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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 23. -2 -68 BOX 7 �,ti,. i ., % � r . � i 61 1 �� 0 litr V.- A�m oil 00636 .�,..,„.. _,�... �.. .,, .,. ..: ., ,. .,b .., :,.t smn i ,.:•..��,,, ., r `-- :'is",, *7'r �-z,��isS�"M:tTM�'z^'.1 ice': YS PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTIO COMPLIANCE FOR SEWAGE TREATMENT SYSTEM 2 PCHD CONSTRUCTION PERMIT # `' 3O- 7 63 Located at Town n a a. POW n Owner /Applicant Name Tax Map_ Z- Lot C OS� Cb S7'7� -�G�1 �1S Formerly Subdivision Name Subd. Lot # Mailing Address Date Construction Permit Issued by PCHD Zip aJ� Separate Sewerage System built by Address Consisting of 00 0 Gallon Septic Tank and 36 0 (=tE 2�%!ke C 1 Other Requirements: Water Supply: Public Supply From or: Private Supply Drilled by " �{ 1 Address Address ��( - Sy/l•' Building Type �� �` �/ Has erosion control been completed? 4! Number of Bedrooms �% Has garbage grinder been installed? N a I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accord ce with the issued PCHD Construction Permit and approved plans and e Stfidards, rules and regula ions f th Putnam C ty Department of Health. 6® n sign P of ssio 7 Address 1 ICJ License # `� �- An person occupying premises served by th� ove sys s s 1a1promptly take such action as may be necessary Any secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals ubject to modification or change when, in the judgment of the Public Health Director, such revocatio ificatio change is necessary. , n By: %� Title: v %4 C Date: l White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Profes onal Form CC -97 BRUCE R. FOLEY Public Health Director DEPARTMENT OF 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (9.14) 278 - 7921 Nursing Services. (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 OWNERS NAME: K S l In U. G f<'o TAX MAP NUMBER: '231-1 E911 ADDRESS: PO to de U is U ti TOWN: Pn 41t'lr s on Gu P w 'Y© pif� AUTHORIZED TOWN OFFICIAL: (Signature) f DATE: 3d 40 It The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is, assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E911 VERFRNI) VI An Ohm PIP' -"Wski5 ~ � Ij nor by.OA" joil cc ' m YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.000741 CLIENT #: 8641 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~°~~~~~~ WALLACE, DOUGLAS P.O. BOX 154 MOHEGAN LAKE, NY 1054-7 SAMPLING SITE: LOT 5 : LITTLE POND HILL ESTATES COL`D BY: DOUGLAS WALLACE NOTES...: KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE/TIME TAKEN: 06/07/00 04:00P DATE/TIME REC'D: 06/08/00 10:05A , REPORT DATE: 06/19/00 PHONE: (914)-734-1187 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE .� TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~=~~~~~~~=~~~~"~"=~~~ RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 06/08/00 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 06/08/00 LEAD (IMS) <1 ppb 0-15 ppb 9101 06/08/00 NITRATE NITROG 0,43 MG/L 0 - 10 9139 06/08/00 NITRITE NITRO8 <0.01 MG/L N/A 9146 06/08/00 IRON (Fe) <0.060 MG/L 0-0.3 mg/I 2037 06/08/00 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 2037 06/08/00 SODIUM (Na) 3.32 MG/L N/A 06/08/00 pH 6.4 UNITS 6.5-8.5 9043 06/08/00 HARDNESS,TOTAL 32.0 MG/L N/A 06/08/00 ALKALINITY (AS 16,0 MG/L N/A 06/08/00 TURBIDITY (TUR <1 NTU 0-5 NTU COMMENTS: - BACT THESE RESULTS INDICATE THAT THE WATE WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more thin 10% of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. , Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.000741 CLIENT #: 8641 NON STAT PROC PAGE 2 WALLACE, DOUGLAS DATE/TIME TAKEN: 06/07/00 04:00P P.O. BOX 154 DATE/TIME REC`D: 06/08/00 10:05A MOHEGAN LAKE, NY 10547 REPORT DATE: 06/19/00 PHONE: (914)-734-1187 SAMPLING SITE: LOT 5 : LITTLE POND HILL ESTATES COL'D BY: DOUGLAS WALLACE NOTES...: KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PE ®' C l Located at V WA- ®��� > Town or Village P/q-�]%M�(��/ C7l Subdivision name j� t/(, Subd. Lot # JT Tax Map',. 3 Block 2-, Lot 600r,- Date Subdivision Approved y - i 7-6% Renewal Revision ft-4 c LA-S W AA-LA t--0- ` / / f Owner /Applicant Name C �} 5� r S Zvq!0 N Date of Previous Approval / �l Mailing Address W J FMK- !u,6 , /U 7 Zip 06'4i Amount of Fee Enclosed Building Type fi 1= Lot Area No. jof Bedrooms -Y-- Design Flow GPD e496) Fill Section Only - Depth '® - 3; t Volume EPCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: gallon septic tank and To be constructed by F t'7 Address Water Suonly: Public Supply From y� Address Qr:_ Private Supply Drilled by / h' Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the "approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. P.E. Signed: ���� R.A. Date Z g _ Address r�hicense # 322 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe Appro a for discharge of domestic sanitary sewage only A f / By: �� 1&Wk;'-yyL Trtle: fL GY Date: lI 't l White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION .. ......... ...... Date: // Inspected by: _s /Z Street Locat' n elWes Owner r 4.11 Town 4 C41— Permit # y ya - IF2 TM # 193 Subdivision Lot #. 1. Sewaee Svstem Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. /�'SWidth Avg.Dpth �� c. Natural soil not stripped ... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands...... ...... .. ........................ II. Sewage System a. eptic to . size - 1,000 ...... ,25 .........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......................................... d. Distribution Box bout outlets at same elevation -water tested ................. 2. Protected below frost .................. ................................ 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ..........................:.... f. renT c es required � Length installed! 2. Distance to watercourse measured c-Ft2. 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.....:.... 6. Depth of trench <30 inches from'surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems 1. Size o pump chamber ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .................... .................:............. 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. HouseBuildin a. House located per approved plans ............. .............. b. Number of bedrooms ................................ .�1............. IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ..:........ ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... I acknowledge receipt of this report: SIGNATURE: 02/96 Title; p� a� - - -Sheet . ( or' _ * PUTNAM COUNTY. DEPARTMENT OF HEALT).1 _ DIVISION:OF ENVIRONMENTAL HEATL)Ei SERVIEES FW, YO4 FIELD ACTIVITY;REPORT Vof f�V . c1nnRFCC; - &M�K Street TownR State 3 Zip �'= s PERSON IN CHARGE 'OR. TAiTFRVTFU1ZFll: _. nafP. /`. /.g . Name and: Title �. = TYPE. OF FACILITY `701 ) am; FINDI tJGS ry x . ;tom Signature and Trtle 77 TT1l1T1T TfT eiT]Tit rr`T\ T] iii I acknowledge receipt of this report: SIGNATURE: 02/96 Title; PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: Inspected by: Street Location 4adf r 110m TZ�1 /a�r<<s l �: 'Der k, � Owner Town _ rrrov Permit # T`4 f 2 3 — X -- C q� Subdivision Lot # xtL iT I,r t r pd41 r, /-// 1. Sewage System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement '? 3'a ®, f012 vq& 3:1 barrier Lgth.- ?s `Vidth_tj�6f Avg.Dpth vc &e5 c. Natural soil not stripped ...................... . ............................ d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a Septic ciank size - 1,000 ......... 1, 250 ......... other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation....... .... ............................... d. Distri tuioh Box 1. All outlets at same elevation - water tested ................. 2. Protected below frost .................. ............................... 3. INIinimum 2 ft.Original soil between box & trenches Junction Box - properly set, ..................................................... 1. ength required 3 Length installed 3 6::� 2. Distance to watercourse measured {-. 3_ vp Ft.......... 3. Installed according to plan ......... ............................... 4. ,Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 - 1 ``/2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems Size of pump chamber ................ ............................... 2. Overflow- tank ............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade.: ............... 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. ouseBuildino, a. House located per approved plans ... ............................... .. b. Number of bedrooms ....................... ............................... IV. Well a Well located as per approved plans . ............................... b. Distance from STS area measured ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1/97 Form PUTNAM COUNTY )[DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 0 Town/Village: Tax Grid # Map Block 2— Lot(s)(O Well Owner: Name: Address:. Sz Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion V Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade 41 ft. Diameter in. Weight per foot _7lb /ft. Materials: Steel _Plastic _Other Joints: _Welded Threaded _ Other Seal: _ Cement grout Bentonite Other Drive shoe: Yes No _ Liner Yes No Screen Details . Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test Bailed _ Pumped Compressed Air Hours _ Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface �- AZ ^ `'- If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 5 ®' Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Completed � ��® Putnam County Certification No. 067 Date of Rep rt �` // P� Well Driller (signature) /,m - NODE: Exact location of well with distances to at least two permanenrlandrfiarks to be provided on a separat&fieet/plan. Well Driller's Name /,?, &),4 11".'et Signature: Address: 'elk ''/ <.� e� IVY. Date:. I White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 �7 le- BRUCE R. FOLEY Acting Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 John Karell Jr.. P.E. Tel. (914) 278 - 6130 Fax (914) 278 - 7921 October 15, 1997 P.O. Box 644 Carmel, New York 10512 Re: Proposed SSDS: Wallace Vista Dolores Road, Lot#5 (T) Patterson Dear TkIr. Karell: Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: "The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard." "You are referred to Article 128.1 of the official compilation of Codes, Rules and regulations of the State of New York, Title 10, relative to the need for approval of individual sewage disposal systems by the City of New York. You should contact city Officials in this regard." OM) Photocopies and group Letters of Authorization are not acceptable. O 1,12) Standard well yield note has not been provided. 3) Location map is to be provided. 0 W) Notes and details are not legible. n �5) Deep test hole data has not been completely noted. 'Title block is to note "Preliminary design for fill placement only ". �•7� Trench plan is to be submitted. U ' " Primary and expansion area is to be noted, furthermore, the minimum of one deep test hole is to be excavated in the primary and expansion area. 6)M Erosion control for the well has not been shown. Upon receipt of a submission, re�.ised to reflect the above, this application will be considered further. Very truly yours, bk,v- u% Robert Morris, P. E. Public Health Engineer RM/mh watershed TEST .FIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST.HO.LFS DEPTH HOLE NO. G.L. �_ 0.5' 2.0' 2.5' 3.0' ).51 4.0' 4.5' ((�� T 5.0 55 L.0f 6.5' 7.5' 8.0' 9.0' 9.5' 10.0' s • HOLE NO. _ Indicate level at which groundwater is encountered Indicate level at which mottling is observed 1U0/lk— Tndicate level to which water level rises after beinla encountered Deep hole observations made byy: i 1 1-1— Date /O /l/1 % Design Professional Name: �11riJ X .T7'L Ak.., Address: CU .S 0-fA c/ 44A. 1014-77ERso /J ti Y Signature: Design Professional's Seal s r Y U AGM, t. i'/ !� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL ' please print or type PCHD Permit # Well Location: Street Address: To ills a Tax Grid # J u l j d Map ;L!;, Block �7_ Lot(s) Well Owner: Name: C)OU j .4tS ' Addrees�s: 1Tdi_ 1r &qm-'a' QQW c Use of Well: _94,, Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served __5 Est. of Daily Usage 3gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _14, New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type K, Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty su division? ........ ............................. ....................... Yeses No �_ Name of subdivision /'T Poo � i Lot No. Water Well Contractor: 7-8'0 Address: Is Public Water Supply available to site? .................................. ............................... Yes No_ Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to b prow' ed on sepaz to sheet/plan.,/ Date: �ii� Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and 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. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue 11 'f Permit Off 'al: Date of Expiration f tqq Title: L Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 11-1 PUT'NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of PQU!a &A.,S WA- LL -A-CA ( OUsk COI)- Z-AUc770 A/ 7 Located at y l Sri- DO LorLf,S C 1� Ay) T;V PAr7�F,7ZS,0 Tax Map it _ '13 Block :. Lot 6 Subdivision of L1771-6 100A1,0 /7L71- L. Subdivision Lot- 5� Filed -kiap =' Date Filed Gentlem,m: This letter is to authorize 'n HILI X'4X&&t-1 rl� a duly licensed Professional E n -ineer � o-zp� ist �d ^�—== mot to apply for the require:': wastewater treatment andior water supply pe mit(s) to serve the above -noted property in accordance —itt? the standards, rul .-s or regulations as promuigated by the Public Health DLecror of the Putnam. County Health Department, and to sign all necessary papers on my behalf in connection with this _natter and to supervise the construction o f said wasteu-ater treatment and /or eater supply sI's er:l in conformity with the provisions of Article 145 a��d!or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Vey truly yours, Countersigned: Signed: .P.E.. R.A., tr 5 3 L7 % (0 Vt,e7 a`. rnpc:T,) Mailine Address d U-14Af4 -,) XO-. 'n P�r�7�.,5oN State /k y Zip - -� 14563 Telephone: 9iy_�7 � =^7�9� T CA-lzN.'J� z-- State_ /Vy Zip /06/42, Telephone: q1 q— �''T� Form LA -97 . . . u _ 2 3 . _ X f +� .:: t .. _ �' • � �a b'Y.�2� t f ^/Y � 4d"f:i�s -G Y `, d APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET for CONSTRUCTION' P R�IIT fE OF OWNER 5 /�- SI•REE LO7:N Sys DATE -C TAX MAP # - D MENTS. PERMIT APPLICATION DISCHARGE (OK) PC -1 DEEP HOLES LOCATED WELL PERMIT P ESe4TATIVE OF PRIMARY AND EXPANSION ENGINEERS AUTHORIZATION 9-��AREA, SHOWN; GRAVITY FLOW, SUFF.SIZE DESIGN DATA SHEET(DDS) .,,rte ID PIT & D BOX SHOWN & DETAILED DEEP HOLE LOG t SF - NO. OF BEDROOMS CONSISTENT PERC RESULTS (3),. & SSDS'S W/IN 200 FT. OF PROPOSED SYSTEM �' PERC HOLE DEPTH '' R� � � METES &BOUNDS CORPORATE RESOLUTION C1USE SETBACK NECESSARY (TIGHT LOT) PLANS THREE SETS - �IOUSE SEWER - 1/4" /FT. 4"0; TYPE PIPE © NO BENDS; MAX. BENDS 45 W /CLEANOUT HOUSE PLAiNa - J. wilSETS VARIANCE REQUEST GENERAL LEGAL SUBDIVISION SUBDIVISION APPPRO� CHECKED 446 Ile"; PERC RATE ✓ FILL REQUIRED CURTAIN DRAIN REQUIRED 'JWES FILL SYSTEMS AL: SLOPE 3:1 TO GRADE O H- GAUGES EII=I PROFILE & DIMENSIONS VOLUME TRENCH EX- APPROVAL SSDS ADJ. LOTS -_ [I] . - CHPROVIDED WETLAND (TOWN/DEC PEF,MIT R & D) � 60 FT MAX DATA ON DDS PLANS & PERMIT SAME MpARALLELTO CONTOURS PRE- 1969 NEIGHBOR NOT TCATION [Z] 100% EXPANSION PROVIDED LETTER BMA ✓' SEPARATION DISTANCES SPECIFIED ON PLAN 100 YR. FLOOD ELEVATION FIE ,UTRED DETAILS ON PLANS O P.L., DRIVEWAY, LARGE TREES, TOP OF FILL SEWAGE SYSTEM PLAN - (NO 0' FOUNDATION WALLS SSDS HYDRA ROFILE GRAVITY FLOW 0 TO WELL, 200' IN D.L.O.D., 150' PITS D/ J BOX NCH/GALLEY mETAILS , PTO � WATERCOURSE LAKE (INC.EXPAN) SEPTIC TANK - SIZE, DETAIL r- F200101 TO CATCH BASIN, 35' STORMDRALN, PIPED WATER WELL DETAIL, SERVICE LINE IF OVER TO WATERLINE (PITS -20') CONSTRUCTION NOTES (GRINDER RATE) NTERM ITFNT DRAINAGE COURSE DESIGN DATA: PERC AND DEEP RESULTS . RESERVOIR, ETCH 150 FT. GALLEY SYSTEMS TWO -FOOT CONTOURS EXISTIN G & PROPOS P.,-- SEPTIC TANKS DRIVEWAY &SLOPES CUT ..�"` - 10' M FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS .WELLS [MENTS: 15' WELLTO V. I• •• 602, o• Y. PIPOPM • •' • •' •' 12' Y •i 51• R DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner 1 fir, eig-n 6err'A�i AddressfC 52>0 'b C-1 aPd3itFF Mmbz I (D Located at (Street) �, y� Sec Z Block Z Lot _p (indicate nearest cross street) Municipality _ Watershed Date of Pre - Soaking A -lS -b6 a Date of Percolation Test 4 -iF(8 C. HOLE NUMBER 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 1 3' 10 3, .Z8 16 -ZA Z �* 3 G0 1 2 3'LS-3�4� .1 S4 -Z 4 1 3 3- 49°-x' l3 7-4 Z 4 7:4- f 4 4'3 h1i- L 4- 7-1 3 8 - -- 5 2 13' 20 - 3.41 Z- 1 Z4 2 - 3 �- Z 2 3'41 - 4'n5 lid Iz �3 - Zo 3 *'OS =4%3Z Z 7,A- C5:0 ?' 44'3 4- 7i4 g 5 1 NOTES: 1. Tests to be repeated are obtained at each for review. 2. Depth measurements tc rev. 9/85 at same depth until approximately equal soil rates percolation test hole. All data to*be submitted be made fram top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCAUNIERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. L 1° 2' UosNl. _ �Aav 4' 69 kdL", , s' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �( �{s �p p8�y DATE:-5-1'4 j 674!9 &,6 DESIGN Soil Rate Used &—to Min /1" Drop: S.D. Usable Area Provided 07,900t No. of Bedroans /+ Septic Tank Capacity &,5D gals. Type kmcAg"c Absorption Area Provided By 4- L.F. x 24" width trench Other d , 1 G T"D N Vi 0,4 OF T. MICHAEL DALY, P.E. P. BOX 1 Address S SEAL IZ FA i THIS SPACE FOR USE BY HEALTH DEPARTNT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PC-1 PUT NAM COUNTY D E PARTMENT O E H EAL TH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: Do LyCZ�� A 2. Name of Project: 3. Locatio T�V /C: �A 4. Project Engineer: fit- a���� 5. Address: �yK �4- 3 License Number: A?A6 8 Phone': 4 6. _T_0e_,, of Project: V Private /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 Type II. Unlisted ✓ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 0. Name of Lead Agency 1. Is this project in an area under the control of local planning, zoning; orother officials, ordinances? ......... ............................... 2. If so, have plans been submitted to such authorities? .................. 3. Has preliminary approval been granted by such authorities ? -- Date Granted:= 4. Type of Sewage Disposal System Discharge.fY .F:� 5�' Surface Water Ground Waters 5. If surface water discharge, what is the stream class designation ?........ 6. Waters index number (surface) ........... ............................... 7. Is project located near a public water supply system? .................. l�� 0 B. If yes, name of water supply Distance to water supply - 9. Is project site near a public sewage collection or disposal system ?..... 1� d ). Name of sewage system 1. Date observed: Distance to sewage system 23. Name of Health Inspector: ?oQ t. Project design flow (gallons per day) ............. . . .........••••• 2. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 26. Has SPDES Application been submitted to local DEC Office? ............... r 27. Is any portion of this project located within a designated Town or State wetland? ... ............................... .............................. 28. Wetland ID Number ........................ ............................... 29. Is Wetland Permit required? .............. ............................... Has application been made to Town or Local DEC Office? .................. t� 30. Does project require a DEC Stream Disturbance Permit? ................... N 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 1 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or `l any other potential known source of contamination? ..............YES or NO N DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ..K........ 34. Are community water, sewer facilities planned to be developed within 15 years? 35. Are any.sewage disposal areas in excess of 15% slope? ......................... 36. Tax Map ID Number .. ......................:........ ..................... �� g_0 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 Class A Misdemeanor pursuan�i o Section 210.45 of the Penal Law. / J SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: PUTNAM - COUNTY DEPARTMEI T_C. & HEALTH DIVISION OF ENVIRONMENTAL `ktALTH SERVICES Date Re: Property of LEI Located at j7 5i7, (T) Subdivision of Section Block �l '2-� Lot k' Subdv. Lot # Filed Map # Date Gentlemen: T. MICHAEL DALY, P.E. CONSULTING ENGINEER This letter is to authorize P. 0. BOX 243 SURWIRA6Y, N.V. 1050 a duly licensed professional engineer V/ or (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 Code. Very truly yours, Signed— Countersign Owner of Property P.E., R.A. , # -� Address T. MICHAEL DALY P.E. W11 j Address CONSULTING ENGINEER Town P. 0. BOX 243 ;SJ4*F11 W')CK, N. Y. 10.587 Telephone Telephone PC -1 J�% PUTNAM COUNTY DEPARTMENT OF HEAL --rH �U APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: rr PIIIANO r-L y 0 D 2. Name of Project:? 3. Location T /V /C: '4. Project Engineer:�0 �liJ1 J''1��i1� -�I 5. Address: -Cgt L"�0&°' License Number: Y10 �w Phone: 6. Type of Project: Private /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 Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 1 v 0 9. Has DEIS been completed and found acceptable by Lead Agency? ........... N JA 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 authorities? .................. 13. Has preliminary approval been granted by such authorities? �` Date Granted: 14. Type of Sewage Disposal System Discharge...... Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... Ll 20. Name of sewage system Distance to sewage system l +1 r /,I, �'- 11 21. Date test holes observed: v'F, 22. Name of Health Inspector: �� G� ZlAkj 23. Project design flow (gallons per day). .................................... Y0® 11/93 2. 0 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or State /� wetland? ................................... ............................... (� 27. Wetland ID Number ...................... ............................... - — 28. Is Wetland Permit required? .............. ............................... �A) Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... f�ju 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, i landfilling, sludge application or industrial activity? ........ YES or NO 31. 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 DESCRIBE: 32. Is there a local master plan or file with the Town or Village? 33. Are community water, sewer facilities planned to be developed within 15 years?� 34. Are any sewage disposal areas in excess of 15% slope? ........................ Q Q 35. Tax Map ID Number ....................:.... ............................... 36. 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 Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES � e'9A —J e1w>1cet'1'!1" MAILING ADDRESS: t cZeLeiW Pam ■• •: ` ID Y :10, Y: 5; •1'. DESIGN DATA SHEET- SUBSUFACE SEWAGE. DISPOSAL SYSTEM FILE NO. Ownerpolo7A�- C 2 Address &,Y.-53a ✓Qz;z� 1-114^ar Af Located at (Street) � � �� •!� Sec. Block 7i Lot (indi"�cate nearest cross street) Municipality Y % ��(� Watershed _N Y6, Jun Date of Pre- Soaking. Date of Percolation Test HOLE NUMBER 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 1 2 3 4 Si S-- SLA-p 5 Y 7W. -,A ifs / i r • - 2 3 4 5 2 3 4 .5 NOTES: 1. Tests to be repeated'at same depth until approximately equal soil rates are cbtained.at each percolation test hole., All data to'be submitted for review. 2. Depth measurements to be made fran top of hole. rev_ 9/85 DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 1'- 2' 3' 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES MTIR BEING V JL- DEEP HOLE OBSERVATIONS MADE BY: DATE: �i DESIGN Soil Rate Used 0 �� Min/1 Drop:- S.D. Usable Area Provided Z- Soil No. of Bedrooms Septic Tank Capacity ) 21,50 gals. Type r-O A Absorption Area Provided By .F. x 24" width trench Other n 19. Name ST lli / Address w* a _ THIS SPACE FOR USE BY HEALTH DEPARZMFM ONLY: Soil Rate Approved sq.ft/gal. Checked by Date .. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of Located at- (T) 191VI .- Date /L' Subdivision of �.- Subdv. Lot # -5 Filed Map # Date Gentlemen: This letter is to authorize` ZAII 17141r,6-t ` f /��- -- a duly licensed professional engineer t (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 Code. =;4 Z Co ersigng:d: _ P.E.,:, # Address Orz-7 Y_ 7 Telephone truly yours, S i g e d ` �� (,' 1i 2-F.0 lli'!' %C�� ��'1. "21 tkit,` Owner of Property Address Town Telephone u' 1 I� DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # 60-7'_� WELL LOCATION Street Address Town` Village City Tax Grid Number 151 d L.Q R ES PA i rFk?SO - d WELL OWNER Name Mailing Address Wrivate 7� t..rUt2 s PA ti 'u 33o 0P IA I,( -I r L1.rwr9.P. 105 Lb O Public ,-USE OF WELL O-RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED 17 - primary 0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify, 2- secondary 0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT C-) gpm /# PEOPLE SERVED _ /EST. OF DAILY USAGE .r,C,o al C] REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION Q ADDITIONAL SUPPLY REASON FOR DRILLING O "NEW SUPPLY NEW DWELLING L1 DEEPEN EXISTING WELL DETAILED EV4I 14 0 as r REASON FOR DRILLING WELL TYPE DRILLED DRIVEN [jDUG []GRAVED OOTHER IS WELL SITE SUBJECT TO FLOODING? YES I_,/- NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name L 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 O ON SEPARATE SHEET ignatik". PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Svbpart 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. Dur ir; all well drilling operations, the applicant shall take appropriate action to assure that any ad 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 co �a u_arface or groundwater. Date of Issue:— Date of Expiration 19 Permit Issuing Official Perini. is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COURff DEPARTMERr OF KBALTH Dhhiaa at Seeaoe.. COMML N Y feel? i to Psuvlde Pali \ a C WMCATB OF PMJANCE CO N Piles FOR, SEWAGE DEPOSAL SYSTEM /, n S. t Ik DDL i z E tea. vl>IitAe _i rr!_E Pons b 14I l_l..: c t,.t Lot# Tax Map . '� - tat fi OwaedAppNewd Nums D 0 LO i2 EN A FFA/ < PA ,.i aenew.l_D� , t* te ° Da of Prevlo>ss Approvd' Mmftg Addl!e.. � X .�� Town R.I tk(t_Clii�I= l l ti ZIP (6,5 / d Date Subdivision Approved 11d' 7 Fee Enclosed U Amn„nt Tn. 11 °si n F-A1 r-1 A- t Lot ::Arose k3 FUI Seed= 0*' Vole Number of Hedtooaa DWV Flow G P D PC /HD Noft d.1. Yegahed When Fill 1. completed Sepenls Sewmy SY.te� a aamm't G.Bo. Biopic Teak and t 11+1. r,-, 1 °d �L �r 2EI (P To in almakaMed by i 'e Ad&ws Water S"*. P6Wk S"* Ft. _ Addre.e on i/ wdoau Sup* Dared Other R"Okearoate y 1 3 ` . K . t I- i 1=L- 6,-T . w _ r1 ` W r 1 repreant1hat I am wholly and completely responsible for the. design and location of the proposed syst above described will be constructed as shown on the approved amendment there to and in accordance with County Oepwtmat of Health. and that on comp*Ion thereof a ••Certificate of Construction Complier be submitted to the Department. and a written quarantes will be furnished the owner. his succe piece in eobd operating condition any port of aid sasrp• disposal system during the 'period of It Once of the approval of the Certificate of Construction. Compliance of the or nal system. or any rs ig will be located as shown on the approved plan and that aid well will'be Installed i rdance with t county Department of Health. Date 2 7 Signed r3r.�ef 1 /1 511: 1=2 YV 1) n Ol/ 1 -.� APPROVED FOR CONSTRUCTION: This approval expirei two years from the date issued unless constl C009 revocable for cause or may be amended or modified when considered necessary by the Comissioner of requires a new permit. pproved for disposal of domestic anitary��wratert By 1088 Date i ro. tIQ1Q* a sew& • dis oafs stun 1 sWs;,a a ions o • ream aeibAylEy iaioner of Heafthwill Isignt by to il�er hat aid bulkier will IRmaAiat•ly4ktppol�OSfi" thedate of the lieu. b 2) tlis�t+th:'dr fled' all described above ►Liss Intl r f. the Putnam V �^+ RA. - *-jtie bL'�161h.,'� n undertaken and if )�►r�r, eMirhe or Ovation of construction r _ Title ���� 6 0�ii; e 1.-". w/ 273,5"iL Subdivision Lot # > o4)11 v Filed Map # Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer_ to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam ;. County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam Code. IFAREQ Very truly yours, t Countersign W Signed: P.E., R.A. # S t �� V (Owner of Property) V Mailing Address State /UZ Zip % 0 Mailing Address: State r-4i/Z- .451" Telephone: Telephone: PUTNA.M COU'l�TTY D EFA.RTMENT- ilk` HEALT DB ISIMINT OF ENVIRONMENTAL HEALTH SERVICES x DESIGN DATA SHEET • SUBSURFACE SEWAGE TREATMENT MENT SYSTENT Owner Lb. V C? LA--S 6VA-U ifs' & e :address gl�Q cl l-' /%Z S ' Located a (Street) VISTA- DoLOIZL S A/,* AV Tar Map 93 Block `Z-- Lot (indicate nearest cross street) 5 'Aunicipality _ dN 0-) . Drainage Basin L,�w f{y,c7Svn/ SOIL PERCOLATION TEST DATA Date of Pre- soaking Date of Percolation Test- Hole No. Time Start - Stop Elappse Time I! n.) De th to Water From Ground j Surface (Inches) Start Stop Water Level Drag In Inches l Percolation Rate Min,Zncn 2 I I tA j� Q I NOTIES: 1. Tests to be repeated of Sam deotlt L'ntil a0r-0X:mat.'l`/ equal, perco1 -atlon axes are obtained at qaC i pe at t� o f 1_ir !f ? in ^- -v0 tni %i a`a . b: -00� 10[i 5t �C,t,le. (:.e. i mlrt ?oi %liP� li:C- � min � ( .� ,,.n; i.Ci1) Al: d_;_ ;0 submi�;ed for review. 2. Depth measurement_ to be made from top of hole. Form, DD -97 - r, .,,�. wf� =c: =.,-- le=a., -.rv''� z-F -Std �c_a � .,,�:"p'?.e -�� r,.:� q h •Yi'1"'�#'i�aeSt4' s ,y„ a Mad" . Du�a!In& r�°G P,D; ,t 11a,Y` AA& Adhd Dt" by OAK . prnMlt; tMt t-anr wMxtr a�i eomMNNy �s�enW/N foe;tM tlsNjn and.loutiai of -. - aNi� +iiniaA wlM;ha ooiistrugal a`s'sotowii on tM aovtawa anioadii+wit tMra to aia MNrA en tanMKbaahnaei a ��cilrtiftMte of ee /Mn1K/M to t1N ONMtnMi li -Al wratai� pMaiiMe wN1 N.1Wwi1hW iM ON Nrr+a ftt= lM� -NwMtq ce""A.aily pw eI -MY Mwga d%P0W1 W Mi "b" anon o ttho lip at tM Grtifi�` of co� wnidion ceii�W a of ;tba erirNii wM M leer_ m Mown M tftw4preial•oNn aid tho MN waa wiq tN instaiNa 7 - C tiiity W R " Oiea �" � i ✓� �. , a r - [�' a S1�A� � ....gyp AplAOvao ROA camy"UCTtt�N: TI N ahMaialiniNrfo twa Ywi troni eM tlate' 1rM1eiMN lg saYM M iitay'ilfrantrndrt0 "a n►erNNd wMn'e- --kbmd 6oc*6 w:y -tiy, to NNi+i.. a "t wr Mrnia. Mr oiad for `uw.au a doin.wle eenttary w- we,-,and/ 3 DeAC[91Mft N ropwv�o Pei* Ise hei •'.. � 1�6iw arc a ly '+' Mari t Yws` Enclosed-- .amiiiint, .� a lC8D NtMMnitli Y 1�aA �YMw P� Y tA;' p►OVeNd sjnt«n(gi 1)�that ttii - " ate %di ql ° am io'riAanoa•with ttw handled! TUNS -a etlen ConioliaieM" i tiMiefp y to tho coinmiloogmr of; tiMahwiN hN fueaaitOrt, tiaha o::art�iin Oy tM'wNM. thatpY tatiNpar wta - pwiod of tiiw`l!l yn► *s tonowme t"aft OfaM ism- atiii.a Mty faiatrs`titir�toi tMt -t1N M ww4ililititM -aiaw .: 'VI lea waft tM:;rtaMarAr. WM M0 reh tM `►rtgoo.' '�liatMa N uwMia canfpiietNn of t bxglna ha_s awnuiaartaken'ana if FAmHti *W-o1 HMKbv ltny tlMilp O►:a1tRltNn_Of tOMt ►YCtt011 N aratar tiiOYN 5 r DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL el PCHD PERMIT # d' yk" WELL LOCATION Street Address __[z o Village City Tax Grid Number- o WELL OWNER Name 0_0 %gr,2 Mailing Address 04�ftvate p O Public CU 5E. OF WELL primary 2- secondary 8 SIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY D ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT tt�!4 gpm /# 13 REPLACE EXISTING SUPPLY Q-nW S PLY NEW DWELLING PEOPLE SERVED <0 /EST. OF DAILY USAGEZQQC gal ❑ TEST /OBSERVATION GI ADDITIONAL SUPPLY ❑ DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE GRILLED DRIVEN DUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: -L_ \°'pa» iA:�LA__' Lot No. .5- WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE YES 4--90 NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE.TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (s 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 a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: Gam` gt ' �' i'i 19 Date of Expiration 19 % S Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller Vo as a.cur5s n } c Wd"-.A -- u,.t eNof'- Jo ion vti 5�0 �y :.% GLA 540 �6a LL � o WITH . II=~ Vl5' c. _....__ 39' 410.5.. 7Ili \:` p �/�. r �•w. d IQ ss- gip. va Z Z a J ' � I -.I - i L o o -AS -BUILT MEASUREMENTS d_scos. -a systen was constructed as Yste-n was 'insoected by ms before constructed in accordance wit s of the Putnam County Departmen ��.._L _� .- _ "Ts is to certify indicated-an this plan it was covered over. h all standard rules that and T'ne and