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Located at
T6*n or Village A
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T. Map Block _Lot
Owner/appllean; t Name J 02 r- r It J—V V—f-/-N I N rm-eWy. Subdivision Name 'gubdv. Lot #
Mailing Addr .. ZIP Date Permit issued
PATT r-10 :i
Separate Sewerage .System built by 605FP4 —Address-4�fFwiM 22,NEFWr—A11-2FJ1--;
Consisting of '1000 Gallon Septic Tank and F• A
Water Supply: . Public Supply From Address
or:-4/1 Private Supply Drilled by W I L I - 191211—WISU-4 JEW t Address 0 A V
Building Type re-7F,--GJ1J26Ur1AL,—Has Erosion Control Been Completed? "(1 -49
Number of Bedroom@ ✓ Has Garbage Grinder Been Installed?
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plarA of t c pleted work copies
of which are attached)_and in accorda. nce with the standards, rules and ations, in accofdance winthe filed oan,,,t t permit issued by the
Putnam County Department Of Health.
Date Cortif led by. aentA—� P.E. --L R.A.
7 L
Address '?'� rAfgrle'112 V9, 1-211115-1 50d,141 1 b Li ..No. ej�104
V
Any person occupying promises served by,th I o 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 sewers" system shall become null and void as soon as 'a pubt% sanitary "war becomes
available and the a - pproval of the private 'water, supply shall become null and void when a public water supply becomes evailabhL Such approvals are
subject to modification or change when, In . the judgment of the Commissioner of Mealth, such revocation, modification or change Is necessary.
Date ze)- B
Title
io
FA lam► �C�I.
a
- -
WELL I;UMYLh'11UN N-LrUml O
Office Use Only
� -
STREET AOURESS: WN /VIL 1 1 Y T G 10 NUMB
` -&- 7C9 Z,41,0
WELL LOCATION
,V I' ,
i a, ,
BREWSTER - LABORATORIES -
Box 224 - BREWSTER, N.Y.
(914) 279 -4945
- WATER ANALYSIS REPORT -
SAMPLE NO. 7175 NEW WELL
SOURCE: Lorraine Braun
Tivoli Rd.
Patterson N.Y. 12563
COLLECTED: 12-8-88
..BY: Mill Drilling, Inc. i
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
0 pet 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
12 -11 -88
Thomas Meyer
Director
i.
PUTNAM COUN'T'Y DEPARTKENr OF HEALTH
_ SIOi3 OF ]�OAL HEALTH
62
Owner or Purchaser of Building Section Block Lot
L0arZA)61 �0
Building Constructed by
T N O W 00A2
Location - Street
Municipality
J?_ IflrnITIALI
Building Type
Subdivision Name
Subdivision Lot #
GUARANTM OF SUBSURFACE SEWAGE 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 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 "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 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 A QI21 L 19�
<L
i
2
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
WL •
rev. 9/85
mk
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Signature,
Title
Corporation Name (if Corp.)
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Address
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1 Lf d� -e , tq� Area 1 . D.00 _ S °3
BtIRd1aQ Tm FM Sectbn.OWY Depth Volame,:
Nuanber of Bedrooms: Design Flow G P ' D 6 6 PCHD Ned ad= Is Required When FM Is obmpletid
Separate Sewerage System to oensW of GaRm Sept& Took �nfi �.
�UDO �. �. F ar Off. Ytt�li
To W cessfncted by 111 r rt Address .
Water Sdppb•t Pailte Si>tpply':Ftrooi Address
an Pelvttte; Supply Dr10ed`by
Other ReQa4etnenta
1 represent that 1 am wholly and boinpletely respohsible for the design and location of the
proposed system(s): 1) that the separate sewage disposal system
above described will beconstructed as shown On't "he approved' amendment there to and. in accordance with the standards, rules all ►egY la l:= O e Y nam
County Department ,of. Meelth, and that on completionihereof- "Certificate - of Construction Compliance" satisfactory. to -the Commissions of Healthwill
M submitted to the Department "and •`a wri_ttan quararitea will Oe furnishetl the owner, fiis successors; heirs. or assigns by the bulldei, that slid Quilder will
place in good operating condition any: part of ,said sewage disposal system during the period of two (2) years immetliately following thedate of the issu-
ance of the approval of the Certificate :of Construction Compliance of :the o►iginal.systern or any repairs thereto; 2) that the drilled well described, above
will be located as spawn on the ipproved;plan sa
.and that klaivell, will.be Inst 11 in accordance: with the s< ardsAr ule and regu aTirons of" the Putnam
County Department Of Health. � /
Date a (. ��%� Signed t�.d/Lt P.E. 1— R.A.
Address ! f'1 4 License No
APPROVED FOR CONSTRUCTION: This approval expires two-year$; from the date - issued unless construction of the building has been undertaken a /d is
revocable for cause or rnay'be amended or modified whin considered necessary by the Commissioner of Health. Any change or alteration of construction
requires a new 'permit. Approved forr disposal of domestic- sanitavy sewage,, rivate w r su ply only.
IS – °/ .. Title
MI
e
DEPARTMENT OF HEALTH
Division of Environmental Health Services
:OUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
LOCATION
Street Address
Tivoli Road
Town Village City Tax
Putnam Lake, Patterson, NY
Grid Number
WELL OWNER
Name
Lorraine Braun,
Address
Lake Shore Drive, Patterson, NY
private
O Public
USE OF . WELL
1 - primary
2 -. secondary
RESIDENTIAL
(3 BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
0 FARM ❑ TEST /OBSERVATION
O INSTITUTIONAL (:)STAND-BY
0 ABANDONED
❑ OTHER (specify]
17
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED3'to 5 /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
)UNEW SUPPLY New Dwelling PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
No public supply,avallable.
WELL TYPE
XODRILLED
DRIVEN
®DUG
®
GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES XX NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: n a
Lot No.
WATER WELL CONTRACTOR:
Name MILL DRILLING, INC.
Address:
Putnam Avenue
BrE 9509
IS PUBLIC WATER SUPPLY
AVAILABLE TO SITE:
YES XX
aQ ,-T
NO
NAME OF PUBLIC WATER SUPPLY: n/a TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN : _ - "` "' -" _ ' ._ _' _ . _ °.... • . _.. _..._._�.
n/a
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION TIE. S T °
12/9/88 1
(date) (signature)
Robert: M. :Mill, President
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 Permit Issuing Official
Permit is Non - Transferrable
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL p
PCHD PERMIT 4/—��,
WELL LOCATION
S reet Address
I NOW �-�
Town Village City Tax
��, o� z5Zr(v`
Grid Number
*702 ilo 41ob
WELL OWNER
Name Mailing
auSCMA-+ 1,00AIQt Oft4M
Address
` k -. ? -LT 2.064 %
J'Private
Y• O Public
USE OF WELL
primary
2- secondary
.URESIDENTIAL ❑PUBLIC SUPPLY OAIR /COND /HEAT PUMP
O BUSINESS 0 FARM O TEST /OBSERVATION
O INDUSTRIAL 0 INSTITUTIONAL O STAND -BY
❑ABANDONED
O OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT s= gpm /#
PEOPLE SERVED '3-5 /EST. OF DAILY USAGE 0,C) gal
REASON FOR
DRILLING
MrNEW SUPPLY
O REPLACE EXISTING SUPPLY
OPROVIDE ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
New CesipaKe
WELL TYPE
®DRILLED
DRIVEN
aDUG
GRAVEL
❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name ��`� �. Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES x NO
NAME OF PUBLIC WATER SUPPLY: WA TOWN /VIL /CITY
DISTANCE -TO `PROPERTY 'FROM NEAREST 'WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION ON SEP RAT SHEE
j3-2-1-e-7 ......._
(date) gna ure
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 s.hall:
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 Putna County
Health Departme tom..
Date of Issue: � 19 �
Date of Expirati 19
ermit Issue f.
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
nrnnat- rtnryv- WAI 1 nr; 1 1 cr-
0 (UUN.UZ L&:KU<11.1t.N ' Ur' H -"i L= - 1J.LVLJ1\J1-' yr J1+Ctiv1\
INDIVIDUAL VM= SUPPLY & SUBSURFACE SEA DISPOSAL SYSTEMS
s' GG'
Name of Owner)
COUNTS
REVIEW SHEET - CONSTRUCTION PERMIT
LF trenca provided
required
60 ft. max.
Parellel to contours
DATE REVIEWED:
`
(Street -Location.)---
_ ..
YES I NO I DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
Plans - Two sets
permit; PWS
ce Request
s/s
SUBDIVISION
Perc
(3) Fill _-
cd
letter
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Pe* -mit Same
REQUIRED DEZAIIS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D r Box;Trench /Gallery; Pump'.pit details
Se zc Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data: perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Q t
�G tter�Cur -_ - rains* (discharge OK)
Perc _. Deep Holes 7 _... _..._ . _ .............
Rec_ sentative c : -_ _� a and expansion
flow,suff. size
Pi L- & _ hewn & Detailed
Hcuse - No. of B_c
wells SSDS's w /ir. ft. of Proposed Systems
Prope_ _v Metes &
Hcu2 -etback Neczs_ ;Tight lot)
�-wer - +,'= J — 110; Ty7ce pipe
ON PL.2_
-- -to P.L. , Drlv ewayr Large Trees;'Ic.:
.o Fou: da--' ,,a *' s .
i;' to Well; r�" 1P_ D. L.
_ to Stra =m, ';�,a r� , �,--L 4ke
Co catch bas_n,3-�c —,,dr'aln,pl -`EQ NC == -= =s�
10' to Water Line (pits -201)
5u' intermittent drainage course
Sentic Tanks
10' from Foundation; 50' to well
15' Well to PL
Q
10
APPENDIX B
PUT'NAM COUN'T'Y DEPARTMENT OF HEALTH - DIVISION OF HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEin%M DISPOSAL SYSTEMS
W51
REVIEW SHEET - CONSTRUCTION PERMIT
required
60 ft. max.
Parellel to contours
FILL SYSTI .S
claybarrier
10 ft.
fill notes
new spec.
depth cauces
100 yr. hood elev.
_... DAT
_B �o d 44Z BY:
(Street Location)
YES NO DOCUMUS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
oe Deep Hole Log
Consistent Perc Results
ol Peso Hole Depth
W.0 Dit _
J .ar�Yr
s/s
SUBDIVISION
Perc
(3) Fill
cd
letter
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Pen-nit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
�Hdraulic Profile - Gra vity Flaw
imensions - Volume
h /Gallery; Pmnp pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder notes)
Design Data: perc and deep results
Two - Foot ^Contours Existing &Proposed
Driveway & Slopes Cut
Footing /Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flow,suff, size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
� ells & SSDS's Win 2.00 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 1'0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTZ�_N'CFS SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Tcp of fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' frown Foundation; 50' to well
15' Well to PL
E
DESIGN DATA SHEET- SUBSUFACE S30M DISPOSAL SYSTEM FIB NO,
Owner Address l•
Located at (Street)
I (\j I
Sec: ' c52 Block G, _ Lot -
(indicate nearest cross street)
Municipality Watershed"iC?c`i
SOIL PERCOLATION TEST DATA RDQUIPM TO BE SUMMED WITH APPLICATIONS
Date of Pre - Soaking - - PTJ Date of Percolation Test _ _ Z7- &7
HOLE - -
NCMM CL= TIME PERCOLATION PERCOLATION
Run Elapses Depth to Water Frccq .. Water Level'
No.. Time - Ground Surface i In Inches Soil Rate
Start-Stop Mina _ Start Stop.` Drop In Min/Sn Drop
Inches Inches Inches
17
- 2 4' ZH —
24-
3 I('- t6 -10' -4S :3O-
2
rZ%
4
3cl Z7 3 En,
3 IU••Oi
5 ,
1
3
4
i
t
Tests to be repeated' at same depth until approximately soil rates
are cbtained.at each percolation test hole. All data to bbe.submittmd.
``. __ for review.;
`'2. ' Depth measurements' to be made fran top of hole.
Y44
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WAS C10Ve4?-bl2 aV� M. TH � V-(�TCW WA,9
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Or Hf�ALTH 4 THE N✓N -fOF-K-- TA-Tfi
p�PAi?l`tyi ANT OF H�ALrH.
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