. ! a
8. If yes, name of water supply Distance to water supply_
;9. Is project site near a public sewage collection or disposal system ?..... _ ija
:0. Name of sewage system %Ac Distance to sewage system
11. Date observed: �$ 23. Name of Health Inspector: 01;�. tLm? ,nN`���
4. Project design flow (gallons per day) ...... ............................... z4>0
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. D
26. Has SPDES Application been submitted to local DEC Office? ............. ... lAr
27. Is any portion of this project located within a designated Town or State
wetland ?......... .................... �b
28. Wetland ID Number .........................../,�
29. Is Wetland Permit- required? .............. ............................... 1J D
Has application been made to Town or Local DEC Office? .................. N� 4
30. Does project require a DEC Stream Disturbance Permit? ................... l� D
31. Is or was project site used for agricultural activity involving application
of pesticides to orchards or other crops, solid or hazardous waste disposal',
landfilling ,•sludge..application or industrial activity? ........ YES or NO ,J 12
32. Is project located within 1,000-feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge.disposal site or
any other potential known source of contamination? ..............YES or NO Q-0
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? i
34. Are community water, sewer facilities planned to be developed within 15 years?
35. Are any sewage disposal areas in excess of 15% slope? ........................ .0_
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-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 Clas A Misdemeanor pursuant to Section 210.45 of
the Pena 1 Law. %/ A
SIGNATURES & OFFICIAL TITLES:
4AILING ADDRESS:
PU'TNAM COUNTY AEPAATMENT OF HEALTH
DIVISION OF LNVIRONMENTAL HEALTH SERVICES
Date 5
Re; Props arty
LQr'ated at VpN _ fix?
(T) �'.�,r,�Ot -� Section 2 Block Lot �
Subdivi,ei,on of Corte Wa-I �R14 -e — -
Subdv. Trot Filed Map E 7.1 ( Dat, a 5 -2.1 CI
Gentlemen:
This 1Qtter is to authorize HIIIr�
6C;ICw /S` C'Jel
a duly licensed prof®ssional engineer 4./' or registered architect
{Indicate
to apply for a C6riate'uetion Permit for a, separate sew9,ge system, to
serve the above rioted property in accordant® with the atandards, rules
or regulations as px•emulatAtad by the Cohimissioner of the Putnam County
Department of 14*alth, and to sign all necessary papers. on my behalf in
conneati.on vr%th this matter axed to superviag the QOnstructi.on of said
bystam or systems in conformity with the provisi.ona of Article 145 or
147, Education Law, the nubtia Health I,aiv, and the Putnam County Sani-
tary Codc, r�
C6untersigned:
P.E., R-A.,, `
Address
4 Y--
Telephone
Very tl %AI)'j/Y0%Irq'
-�--.-
Signed.
Owner of Property
Addre5n -
0(4�4� AJ V
Town
Telephone-
�X G t�OGK �iSt . eaX
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io
i7
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�fHAT THE S�WAv�
A
�AN A-.) ANC -( HAT T H F—�
THE 5 -�eTEM VVAS
ale OANGE W hTH AL-1.
R2 1QEGUL,ATIONS OF
2
3
4
5
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ri�IelQi A v a
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SE ►?T 1 G
AN K-
RPA b
Putnam Cow
Avision of Ens
tpproved a# not
applicable Hul(
?utnam Co�unt�y I
J
AS -WILT
VIMNSION GNA12T
N�
A
t3
I
(G) I !o .0'
(t7) 30.0'
lob 0'
3
101 �O.'
1 10.0'
q
( 03.0'
1 13.0'
5
I. O(o 0'
1 10.0'
( 23.0'
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