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14011
ARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
/+
PCHD CONSTRUCTION PERMIT # —% q — C/'5- -Ltt, _ %. _ 6).. t4
Located at E .A5T 6,4(2,4i C_H /eO/W
Town or Village
Owner /Applicant Name (�,�A55 t (-i bOA L-D"5 Tax Map (P-1
%Ar7-E_i2 50 / (T)
Block �_ Lot 4
Formerly 69 .SA+�) Subdivision Name 67 0_., tA/S PAA/ IKSO G
Subd. Lot #
q
Mailing Address P0,60 ; rS77 1, ��1a1.SJ�� /�% i / o J (% �% Zip
Date Construction Permit Issued by PCHD �� 5
Separate Sewerage System built by Waltenbery Excay. Inc Address pleasant Dr - Rrpwstpr
Consisting of J ZS D Gallon Septic Tank and _3 q S—LF Z-Pl 7-11?_�6, A)Cl l ZETI
ab LIL_ P9 I IV eS)e fil-I-N51e Al,
Other Requirements:�i4NS /o.�/�
, Water Suq &:
Public Supply From Address
rQ � Private Supply Drilled b ilton Hyatt Address RR_ B., 104 Pattersdbn
- Building Type -/� 0.0 UZ-AI . Has erosion control been- completed?
Number of Bedrooms 3 Has garbage grinder been installed? A/0
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 accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putn County Department of Health.
Date: VZJ� Certified by �_ P.E. R.A.
Address CU�IT/VA A6
2
N �� s� 3 2_'
License # %
Any person occupying premises served by the above system(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 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 are subject to modification or change when, in the judgment of the Public Health Director, such
revocati , m dificati r change is necessary.
By: Title: A�. <, Date: C
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
>,. ' .
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
,cast Branch
Town[Village:
Tax Grid #
Map( Block -- Lots)
Well Owner:
Name: Address:
C -ASSA, AMC5
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 A Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length _aLft.
Length below grade ft.
Diameter 7 in.
Weight per foot _L71b /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded Threaded _ Other
Seal: X Cement grout _ Bentonite Other
Drive shoe: X 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
%-
ti!
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type c �.., Capacity
Depth AF6 Model 6O[��
VoltageMb HP
Tank Type fy l l Volume xo
Date ,Well Co p eted
Putnam County Certification No.
Date of V4;2 L?Fj
Well Driller (signature)
NOTP. ExacUlocation of well with distances to at least two permanent lagamar7to be proviaea on a sepape sneevpian.
Well Driller's Name r
Signature:
Address:
Date: 7- Yacl
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
NORTHEAST LABORATORY OF DANBURY
CT Cert: PH -0404
39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471
LAW (203) 748 -7903 - FAX (203) 748 -0652
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
HYATT PUMP SERVICE, INC.
RR2, BOX 141C
HOLMES., N.Y. 12531
SAMPLE SITE:
SAMPLING POINT:
SOURCE:
TREATMENT:
TEST PERFORMED
BACTERIAL:
Total Coliform (Bacteria)
PHYSICALS:
pH
Turbidity
CHEMISTRY:
Nitrite N
Nitrate N
Alkalinity
Hardness
Iron
Manganese
DATE SAMPLE COLLECTED: 8/3/98
TIME COLLECTED: 9:15 A.M.
COLLECTED BY: C. HYATT
DATE RECEIVED @ LAB: 8/3/98
TESTED BY: LAB #11471
REPORT DATE: 8/5/98
CLASSIC HOMES, GREENSPAN LOT #4 EAST BRANCH RD.,
PATTERSON, N.Y.
IOTCHEN FAUCET
WELL
NONE
RESULT:
0
7.36
2.5
<0.01
<0.2
63.0
68.0
<0.03
0.010
Sodium 3.6
Lead <.005
ml = milliliter mg/L = milligrams per Liter
* *Notification Level ** *Action Level
M[AX7MUM CONTAMINANT LEVEL
per 100 ml 0 per 100 ml
no designated limit
NTUs 5 NTUs
mg/L as N 1 mg/L as .N
mg/L as N 10 mg/L as N
mg/L no designated limits
mg/L no designated limits
mgt ... . _ . '030 rng/L;
mg/L 0.30 mg/L
[Note: Combined Limit for Iron plus
Manganese = 0.50 mg/L]
mg/L 20 mg/L **
mg/L 0.015 * **
ND = none detected NTU =Units
RESULTS BASED ON SAMPLES SUBMITTED8 /03/98
SAMPLE, AS TESTED ABOVE: �X OTABLE or OT POTABLE
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
I..
Laboratory Director
*NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 9 OUTSIDE CT: 800 - 654 -1230
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Cl s s s i a Builde mss --L d. (Kent n„ wont) 6 7/ 1/ 4 .
Owner or Purchaser of Building Tax Map Block Lot
Same
Building Constructed by
East Branch Rd (Doansburg Rd)
Location - Street
Modular raised Ranch
Building Type
Patterson
TownNillage
Greenspan
Subdivision Name
4
Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is 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 treatment 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 Public Health
Director 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: Month I JulkyDay 1 Yea.1998
General Contractor (Owner) - Signature
Classic Builders Ltd
Corporation Name (if corporation)
Address: PO Box 385 Brewster
State New York
Signature.
Title: P
Corporation Name (if corporation)
Address:
Zip 10509 State
Zip
Form GS -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
2e_ �A 5 ip, o v! 7/2 0/F9 IN INSPECTION
Date: 7 (:; �'.�
Inspected by: a
Street Location gA5- -. D Y?dAl ct ��Q, Owner Z, p
Town. Permit.#
TM r G 7 —1 —zf lolc�l r .�ewl Subdivision Lot # `
�vlG�M�JPA�n�_____yi(e(P►"S v
1. Sewage System 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 ........ ,25 ........other ................
b. Septic tank installed level ................ ...............................
c. 10' minimum from foundation .......... ...............................
d. Distribtuion Box
1. All outlets at same elevation -water tested .................
2. Protected below frost .................. ...............................
I. Minimum 2 ft.Original soil between box & trenches
Junction Box - roperly set ..................... .......................�.......
. ength required Length installed ff
2. Distance to watercourse measuredt2., BO Ft..........
J. Installed krope�Tiqn rding an ......... ...............................
4. S1�"f h ace 1/16 - 1/32" /foot .............
5. 1 fro 20 ft.- foundations..........
6. Depth of trench <30 inche ce ..................
7. Roo o d C� c .......................
8. Size f r - z' lam ter lean ....................
9. Dept of gravel in trench 12" minimum ...................
10. Pipe ends capped ........................ ...............................
g. Pump or Dosed S},stems
1. Size ot 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/Building
a. House locat6d per approved plans . ..............................0
b. Number of bedrooms ....................... ...............................
IV. Well
a. Well located as per approved plans . ...............................
b. Distance from STS area measured Cy ft ...........
c. Casing 18" above grade .................. ...............................
d. Surface drainage around well acceptable ........................
V. Overall Workmanship C
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 watercours(
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate ... ...............................
i.. Erosion control provided ................. ...............................
Rev. 1/97
6f,111 N`e_4 5 5- F
1,1 QQIitm Oovar D!Anm6fr or=AL7!
CUMOL ILY. low PY�sv� lwoaft A
Dkdti� f><I�fle�adel Balms S�friw.
!l16t � �8'NA� Di+tlOLt =YS'1'®t /
Alf, t Vddo
Isetled fit i
swbdk der A, /� / / �/ Lot P •S Tax Map ? Nub jot
,J
Dated , A�aovd
Kefts A�ilar / C- rj / To . ' �� . O�►�, zip
Dare Subdivision ARproved 9 d Fee Enclosed ❑ Amnnnt-
SWUlnt Type //' ��J, /`! /� /U Let Am 2 Fla Section oa* Depth Vain.
Nsgtier d 1leieow Design Plow G P D P(HD NedSndeO b Itepdred Wbea FM b bwglded
SoNeoto Sawwp $711601111 00 asotdd of -�GoYw Sqp* Took sad .i %f
To be ew4.lda b /; f `/� �', Addrooa
Wa>: Supply Bra. Address
on & wane. Supply Drdlod b " Zvi /li/ _Atbbws � k /yl t r /K
otb.r 1R.elglle.o.t.
1 represaot1hat 1 am wholly and completely responsible for the design and location of the proposed system(s). 11 that ter separate swv disposal Belem
above described will be constructed as flown on the approved amendment there to and in accordance 4ijgahe standards, rules a requ ns o Dam .
County De0artment of HMIth. and that on completion thereof a "Certificsts of Construction Cap�pitinp" satisfactory to the Coftmissioner of Health will
M submitted to the Department. and a written guarantee will be- furnwhed the owner, his to `'s. Mks or assigns by the bu11A!► that said builder will
place M go" Operating condition any part Of nkt sawap disposal system during the period 4wo (2) yaws Immediately following thedate of the iesu-
Sam of the approval of the Certificate of Construction Compliance of the original system Or l y repairs therato; 2) that the drilkid well described above
sW be located as WHOM on the approvaA plan and that fold well will be Installed cco nca the standards. rules and rpu a�T oiT ni of the Putnam
County oepmpwm of Health.
Date / Signed ' ' P.E. P.A.
Address �%�� � ( � .. .,License No
APPROVED FOR CONSTRUCTIONS This approval expMes two yews from the date issued unless construction of, thwbuiW }nb has been under taken and is
revocable for cause or may be amended or modified when considwod naasta 6y tM"Zornrlt ssloner Of Hwllh... Any..cAirige or alteration of construction
requires a now p9"" t APW/ 9v�1� dizoo"_l of domestic fa= ltar�sawa and ps_i6at�Mra p�fhr o� _: _ —
ReV . / /]ms's/ 77 Y `. 1!_--er -�� Title • ✓'�(_
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own !fit IIM QWAM MOM �M
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Date 'Subdi�ision= Annro�ed ; f '' �r
Yar.� /9/ii
Nt1 d :Me Mittws 'Dea)Da Hsi G P D �aU.
iy! 8�trll�e a Maittiit d y
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Sawb.Dd by
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1' Iaoraant;'thatH am' :wta11Y ariAJcompNtNy ntporisieli for the daiMri aMl klcatG
aboiis disCiitiad w11Ybi taiftruetad as -ommon oe the aiikowa amandma -t ttiire t
county _:Oiipwivi gt ;of - MMItr4 and ttiaton?coeanpbtbn;,tharaof a <'Cartitkiti
M tY�aanitti0 to 'tM .OpNtnlant, an0 `a wrlttan duaiantin will afumishoA t
tea M- 'taoe� o�waNilta eondltbh any`part of sa10 sswaN dkpotal systin+ °t
a�or. if tail ::40i"il, =0f tth <,CartHleat , of, Conftructbn ;COmpNnq of athi 6
f1lMlala betatW M thoire 011 tM,aOpolrad pMn and that YW.wall wilttN lnttillad t i
elm
sit+
a
AVPROVEDsFOR CONSTRUCTION: ThN aoplawil xvMas iwo yaa►s from tha'
i rwoeaeb for aaY"'Co! ,may ha' anwwed oI Inodttiad when conlWane nsnsN►
n0ufns'a' iaw sett. i . 1 of donaasik tantta y tow a
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anp' rYtidactory to tha Commis&& q of "with Willi
� MMsor asiips'ey thi`tiutl0a►,.ttart "YId WNW will
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maln time 012) that thweriii d will'Oowftw,abovo
ttarWardi, huNS and revue a oiii ns: ;o/ thfa' Putiihm
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P.E. luc-
b fr ^ Liconse No
R►uc�tbn o1 tM buiMinq )rata hom'und"kin- -and it
H hWttfi, tsj n x "nip or, ottarstjOm of, coriitruction
Title (�
JOHN KARELL, JR., P.E.. _....
335 CUSHMAN ROAD
PATTERSON,. NEW YORK, 12563
July 20,-1998
Kent Dumont
Classic Builders
PO Box 385
Brewster, New York, 10509
N
BILL FOR ENGINEERING SERVICES RENDERED
As Built Work
Lot .# 4
East Branch Road
Patterson ('T)
Fee ............ $ 00.00
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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
PCHD PERMIT
WELL LOCATION
Stre t Address
Town ytllage City
Tax Grid Number
WELL OWNER
Nye Mailing
(Y� .
Address
�
aPrivate
O Public
USE OF WELL
1 - primary
2- secondary
G- !!SIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O
{AMOUNT OF USE
YIELD SOUGHT ^gpm /#
E3 CE EXISTING SUPPLY
EW SUPPLY NEW DWELLING)
PEOPLE SERVED /EST..
❑ N TEST /OBSERVATIO
13 DEEPEN EXISTING WELL
OF DAILY USAGE2e- '/gal
Q ADDITIONAL SUPPLY
?REASON FOR
;.DRILLING
DETAILED
REASON FOR
DRILLING
IWELL TYPE
RILLED ODRIVEN
®DUG
aGRAVEL.
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES _ �'NO
IF WELL IS LO ATED N A REALTY SUBDIVISION, NAME OF SUBDIVISION: �-� /g
/ TMA Lot No.
WATER WELL CONTRACTOR: Name q� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �0
NAM OF.PUBLIC WATER SUPPLY: T if N
iDISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH ,;.-SOURCES OF CONTAMINATION PROVIDED3
ON SEPARATE SHEET
o
(date)
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 co urface or groundwater.
Date of Issue: 19
--!Z ��.- --
bate-of Expiration 19 ;51",-
7-- 'Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89, Yellow copy: Bldg. Insp. Orange copy: Well Driller
i
,r
PUTNAM COUNTY DEPARWMi T OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-
Date-
Gentlemen:
Re: Property of r� ,� i� �/,/G�r• .
Located at
Section Block Lot �.
^, Iirn;ce�li
This letter is to authorize
a duly licensed professional engineer or registered architect _
(indicate)
to apply for a Construction Permit for a separate-sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulgated 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.
Countersigned:
P.E., •A�, 7G�2- J
2aaress
7ofin P.:Anniso(tj
h3 (f
Telephone
Very truly yours,
CVeASPAIV AsSoc1'ATES L . p 191 .
Signed - "1het/
Owner of Property
Ak
.; � e;S ?P
I l oo► l k lJ ��rA�L1 N ' 1�� ! D
Address
(CI `SgSI
Telepha t
PUTNAM COUNTY DEPARTMERr OF
DIVISION OF I• •' ' E v SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner �l���r /T ✓ ✓ac , L %� Address
Located at (Street.) �T,�r �i Sec. G % Block /' Lot
(indicate nearest cross street)
Municipality /� �% Watershed
Date of Pre- Soaking
Date of Percolation Test
HOLE
NUMBER Q,OC:R TIME PERCOLATION
PERCOLATION
Run Elapse Depth to Water Fran
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
2
4
5
1
2
3
4
5
A
NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole. All.data to'be submitted
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION .
DESCRIPTION OF SOILS ENCOU UMED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
1'
2'
3'
4'
5'
6'
7' 9'
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: DATE:
DESIGN
Soil Rate Used 1.' Min /1" Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity LJ y gals. Type
Absorption Area Provided By _g L.F. x 24" width trench
Other �c Ess►ey�
W 3 Signat'
Address s %j `' S
l Z• A
01�-iF of ca �W —
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: - "Vvv. -
Soil Rate Approved sq.ft /gal. Checked by Date
"Tais is to certify that -
the sewage disposal system was constructed as indicated-on' this plan and
:.that the systen was "inspected by me before it was covered over. The
system was constructed in accordance with all standard rules and :
regulations of the Putnam County Department of Health and the Nei York .
dt .:
State.
Deparbrenk of Health."
4
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