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PUTNAM COUNTY DEPARTMENT OF ALUM
HEA
Rev. 3/86
Division of Environmental Health Services; Carmel, N.Y 10512
Engineer Maet Provide P 8 3- 8 7 '
4.6, D Pentit N
4V 11
CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL•SYSTEM- T. Patterson
Located at Yates Utica Roads
Tai Map 51 r
Village 2
Town o
Christie &Robert
Lassiter
Block Lot
Owner/ licent Name FormeH Subdivision Nam utnaIil . Lk 'Sal dv. Lot.
app _y 292 -8 Incl
MawngAddrese 21 Reading Rd.; Patterson, N.Yyip_ _12563 DatePeemirlsened Sept. 11, =1989 5.0.2433
Separate-Sewerage System built by .Move Int. Inc. Address New Fairfield, Conn.
Consisting of 1000 Gallon Septic Tank and 222 L.F. of Laterals 24" W. 1811. deep
Water Supply: Public Supply From Address
or: _.X Private SuppiyDrWedbyBoyd Artesian Well Address Rte. 52, Carmel, N.Y. 10512
Modular As required.
Building Type Has Erosion Control Been Completed?
Number of Bedrooms TWO Has Garbage Grinder Been Installed? No
Other Requirements None
I certify that the syatem(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 accoidance with the standards, rules and regulatio a, in accordance with the filed plan, and the permit issued by the
Putnam County Department Of Health. -
Date 31 August 1989 certified by P.E. X R.A.
Address ,.'RD9 -Fair St. , Carag. N.Y. 10512 License No. 29206
Any person occupying promises 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 sewerage system shall become null and void as soon as a' pubs% unitary sewer becomes
available and 'the approval of theL piivate.wMer supply shall become null and volt! when a , public water supply becomes available. Such approvals are
subject to Will ti or /jchangge when, in 'the juegment b4 the'Commissioner of Mea th, ch revocation, modification or change Is necossssaarrye.
Date�s� 3� Title
}
Ac f )\
a
* ` r
WELL UUMYLLT1UV MmruAl
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
STREET ADDRESS: wNiVll / 1 Y TAX GRID NUMBER
k,47z-5 �' � .ale, Pu &6 /0,4 7 -kS,0
WELL LOCATION
WELL OWNER
NAME: ADDRESS: OWIZZZ 6177C.4 bp_ / (/E
R013�e7- 6GlfelSi7t l- �+SSTEi2
I 8IVATE
PUBLIC
USE OF WELL
1- primary
2 - secondary
V RESIDENTIAL, ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O A ANDONEO
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED _�/ EST. OF DAILY USAGE _.'E" gai.
REASON FOR
DRILLING
:19: NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA .
' WELL DEPTH D ft.
STATIC WATER LEVEL ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY )Q COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH ft-
MATERIALS: ,8 STEEL O PLASTIC O OTHER
CASING
DETAILS
LENGTH.BELOW GRADE ZQ ft.
JOINTS: O WELDED ATHREADED ❑ OTHER
DIAMETER in.
SEAL: )&CEMENT GROUT ❑BENTONITE ❑OTHER
WEIGHT PER FOOT. Ib. /ft.
DRIVE SHOEVES ❑ NO
LINER: ❑YES CVO
SCREEN
F I I
� r
D ��C
DIAMETER (in)
'SLOT SIZE LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
0 YES ONO
HOURS
SECOND
- -- -- - -
-
GRAVEL PACK
O YES
❑ NO
GRAVEL DIAMETER
SIZE OF PACK in.
TOP
DEPTH ft
BOTTOM
DEPTH ft.
WELL YIELD TEST I If detailed pumping
METHOD: ❑ PUMPED 1 tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER i ❑ YES O NO
WELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach. .
DEPTH FROM
SURFACE
water
Bear-
ing
Welt
Oia-
meter
FORMATION DESCRIPTION
CODE_
It.
it-
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Land
SuAace
F�,¢GTIJ.�E,d LCd G-E'
�
G•e� -�✓rrE
W
E'LS l,3Ao2 — S 6 f
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
❑ COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE'.
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
\.MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME & yv A/rL;51fi &)g-L L Co _7— e DATE /
ADDRESS Rovr� �°Z SIG
�/g�/�EL� ILIC110 j
/1
° Yorktown Medical Laboratory, Inc.
321 Kear Street ;
- Yorktown Heights; N. Y..1.0511g
(914) 245 -2800
Director: Albert H. Padovani M. T. (ASCP)
T- -1
JOHN N. CALBO
BUILDING INSPECTOR
TOWN OF PATTERSON
ROUTE 164 & 311
L PATTERSON,NY. 12563 J
LABORATORY REPORT ON THE QUALITY OF WATER
LAB # - --
Date Taken: 8/24/.89 Time: 3,3OPM
Date Rc'd: _a /�`+!�`, Tiu-ie:
Date Reported: AUG. 1989
Collected By:
Referred By:
Sample Location: Outside Tap
Lassiter: yates Dr ve
Patterson NY.
Phone # 87b-6319
Phone # Sample Type:
Repeat Test? (check each)
INORGANIC NON- METALS mg /L
MICROBIOLOGICAL CFU /100m_L
Acidity
GENERAL BACTERIA
_
_ Alkalinity
LE 2
Chloride
Standard Plate Count
_
_ Detergents, MBAS
_
(CFU /1.OmL)
_ Hardness, Total
_ Nitrogen, Ammonia
MEMBRANE FILTRATION TECHN E
_ Nitrogen, Nitrate
Phosphate, Total
Total Coliform
—
Sulfate
_
Sulfide
— Fecal Coliform
_
_ Sulfite
Fecal Streptococcus
METALS (mg /L)
MOST PROBABLE NUMBER TECHNIQUE
— Copper
Iron
Total Coliform Index
- Lead - -:
-
- Manganese
_ Fecal Coliform Index
— Mercury
Sodium
KEY FOR TERMINOLOGY
_ Zinc
CFU = Colony Forming Units
CON = Confluent (q.v. TNTC)
MISCELLANEOUS
LT = < = Less Than
GT = > = Greater Than
_ pH (units)
N/A = No.t Applicable
Color (units)
S/A = See Attached
_ odor (TON)
TNTC= To*o Numerous To Count
Turbidity (NTU)
_
REMARKS /COMMENTS (For Lab Use)
4 Potable
Non- potable
_ STP INF
_ STP EFF
Other
Sample Status:
(check each)
Outgoing
HN0
_ HCl,
_ H2SO4
NaOH
ZnOAc
Na2S203
Other:
Incoming
LE
4 °C
_ GT.4
°C
pH
LE 2
pH
GE 9
_
_ pH
GE 12
_ Other:
ELAP No. .10323
THESE RESULTS INDICATE THAT THE WATER SAMPLE (Was) ( USLE (N /A) OF A
SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YOR PUBLIC DRINKING
WATER CODES, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (Did) (Didn't) UDRIN MEET THE
SATISFACTORY CHEMICAL QUALITY STANDARDS OF THE NEW YORK PUBLIC G WATER
.CODES, FOR THE PX%1 TERS (tSTED, AT THE TIME OF SAMPLE COLLEC
X1 � V /`�( % 2 /86(Rvsd7 /87)RWE
.. �. .. r_ . - -___ § =e m / w n1 Tld A.
r
Owner or urc aser of Building _ Munic pa ity
i
Building ConstructE y. Section
Locat on - A,_r• Block
lw
Bux 141pg ,• ,> Lot
GUARANTY OF. SEPARATE SEWAGE SYSTEM:':.
I represent. that I' am.'wholly;'and .aomp1 tel3Y;`'responsible for the '
location, worlQnanship, 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`" guaranty'•_'to'the`owner,' his`succes-
sors, heirs or assigns, to. place in. good'operat ng.- condition. any part of
said system constructed by me which fails' to'`oparatafor a.:period :of two
years immediately following the date `of -" nitial'..use' :of:.the�- sewage disposal
system, or any repairs made by .me to: such..system';excep;t. where the failure
to operate properly is caused by the wil.1ful or negligent.'act_ of :•.the .occu-
pant of the' building utilizing the ..;system.
The undersigned further agrees to accept as °canclusive `;the :`de�
termination .of the Director of the: Division' of r'zvironsnental Health Ser
vices of the Putnam .County :Depar.tirent of: Heal:thTas `to whdth4-r or ,.not -'the `
failure of the .-system to 'op erate was dAus.ed :by the wi lfu > or negligent
act of the o- ccupant of.the: buildin ten
Dated this
ee day of-
S7r 19 ;Signature
f cc-rporation, give name
and addre s s)
THREE (3) COPIES ARE REQUIRED WITH THREE (3 )'COPIES OF FINAL PLANS. BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE, OF DATE CAF .FIRST .USE' OF SXSTEM. .
Division of Environmental Health Services, Putnam Cotmty'lepar.tment`of Health
e
M
n gr]�r Sim D Cv
Crivia�_
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• INSPDC'()R:
Signature aril Title
-,.PERSON IN a RGE OR INTERVIEWEDz
I adiknowledge
this Fief "Aati.vity Report._"
SIGNATURE :_
"
TITLE:
.6/86
l_!opIf!so!It that 1'qsm wholly ano "completely re poi
epqvejvlescribeq W1W,be'eqnstructed as shown'
County Department 0 := !HeWtti,.'ond that bh', corm
-
a submitted to the-.69'pIa*i
plac6" in good operating': any "lOW-of, I
once of the i'pordvii-of..,the-'Ciirtificate'-"of'C6"nii
Co4hty Department of,. Health:.
Date
ghl.
'Address ...... .....
VED-A6R:COIN�t' i �4 the - 8W issued
Aplpftp T-F�YMON.:.T,hiS 80provareipkes wp0:yI_
revocaple,for c8use,or, ma y, be amended -,or. modified when con c ry the -,Com stoner
s a 'now 'permit, �Approved for mist q,w or
r ui!q, d is pr 0--6- 8' 1, d d 0' r
Ray.
1/87 Data ----------
I
plianc8,' sati ia to ; I - t6n,"'. f, — -
Itpe" ?mm ss, or o. H Ith will.
k c-tpr ' y i So I .
�rs,` h61ri'6r-.issignslkiy:,the�'bijilder; that said 6uildir -hill
W * Or(2j�,jodi -isim-
ii-pa#i ihoroto;i) that the drilled well descritiecl'ibove
he _itindirds, iuies GWd:roq-uTaTr3ns3f.1 -the Outnim
P.E.
onItruction `-.o"f the bu iiiinig has'•been undertaken and is
Any cliarige pr'alteration of construction
Ily Y'
PUTNAM OIU_NtY DEPARTMENT
Engineer Provide P6ritilf
of E6 e. N.Y.,10512 to
OF C AN
Pe T 7
FOR -:SEWi6
CONSTRUCTION PERMIT,. SYSTEM
Town or Ylllage
S. bd. "lot ..-#-
ev
Ow�r /Applicant Name A
Address'
F -7
Depth Voittme
l_!opIf!so!It that 1'qsm wholly ano "completely re poi
epqvejvlescribeq W1W,be'eqnstructed as shown'
County Department 0 := !HeWtti,.'ond that bh', corm
-
a submitted to the-.69'pIa*i
plac6" in good operating': any "lOW-of, I
once of the i'pordvii-of..,the-'Ciirtificate'-"of'C6"nii
Co4hty Department of,. Health:.
Date
ghl.
'Address ...... .....
VED-A6R:COIN�t' i �4 the - 8W issued
Aplpftp T-F�YMON.:.T,hiS 80provareipkes wp0:yI_
revocaple,for c8use,or, ma y, be amended -,or. modified when con c ry the -,Com stoner
s a 'now 'permit, �Approved for mist q,w or
r ui!q, d is pr 0--6- 8' 1, d d 0' r
Ray.
1/87 Data ----------
I
plianc8,' sati ia to ; I - t6n,"'. f, — -
Itpe" ?mm ss, or o. H Ith will.
k c-tpr ' y i So I .
�rs,` h61ri'6r-.issignslkiy:,the�'bijilder; that said 6uildir -hill
W * Or(2j�,jodi -isim-
ii-pa#i ihoroto;i) that the drilled well descritiecl'ibove
he _itindirds, iuies GWd:roq-uTaTr3ns3f.1 -the Outnim
P.E.
onItruction `-.o"f the bu iiiinig has'•been undertaken and is
Any cliarige pr'alteration of construction
Ily Y'
DEPARTMENT OF HEALTH
Division of Environmental.Health Services
TWO COUNTY CENTER - .CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL __ -
PCHD PERMIT #/`�"fQ
_yf
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
Yates & Utica Roads T. Patterson 51 -1 -2
WELL OWNER
Name Mailing Address
Robert & Christie Lassiter 21 Reading Rd., Patterson, NY
diPrivate
12503 public
USE OF WELL
1 - primary
2 - secondary
URESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
® BUSINESS O FARM .O TEST /OBSERVATION
O INDUSTRIAL O INSTITUTIONAL O STAND -BY
Q ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT Five gpm /�� PEOPLE SERVED Six /EST. OF DAILY USAGE 400 gal
REASON FOR
DRILLING
UNEW SUPPLY OPROVIDE ADDITIONAL SUPPLY
❑REPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
Residential Supply
WELL TYPE
DRILLED
DRIVEN
ODUG
®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Putnam Lake Lot No. 4292 -8 Incl.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
. -- DISTANCE - "TO YROPEitTY- I'ROK- NEAREST -WATER MAIN:. Over one mike --- '--- •--- •-- - - - -1- -- - - -` --
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED (See Dwg. #l,Job #S.0.2433) By John H. Prentiss
ON REAR OF THIS APPLICATION IL-]PN,SEPAR4TE Sj1EET P.E.
12 August 1987
(date) (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.
Date of Issue: 19
Date of Expiration: 19 ermit Issuing icia
Permit is Non - Transferrable W-te copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
responsible for the del
County: -Department 'df.':Health. and that'on co mpletion thereof 'a."Certificate-,Of:Constructi,
b6 shad ithe -owner,, is'
submitted to the 6epahme-nt and a.,wri .written wilLbe. ur�i
Plac-e •.n, good,. ope- operating: condition any .,Part, of -said sewa go .'disposal system during', t
a ' per
ance of th a appro val iof the -CiriMe ate' 6f Construction, C f tysion
,111661i�t;d, as 4cg
cenihW appro"ved plan and:ihit said well a or &nee
COUntY Department of kel'aliK�V
Date Atl Signed
APPROVED FOR .CON 5TRUCTlON:ThiS approval -e�plres,t d.year r s from - the date issued u
,
r e vocablefor cause orj-Miy'6i amended or modified when Cirildarein6c6s r y by the C
Muires a now permit "App"rovled --'for Oisposa.1 6f.deivireest I sane a, !y
1/87 Rev.
Meet.
9
0
osed I systems) I ;' I j- 1[hat t . he" separate sewage . disposal system
ince with the standaich, ru lies-MT—regu lat lonize? TFS V41narn
.Compliancall satisfactory to the Commissioner. of Healthwill
Iccissars, heirs',orassigns.by . jhe builder, that said b6lider %Q1 11
d of two (2) 'years immediately f6illo"Winil'the date of. the Issu-
,r'any r I epairs thereto-.1).that the drilled well. described above
vith the: 1 , standards, . ruias:and_ 'rqiq-uTa'9 ens 7f the ' Putnam
P.E. R.,A.'
Llcanse.No
ess construction of :the, building has been- undertaken and is
stoner df,He I alth. Any change or . alteration . of construction
Y.
PCTItMM COURrY DEPAREM1W OF HEALTH
DIVISION OF HEALTH SEMCES
DFSIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO,
OwnerChri Ai a la6r+ Loss 4er Address Wier 4 t i Get 9m ads
Located at (Street)NQw►6rq k Sec. �j�L Block _(_ Lot ,2
(i.ndica nearest cross street)
Municipality pd -C+y-r S o» Watershed Cam,,,
Date of Pre- Soaking rN a_�� Date of Percolation Test
11 t8
z 1 It &I 1 A.►1 1.1h
HOLE
NUMBER C3:pCR TIME PERC aMION
PERCOLATION
Run Elapse Depth to Water From
Water Level
No. Time Ground Surface
In Inches
Soil Rate
Start -Stop Min. Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
24
3X33.1 !3 A ' I
4
2
z 1 It &I 1 A.►1 1.1h
414.61 14.11'
6A
3
4
5
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 sutmi.tted
for review.
i
2. Depth measurements to be made fran top of hole.
rav _ 9 /R S
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.' �
G.L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
ill
i[. r ®`k
12' T: S. = ro bse 11 L. 8. S, Lm PI
k]
L B, r.L. � S LA ` S. L.
F�.g. X j I V.P. Go
13' R. S, t.'r. go lea,
4w ,,/ Loom
14.1
INDICATE LEVEL AT. WHICH GROUNDWATER IS ENCOUNTERED No we
INDICATE LEVEL TO WHICH WATER LEVEL RTC AFTER BEING ENCOUNTERED None
DEEP HOLE OBSERVATIONS MADE BY: H, F. r. w1 w . m. 64 P. C. ®.41 DATE: I ®
DESIGN
Soil Rate Used 8 -10 Min /1" Drop: S.D. Usable Area Provided
No. of Bedroams Septic Tank Capacity 100C)-gals. Type@fi n
Absorption Area Provided By a!- wigtzb 4' k- Oakes
Other LQ -8 -R C. 19 L" hL I- IAcL 'dD (212 Fps)
Name
Signa
JOHN H. PRENTISS. P.E.
Address RD9 FAIR ST 914 -87® -5170 SEAL, �
&Mt, NEW YORK 10u12
I,tF
41,
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: N�F rHE S- SEO�
Soil Rate Approved sq.ft /gal. Checked by Date
1 Aj
I I 4g1 = I 1 300
1 �
- - -- - - - - -- r%B0�
4�Z 99 -
1
8
q Z9 6 //'90>
/92) \ 1
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0.
J
I
`5 I �► `®
:F-4r PC•A'ii0Q-'? IL1DtCAMD WEZEO&J Si (-lJtt- r 'tUa:r f}Jl�i
c tO -( VA-5, FOePAP_.ED 11.1 ACClcf-- 1G n( 4 -ME
Jil�Tii Km CCOE- OP PV-A='IC.E. PDe LduD 5u✓2NV-'A, AOOPfEn
p{ 11tE UEk1 SrR A440cjATtC pj/ nr ShIGZ� L4L
AWC:> C49=R:AnoA -v7 SN41.-L 0_44 o1,ILY
-WE. FF-P- ioA_t FZm tcfl fCiAA T}!E rat �/E~( (� pEnEFAZEO Aj_ic>
v [ Nth -to I'AF- nT-LE CoA� A J > LF.- b.CpU.iCa
1�TTitJTlCA 1 L-t6TE 7 HEOsc*J- Aj2r -. L_m
i7 F
�5
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