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631- 589 -8100
24. -1 -94
BOX 9
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00785
R'V'; 3186
'E OF; CON
Located
McWng Address -J
e"
PUTNAM COUNTY DEPARTMENT OF HEALTH a
Dlvielon of Environmental Health Servlcex; Carmel; N;Y 10512,
Erig)?aeer.lVlast Provide _
r„
PiC H D. Permit;M
STRUCTION COM' UA'NCE FOR SEWAGE DISPOSAL SYSTEM 0. E r S O n
% 24• owe; or ,V
Map e L-
�3' Tai .Block Lot
Formerly Subdivision Name %Subdv. Lot #
v rd a G /j :— Zip Date_ Permit Issued
Separate Sewerage System built, by Address
Consisting of / L o
AL 4[7 i-e?AO h
Water Supply: Public Snpply�From Address '
/I ors �___;private Supply Drilled by Address
Building TyPC I Has Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed? _[yQ
Other Requirements
I certify that the syetem(s) as listed serving the above premises wake constructed essentially as shown,pp the plans of the completed work ( copies
of which are attached), " in accozdaece with the standards, rules and reulitions, in Zcor ce'with a f ad plan, and the permit issued by the
;Putnam County Departmen�t jOff health.
Date ��.� i ' (. certified by /� p r P.E.. /1_lkzrd�
Address 1"� 1 ya7Yq�I[ Vt'T IC4°- �un��C , C7re_, -,S4-r , 1 9 License No.
Any person occupying premises served by the above systems) 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 sewerage system shall become null•and void as soon as a pubs% sanitary sower becomes
avaliable and the approval of the private water supply shall become. 1 nd vold when a ublic water supply becomes available, such approvals are
subject to rho ifiatlo o► change when, in the•judgment of the 1 stoner of Heslt eh revocation, modification or change b necessary.
Oats By Title
_.. ...... _ .. _ .... -- - _.........
ti.
N
PUMAM COUN'L'Y DEPAFM', 'r OF HEALZE
DIVISION OF ENVIROMWEAL $MTH SERVICES
Owner or Purchaser of Building Building Constructed by /
OG•�Y�l�I e G� a��
Location - Street'
z4 /
Section Block Lot
Subdiv Sion Name
p��
Municipality Subdivision Lot
Building Type
GUARANTEE OF SUBSURFACE SEWhGE 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 shoran 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. falls 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 12 day of 1917
General Contractor (Owner) - Signature
mss �'�� - U►�,c... --
Corporation Name (if Corp.)
,t- dat:ess
Signature
u
Title ��c-t' �tX-
:Gv�c•Lc�� �, � J-_ TL)
U
Corporation N,ame� /(if rp.)
P ess
J
a, -<
:.. *
W �4
WILL UUr1rj1LiiUN AL,rUtti
DEPARTMENT OF HEALTH
Division Of Environmental Health Services -
PUTNAM COUNTY DEPARTMENT OF. HEALTH
Office Use Only
—
S
—7:2
/ \
WELL LOCATION
STREET AOURESS: (f wNr I I TAX GRID NUNiSER:
i- > L �3n,. eoZSn,.T
WELL OWNER
ME. ADDRESS: rvki vi 0L
,�. V\ LAS S ` >zAen Lv, tj o , 0 $ 0 �
PRIVATE
a PUBLIC
U E OF WELL
1 primary
- secondary
RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF,USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[1RfiPLACE EXISTING. SUPPLY ®TEST /OBSERVATION ❑ADDITIONAL SUPPLY
SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WE ' DEPTH jc ft.
STATIC WATER LEVEL ft.
DATE MEASURED Q
DRILLING
EQUIPMENT
ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT O CA LE PERCUSSION ❑OTHER (specify):
WELL TYPE
O SCREENED SIOPEN END CASING O OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH — ft
MATERIALS: STEEL ❑ PLASTIC O OTHER
LENGTH BELOW GRADE' ft.
JOINTS: WELDED P THREADED O OTHER
DIAMETER in.
SEAL: VCEMENTGROUT ❑ BENTONITE OOTHER
WEIGHT
PER FOOT ___1_`7 1b./ft.
DRIVE SHOE fl'YES ❑ NO
LINER: O YES ONO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL 'PACK
O YES
fiLNO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST -If detailed pumping
I
M '00;
ar O PUMPED 1 tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED O OTHER ❑ YES ❑ NO
�IELL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Pear-
In9
Well
Dia-
meter
In I
FORMATION DESCRIPTION
t:.7nE
tt
it.
WELL DEPTH
ft.
DURATION
hr. min.
ORAWOOWN
It.
YIELD
. gpm
Land
A q .�J
u
c�5
ti�►N. �—
��S
as
�V�
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? O YES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
w�D�A�III NAME-- �� DATE
ADDRESS D•1 ;� SIGfA(TURE
3/ 0 t
A �,,a
G -
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
\ Brewster, New York 10509
(914)278- 6108 - (FAX) 278 -2658
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
September 12, 1997
Robert Morris, P.E.
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS Compliance - Lot -13
Big Elm Subdivision
Courtney Lane
Patterson, New York
Dear Robert:
Enclosed are the following:
1. Four (4) prints of Drawing S -13 "As -Built Plan ", dated 9- 11 -97.
2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 9- 12 -97.
3. "Guarantee of Subsurface Sewage Disposal System ", dated 9- 12 -97. -
4. Well Completion and Well Log Report.
5. Water Analysis Report,
6. Bank Check in the amount of $200.00 payable to Putnam County Health Department.
If there are any questions concerning the enclosed, please call.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harty W. Nichols, Jr., P.E.
HWN:RTL:bd
88044 -13
I
e.,
s
O
moo,.
IRON P/A/ SET
I
PROJECT
8 /G. ELM SUBDIVISION
IS/ON
COURTNEY LANE - L07-013
RON P11V
SET PATTERSON, NEW YORK
CLIENT :
ROSS ALAN
25 BYRAM LAKE ROAD
ARMOA K, MEW YORK
LAURENT ENGINEERING
ASSOCIATES, P.C..
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
(914)278 -6108 - (FAX) 278 -2658
CONSULTING SITE,ENGINEERS
DRAWING TITLE
AS -BUILT PLAN
/-07-# /3
SCALE /a 30,
OF NEW ' `'
r09 DATE 9-//-9.7
- --
c� Q� �RAWN BY : iQ,7. -1
I * Q c CHECKED BY : HWN
Uj
L .. 2 JOB No.:
86 044 - 13 _
124 ��� DRAWING No.
�Of ESSIONA
S ®13
10/01/1997 12:10 914-278-7754
�-'NORTH AMERICAN
LABORATORIES, INC.
NO AMERICAN LABS
CERTIFI CATS OF LABQRAJORY ANALYSIS
LAB ID NUMBER: 97-5970
CLIENT- Ross Alan
2513yram Lake Rd
Arnionk NY 10504
SAMPLING LOCATION:
COLLECTED BY:
DATE COLLECTED:
BATE RECEIVED:
:DATE OF REPORT:
Hall bath: Lot 13, Courtney Ln, Brewster NY
R. Alan
09/26/97 TIME COLLECTED: 9:20 AM
09/26/97
09/30/97
PAGE 01
:ANALYTE
RESULT* UNITS.
MAX CNTMT LEVEL"
MMOD
ANALYZED
Total coliform
Absent
Must be "Absent"
5MI8(9223)
E. Cob
Absent
Must be ".Absent"
SM18(9223)
09/26/97
This sample, as submitted to the laboratory, and as compared to the New York State limits for drjnkdng
water quality for the tests performed, was:
Z ACCEPTABLE, NOT ACCEPTABLE,
Richard W. Emerkh, Laboratory Djrector
NYS ELAP #11218
CT Lab Approval #PH-0171
Underlined results are unacceptable accor-ding to health department anti /or US EPA codes.
** Maximum Cor,Eaminant Level (rftaximurn Permissible concentration allowed by health departinentind /or OS EPA codes).
IoAr,
PUTNAM COUNTY DEPARTMENT OF I?EALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES .
FINAL SITE INSPECTION
Date:
4,�� Inspected by: S ' tea.✓
Street Location v.�,�� y: Owner �1 USS M_4A,"
Town % %F45c):U Permit # 9�
TM # Subdivision Lot #. 13
1. Sewvaee Svstem Area
a. STS area located as per approved plans ...........................
b. Fill section - date of placement
3:1 barrier Lgth. Width 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. Septic tank size -1,000 ...... ........other ................
b. Septic tank installed level ................................................
c. 10' minimum from foundation .......... ...............................
d. Dist 'bution Box
1. All 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. rT enches
T.Zeg h required S_ Length installed
2. Distance to watercourse measured `t' 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%" diameter clean ....................
9. Depth of gravel in trench 12" minimum .......::..........
10. Pipe ends capped .......: .:.:::::::::::::::.............
.. ..................
g. Pump or Dosed Systems
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. House/Buildi g
a. house located per approved plans .............
b. Number of bedrooms ......................' c i ,- e...........
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. Erosion control provided ................. .............................:.
Rev. 6/97
,-- -,--
c-,
36-
� 8�
�g
_ F0 TMM COUM DEPA4'Y11oMIT OF MULALTH
Dl�blesi a[ Vital HeaNA Saevloeo.`Camel. N Y 1OS11 to Pasivlde PeesD a,.
C6R1lPICATS OF
CO N P
FOR S6WA8B.DMMSAL SYSIBM
Pewit
Coated at KTAJ gy jtfiN . _ ow,. ur
Swdlvlda. Natua Subd Lot a �-� Tai Map �- Hloeh
Renewd_O ReAdoet -p '
OwnedAppSwo Nestle ,eO. S fH Lj4iy
Date of Previous
•,Approval l/
Maw Addrsia/12><im �i�iE I�TJ Town /-f H�/O�F -- z
Date subdivision Annroved . �'� —�0 Fee .Enclosed amn,,,,f �D • D
amiag Type . - TI / Lot Area FM Seellon 0* Depth volume . .
Native of RedNM= Detl@a Flow G P D AM Notl9ntlon b R p hed Wban Fill n mnmm& ed
Sepoeate Saw =V Sydm to coved al Gallon Sepdc Tali and ✓ AM I
To tea caeab uded by Address
Water SuP*: PtM& sup* From —rte, Addreae
on, Private Sopptr RAW by ! ✓ b --Addreas
Od m R6mdmwtinoa
1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(Q. 1) that the separate ssw di eel s stem
above described will be constructed as shown an the approved amendment there to and in accordance with the standards, rules a regu ns o ream
County Department Of health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Mwlthwill
tier submitted to the Department. and a written guarantee will be furnished the owner, his successors, heirs or assigns by the bulkier. that said builder will
Piece in food operating condition any part of sa .swage disposal system during the period of two (t) years Immediately following the date of the Issu•
once of. .the approval. of.: the, Certificate of 'Construction Compllenca of t,@ original system or any repairs t eto; ) that the drilled well described above
valet M IoCatxO at Yiarrw on tM approwA plan and that a.ld well will be fns 1 in actor ce wit the sta ros, s red rapu a�Toei of the Putnam
County IF MaaRn.
Date S nod
y o' -.,� q % P.E. R.A.
Atldrecs / I' r' e , v Licenp No
APPROVED F R CONSTRUCTION- This approval expires two years Som dad issu unless construct on of the building .has been undertaken and is
revocable ��Uss or may tea amended or modified when considered by the O missioner of Health. Any change o alteration of construction
raquIIP)oroved for disposal of domestic sanit and /or r star supply only. n
Rev.
aIL�
10/88 Data ev Title
RE: Individual SSDS
Big Elm Subdivision - Lot #13
Courtney Lane
Town of Patterson, New York
Dear Robert:
Enclosed are the following:
I Four (4) prints of SS43 "Proposed SSDS - Lot #13", dated 4-4-97.
2. "Application For Approval of Plans For a Wastewater Disposal System".
3. "Construction Permit for Sewage Disposal System", dated 4-7-97.
4. "Application to Construct a Water Well", dated 4-7-97.
5. "Design Data Sheet".
6. "Letter of Authorization", dated 4-7-97.
7. . "Corporate Affidavit" dated 3-6-97.
8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only".
9. Money order in the amount of $300.00, review fee.
We would appreciate your review, approval and issuance of the Construction Permit at your
earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
1
TV L6
Harry W. hols, Jr., P.E.
A
A N!
HWN:TR:bd
ij
88044-13
cc: Ross Alan Inc. w/enc.
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
(914)278-6108 - (FAX) 278-2658
HARRY W. NICH 0 LS JR., P. E.
CONSULTING SITE ENGINEERS
April 8, 1997
Robert Morris, P.E.
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509,
RE: Individual SSDS
Big Elm Subdivision - Lot #13
Courtney Lane
Town of Patterson, New York
Dear Robert:
Enclosed are the following:
I Four (4) prints of SS43 "Proposed SSDS - Lot #13", dated 4-4-97.
2. "Application For Approval of Plans For a Wastewater Disposal System".
3. "Construction Permit for Sewage Disposal System", dated 4-7-97.
4. "Application to Construct a Water Well", dated 4-7-97.
5. "Design Data Sheet".
6. "Letter of Authorization", dated 4-7-97.
7. . "Corporate Affidavit" dated 3-6-97.
8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only".
9. Money order in the amount of $300.00, review fee.
We would appreciate your review, approval and issuance of the Construction Permit at your
earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
1
TV L6
Harry W. hols, Jr., P.E.
A
A N!
HWN:TR:bd
ij
88044-13
cc: Ross Alan Inc. w/enc.
APPLICATION FOR APPROVAL::
-OF:-PLA14S..- FOR *.A:-.WASTEWAT.ER -.01SPOSAL.SYSTEH
Name and Address ..of. .,Appl. f0e, -ass
. - ._ .... .... '. .'..; ..:fin- �o�;�. - n��y _ . - :.. .:.
ayp—AM pew_t)
S,,sv
2 Name of ProJ ect 3._-_Locatjon T/1! /C:
i I I b r o o k e 'O'f f i ce Address: Cent:
4.. Project -Engineer:
Bre; -istef, NY. .10509 *509
License Numiber,-- Phohe': (51 3.
J
6.. Type of'
'od Servie
ate/Re'�Idential, FO'*
.c
v
Apa rt me n t s
Institutional Mobile .16A 'ome" Park
Office'Building ..' -Realty .`Subdivision .&he"
F..(specify):
V., Is.-this project. subject t o' State' Envir6nm.ental,-(�uality Review (SEQR)?
TYDe Status (Check One) Type .l. .- Exemot
T' -
Type-11. Unlisted. X
Wo Is --a Draft En'vir . onmental Impact .Statement (DEIS)..required? .......
9. Has DETS"been completed 'and founi'd acceptable by ,Lend t'%gency?• A)M-
0. -Nanie of Lead Agency /t� f
1. Is this project in an area under - the control of -local planning., zoning,
or other o-IF-IFIcials, ordinances? ..........................................
''f so, have plans been sut-.mitted to such.'author.i ties?.. .................
ep qran.te� by such-author
H'as preliminary approval be' !ties? Date Gra'nted-._A�_,
Type of Sewage Dis*posal: System Discharge...... Surface Vater' Ground F,F.t,ers
If surface water discharge, what is the strew, class designation ?........ A) 44
Waters index.number (surface) .. . . . . . . . .
...................................
Is project nee located
L a publ is water supply system? .............. A) 0
yes, narze or. w ate r supply Distance to water supplv
Is ;)"-Oj- cl-site f--.ear a public sewage collection or disposal .......
Of se-reage system A)IA Distance, to sewage syster.
, 7
observell-J:
t 11 inspector:
desicfl (-allons per day) ..................................... .
Z)
t5: Is State Pollutant Discharge Elinination"System '(SPDES) ' Perm, it.required ?..
26. Has SPDIES App ication been: sub,7itted "to. local :DEC'Office. , ..... .
27. Is any portion of this project .located within a_ des 9nat6 Tow'n or -State
......: .. . . .. . .. iwetland ?..... � .. .
23 Wetland..I'D..Number. .. .. ....................... .........
29. 'Is Wet-land .Permit requ i red? .•.. .: .... ......................... 0
Has appl ication been 'made to Town or Lacal DEC Officer ..............:. Ply
30. Does project require. a DEC Stream Disturbance Perim it? ..., ...::.......... . . N�
31 . Is or was project : site - -used for- _a5r- icultural. activity involving application
OT pesticides to orchards•o� other'"crops solid, or hazardous waste disposal,
landfilling, sludge application or industrial activity? YES or:rh'0.
32. is project- located -,within i;000•feet.O existence of abandoned landfill,
hazardous waste site,'salt.stockpil,e, landfi1.l;;sludge disposal.site-or b
any other potential known •source of contanination ?...... • - - • - ...,.-.YES or h0
.DESCRIBE:
33. Is there a local master plan or file`Hith the Town or Village? ....... IUD
3;. Are co, —, unity water, sewer facilities :planned to be developed within 15 years ? - I)O
35. Are any.' sEwage disposal.. areas in excess of i5- slope? Dl) C)
16 :
Tax !Hap TD Number .. ............L�
r. :,pproved.Plans a re' to'be; returned to: ................. Applicant X E n 9 n .r
the applicatio.niis signed by a person other than the .applican, shown in Iten.i, the.
pplication must be-accompanied by•a Letter o-F Authorization: -Failure to comply with this
rovision may be 9 ou"nds for the rejection °of any sub,-fl ssion.
I hereby affirm, under penalty of p-erjury;. that information provided on. this
fon is true to •the best -of my knouredge end be 1 r'ef. False stat�,ents 'Wade
herein are ' pun ishab Ie as, a Cla s A Hisde:,-reanor punst� ant to Sect ion 210.45 of
the Penai Law. .2 JJ n A- .
<<;7UacS & 0; FzCir,L TITLES:
-iillbro A Office Centre.
!_ "itG ADDRCSS: Brewster', NY 1050;
. 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
WELL LOCATION
Street Address
e
To Village City Tax Grid Number
0% - - L'
WELL OWNER
Name
SASS
Mailing Address
CIPrivate
O Public
1 E OF. WELL
primary
'2 - secondary
ORESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY . Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION'
[]INSTITUTIONAL O STAND -BY
OTABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED � -� /EST. OF DAILY USAGE al
REASON FOR
,,DRILLING
O REPLACE EXISTING SUPPLY D TEST/ OBSERVATION 13 ADDITIONAL SUPPLY
SINEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
!DETAILED
REASON FOR
DRILLING
NOW K,9r, /
WELL ' TYPE
LARILLED
Q
GRAVEL
[:]OTHER
-IS WELL SITE SUBJECT TO FLOODING? YES. NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
i
Lot No.
-WATER WELL. CONTRACTOR:..._Name . - _- .-- T�j7_---- _ - _ -- -- -- _- _-- - - -... _ _ _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
ffJON SEPARATE SHEET
7'-
(date) IV signature)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
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 drill operations be contained on this
property and in suc / manner as not to degrade or othe i co nta nate surface or groundwater.
Date of Issue: L 6 19
Date of Expiration 19 Pe it Issuing Of icial
Permit is Non - Transfer able White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
Pu tn a "',qu n ty 1-3ee p a i tnj e.n t of - H e a I t
ne
Divis f Environn t al., Sdni'tail`-
AFFIDAVIT CORPORATE O4 NER APPLICATION
FOR PERMIT. APFiLICAT-ION SUMMED- TO
.PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health In the matter of application for
represent.
that J am an officer or employee of the corpor&ti'on and bm.`authoriz'ed:.
to act for
---- ------
(name of corporation)
having offices at
L
AX y Whose officers -are
President A �s 1416"1
Waa�e_ Wna TdUr—ess
Vice-President
(Na_mea_nd_A_ddFe_ss) — — — — — - - I
--Secx,6tary
-- — — — — — — — — — — — — — — — — -- —
(Name and Address.) — — — — — —
f
Treasiirer'
— - - — — — — — — — — — — — — — - - — — -- I - — — — — — — — —
(Name and Address)
and 't�ialt I-'6rdand will be individually responsible' f66*an'j` or all sptp
of• the- c.orporati on with respect to the approval requedted and-all.sub -`
seque'h*t acts '.relatinig -thereto.
Sworj- to befor e 'm e. this day Signed
of
1997 Title
_Nftla-ry Publib"
Corpor4te Seal
PUTNAM COUNTY-DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of
Located at
(T) Pq7 j� -7 Section Block % Lot
Subdivision of
Subdv. Lot Filed Map #`f�, Date
Gentlemen:
This letter is to authorize
a duly licensed.professional engineer \I- or registered architect
(Indicate
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards,'rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Educati
tary Code.
Q
rA aNE
�A
r
Countersigne
R.A. ,
e Public Health Law, and the Putnam County Sani-
10
\9!r
Very truly yours,
d' No. 56124 cy� Signed
p P�' Owner of Property
H0 F ESStON
Address
I L- W9O DFP60 G�NTj2�
Address
Telephone
/7/"- ��. jU y
Town
Telephone
IF1M COUNTY DEPAiZ I OF
DIVE .J OF HEALTH S , .. .
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTTM. FILE NO.
Owner 0 5's 4,14,V Address 2 GA K,E PP.. A/ Y /6 S-0
�
Located at (Street) iVo . 2-2- ,(3/ G.... EGivJ- .../QD_ .. Sec, ......Block . 5...: Lot 7 Z
( indicate nearest cross--street) _...... ....._ ..................... ..... ........_..................,,..
Municipality �i9 �iS�S '� . Watershed .. C%To 7-61V
SOIL PEZOQI,ATION TEST DATA RDQUIR .TO BE SUBS WITH APPLICATIONS
Date..of . Pre- Soaking . o / S .7 Date of ..Percolation Test S o I 89
HOLE_ _ _... ..
NL2 . CL= TIME PERCOLATION
Run ....
_Elapse Depth to Water..Frcm Water.LeveZ
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 :•;'
5
NOTES: L. Tests- _to -b6- repeated at same depth - until approximately equal soil rates
are obtained at each percolation test hole. All data to'be subnitt�d
for review.
2. Depth measurerents to be made from top;of hole.
rev. 9/85
2 /0.39- Il;o9
=3�
Z�''
2s��
�3� �,
17
�.
5
4
5.
1
2
3
4 :•;'
5
NOTES: L. Tests- _to -b6- repeated at same depth - until approximately equal soil rates
are obtained at each percolation test hole. All data to'be subnitt�d
for review.
2. Depth measurerents to be made from top;of hole.
rev. 9/85
TEST PIT DATA REQu= To msuammmwim _AP-PEICATION
DESCRIF- '7)N OF SOILS ENCOERUWM:IN TES' DLES
DEPTH HOLE NO. /-f
HOLE NO. HOLE NO.
G.L.
3'
/c/-w S Ait/V
.4! SILT.
�>%z 7
.
5,
6'::
7'
10' 1114 Tzf�(/�T�P.:'.
12'
13' - ........._- .
14'
INDICATE LEVEL AT WHICH GROUNDWATER
IS ENCOUNTERED 1�16ll/,C
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:
C, /� (a A) ) TCAJ 6^ 6 c'1'47" DATE:
;.....
DESIGN
Soil Rate Used 16 Z J . Min/1"
Drop: S.D. Usable Area Provided 7 0 0 0
No. of Bedroans ¢
Septic Tank Capacity 12.5-0 gals. Type c
Absorption Area Provided By s7/ L.F. x 24" width trench
Other DoS /X/(,- 0/0, S7! 17-
op.
S YST41, "44001 r,5'v
Name G,gvj'.c,/ �is� < /�v�Ei,?�•ciG /�SS� �. , p, C. Signatur
is S
Address 7Z /--/a SEAL
1
O No. 0458
1-04 TT.Ei?S� �v ,�� / Z sG 3 `esOFESS�®
THIS SPACE FOR USE .BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by
Date
• • • �,
NO
: • • • •
Bedroom
. Bedroom
it 1
PUTNAM COUNTY DEPARTMENT OF HEALTH
HOUSE P'LANS' AF `tg0VFD F-C
50.0" �
BED.M0!,i G0!jN,*r 0P.L ..
c / Wood Deck j
- - -- — - 7 /� 8'x12'
Signature & Ti -ie
ate
Breakfast Area
Living 12'4" x 11'4" Family Room,
Room ,e�n�� .. A-41AII
i
i
I
i
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REV W SHEET for CONSTRUCTION RRMIT
STREET LOCATION � Z_ NAME OF OWNER
BY B. HEDGES R.MORRIS OTHER DATE L& q TAX MAP # -�-
DOCUMENTS.
fRMIT APPLICATION
-ELL PERMIT PW S LETTER
4M GINEERS AUTHORIZATION
DESIGN DATA SHEET(DDS)
m RPORATE RESOLUTION
1 11 1 PLANS THREE SETS
OUSE PLANS - TWO SETS
VARIANCE RE Q UEST
t SUBDIVISION
GAL SUBDIVISION
BDMSION APPROVAL CHECKED
RC RATE
L REQUIRED DEPTH
= CURTAIN DRAIN REQUIRED =STANDPIPES
GENERAL
=EX-APPROVAL SSDS ADJ. LOTS
= WETLAND ( TOWN/DEC PERMIT REQ? )
= DATA ON DDS PLANS & PERMIT SAME
= PRE- 1969 - NEIGHBOR NOTIFIFICATION
= LETTER_BI/ZBA.
L-LJ 100 YR. FLOOD ELEVATION
REQUIRED DETAILS ON PLANS
EWAGE SYSTEM PLAN - (NORTH ARROW)
9DS HYDRAULIC PROFILE = GRAVITY FLOW
NOTES (GRINDER NOTE)
JN DATA: PERC AND DEEP RESULTS
FOOT CONTOURS EXISTING & PROPOSED 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
EWAY & SLOPES CUT
' TO WATER LINE (PITS -20')
WG /GUTTER/CURTAIN DRAINS
ION CONTROL; HOUSE,WELL, SSDS
[ON CONTROL NOTE
& DEEP HOLES LOCATED
ESENTATIVE OF PRIMARY AND EXPANSION WiTIC TANK
COMMENTS:
Y
EXP. AREA; SHOWN; GRAVITY FLOW, SUFF. SIZE
rED PIT & D BOX SHOWN & DETAILED
OUSE NO. OF BEDROOMS
& SSDS'S W I' . F PROPOSED SYSTEM
TY MET & O S
KEa� USE SETBA C (TI HT LOT)
OUSE SE - 1 E PIPE
NOBENDS; S 45.
FILL SYSTEMS
YBARRIER
0 FT HORIZONTAL: SLOPE 3:1 TO GRADE
ILL SPECS =FILL NOTES
FILL CERTIFICATION NOTE
DEPTH GAUGES
FILL PROFILE & DIMENSIONS
VOLUME
FILL IN EXPANSION AREA
TRENCH
F TRENCH PROVIDED =60
PARALLEL TO CONTOURS
= 100% EXPANSION PROVIDED
FT MAX
10' TO P.L., DRIVEWAY, LARGE TREES TOP OF FILL
2O' TO FOUNDATION WALLS DJ 15' WELL TO P.L
100 TO WELL, 200' IN D.L.O.D., 150' PITS
100 TO STREAM WATERCOURSE LAKE (INC.EXPAN)
LOCATION MAP
— �' INTERMITTENT DRAINAGE COURSE
W/l,' 00 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS
5' MIN TO C.D. S= >5%,20'- 4 %,25'- 3 %,30'- 2 %,35'- 1%,100' <1%
DISHARGE /100' WITH 182 CONS DAY DIS.
' FROM FOUNDATION; 50' TO WELL
IN1F MIL LER $ BA /RD
S 12 021 "06 W 184.18
o. "d
0
0
O
O.
^n
n
N �\ LOT# 13
Au
4.
QJo
� N, :�1
0
Ott
V Ell
� � OG�G , • p� P•
Rye
AS eviL r �sa.
D /MENS /ON CHART
/v . A B
—. —
20.0
2 ;
57.0 2 1.0
5 62.0 27.0
P/N FOUND
/RON P/N SET
i
P/N SET J
ANGLE
PIN SET
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6lERT /FY THAT THE SEYV,4GE D /SPOSAL F�r� t ,�` �F��3 98�` =rJ� t� ��
SAS CONS'Tf?C/CTEQ�~AS /ND /CATEO ON TH /— - �.- --�.- -- � .,� �. - ,..� L;j
�Th!A'T THE ,SY.S'TEM�N/,�45 /NSPECTEDBY ` °t a - �����a /4h /O` /� �' 5 5�-0,� ti
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LM WAS ,CONSTlzUC.TEO, /N ACCORDANCE f � t
' STANDAROr A ES A/VD 'REGUL A T /ONS .a /� / / kO to D
A
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-NAM COUNT Y DEPARTMENT OF HEAL Th'r:'- �� . � �' �`< ' " ° � > � �' � �' a ;. -71 / 7 i /�/ 4 fp � a ,1 ' ��/
�EIiY YORK STATE DEPARTMENT OFHEALTH " � � a " . 11
, 7 O v� 9 7 <!o D
1. d r Y x % I . • � x r�
?OC 1T /ON BASED_�ON SURVEYGK'�PROPERTY x j je # M
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N° 49�09'l ",' <DATED JULY 515,, /997fi X20 ��38Y -0 y 4/ .'C�
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