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00778
PUTNAM COUNTY DEPARTMWff OF HEALTH
j ,�� r Dlvidon of Faivteoomental HeaNb Services, Caemel, N.Y 1OS11 •
Mad Provide -/
Birealt
it ®t
Owner /appilcent:
• Yl d / �- � � f 7/ mil. - i./ \/ � .�
Separate Sewerage System• bull( by-
Candstin
,8 of
I Septic Tank. and
Fj
Water Supply: Public Supply From Address
art
Private Supply'Dewed,by- {� F�'i' Address
t ;
Building' Has Erosio P
00-A Lot -Lot Size 0, 9ga /
Number of Bedrooms / -HAS Garbage Grinder Been Installed? /v0 l�
Other Requirements
I certify that the system(s) as listed serving the above premises.were constructed essentially as shown'on. thjp plans of the ccgpleted work ( copies
of which are attached)','-and in accordance with the standards, rules' and regula ions; in, accordance' th the led , and the permit issued by the
Putnam County Department Of Health'.
Oats �f Certifiatl by ,1 P.E.
Addratt 13 c' J� "'` f 5 License No.
Any person occupying premises nerved by the' above syitamlN shall ,promptly take. such action as may be necessary to sawn the correction of any unnnita►y
conditions resulting 'from 'such utige.. Approval :of, the separate, sewerage •system shall become null and void as anon is a pull(;: unitary rawer becomes
available and the approval of thi. private, 4atei.- supply, shall pecoine null aid- void when a public water supply. beeonw available. Such approvaU are
Wblect to modification or than" when, in ilie`ludgment of the Conimisslonar of Health M revocation. modification or change 1s necnury.
3/89 ate Title
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SAMPLE NO.
SOURCE:
BREWSTER LABORATORIES
Box 224 - BREWSTER, N.Y.
(914) 855 -1930
- WATER ANALYSIS REPORT -
8227
Robert Heller
Andrea Place
Patterson, N.Y.
COLLECTED: 12/30/91
BY: P.F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
TEST WELL
/ ' // '�y
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
1/1/9.2
0 per 100 ml.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES'
b b,e.j
owner or Purchaser of Building
'e�Ss Wg,
Building Constructed by
a4 - _
Section Block
Loca o - Street Subdiv s' n Name
Municipality Subdivision Lot #
GUARAt= OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
� 71,1 %l
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 inrnediately 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 detenuination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building utilizing
the system..
Dated this � day of, C, 19 Signature Q 2
Title
Contractor (Owner) - Signature
Corporation Name (if Corp.)
So 3. 02 C4A -14 l Z&
Address
rev. 9/85
mk
Ti',M e
.More daicribN will be, "i
cemoty Osfwtm 1 of
Mei- III : WOOD
dace to pod .dt>watlm
aher Pi-ti aPin e
will be wooed N Merin
cew lv DowtMant 'ef.
APPROVED OOQ
iasOCm- for ewie
NQL* e a Raw P
AY. / 8S
W Am
Am
Daalp FIsw G, 'p- ID— O (%
n...� gOPO �YJ (� C
TUN approval ""Piro to
Oder OMIlled win con
M dioPoitl of dowAN k
y
-c.
0
ryRMi(p; l) that the rpkret! t/w di�poYl yntNn
with tM gaMNd S. iuNS rgir a O
qOltaww satisfactory to the CommisMorw of lleeRhwin
mis.;ilrs or asNps by ti buimw. that YN Mulder win -
two t!) yieri MnrnMlatNy followkra thedato Of the NOW
jr. no" tMrati 2) thd thoANM we" doMf od aiew .
tM poief ; Ms. s the - /utwarn
/.E. ILA.
onftiuction of the twWing has been undertaken .and is
Hof n or alteration of construction
Title
W.
WIA
Date of Pre- Soaking Date of Percolation Test.:. '
L7 8 q
HOLE
A 2 z 1126
27"
34
9 -7
NL14BM . COCK
TIME - . _ ...P.ERpOLATICN
Run
Elapse Depth . to, Water. From
Water Level.:_..
_
No.
Time - .. Ground Surface .......
In Inches
Soil Rate
p Start- Stop
Min. Start Stop''
Drop In
-Min/In Drop
'
Inches Inches
Inches
• 3 2.'/3 - 2.39 : 2 G v` - z 7" Y'� $ 7
4
l
)W_ 4.0 Z ; 2 � Z ¢' z 7'- . �'� 9.7
4
5
1
N=: 1. Tests to be repeated at same depth until approximately equal 'soil rates
are obtained at each percolation test hole. All data to' be sutmittisd
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
A 2 z 1126
27"
34
9 -7
• 3 2.'/3 - 2.39 : 2 G v` - z 7" Y'� $ 7
4
l
)W_ 4.0 Z ; 2 � Z ¢' z 7'- . �'� 9.7
4
5
1
N=: 1. Tests to be repeated at same depth until approximately equal 'soil rates
are obtained at each percolation test hole. All data to' be sutmittisd
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
TEST PIT
12'
13'
14'
INDICATE LEVEL AT WHICH GROONEWATER IS ENOOUNTERED /i/��✓�
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING F.tJMTEM �✓
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used g"�'' Min/1" Drop: S.D. Usable Area Provided
No. of Bedroans Septic Tank Capacity /-? Sy gals. Type c N c
Absorption Area Provided By 9� S� L.F. x 24" width trench
F NEW
Other 0 Y��
r O
Name 4154u c17 4116 - •V,F,��l t/� S�c. , �C . Signatur
1k
Address 73 ��9J�7 /it C :) pi ?. SEAL
fVo. 045 r�,
PA T% 4'R.S o ti - IVY / C 3 �FESS►o
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft/gal. Checked by Date
LLJI.tC Ltt >, m � yr
Ou.L ►7 L LV —k-"rl l r.rc ' ■ ,ux 1r.J�;f �jJLG7
r
DEP'T'H
j+
HOLE NO., �(
HOLE NO. B. HOLE NO.
n
4/�•:.
S ArV/
SAi� /I7
12'
13'
14'
INDICATE LEVEL AT WHICH GROONEWATER IS ENOOUNTERED /i/��✓�
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING F.tJMTEM �✓
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used g"�'' Min/1" Drop: S.D. Usable Area Provided
No. of Bedroans Septic Tank Capacity /-? Sy gals. Type c N c
Absorption Area Provided By 9� S� L.F. x 24" width trench
F NEW
Other 0 Y��
r O
Name 4154u c17 4116 - •V,F,��l t/� S�c. , �C . Signatur
1k
Address 73 ��9J�7 /it C :) pi ?. SEAL
fVo. 045 r�,
PA T% 4'R.S o ti - IVY / C 3 �FESS►o
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft/gal. Checked by Date
PUTNAi ,':v
X_ -1 'T 1d`. DEPARTMENT OF HEALTH
t._!!! Lid +; L')
APPLICATION; R _ Pe�017At�:.QF PLANS FOOR� A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: /% e= s
2. Name of Project: 0�a '« �:S�S 3.._• Lbcation/V /C•�'�
4. Project Engineer: , -�� �G�i i �'S -% 5. Address: '7?
av n �
License Number: Phone. j
6. TLM of Pro ect: ?
_ Private /Residential Food.Ser:vice .;..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? ............. C )�
9. Has DEIS been completed and found acceptable by Lead Agency? ...........
10. Name of Lead Agency
i 11. Is this project in an area under the control of1oca1 planning, zoning,
or other officials, ordinances? ............ ............................�G�
j 12. If so, have plans been submitted to such authorities? .................. :04
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 ?........ AJI�
16. Waters index number (surface) ........... ...............................
.17. Is project located near a public water supply system? ..................
118. If yes, name of water supply I'V4 Distance to water supply
19. Is project site near a public sewage collection or disposal system ?..... CC)
20. Name of sewage system ���/ Distance to sewage system
�21. Date observed: �v 23. Name of Health Inspector:!r'?•G!/fZ�icA -`�{
:24. Project design flow (gallons per day) ...... ............................... �����
in
1 2.
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. -- A), ->
26. Has SPDES Application been submitted to local DEC Office? IL%�,/+
27. Is any portion of this project located within a designated Town or State
wetland? ............... ............................... .................. 019
28. Wetland ID Number .......................................................
29.-Is Wetland Permit, required?.............................................. —)–)a
Has application been made to Town or Local DEC Office? .................. /J /A
30. Does project require a DEC Stream Disturbance Permit? ................... 0
31. Is or was 'Project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste disposal;`''`
landfilling, sludge application or industrial, activity? ........ YES or NOS)
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 , )0
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ........... �C=
34. Are community water, sewer facilities planned to be developed within 15 years? ti G
3.5.-Areany-sewage disposal areas in-excess of 15% slope? ::• :.:................�eS
36. Tax Map ID Number ............................................................. 24.-1- 8�0
37. Approved Plans are to be returned to: ................ Applicant Engineer
:. Zf 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 Misdameanor pursuant to Section 2f0.45 of
the Penal Law.
,.SIGNATURES & OFFICIAL TITLES:
7
MAILING ADDRESS:
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL �/l
PCHD PERMIT #LI!! 191
WELL LOCATION
Street Address Town/Village/City Tax Grid Numper
( G� -� =7.�
WELL OWNER
Name
��5/S
Mailing Address rivate
O Public
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL
® BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
® FARM 0 TEST /OBSERVATION O OTHER (specify
C31NSTITUTIONAL ❑ STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED?).'; /EST. OF DAILY USAGE KCT-OSal
D PLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION 13. ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING), ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
WDRILLED
®DRIVEN
®DUG []GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ali
Lot No.
WATER WELL CONTRACTOR: Name T69 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: MIA TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCNON SOURCES OF CONTAMINATION PROVIDED
SEPARATE SHEET
(date) (s ature
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 operatiol be contained on this
property and in such a m er as not to de rade or other i c tam' ate u f r groundwater.
Date of Issue: 19
Date of Expiration 19 P t Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
�XisT: Wtt,L
LAN
li
i
Sli
�KDP�K1
TA X M
DROJECT
f
A3 -GUILT DIMENSION CHART
N °
A
E3
l
45
l9
2
Co 3
(o O
3
Cob
G5.5
4
73
71 .5
5
-75 .5
-75.5
G
85 .O
85.5
7
01 .O
92.0
8
°>7 .O
9b.5
9
99 .0
-7&. O
10
1.03.0
8Ar.0
l 1
107 .O
8g, O
12
11 1 .5
05.o
13
11 co .5
101.0
14
I I Co . 5
105. 0
15
59 .0
I �o
G Co . O
17
72 .O
92.0
18
78 .0
91,0
l9
85.0
102.0
20
)O .O
lO G.O
TH15 IS TO C,6,KTIFY THAT THE SEWACGE DISPO, AL
SYSTEM 'NA5 CONSTRUCTED AS INDICATED ON THIS
PLAN AND THAT THE SYSTEM WAS IN5PECTED E3-
ME 15EFOIKE IT WAS COVF--K.ED OVER .
THE SYSTEM WAS CON5TKUCTF0 IN ACGOIKPANGE
WITH ALL STANDAK.D KZUL.ES AND KZI~GULATIOMS
Of✓ THE PUTNAM COUNTY DEPARTMENT OP HEALTH
AND THE NEW YOK.K STATE DEPARTMENT Or HEALTH .
NOTE . HOUSE AND WELL, LOCATION TAKEN pICOM
SUKvEy OF PRDPEKT`t' aEIt,1G LOT 18
K,E;0,5ED DATE DEG, 12, [,"I AND
PIZEPAKEF -P 5Y TARRY P>E2GENGlOK.FP- GOLLINS, L,S..