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PUTNAM COUNTY NO OF HEALTH
Div! *s' a 116Ir menW HeaNb Servloer, Carmel, N.Y lOSls'
r Engineer. ust provide
P:C H.D. Permit
F CONSTRUClloN COMPLIANCE FOB SEWAGB_DISPOSAL SYSTEM
-- Town or
a" 'TAX M�p_glocb
Let
4
a Formerly Sabd(vlsfon
•..: Name � rl YiN C Yllt, LOS, ej
v aP .��A Subdv. L6t 4
Z
Amount ... Date Permit I'ssued:;
�► 9
em ballt'by Adores.
f 04 Q .. Gallon se "t(c`Taok end �%!� I
P r. . ,.
Water Supply: - Public Supply From Address
Su
Oki LAddress Aik, A.ewtiit
Building i���,�G� Lot biz ,%S3 ,HaS EIOSlOtLCnntrnl .Raon "Cnm leted?
Number of Bedrooms � •Has Garbage Grindw Bien Installed!: /y 0
Ofber itegafiemente •
I certify that the syates(s)' ae listed serdinq'.the above premises were constrdeted essentially „ae shown' on plans ,b! the completed work ( copies
of which are attached)/ and iq accordance with - the:atandards rules-:and; r '1 ione,"ins cordance with the led p n, and the permit issued by the
Putnap county Department o! Health
Oats ” /'7 Cart y . P.E. RA.
I►ddress y� G lk�nss No.
Any parson "pccu0YUq "pnmises,sarvap bY. the abov. system(y shall promOtly takasuch aetbn as may bi naoassary to neu►. the corredlon of any ununitary
condltlons resuItIng* from' such `us q .: Appro6al of the aparsts "sawa►a� .sy4m n ,shell 6seorne null -aW vokt.as so" as a pubt;: onitary saves► bsconm
avellatll. ana tha approval of the priests water. supply, shall Oaeomn null an0 vo bsrr 2 fr~a Pt>ty OaobfllM wallable. Such approvals we
subject to Modifkstbn or change ;wASn, In the JudOmaht of tha''Comen _ ner:of MMIt moAHteatlon Of eAanOa b naeassar
3/89 oat. Tula
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PUI'NAM COU M DEPARTMIIr' OF HEALTH
DIVISION OF ENVIMR�L HEALTH SERVICES
/A rf CTo
Owner or Purchaser of Building
Building Constructed by
Location - Street
N f �(
,
Municipality
Building Type
Section
4 2, Z
Lot
C.1- vz. �� s wh � U� I -�►.
Subdivision
2
Subd vision Lot v
GUARA= OF SUBSURFACE SESIZAGE 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 shorn on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Departrri-ent 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
"Ceztificate_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 1-4 day Of 5---vp�-- 194--t Signature
Qa' Title
/
Gen' / Contractor (O,aner) - Signature
1, 3 P4,► Aee-
Corporation Name (if Corp.)
Danb "vh CT
Address
rev. 9/85
Mk
LTL
corporation Na4re (if gbrp. )
S 0_ �
F�'dress �
ELL LOCATION
WELL OWNER
USE OF WELL
1- primary
2 - secondary
WELL COMPLETION REPORT
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
STREET AOURESS. TOWNIVI
East $ranch Road
NAME:
Classic Homes
-9� RESIDENTIAL
❑ BUSINESS
O INDUSTRIAL
Patterson, N(J,
ADDRESS:
Zric° P�
❑ PUBLIC SUPPLY
❑ FARM
O INSTITUTIONAL
Office Use Only
TAX GRID NUMBER: I
o PBIVATE
O PUBLIC
❑ AIR /COND./HEAT PUMP O ABANDONED
O TEST /OBSERVATION ❑ OTHER (specify)
❑ STAND -BY ❑
MOUNT OF USE YIELD SOUGHT 5 gpm. /N0: PEOPLE SERVED 24—/ EST. OF DAILY USAGE gal.
REASON FOR []REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
DRILLING ggNEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL
DEPTH DATA WELL DEPTH 30.' ft. I STATIC WATER LEVEL 50 ft. I DATE MEASURED 7112194
DRILLING ❑ ROTARY -IR COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE 1 ❑ SCREENED
O OPEN END CASING
CASING
DETAILS
TOTAL LENGTH
LENGTH BELOW GRADE
DIAMETER
WEIGHT
PER FOOT
SCREEN
DETAILS
DIAMETER (in)
FIRST
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
WELL YIELD TEST
METHOD: O PUMPED
Q COMPRESSED AIR
O BAILED O OTHER
WELL DEPTH DURATION
It. hr. min.
200 1 30
305. 6 –
If detailed pumping
t tests were done is in-
! ormation attached?
10 YES ONO
DRAWDOWN YIELD
It. gpm.
200 3
220. 30
WATER AWCLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? AYES ONO
ANALYSIS ATTACHED? 15cYES O NO
PUMP IHFO�ATION
TYPE su ers i b l e. CAPACITY 10
MAKER DEPTH 240
MODEL 1057SO7 VOLTAGE 230 HP3-a-
.,S OPEN HOLE IN BEDROCK O OTHER
°1 — tL MATERIALS: -,@ STEEL O PLASTIC O OTHER
ft. JOINTS: O WELDED =@ THREADED O OTHER
in. SEAL: €&CEMENT GROUT ❑ BENTONITE O OTHER
Ib. /it. I DRIVE SHOE. O YES D NO I LINER: G YES O NO
'SLOT SIZE LENGTH (It) DEPTH TO SCREEN (ft) DEVELOPED?
O YES O NO
- _.._ ... _._ .. -. _ -.. HOURS
IDIAMETER ITOOPTH P I BOTTOM OF PACK in. tt. DEPTH ft.
WELL LOG It more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM Water Well
SURFACE Bear- OIa- FORMATION DESCRIPTION cone
ft. ft. foq Inetcr
Land Hard n .& cobbles
Surface
98 Hard black & grey granite
STORAGE TANK: TYPE dia,phraam _
CAPACITY .62. -4 G
WELL DRILLER NAME a1dI1.1.. DR&L,
1 °
ADDRESS PUtnam AVentle rJA
Brewster, NY
e
NE '� rI'ARVI'ON ENVIRONMENTAL LABORATORIES INC.
A Division o/�Northeast Laboratories, Inc.
DANBURY: 11.0. Box 2328 • 22 KENOSIA AVENUE • DANUURY, CT 06R 13 -2328
BERLIN: 129 MILL STREET • BERLIN, CT 06037
C'I' Cerl: 1111 -14114
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING, INC. DATE SAMPLE COLLECTED:
9/7/94
PUTNAM AVENUE TIME COLLECTED:
11:05 A.M.
BREWSTER, N.Y. 10509 COLLECTED BY:
ROB
DATE RECEIVED n LAB:.
9/7/94
DATE(S) TESTED:
9/7/94
TESTED BY:
TEL
REPORT DATE:
9/9/94
N.Y. STATE CERT. NO. 11471
SAMPLE SITE: CLASSIC HOMES INC., EAST BRANCH RD., PATTERSON, N.Y.
SAMPLING POINT: WATER TANK
SOURCE: WELL
TREATMENT: NONE
TEST PERFORMED-- RESULT: RECOM51ENDED LIMIT
BAC'T'ERIAL:
Total Coliform (Bacteria) ABSENT ABSENT
C11 ENJ IS'TRY:
Chlorine Residual * mg/L - - - --
nil = milliliter
mg /L = milligrams per Liter
RESUUFS BASED ON SAMPLES SUBMITTED /COLLECTED: 9/7/94
SAN'1 111.E, AS TESTED ABOVE: POTABLE or [3NOT POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
*BACTERIA SAMPLE COLLECTED IN A SODIUM TRIO SULFATE BOTTLE.
( °1 I )ANINIm' ARIBA (203) 749 -7903 — FAX (203) 748 -0652 • CT: NEW BRITAIN/HAR1TORO AREA (203) 828 -9787 — FAX (203) 829 -1050
TOLL FREE WITHIN CT: 800- 826- 0105.OUTSIDE CT: 8W -654 -1230
F m
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NUNN I II Dodpllow,G P D PCHEINeliftwilam, la itegiob sd W6aa M in ftiiiP a
S@PNRN" S"Wee. loa omit et C.aYost SIPPOIC To" slid
TIO
4*08=budsd by AtLtiera
Water Add.m.n.
an by ,
SEPPI► � AddteM
ion of 'tflo proposed t he i t he rah "ig4i di' set system
abo" described will pi constructed f;.~n," A * &Pprd"i amendment loire, to, and loaccproance.w(th the standards. WHIS regulallo"SW Ini -Purn-aw
County' mant' of Health. Jmdth8t#P�cofa oiadonstruction compliance- satistactori to the commissioner at Health will
0 the"D nd- writtonlz -hls'i6cciiiors; Saki or anigns by the bulkier. that said bulkier will
Sparifiviat. a'. a the o�*6er.
place in good :0
Sao 1 a of the am
will be WAOd is
COMaty. DOPSOM
pate
APPROVED FOR CO
r*40c4bI . a for Cause OF
"quires a IMW OWMI
Rev.
10/88 ele
-system 44ring the pitiod'of two
of the OrWaIll-SYSt Or May C44
In
vediately following tfN date of the Hach
t) that the drilled well d4licribIld 86WA
kis I rp as of the Putnam
N.A.
tense No
a building has been undertaken and is
V change or alteration of construction
Title
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT-A WATER WELL F -a?
PCHD PERMIT #
WELL LOCATION
Street Address
Town Village City Tax Grid Number
WELL OWNER
N
Mailing Address
'I 02 U
QPrivate
O O Public
USE OF WELL
1G - primary
2- secondary
PRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
OPUB IC SUPPLY OAIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
13 ABANDONED
O OTHER (specify
O
(AMOUNT OF USE
YIELD SOUGHT gpm/ # PEOPLE SERVED-* -65r/EST. OF DAILY USAGE boo gal
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION 13 ADDITIONAL SUPPLY
19 NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
DRIVEN
[]DUG
GRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES V-' NO
.IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: M
Lot o ..
WATER WELL CONTRACTOR: Name 222 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
ON SEPARATE SHEET
(date) r-r— ( gnature)
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
thirt -y (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 suc a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 3
Date of Expir ion 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy:.Well Driller
p.iJ7CNA.M COiCTZVT'X' ]j�pP,,Z'Y'MENT OF" HEA.l'.T
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
` 1 /\
1. Name and Address of Applicant: 1�. ,�/}{�(��•
2.
4.
�-1
7.
Name of Project; f P0 GJt�_t.2 4:��r,>ly 3.•_; Location DV /C:
Project Engineer: 5. Address:
License Number: X1012 • • Phone: 2'ik� _ GfoB
Type of Pro ect:. , _•
Private /Residential' ' Food.Service = •.•Commercial`,*
Apartments Institutional Mobile Home Park
Office Building. Real ty..Subdivision Other (specify)
Is this project.subject ' to State Envi.ronmental•Qua'lity- Review (SEQR)?
!S63ft Status (Check One) Type I.•. Exempt ✓
Type II. Unlisted
y
8. Is a Draft Environmental Impact Statement (DEIS) required? ............... fJU
s. Has DEIS'.been''completed and. found accept.able•by-Lead Agency? ......:... iJ /A
10. Name of Lead. Agency
tt
. Is..this project_ in, an area under the control of -local planning, zoning,
or other officials, ordinances? ......... ...........' ................... 0/)
12. If'so, have plans been _submitted to such. author :s ties? ...................... rJ /A
13. Has preliminary approval been 'granted by such authorities ? Date Granted:
14. Type of Sewage Disposa•1: System✓,'Discharge....... Surface Water v Ground Waters
15. If surface water discharge, what is the stream class designation ?........ .
:6 Waters index number ( surface) ........... ............................... KfA
:7. Is project located near a public water supply system? .................. rJ�/
S. If yes, name of water supply W /A Distance• & water supply ,
.9. Is project site near a public sewage collection or disposal system ?..... rJo
O.'Name'of sewage system Distance to sewage system
•1. Date observed: 23. Name of Health Inspector:
4. Project design flow (gallons per day) ..................... 4>62f?
25._ Is State Pollutant Discharge Elimination System._(SPDES) Permit requi- red ?.._ 6Jo
26. -Has SPDES Application„ been submitted to local DEC Office? _K)T1,A
27. Is any portion of this project located within a designated Town or State
wetland ?......... .................... . ............................... J.Jd
.28. Wetland. IQ. Number.. .. .:..... . ................ .................... _ 014
29..•Is.Wetland Permit-required? ................................................ alp
Has application been made to'Town.or.tocal DEC Office? .................. EJ�A
30. Does project,. require-, a DEC Stream Disturbance Permit? ...................
31. Is or was •project site used for. agricultural activity involving application
of pesticide$ to orchards or other crops, sol id, or hazardous waste disposal','
landfilling, sludge application or industrial activity? .......... YE8•or NO- �.)v
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 IJd
DESCRIBE: '
33. Is. there .a local master plan or file:wi_th the Town or Village?
34. Are community- water, sewer_facil.ities planned to be developed. within 15 years? UN KNAO0
3.5. Are any sewage disposal areas in- excess of.' 15% slope? .......................... 90
0
36. Tax Hap ID Number ............. .........................:.:... 2 .. 2
.......... �c- 2.x.
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'tUds
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 state.2rcents made
herein are punishab7e as a Class A Hisdar=eanor pursuant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
',AILING ADDRESS:
PUITM •• UMY DEPARTMEM • BEALTH
DIVISIM OF--ENVI11CtMR4ML •MLTH -SERvIcEs
DESIGN DATA SHEET-SUBSUFACE SEWAGE- DISPOSAL SYSTIM FILE NO.
Owner
Located at (Street) _f:�±Z 04L�J,!!�H Sec. Block -12- - Lot .2,
. Undidabe bearest cioss stre-e-t—y
manici,. i ed
SOIL PERCOLATICN-TEST DATA REDUMED TO BE.SU&MI= WIM APPLICkrK.CNS
Date of Pre-soaking
Date of Percolation Test
HOLE,
NUMBER C= TIME
PERCOLATION
PERCOLATION
Ran Elapse
..Depth to
Water ]Frcm
Water Level
NO. Time
Ground
Surface
In Inches
Soil Rate'
Start Stop Min.
.-Start
stop
Drop In
HirVIn Drop
Inches
Inches
Inches
2 1 - .4, r7,_2:0 5 -'ed
2
I
DEP'T'H
G.L.
�d
1'
2'
3'
4'
5'
6'
7'
81
Al-41.
9'
10'
j T
TEST PIT DATA REQUIRED TO BE . MaTTE D WI'T'H APPLICATION
DESQZIPTION OF SOILS F 4CWNTERED -IN TEST HOLES
HOLE NO. , ' SOLE M. 2 HOLE NO.
12':.
13.1, _
14'
INDICATE LEVEL AT WHICH .GROUNUATER IS ENOOUN'1ERED rt.1
INDICATE LEVEL TO, WHICS WATER LEVEL RISES AFTER BEING ENOOUNTERED 4/A
.DEEP HOLE OBSERVATIONS MADEi'BY: M15 i d (AS DATE:
DESIGN
Soil Rate Used Min/l" Drop: S.D. Usable Area Provided.
No. of Bedrooms Septic Tank Capacity 6o O ' gals. Type
Absorption Area* Provided By j L.F. x 24" width trench
Other
Name - _.. Signature...
Address SEAL,��'
THIS SPACE FOR USE BY HEALTH DEPARTOIT ONLY:
' Soil Rate - �
Approved sq. f t%gal: > Checked by - Date
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Cs ono .Env ronmental;Health 5erviaee
roved as -noted for -conformance with.
licatle Kules_and;Regulatidal of the
Zam;County Health Department:
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