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631- 589 -8100
25.41 -1 -32
BOX 10
00965
IL
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IF L
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00965
PUTNAM COUNTY HEALTH DEPARTMENT
v DIVISION OF ENVIRONMENTAL HEALTH SERVICES
__._..____.___�__ -..- ---- .._._._�..cQr��r>,c�t- CQ'11� cFwe��- �- ��e��e�s�- T•�v��slvl-- e���ets� - -- - -- -
VA NO Intemal Use Only PERMIT # - v
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Fails Res. Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION L TOWN P3 ffow) TM # ;21-1-11-1-32-
OWNER'S NAME 6.etd,.q PHONE #
MAILING ADDRESS
APPLICANT 70,M es
Name & Relatirfrfship p.e., owner, tenant, contractor)
DATE FACILITY TYPE.. - %4a>K PCHD COMPLAINT #...
PROPOSED INSTALLER PHONE# ff4 -
ADDRESS %c, .viz. t�ti REGISTRATION /LICENSE # fG -�'�/
r-
Per ,pQsl (Include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair. _ , ,, _ ..d ,
J--
SIGNATURE
(off
"'- t-, - th, fa S*rdc- -it
ply with -► 6 ciiidtions of -tt is pbrmn.141vr- uis- se-p`ue
TITLE A.)-11/11--
c --
DATE Ocf f'o
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. location of Installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditiorms
4. The proposed SSTS repair is considered a best ft design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backiilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
sal Approve Proposal Denied ❑
In or's Signature & Title ' Date Expiration Date
is in compliance with
Yes O
No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
1 is
PUTNAr4 COUNTY DEPARTMENT OF HEALTH Y
V • Dlvieion of Environmental Health Serviced, Carmel, N.Y. lOSM Mast Provide �^•�1.... S�
bti
P.C.H.D. Permit IF _.._
ng- (Y►NCTgQf`IrnN COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM f-k-r—
,� T,aWW
�}
Lots > i— Ta:—r— "`_'Block I,ot
paper% ' ' on Name �...+f�`"�P Formerly _ Sabdivlelon Namn�r sr - tr:+��. ze1.�v..Lot. A'
j.
r 6-1
TaP Data Pezm�t Ispned ZD 8
Separate Sewerage System
Paste stag ,b�
r I
of Gallon Selt1C.$'aak .4 : l..
Water Supply:_llc Supply From Address ' ;
ors Pdy"e Supply rilled b %% Address.
PP1Y Y .
dIng�G,2J,�(t. -. , „.. tl�'Y,�. Has Eroshin CoateolBeen CompletedY
N4mber;gd: o`ms li Has Garbage GrhulerD en Ins`ta ledY
1
:�..1: UTNAM. Cp 1
I'certify'that- th 'eyetem'se) was l gEed-•aervipq ttie above premiavere conk, _ ly osl �Et s f c ias
of whiclr are at ed) and in. accordance with the pt darda ryless and e Y e t�e ilefl 1, the
1?'y'tswn ;�#t,: t� a9�� '.ti• � ,�^ �u�d
O 77 is
D#te ! ..Y N+ x� � t . b P.E. RA.
} "rat t.i A& E,iYrd'�"� -' r'�C - u z ...Llcetl<l N8•. ..,_,_ ..s..,, l
Address ems_
A person occupying pf emises served by the above systeirk, shall p dti�nplhy take such �ttiQll as`;ney, t!s n sstiry to �sessre the correction of, any unpnttary
rx__- _,.,._
eonditbns ressilf1ny fro� iCRlf'usrge Approval of the- separiits- sewer agay;ystem- shall..t�ltegtne null and Void as soon at a pubt .'tanitar�r`WWW become;
avallable and the aPpr2l :oi fli di�rlvefb #,Ater supply shall become null an . it d'wlfen a Publk a gwxa suoplyj -qw aVatlaDl� Such-- approvals• ari
sssb)ect to modificstlon or change..when,..iri the .ludgmenL o.L...tt1t4 LRfnrtif�e► of Weal h, suCfi ie4datlon, mbaiflcat n o ghjNgs )� s►�easlli�lj ”
r
Dater+ $Q.T'...G. "„ - 9� -'
..... . .... .
l7iVEA: p YE5 ^Lp NO
J a
S ❑.NO :
GREEN
" - IHAMETER (in) . ; ••SLOT SIZE LENGTH (h);:' 'DEPTFi'TO SCREEN (ft) DEYE p�A,ED?
lETk�i1+ FIR
r* a, tst�un
-- ..._ p - _ -- w -.. _ _ E
G ,EL'GK a YES GRAVEL DIAMETER
TOP BOTTOM
BILE OF PACK In. OEPI F{ R, DE n•
WELL YIELD 'TEST ; If detailed pumping � j j 1 If more detailed formation descriptions :or sleye analyses-
METHOD: METHOD: O•PUMPED j tests -Were don6is i6- . !�', ELL LO'�,..,..are avaiiabi��ptease aitach.' -
OQNPRESB Q A.: 1R I 'for mion attache?` `aaucEM1 _� wexlg �'At
DIa=
O BAILED OTHER ; LI YES �Q "�� i y r `,�t1er L "FORANDON DESCRIPTION p0E
i In 1
WEL�.OE . O.URAVIT. `.ORAWOOWN YIELD surface
yq Ii; hr- min. R, 0m.
o�
WATER . TEMP,
QUA14fY O.CLQt10Y :, HARDNESS ' -•: -
0 COLORED ANALYZED? OYES .,ONO
PUMP.::INFOAfIflATION �_.. .. ,:•:.r:, -
TYPE- CAPACITY
MAKEA DEPTH
t0E1: VOLTAGE HP
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME y►ul
AOORESS
M/ 10j
DA< /- 2-8e
6-1 7 C-
EIA-1 r-J<5
TYP
T I
Q
75 A
DRZKJI
15rltLCT-LjJze
-Tt-
L4:N4' tiicRE
T'F-
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ojrL.F-T-
LIN
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31
V:Z'l 1
V lii•lVf�'iS, yr v
Owner /aicant Name AgAP L �? �' r Formerly. ' Subdivlsiori. Name . 1�Sabdy Lot p l
t0 3><Do
Mallfng Address Ido I AIfe- yzIEtmD : • TAP ZIP Date Permit issued /S?
Separate Sewerage System: built by' •� �.` .:yt' Address
Consisting of Gallon Septic Tank and
Cob G. ol< rx 4 ` CarL t .rES
Water Supply: Public Supply From Address
ppiGKS 1.1�[1ff= !r:"kLei Address • [ eY` F atal► i ' "�
or: Private Supply Drilled by
Building TypeokhKs! CM te.�Y RES Haa Erosion`Control Been Completed? YES M
Number of Bedrooms 3 Has Garbage Grinder, Been InstalledY
t�L t5
Older Bequlremeuts � .• .. .. PUTNAm (} �',QCU T
mu
I certify that th system(s).as-listed serving the above premises were cons a nt ly as'sh on't e p I. tMd,tGq lebL work ( copies
of which dre at ta ed);_and in accordance with the standards, rules and i d cordan e` the filed.plari, and the perm issued by the
fttnam County Do rtme of ealth O.
Z7i
Data ! Ceitifietl by P,E. i/ /R.A
License N
Any person occupying premises serv" by the above systems) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions •resulting from such,usaye. ApproJal..of the separate seweiage system shall become null and void as soon as 'a pubG_ sanitary sswer' becomes
available; and the approval of the private WaterSUDply shall- Dacomo null: and .void When a public water supply becomes available. Such approvals are
subject_ ttooimodificationn' or change when.'in 'the judgment of the Corrimifsionei of Health, such revocation, modification or change Is necessary.
Date
/ll/'LQ.�i .2�J Z g Title
111T T1TT1ATIT
a. D
WL Lj1j l,VrLr1jl111ULN MCsrVL%1
Office Use Only
A.
PUTNAM COUNTY DEPARTMENT OF HEALTH
_DLVISION. OF ENVIROrAL HEALTH SERVICES
21F A 1 3 2--
Owner or Purchaser of Building Section Block Lot
FT
Building Constructed by
GA
Location — Street
Municipality
I'/-?- sr%-0 2Y
Building Type
r°- :S/V;z
fvTNP•� L-P•KE
Subdivision Name
Subdivision hot #
Af4�
ir' M COUNTY
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM PUTDEPT.' OF
HEALTH
K:: 1
ar:
(y >i
I represent that I am wholly and completely. responsible for the location, j.
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
"Cer._tificate. of. Construction;; Compliance "__ for.. the sewage- dis opposal_ system,. or
repairs made by me to such system, except where the failure to erate - 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 Environinental 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 day of fEt5 19gZ Signature
neral Contractor (Owner) - Signature
Corporation Name (if Corp.)
14 7V fiA4 "'
Address ,
"o 6n '7
rev. 9/85
mk
Corporation Name (if Corp.)
Address
PUTNAM COUNTY DEPARTMENT OF HEALTH NO.2 8 2 - 8 7
....... ,_ -------- - --- - - -- -- - -- - - -COMPLAINT OR SERVICE REQU.EST...FZEC03R — - - -- - - -
TOWN PATTERSON DATE 5/14/87 REFERRED TO
TAKEN BY JP TELEPHONE CALL XX IN PERSON LETTER
CONFIDENTIAL (H) @2.79 -6976
REQUEST FROM ROBERT BEROK TELEPHONE (W) 278-9292
ADDRESS 4 FERNDALE ROAD, BREWSTER, NY 10509 (T) Patterson
ENVIRONMENTAL HEALTH: Home Sewage Rodents Refuse Public Water Food Service
Migrant Camp Other 24
COMPLAINT OR REQUEST PERSON BUILDING BEHIND HIM, FAINT ODOR IN CORNER OF PROPERTY,
WATER CASCADING, DOES NOT WANT STREAM ENCLOSED.
Directions: Go to monument bear left on Haviland Drive, oast new bar, Kermits.
1/8 mile past Kermit, lake close to road, follow rd, on right, off Haviland
ACTION hor gY' all around lk, sign Homer Rd, then GgE and, trn L on Garland,
FINDINGS tremendous piece of property -walk property to back, will see stream,
stream has sludge or whatever..
FINDINGS
DATE FINDINGS
PROBLEM ABATED
DATE PERSON NOTIFIED
✓i .S �'-� -r Gas ��v� �f
ESTIMATED TOTAL MAN HOURS SPENT
7'7
Sheet of
NAME 'T d
r/1 ✓
�`" Fp��
INSFUMUN
Orig. Routine
H
—
Orig. Canplain
�-
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_
Orig. Request
� b Street
Town
TM No.
Ccaripliance
Cm plaint Comp
NAMING ,ADDRESS
Final
P.O. Box
Post office
Zip Code
_ Group Illness
Construction
- TELEPFi01�
'
Reinspection
Field, Sampling only
Field Conference
k r"
Name and tle
TYPE FACILITY
Other
TIME PiRRIVF;D
TIME LEFT
`17
Explain
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sue. >•�'% .� --�.. y
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TELEPHONE:
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TELEPHONE:
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FILL NOTES; (WHEN APPLICAI
1. Fill mus/required allowed to
placemen be inspe E
Health fceptance pi
system. of pla ewer
DepartmeHealt .
2. Run of bill hall be
free of or other ur
in -place ol tion rate
soil aftrequired s engineer tect shall the fill r stabilizat 3. Impervioll, clay Dar with lit r no sewaq.e
60501 .
2
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SNOISIA3a
NO
�m�av�
,rW^ °'Y "'�:Te'c^_.^_�+'A*�.E ir+"P=T v'vr'*�y'r- ,•g1C'TG '@- �� ?
1 PUTNAM COUNTY DEPARTMENT OF HEALTH
Rev. 3/86 :` Dlvisioa of Envirorimeafal Health Services. Ca0 N..V. mi? Etigin. t. Provide Permit # ;
�* on CEIIII CATE OF COMPLIANCE •`' ?
CONSTRUIUMN PERMIT FOR S AGE,'DISPOSAL SYSTEM Permit "
Lot_ . #3
.i
Patterson
Located at Garland 1 -Road vulege
Wn
Sabalvieion Name Putnam Lake Sabd. ref a 3110-3100 Tax Map 22 ' Block '2""
Loy 16 ±p /ol5
John - Bertrwn Renewal_ �_ Revision p
Owner /Applltxnt Name i
Date d.Prevloae Appropal
u
rl� 415
Maiw,g Ad,IB 109 Fairfield Drive Towz< Brewster; N`,Y UP,, `
Baildiog Type L 1: Fain. Res Lot. Area 22 , 000 SF• . - > iu Section Only Depth Vulmme
Number of Bedrooms 3 Design Flow .G/P /D
6
OO POW Notif ca- thin is Regnired When FIUh; completed
i
Separate Sewerage System to consist of QQ —Gabon Septic Tank and s j
. + ..
r•.
to be determined
To be.constrdeted by Address
Water Suppy,; Pttb*SgpP�y From Address 1
z i
6r. X_Pdyate,S"$y Drilled by to hP �. _Address
Y. Other Requirements
D:stributiori ;box, 6' Curtain Drain ,'
represent that.! f am wholly and zompletely, responsible forthe design antl location of the proposed system(s); �1 -) that the separate tlisposaI i4 ste'm
y.
above described .will be constructed.as, shown on the. approved amendment,there to. and in accordance with the standards. rules an regu a ions o e.' .0 nam.
County Department' •of Health 'and tliat on completion, thereof a Certificate of.Construction Compliance" satisfactory to the Commissioner ot,Healttiwill i
be submitted to the Department ";antl. a wntten guaranfee will be.'furnished the owner, his successors, heirs or assigns by, the builder, that said buildertwill
place in good. operating condition any of 'said-'.
said`'sewage disposal - system,-auring the period, of two (2) years immediately •following the.daWe f the,issu• - -3
ante of the, approval of the Certificate of -Construction Compliance .of the origMill system or.any repairs thereto;.2) that the drilled"well'tlescribed above
Will be located.as shown on the approved' plan and that said�¢vell will be Installed' in: accordance with. the "stand - _ s,. rules and regula T;Ions of. she Putnam
_ County' epartment of Health
Date $t gned P.E R A
Atldress Ca ffiih Assoc". P.C. Rt 5 armel N.Y,1051Zi6ense No 26008
APPROVED FOR CONSTRUCTION This approval expires year from the :date issued unless construction of the building has been undertaken and is
revocable '.for cause or may be amended or modifled."in considered necessary by the Commissioner of Health:' :Any change or alteration' �of'construction
requires a' w' permit. ppr3ved,f6r disposal of domestic'saniterysewage, and /ro riv water Supply only. ?
2 it Wig'
D
Ji
at 6,094 Z 8 Title✓ / //! �/.
n
9
(' ) I WILL HAND DELIVER MYSELF
( ) PLEASE SUBMIT TO THE SPECIFIED DEPARTMENT FOR ME
SIGNATURE
6
APPLICATION FOR PUBLIC ACCESS TO RECORDS
TO: RECORDS ACCESS OFFICER DATE:
Name of Agency JOSEPH L. PELOSO, JR., PUBLIC
INFORMATION OFFICER
Address
I HEREBY APPLY TO INSPECT THE FOLLOWING RECORD:
e-v TS /-- 3
An=
Signature_? ` Date
- ZNS/ 7 Zr
Representing _
Mailing Address
APPROVED u
DENIED
Record of wh
FOR AGENCY USE ONLY
C
l!
this agency is Legal Custodian cannot be found. tv ? rn
Record is not maintained by this Agency
Signature
Title
cf,cm
Date
NOTICE: YOU HAVE A RIGHT TO APPEAL A DENIAL OF THIS APPLICATION TO THE PUTNAM
COUNTY EXECUTIVE.
s
Name Business Address
WHO MUST FULLY EXPLAIN HIS REASONS FOR SUCH DENIAL IN WRITING SEVEN DAYS OF RECEIPT
OF AN APPEAL.
I HEREBY APPEAL:
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Erika Waring
Board of Assessors
Patterson Town Hall
Routes 311 & 164
Patterson, New York 12563
10/2/91
Re: Bertrum
Garland Road, Patterson
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Dear Ms, Waring:
Enclosed please find copies of the approved Construction Permits
for the lots referenced in your letter`(copy attached).
If you have any furth.er,questions,I may be reached at the above
number.
V uly yours,
t. 1 ,
Christine Johnson
Intermediate Clerk
CJ
Supervisor
Lawrence Lawlor
PATTERSON TOWN HALL
Routes 311 and 164
Patterson, N.Y. 12563
TOWN OF PATTERSON
BOARD OF ASSESSORS
. (914) 878 -9300
Department of Health
Div. of Environmental Health Services
110 Old Route Six Center
Carmel, New York 10512
Assessors
Frances Kardausk,-
Edmond P. 01connc
September 29, 1991
RE: SSDS Construction Permits
John Bert=
(T) Patterson
Dear Mr. Morris;
Could I please trouble you for the lot numbers for the three SSDS
construction permits that were issued. We have just received split /combines
on these tax map numbers and I would like to be sure that the current
information corresponds with our records; -
25.41 -1 -32 (22- 2 -16), lots 3100 through 3110 = 11 lots
25.41 -1 -29 (22- 2 -13), lots 3117 through 3122 = 6 lots
25.41 -1 -31 (22- 2 -15), lots 3111 through 3116 = 6 lots
Thank you for your attention to this matter.
Sincerely,
1
Supervisor.
Lawrence Lawlor
PATTERSON TOWN HALL
Routes 311 and 164
Patterson, N.Y. 12583
TOWN OF PATTERSON
BOARD OF ASSESSORS
(914) 878 -9300
September 3, 1991
Chairman
Erika Waring, S.C.A.A.
Assessors
Frances Kardauskas
Edmond P. O'Connor
Eepartment of Health
110 Old Route Six Center
Carmel, NY 10512
To wham it may concern: Re: Tax Map # 22 -2 -15
and # 22 -2 -16
Per my telephone conversation with your office, please provide written
confirmation as to which 10 lots received Board of Health Approval
certificate to John Bertrum.
Sincerely,
' Erika Vwring
eM TU 21• • •' Z Ka 1 •••' I-i Z 0 VA fu 1. 120 ►: 6.71 DI -1014 41�"
IDIDMUML WAM SUPPLY /SUB.SLIRFACE SEWWE DISPOSAL SYSTEMS
FIELD INSPECTION REPORT
..�v ` -mss• /� � INS P.'
(Name of Owner) (Street Location)
INITIAL SITE INSPECTION I YES I NO ( :s" CHI'S }
Wetlands on, /or proximate to property ..............
Property lines or corners found ...................
Can estimate house location ........................
Will driveway need cut ..........................
Must trees be removed - note these................
Deep holes representative of entire SDS area...,...
Additional deep holes needed......................
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc.,..
Adjacent wel. is /septics ........................ _
D. H. 1 Lot D.H.
%2 Lot
Depth to G.W. Depth to G.W.
Depth to rock D64pth to rock
Soil Descri
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
Soil Descril
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
11ti1'�:
u.n. - Lr've!j nu.Le
G.W. - Groundwater
D.R. 3-
Lot
Depth
to G.W.
Depth
to rock
Soil Description
0 ft.
I
3 ft.
Width of trench average
6 ft.
Slope of tile line and trench acceptable.........
9 ft.
12 -ft.
11ti1'�:
FINAL SITE : INSPBCTION INSP.BY:
YES
NO
OCMMEN 'S
House SSDS located per approved plan .......
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Room allowed for expansion trenches ..............
Over 100 ft. from watercourse ....................
s
Natural soil not stripped or SDS area
unnecessarly graded ............................
10 ft. maintained from property line and
20 ft. from house.. .....
Distance well to SSDS (ft.) .......% ..��:........ .
Number of bedrooms checks .........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ................
15 ft. of.peripheral soil horizontally
from trench ..... ...............................
Boxes properly set ...............................
Could surface runoff fran driveway, roads,
ground surface, etc., channel near SDS area....
-
Does lot drainage appear OK in area of SDS....... I
I
FINAL GRADNG OF SITE ACCEPTABLE ..................
4-CI-7-3
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
T.nt '4 PCHD PERMIT # I a °f3
WELL LOCATION
Street Address
Garland Road
Town /Village /City Tax
Patterson 22-2-16+
Grid .Number
WELL OWNER
Name
John Bertrtnn
Address
100 Fairfield Drive, BreW.9ter,h.Y.
dPrivate
1 O.Sop Public
USE OF WELL
1 - primary
2 - secondary
1)'RESIDENTIAL
O BUSINESS _
❑ INDUSTRIAL
❑PUBLIC SUPPLY (DAIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
IDABANDONED
0 OTHER (specify,
0
AMOUNT OF USE
YIELD SOUGHT min, 5 gpm /# PEOPLE SERVED 1 Fam /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
IMNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY
❑REPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
a available.
WELL TYPE
®DRILLED
®DRIVEN
❑DUG ®GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Putnam take
Lot No. 3110 -3100
WATER WELL CONTRACTOR
Name
to be determined
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY
DISTANCE 'TO *_P1C0PERTY FROM' NEAREST" WATER MAIN.- Greater t si���734iI r,�
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
�® ON REAR OF THIS APPLICATION
(date)
Lq
sf??� e )
PERMIT
plans
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: .^f �� 19�____��
Date of Expirati 19_ <` Permit Issuing -Off
Permit is Non-Transferrable 46
APPENDIX B
PUTTIAM COUNTY DEPARPP .OF HEALTH - DIVISION OF HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET - CONSTRUCTION PERMIT
- -
V% ,A P -st - - DATE EWER: - 2 [L
BY:
(Name of Owner) (Street Location) COMMENTS YES NO DOCUMENZS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
IF trench provided J..
required I
60 ft. max.
Parellel to
s/s
SUBDIVISION
Perc
Fill
cd
House Plans - Two sets
Well / permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sew Tacl
t1 fi a System Plan - (north arrow)
e System Hydraulic Profile - Gravity Flow
Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
iell Detail, Service Line if over
nstruction Notes
sign -Data: perc and deep results .
c FCx�t--Cortours -E ''-st-ing. & _Prccpos - --
Driveway & Slopes Ci
(3)
(discharge OK)
Deep Hots
presentative of primary and expansion
lion Area;shown;gravity flow,suff, size
If Punped Pit & D Box Shown & Detailed
House - No. of Bedroans
Wells & SSDS's w /in 200 ft, of Proposed System
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1/4" /ft. 4 "0; Type pipe .
No Bends; Max. Bends 45" w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fi*
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, lake (inc. expa
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercour.
101. to Water Line (pits -201)
50' intermittent drainage course
10' fran Foundation; 50' to well
i' Well to PL
WO (( t) -L A r (►c ";'lTtc%' 1
DESIGN DATA_SHEET- SUBSUFACE S&A7AGE DISPOSAL SYSTEM BILE -NO: -
I Fpkd \�e h vc �rsr I oSO9
,Owner � hr.,z gzr�triL rv► .Address i 00 (t�
Located_ at ( Street) Gc1 r l a ;,� c� �'� a.t� Sec. 2, Block . 2L Lot ( P /,, /,5
(indicate nearest cross street)
Municipality Pom e rso n, Watershed Cro ton
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking 2,3 /13 6 Date of Percolation Test i •:)- L4 /S. 6
HOLE
NUgBER CLOCK TIME PERCOLATION 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 /7n Drop
Inches Inches Inches
NOTES: 1. Tests to be repeated
are obtained.at each
for review.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. . All data to- :.be submitted
be made fran top of hole.
24
S
2 9 :z1-
- 3 y- a3 -1o:19
36
12-
4 (0 20- ll 05
AF
7,0-15-
23
3
1 S
5 ii:o6 - /1 -5i
¢s
2 1
2Q
3
15
1 �4 7— tD,09
��
2. I
24
3 .
?
2 (0:i0- 10 :40
z
24
3 1 0:4), —il 2.4
.14
4 (1.25 -12 13
LI17
�I12?
3
i6
5 12: iS- (:'03
24
3
/6
1
3
NOTES: 1. Tests to be repeated
are obtained.at each
for review.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal soil rates
percolation test hole. . All data to- :.be submitted
be made fran top of hole.
5'
6'
7'
8
9'
10'
11'
12'
- HOLE NO.
- HOLE NO.. -.
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENOOUNTERED None
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTER D NIA
DEEP HOLE OBSERVATIONS MADE BY: .DATE: I o1z I G
DESIGN
Soil Rate Used (6 -7,o Min /1 Drop:. S.D. Usable Area Provided 2275 E
No. of Bedrooms 3 Septic Tank Capacity I o0o gals. Type Ma
Absorption Area Provided By404140+L48 +4$ L.F. Oi �re- cc&A C VIC. tr-i r2dI es
Other . &O'K brc"A - —
Name Cc\ 5 Jz -k A Q.5 SoC (ores Signature
Address R 5 2- SEAL
!Y 1�5fz
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate.Approved sq.ft /gal. Checked by Date
PUTNAM COURrY DEPARTMU OF HEALTH - DIVISION OF ENVIRONME UAL HEALTH SEMCES
INDIvIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTFMS__._
FIELD INSPECTTION REPORT
/J
4 DATE:
(Name of Owner) ( (Street Location) INSP. BY:
INITIAL SITE INSPECTTION YES NO CCMMENTS
Wetlands on /or proximate to property............. -
Property lines or corners found ...................
Can estimate house location ........................
Willdriveway need. cut ............................
Must trees be removed - note these.................
Deep holes representative of entire SDS area......
Additional deep holes needed ......................
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells /septics ..................... .....
Drrrocc to nrnnngPa wel l l oration for drilllna.... .
D. H. 1 Lot
Depth to G. W.
Depth to rock
Soil Descri tion
0 ft. �R i %fir• ,�
3 ft.
g . ft:.,
/d
12 ft.
�" o ,s Dep 2 Depth GG..W.
Depth to rock
z ff
`� � •mss 5 W '� °��
Soil Description
0 ft.
3 ft.
6 ft.
/411 oe
-9 ft
12 ft.
D_H: - Deep Hole
G.W.- Groundwater
D.H. 3 Lot
Depth to G.W.
Depth to rock
0 ft.
3 ft.
. 6 ft.
12 ft.
DATE: I YES I NO I COMMENTS
FINAL SITE INSPECTION INSP.BY:
House SSDS located per approved plan ..............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Roan allowed for expansion trenches......:. .......
Over 100 ft. fran watercourse ...................
Natural soil not stripped or SDS area
unnecessarlygraded.............................
10 ft. maintained from property line and n,
20 ft. fran house ..............................
Distance well to SSDS (ft.) ......................
Numberof bedroans checks........ ..............
Stones, brush, stumps, rubble, etc:, greater
than 15 ft. from nearest trench:.. ...........
15 ft. of peripheral soil horizontally
fromtrench....... ........................
Boxesproperly set .... ...........................
Could surface runoff fran driveway, roads,.
ground surface, etc., channel near SDS area....
7 PUTNAM COUNTY DEPARTMENT OF HEALTH`; �. f
Division of ithi iiotimehta/' Health Services,
CONSTR TIO,N PhRMIT FOR SEy :Y WCG�DISPOSAL $_E y,
a T 77 Town or V7llage
Loeated at "1=LC y T Map Bloc
Subdivisioni3 Lot / �h Jobe
Owner - _ MAddress
Building Typi Lot Area -
Narnber of.Bedrooms Desl n Flow ��� Total Habitable S�tace " Square Feet
Separate Sewerage` - 'System t§ con 7sri f G'aMISept c Tank...s anq
r
lbe constructed by Addre s`
Water Supply ubli Su From - -
!� F Ovate ' b t) i
OtherE Requirements k
r
4 representythat I am whot tl corriplet ly �►es ons�bl , _- �desi9n,a`nd location of the proposetl systems) �lj that the separate sewa§ olsposal system
above "descr -ibed wh be constructed'as sh `n;ion a a'" roved a endrnent' there to and insaccordance -with tfie,staridards rules an regu a, Ions o e u nam
n
County„ =Department of Health, and th t onco Eion there fs Certif,�cate ,of ConstructionuCompliance << safisfactory .tosthe:COmmssioiteF Of'Healthavil
be submitted "to `the D,3par'.trrlent; -and a Witten - ill be furnished:`the ow.her his - successors; _heirs or assignsay`the_:6uilder .that seid:Ftuilder will
place m'good Ioperatmp cohddion.`any part, of id -- sewage disposalY system dunng'the period of- two " {2) year; im -; Hiitely following 'thedateof the issu=
ance Hof the approval of the Certificate "of' Coast cUon Compliance;: the; or.igina ystemyaf any ' repai -r`s thereto 2) ttiat_the'tlrilled well described) above'
will be located as shown on f_he approved plan and tha `said..well will he.?i stalled' .in rdance with .the standards rules an`d regulations f `06 "Outnam
s County - D artrnert of HeAltl j
a �r - -
k -
3 x Address s ` Y :- �A -' ,License
r APPROVED FOR CONS lJCT70fY Thls approval'expues _ rom.t e, date: unless construction.'of the bwlding has been';undertaken "and'is '-
dvocatile'for cause`or may'•__ amended or- mod�fled when considers d,necgs by the': Commissioner rof, Health;,' Any change ,or'- alters lon of eonstruction .
reguues a new permit r App ved :;for drsposiRof domestic isanitary ;ewag_ and' ;prwatej water, supply only
fv Date ° BY e s.f xTitle
r _ ss
VA
,�w1,04 }S.. �ti a'-:£'# Wit., >.�`°. v �✓ n _ _
Date Aug.25.1976 2A1
Tel# 931 4466
Re: Property of Rita C3falii- Rrj$c4l Rnildarc Tne— acting £nr. P;)1 u(os}.►hoc +e„ AVe.B3CNY
- - -.. _
Located at Garland Rnad Putnam Lakes 10462
Section Block Lot 3180 to 3WIS incld-
,Gentlemen:
This letter is to authorize George A Haughney a duly
-= licensed professional engineer X - - 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 pro-
visions of Article. 145 or 147, Education Law, the Public Health Law, and the
_
._Putnam County- Sanitary Code.—
6 r.
., .,`tie i ,�c ,• _
Countersigned:
W
Uj
:P.E., 'R.A. � : -
��.,,.
Route 52 F'Eoh..• -''
/ � J
S �
.Address .,i r�T�ve�'
Carmel , New. York''1'U i'�
(91.4) 225 -9353
Telephone
Very truly yours,
Signed for Rugel 'Builder Inc.
Russell J. Gelso:, Viae President
Owner of Property / '4
2215 Westchester Ave Bronx NY 10462
Address
212 -931 -4466
Telephone
PUTNAk..COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Address
Located at (S reet Sec . Block Lot ,�160 - 1 -TIO9
4&ic*aeneared cross street)
Municipality. MM022:2 Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE •SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
apse
Depth to
Water
Wat-e-r-TEvEel
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Min. /in drop
Inches.
Inches
Inches
Lf7 NN;�� ate/ �`° /
1
2 ..
m
5
1
2
3
4
+r W
Notes: 1) Tuts to be repeated at same depth until a
rates are obtained at each percolation test hole. A
oxi atelyy equal soil
data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH•APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE 140. HOLE NO. ' f -HOLE NO.
6"
12"
18"
2 ,
3011
3611
4211
48"
54
60"
66"
7211
78•'
84"- -
INDICATE LINTEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Date
rM
DESIGN-
Soil Min/1 Drop. S.D. Usable Area Provided O'6
No. of Bedrooms Septic Tank. Capacity j
Absorption Area. - Pro — ByZO,'P L.F. x24" � '— ���� _ wi' �Yf`' r.,ench.
Name I igna
K
Address a,141�5w L
o
�i A". 0
.AE 043 °00• ;�` ``�
y �f�7-- ��15111�12
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by Date
N- .
- .
VACANT
-- -- -- -- - - — Z.
,ZS � O 41,::e
� n r1E5— � '� ,i —nUu'r 'PIPS -7 G+ia.InlEl_•
�izt{ ^ rte'^ _soL f C p; o�oscc' i ,r 1: l
\\0 PcoPose� I , G'Curtgn
` o i
�\ 36r,-, !� I 1000 GAL ?O'
tI'f _ VI ST f10 Ui�uf
Loi P,3
22.5 Gu3,C, VAR T_>5 MES
9 i Area 22 ,000 SF!
Po a
rop se
19� - 100
i� @oJ7a:�G1� P326 TG 13G FI -T7 "!�1'ArCD PRop62T
2
p,��/ A LIGEIJ'3ED L..ANT3 SUT2VEy6 -e, C.oR N6
' t
T41t9 t5 TO CBKTl" TWh j 114E rvewbe.& PMOV66L 6`1STeM lvt.-.-
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Pcm,, `(GYtK Su.-re vEPa2TMeWT CF HFS`t -TM. 1 O�
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