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BOX 9
i 6 1}
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00779
-- + — •
Rev. 31 PUTNAM COUNTY DEPARTMENT OF HEALTH . '
e o Divislon of Environmental Health Services►, Carmel; N.Y 10512
J Engineer Mast Provide
P:C.H.D. Permit N -- '
CE CATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPO SAL SY STEM
Q�l./° Yfp�
Towner V!!70.
p
Located at / �' �� 1- `1�L1 '"'� Tax Map _ Block Lot /_1—
Owner /applicant Name
Mailing Address
Subdivision Name Subdv. Lot N
Date Permit Issued°"! (2-
i'
! Separate Sewerage System built by w Address
Consisting of % Gallon Septic Tank and
Water Supply: Public Supply Prom Address
or: Private SnPPIy.Drilled t. Address
Building Type Has, Erosion Control Been Completed?
Number of Bedrooms / Has Garbage Grinder Been Entailed?
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and zeg l ions, in accordance with the P ed lan, nd the permit issued by the
Putnam County Department'OflHealth. /
Date (A .. Z,S %` 4 2,. P.E. y R.A.
Certift by
Address
-73
4 License No.
Any person occupying premises served by the above systerri(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. ; Approval of the separate sewsrage.systom shall become bull and void as soon as a puW% sanitary "war becomes
available and the approval of the, private' water supply shall become. null and void' when a public water supply becomes available. Such approvals are
subject to modification or change' when, in the Judgment of the CommissiQtter of Health, such revocation, modification or change Is necessary.
bate
4
0
PUMAM COUN'T'Y DEPARTMM OF BEAL171
DIVISION OF EN MMMENTAL HEALTH SERVICES
Owner or Purchaser of Building
%l 0 5-( c<.� -t .��I C,
Building Constructed by
Location - Str
101 %ee-ysak N
Municipality
)L a J
Building Type
24, 1
Section Block Lot
IAO z
/L__I
Subdivi ion Name
/q
Subdivision Lot #
GUARAA7ME OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
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 Environmental 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 —2fl day of u L 19 '� Z Signature
055 Al Ott- Title
/tA,
Gen Con actor (Owner)-- Signature
P-4 55 Ak4l . ", . r—
Corporation Name (if Corp.)
a5_6 Z,&� 4 "k
Address A/_y
rev. 9/85
ink
4T
Corporation Name (if Corp.)
Address
BACTERIOLOGICAL EXAMINATION
Cofffosm Court, MF Method 0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
9 -16 -89
Thomas tvlere
Oiredol•
BREWSTER LABORATORIES
Box 224 BREWSTER, N.Y.:
(914) '279.4945!...
.
•
...............:�.�•..: � : '•,:•.,. ; :.,
:`._;.::
.� . � _`�
WATER;..
ANALYSES REPORT
_,.
...
� •;Y �i`. •
�
III
'
...
it. _'�:..' '�i�
.. r��! .•�•
� 't•.'�•:: +ter; �':. ..
SAMPLE NO.
—7513
::..
WELL' *`,-
SOURCE:
LOT# • 19
Big Elm
Rd.
Patterson, N.Y. 12563
COLLECTED:
9-15-09
BY.-
Ross Alan
BACTERIOLOGICAL EXAMINATION
Cofffosm Court, MF Method 0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
9 -16 -89
Thomas tvlere
Oiredol•
T.TTr T T r 0MPT FTTnN7 V r DnPT
�? .tea „—._.. ____ _r __.._, _.�_ ____
y -� DEPARTMENT OF HEALTH
* �t
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
�
WELL LOCATION
STREcT AOURESS: T0wNiviU.AG1j TAX GRID NUfaBEfi
B� m . R .. .:
WELL OWNER
H AooRE s
/�SS L 2S .B �l �}rmar� /V X
pgIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
IlfRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP . ❑" ABANDONED ' .
❑ BUSINESS ❑ FARM ❑ TEST/OBSERVATION.' ❑ OTHER (specify)
O INDUSTRIAL ❑ INSTITUTIONAL' ❑ STAND -8Y ❑
MOUNT OF USE
YIELD SOUGHT !:E gpm: /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
O REPLACE EXISTING SUPPLY ❑ DEEPEN EXIS71NG�W�ELL
DEPTH DATA
WELL DEPTH 705- ft
STATIC WATER LEVEL �fL
GATE MEASURED
DRILLING
EQUIPMENT
O ROTARY COMPRESSED AIR PERCUSSION O DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED O OPEN ENO CASING dIOPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH ft.
MATERIALS: STEEL ❑ PLASTIC O OTHER
LENGTH.BELOW GRADE �D ft
JOINTS: ❑ WELDED THREADED O OTHER
DIAMETER in.
SEAL- O CEMENT GROUT 8ENTONfiE ❑OTHER
WEIGHT
PER FOOT 17 Ib. /fL
DRIVE SHOE YES ❑ NO
LINER: O YES eNO
.SCREEN
DETAILS
DIAMETER rn)
SLOP SIZE
LENGTH (ft)
DEPTH EFiI (!Q
OEYELOPED?
FIRST
_n`vus o uo
1i0
SECON
PI
GRAVEL PACK
011
O NO
GRAVEL
SIZE
OF PACK IR
TOP
DEPTH tL
eorI
OEM IL
WELL YIELD TEST If detailed pumping
Mgt00: O PUMPED tests were done is in-
tl COMPRESSED AIR , formation attached?
O 8AILE0 O OTHER i ❑ YES 0 NO
WELL LOG it more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
water
Bur_
ing
well
Oia_
meter
lin
PoRt (AItON DESCRIPTION
C30E
tt
tC
WELL DEPTH
t<
DURATION
hr. aim
ORAVIOOWN
ft.
YIELD
9Cm.
Surrface
D '
45,
fA Rd
70
6
7
/s
705
✓
6"
'ss
WATER CLEAR TEMP.
QUAUTY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
AMATT & SONS, INC. DATE
ADDRESS Well Drilling siGin(TURE
Rte. 311
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
unnct vnrTerc UP
S
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
9 -16 -89
Tho i Meye
Dim or
BREWSTER LABORATORIES.:.:
Box 224 - BREWSTER, N.Y...
(914) 279 -4945
f.t
-
WATER ANALYSIS REPORT:..
.
SAMPLE NO.±. 7513
WELL`']
SOURCE: LOTV19:
Big Elm.Rd.
Patterson, N.Y. 12563
COLLECTED: 9-15-09
BY: Ross Alan
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
9 -16 -89
Tho i Meye
Dim or
wow &"tn raft 9141rtr rw
atti_�rthNM'l*>Oftialt ti_
I rop"wat, that I am wholly WW Completely retoonsiCle fo► tM ditljn and'wutlon of't
46WO dawiMd. wlttM'o01%304 lad es shown oft the sWowd atnla"irient there to nid in
fJeiflltll pgommot, of "nab, ails that on C011gM:bn.tlNryOf.i "Coltifit+te, of Coll
flrinNtM to t11e 0yMt1hM. saw a �nfttan jwrai�to .will ;be furllithad the of m
/titta M, tlaod a>MrMtM ow*Nbli any pMt' of ON wwga AtfOOYI if/ftMl OurMi�`t
aha of tam' approail of ,tow - Cwtilkete ,of,Comstiv ton' Cornplelha- of the orlebul
will tla boeta� at thaww ow tM MMOwd MM'aJM /hat "aid will wile Oa Ind M
"f',wllty pa/af:11 st Of
o�.
'APPROVED RCR COMiTRUCT10Ni Thai MMOMI eitpMOf two yfifif from the datii I
�IMOfable tor, fy11f� M!!lay M anlwdad- of-n""Od wMn'COnfielare0 ni.P@Wy by. iha C
faNliga ,a Naha owtmL . ANrdrM for 77-, of donthdlk faltNary ai % .
/,
0
-s.
I \j
M- orptotfd syftam /pi 1) that tM a a►ata Mira a.dl al fyftwn
aCCordfna with thestan0ardf, rules an rgla f o umnsm
ftrtatlon Com0lleilto" olisfadory to the ColmelffbllW of Hm*hwiN
hit, S mrian;'hobsor afws by thi.buiNW. that aid builder will
M period, of two (2):yaWf bmnWytoly'foll@Wlq tMdata of the laahr
:YStM1 of alit' rw&s tharoto -i t) that the drilled WMI dome". more .
aCCarOs,noa: ;Wmh -the di ru and, rep" a o11 l�s of tM ftd"M
p.t. R.A.
Lkonm W •
stlaad; unlaf,eonstiuetbn of the building -has been undertaken and If
Omlillwbonw. of. Malth.:Any Malifo or alteration-of Construction
prNatO ;watW Wily Oltly
h
'
. �AY CO ��IRZ AlI1lM Or KBAIM
pd d6skfr� l HAY M.Ie�. t,1�f1. N T lIm 4111cm
11MCOMPSAAM �
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ai aalilp •
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4f1�
Cfi
Dale d
A� &lb=
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P
iari. "Qi n,� AVPIi. _ ••=�
A'o�r 3 -� 'a: - -: °. Fee Enclosed am��,;,r 3oa
Q . i �
Ili alr at laiaa�a
Atom
` - / Daalp plsw`G P. b D0
PM Nedb a"
• - _, Yalit�i
It =¢M �Ywi''l� B a�iM��
. i�.s. lw....a`l.11ds,
hr aasat`ol ' +�� Gaiai Sajlla Tank
;_ .
wow &"tn raft 9141rtr rw
atti_�rthNM'l*>Oftialt ti_
I rop"wat, that I am wholly WW Completely retoonsiCle fo► tM ditljn and'wutlon of't
46WO dawiMd. wlttM'o01%304 lad es shown oft the sWowd atnla"irient there to nid in
fJeiflltll pgommot, of "nab, ails that on C011gM:bn.tlNryOf.i "Coltifit+te, of Coll
flrinNtM to t11e 0yMt1hM. saw a �nfttan jwrai�to .will ;be furllithad the of m
/titta M, tlaod a>MrMtM ow*Nbli any pMt' of ON wwga AtfOOYI if/ftMl OurMi�`t
aha of tam' approail of ,tow - Cwtilkete ,of,Comstiv ton' Cornplelha- of the orlebul
will tla boeta� at thaww ow tM MMOwd MM'aJM /hat "aid will wile Oa Ind M
"f',wllty pa/af:11 st Of
o�.
'APPROVED RCR COMiTRUCT10Ni Thai MMOMI eitpMOf two yfifif from the datii I
�IMOfable tor, fy11f� M!!lay M anlwdad- of-n""Od wMn'COnfielare0 ni.P@Wy by. iha C
faNliga ,a Naha owtmL . ANrdrM for 77-, of donthdlk faltNary ai % .
/,
0
-s.
I \j
M- orptotfd syftam /pi 1) that tM a a►ata Mira a.dl al fyftwn
aCCordfna with thestan0ardf, rules an rgla f o umnsm
ftrtatlon Com0lleilto" olisfadory to the ColmelffbllW of Hm*hwiN
hit, S mrian;'hobsor afws by thi.buiNW. that aid builder will
M period, of two (2):yaWf bmnWytoly'foll@Wlq tMdata of the laahr
:YStM1 of alit' rw&s tharoto -i t) that the drilled WMI dome". more .
aCCarOs,noa: ;Wmh -the di ru and, rep" a o11 l�s of tM ftd"M
p.t. R.A.
Lkonm W •
stlaad; unlaf,eonstiuetbn of the building -has been undertaken and If
Omlillwbonw. of. Malth.:Any Malifo or alteration-of Construction
prNatO ;watW Wily Oltly
CaUl'Y DEPARna= OF HEAL
3 DIVi,( ::d - OF RNIlnZENTAL F0=_faZV1 -3
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Address Z.s Jy/01 M 241LERp -AXW70,�11C' 1/Y 16sc) ¢
pCO�aA� '
Located at (Street) No - z 2- 9 /l. ,eiV1 :RO. Sec.. _e�; 9 . Block 5 Lot 7 Z
(indicate nearest cross street)
Mnnicipaiity �°� 774 1?-', o1V Watershed ego TO JI/
SOIL PEROOI,AZ'ION TEST DATA REQUIRED TO BE SUBMI= WMH APPLICATIONS
Date of Pre- Soaking Z 7 65 Date of Percolation Test 712 7 S S
HOLE
NUMBER CLOC'R TIME ... P�.�TION - .
PERCOLATION
Run Elapse Depth to Water Frcm. Water Level
No. Time Ground Surface... In Inches Soil Rate
Start-Stop Min. Start Stop Drop In Min/In Drop
Inches Inches. Inches
1
A 2
27,
5
2
%0 ' Z:OZ{.,
:�Zo .
����
27n
3n
6,7
4
".
5
1
TEST PIT REQUIRED TO BE SUBMITTED WITH "PLICATION n >.
DES ,)N ' OF SOILS ENCOUNTERED IN
DEPTH HOLE NO. HOLE NO. 3 HOLE NO.
G.L.
2'
3'
4'
5'
6''.:
7'.
8' C
9' W4 T,E,P WA 7",g'R
10' uUt
12' pUTNAM �AF- ACTH
i
INDICATE LEVEL AT. WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL 'DO WHICH %%TE t LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:' 6 'A) P c o c It DATE: z 9
DESIGN
Soil Rate used. '7 Min/1" Drop: S.D. Usable Area Provided .so v
No. of Bedroans ¢ Septic Tank Capacity / Z Sv gals. Z`YEe
Absorption Area Provided By L.F. x 24" width trench ,
OF NEW �`
Other
. O
Name ,1,jgt 0117' IAY,, /ASS oc• Oc,Signatur
Address
0. O N o
FESS10 , /
THIS SPACE FOR USE BY HEALTH DEPA TMENT.ONLY:
Soil Rate Approved sq.ft/gal.
Checked. by > < Date
P UT NAM C OUNTY D E PARrMENT O F HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM,
A / . .
1. Name and Address of Applicant:
2. Name of Project: _� os',aJ 5:Si1is 3.._. Location(q/C:
4. Project Engineer: t - V!� LZA__111c e, i 5. Address: 7-3
License Number: Phone: 7 d ^0
6. Type of Project:
i.. . _..
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 (SEAR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted Z
8. Is a Draft Environmental Impact Statement (D EIS) required? ,o
9. Has DEIS been completed and found acceptable by Lead Agency? ...........
10. Name of Lead Agency
11: I -s- this. project in an area under the control of local planning, zoning,
orother 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) ............ .................:.............
1T. Is project located near a public water supply system? ..................
18. If yes, name of water supply AJ /9— Distance to water supply
19. Is project site near a public sewage collection or disposal system ?..... AL, _
20. Name of sewage system '/U LA- Distance to sewage system
l
121. Date observed: 23. Name of Health Inspector:.A,. tit, RJ2.4.61.41
124. Project design flow (gallons per day) ...... ............................... 8 46
1\
2..
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. Wo
26. Has SPDES Application been submitted to local DEC Office? l ZA
27. Is any portion of this project located within a designated Town or State
wetland? .................................. ............................... Ala
28. Wetland ID Number ........................ ............................... JV —
29. -Is Wetland Permit- required? �.' ............. ............................... .
Has application been made to Town or Local DEC Office? ..................
30. Does project require a DEC Stream Disturbance Permit? ................... NO
31. Is or was project site used for agricultural activity involving application
of pesticides to orchards or other crops,"tolid or hazardous Haste disposal; 4' `
landfilling, sludge application or industrial activity? ........ YES or NO
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
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?d
35..Are. any_..sewage disposal areas in excess of 15% slope? .........................
A
36. Tax Map ID Number ...................... .... ............ ................. 21#-1-07
.37. Approved Plans are to be returned to: ................ Applicant Engi nee r
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 Misdemeanor pursuant to Section 210.45 of
the Pena 1 Law.
SIGNATURES & OFFICIAL TITLES:
MAILING ADDRESS:
17
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