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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 22.55 -1 -25 BOX 11 I ro I rrm ' I ' is J41 L *Lrri I V-41 01115 ev PUTNAM COUNTY DEPARTMENT OF HEALTH r r Division of Environmental Health Services, Carmel, N Y ti10512 s ti° h Engineer "t:. Provide P C.H D Permit KIWI CATE OF trONSTRUCT19 COWLlANCE•FOR SEWAGE3DISp.OSAL SYSTEM' '. T7E.C��O i I wn or,VWag To a 1 Lora t - -��A,h Ta: Map t Block —� _iL ©©ot _G.�- O,ivner /applicant Name No►,o1 Ay, L s Formerly `,'f�tiVl•�t� Sabdlvlsl NaNme� ^I.L110E V Saba 7u� Mellbag Address n bV Cif' t o�09 2 (� Zip —i Date Permit Issued i Separate Sewerage System ballt byYrt7 Add=ees }�1(,'i�i �'• 1 r 4 Consisting of Gallon Septic Taak,aad 4"Cw Y, D Lfr O F xQ - Al "Water SapPU V. Public Supply From } Address ( or: ✓ Private'Sapply.Drelled by.e�`Q�1 L� 1> Address 1�1�6iAlr t Fi� 1J,�, ' Bullding,Type � 2t�lo Pi�IAtV tHas Erosion Control Been,CompletedY _ , � Namber of Bedrooms i Hae'Garbage Grlader'Been InstalledY rt Other Regalremente I certify•that the system.(s) as listed serving the; above premises were constnicted_esaentially as,;ehown onCthe plans'of' he completed .work' (copies I of which; are attached) rand in accordance with the. standartia rules and zeg6latione; in ac th th filed;pla d the permit issued by. the Putnam County Department Of Health' y n: n�a - date .�/` Certifwd by ` O E� R A► 464, ., k Address �^� }n onac nls 1 Llcena No �6 zt Any 'person occupying piemises� served Dy th'e atiove_system(sj_'stialt promptly. take such pctfon aa'may be,neutsary.to aCUn tM correction .of atny unynitary co`ndltio °ns resulthq from; wch uiage Approval of,the�sepprate; sewerage °system shaltbeeomeynull.aetl voltl asaoon as =,a Oub(':.Yp(Ury."war,, bGeomis 1. avans+um,,andithe'approval of tha, private water supp(Y shall become null and voidiwnen` a .puplk water -' 'supply becomes- avallabli.' Such approvals• are :ubieet'.•to'modNkitton or: change ,wheh .in` the )udgmenf of the Cornptlssio�ar of h revocation, m tlon'o :ehanpa ls.'nac�stlry. Date m WELL TYPE CASING DETAILS ❑ SCREENED ❑ OPEN END CASING, 3S�tiii':�a!1,'^L+• ,,. • r,:•_. ....w..::nee..w.le...is`�.i1: a:�.:.. .> YEA• .tJ:C1?.Sl3siwRt7�1.•i9tiFA.Ai4 t' t'fL.'.....:•�:• vyMS- ilia: gYra' •� ut•rlt.t vae ua0 WELL,COMPLETION REPORT. 41 • _, I DEPARTMENT OF HEALTH . M 00: O PUMPED t LENGTH.BELO.W GRADE Division Of Environmental Health Services — JOINTS- O WELDED _..........._: _ .•... = PUTNAM BOUNTY DEPARTMENT" OF' HEALTH DIAMETER 6 in. STREET AOURESS: TOWN /VILLAGElCIIY TAX GRID NUMBER: ❑ BENTONITE O OTHER . WELL LOCATION • Java Road Putnam Lake, _ Patterson, New York 19 WELL. OWNER NAME: ADDRESS: PBIVATE Modular Construction Concepts, Rte. . 22, Brewster, NY ❑ PUBLIC LINER: OYES O NO USE OF WELL W ESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./`HEAT PUMP, ❑ ABANDONED ' 1- primary. ❑ BUSINESS O FARM ❑ TEST /OBSRVATION ❑ OTHER (specify) . 2 - secondary O INDUSTRIAL ❑ INSTITUTIONAL • O STAND -BY ❑ AMOUNT OF•USE. YIELD SOUGHT 5 9pm. /N0. PEOPLE SERVED 2 / EST. OF DAILY USAGE 250 gal. REASON FOR NEW SUPPLY ` = '❑ PROVIDE ADDITIONAL SUPPLY C1 TESTi08SERVATION K =r DRILLING `If EPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL ' DEPTH DATA WELL DEPTH 200 ft. STATIC WATER LEVEL �ft. DATE MEASURED 7/21/86,. DRILLING ❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG EQUIPMENT. ❑ WELL POINT ❑ CABLE PERCUSSION ❑. OTHER (specify): ' WELL TYPE CASING DETAILS ❑ SCREENED ❑ OPEN END CASING, OPEN HOLE IN BEDROCK ❑OTHER TOTAL LENGTH 41 ft MATERIALS: STEEL O PLASTIC O OTHER M 00: O PUMPED t LENGTH.BELO.W GRADE 40 fL JOINTS- O WELDED OrrHREADED O OTHER DIAMETER 6 in. SEAL: CEMENT GROUT ❑ BENTONITE O OTHER . WEIGHT'PER FOOT 19 1b. /ft. I DRIVE SHOE*fES D.NO LINER: OYES O NO SCREEN DIAMETER (In) 'SLOT SIZE LENGTH ill) DEPTH TO SCREEN. (it) DEVELOPED? DETAILS FIRST. • O YES 0 NO SECOND ... . , .. .. HOURS ... GRAVEL PACK O O YES G GRAVEL O NO S SIZE: WELL YIELD TEST I It detailed pumping M 00: O PUMPED t tests were done is in- s 0 WATER o{CLEAR'` TEMP. QUALITY O CLOUDY ,• HARDNESS O COLORED ANALYZED? EVES O Nd ANALYSIS ATTACHED ?RYES O NO ?UMP INFORMATION TYPE submersible CAPACITY MAKER COULDS COULD DEPTH 150' AODEL 7EHO5412 VOLTAGE230 Hp TI_ DIAMETER TOP BOTTOM OF PACK In. DEPTH `it. DEPTH It. If more detailed formation descriptions or sieve analyses WELL ELL LO G are available. please attach. DEPTH FRO41 Water Well SURFACE Bear. D'a' FORMATION DESCRIPTION COOE It. fL ing meter Land 10 Sandy .silt & boulders I 10 281 Soft fractured bedrock 2'8 200 Medium ts2 a Be rock t I t I 1 STORAGE .TANK TYPE �niaphra4m — —� — CAPACITY 44.'' GAL. 13h WELL DRILLER NAME DA 6 / 8 6 MILL DRILLING, TN AODRESSputnam Avenue SIG?19TURE �� I t Brewster,.NY.10509 Robert M. Mill, Pies. MW N�i� } 4 9 -ib .K..� ✓ckf �s, .*-yy s. "% � aF3 _ �: Y "�s % � � � f �� -.. y ri 4 4�Q��;�p��y.��" Kif t $j,��y f�'�yy, t� 4 W W" . � 'ti'%q{�."!�`�^'� +yam✓ !� - - � �. ! d l �.- er, 44 k' 7A £� d(}'�y _ �� �+ }��+�p�y�� y Q}� �p� ,,. •wr .el�"'��i{. P.'•^. ,d$ fo uY3 !r ISgS A # ,,,Satrtr 1' S� ..- S G.+ ? t F. 'ia �.R.[SMY fiVTIJ � '+� l.e V }•4 W . =`. ' g. t-u" tP� III 21M "tI "`r �1NA1i T `tom tw IN Or '55— * .l' ;,.� s< V - 3 M".` A 'p . ,[� �n � �"� }) l � � -^-, r( , } � d ,¢ �- 4 ,� � J �'' `% '• ��`., S 4! �a+rnr UI�# '+ y.a. Allli� 1-11. S try. A '�� 'ks, o�' °,'✓: �vr �yr.. d' �a 3 ,�,fk' 1,� tir,. ���° "k's�,.%� >� y i � i'� <� � � �[ . � � � z i.. �F tij� C -}g, ;es �1r . ,r, --}• } r 't„ °.'fie- ". h �� k t h +r�^'�R4ppp� r , r _ Y bt StS' r t MW N�i� } 4 9 -ib .K..� ✓ckf �s, .*-yy s. "% � aF3 _ �: Y "�s % � � � f �� -.. y ri 4 4�Q��;�p��y.��" Kif t $j,��y f�'�yy, t� 4 W W" . � 'ti'%q{�."!�`�^'� +yam✓ !� - - � �. ! d l �.- er, 44 k' 7A £� d(}'�y _ �� �+ }��+�p�y�� y Q}� �p� ,,. •wr .el�"'��i{. P.'•^. ,d$ fo uY3 !r ISgS A # ,,,Satrtr 1' S� ..- S G.+ ? t F. 'ia �.R.[SMY fiVTIJ � '+� l.e V }•4 W . =`. ' g. t-u" tP� III 21M "tI "`r �1NA1i T `tom tw IN Or '55— * .l' ;,.� s< V - 3 M".` A 'p . ,[� �n � �"� }) l � � -^-, r( , } � d ,¢ �- 4 ,� � J �'' `% '• ��`., S 4! �a+rnr UI�# '+ y.a. Allli� 1-11. S try. A '�� 'ks, o�' °,'✓: �vr �yr.. d' �a 3 ,�,fk' 1,� tir,. ���° "k's�,.%� >� y i � i'� <� � � �[ . � � � z i.. �F tij� C -}g, ;es �1r . ,r, --}• } r 't„ °.'fie- ". h �� k t h +r�^'�R4ppp� GP►�Io�on�EV� 7 'Owner or Purchaser of Building Section Ib10QQL,A9_ OAT, C0I'�CEPTS - Building - Constructed -by---- _ .. _ __....__ ... -:. Blo -ck >ZUAD g Location - Street Lot PATTE 6o5 Pu-*M ( A a Municipality Subdivision-Name 9- FS I�HT7 -7196(- '707 Building Type Subdv. Lot # GUARANTEE OF SEPARATE_SEWAGE 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 success - ors, 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 initial use of 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determin- ation of the Director of the,Division of Environmental Health Services of • the• - Putnam•-.County -- Department of Heal- th --as • to,• whether• -or•- not- the fail- ure 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 d 1956 Signature�L Title Corpora i n Name if corp. coy` A Address - - - - - - - - - - - - - - -V �. � - - - - - - - - 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 OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health BREWSTER- LABORATORIES - -- _.. _. _. - - - -.- - -- Box 224 - .BREWSTER, N.Y. (914) 225 -2072 — WATER ANALYSIS REPORT — SAMPLE NO: 6258 SOURCE: Modular Construction Concepts well Java Road Putnam Lake `L Patterson, NY COLLECTED: August 4, 1986 BY: Mill Drilling, Inc. BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method 0. per 100 ml. ql This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. ECEI E. ® TX PUT��►i , ►EA`, DEPT. August 6, 1986 § r z 1 w.:i#t 7"� a`c^r�.� ,� :t r ENGPNEER TO P<ROyIDE PERM IT`.# �PUTNAM CO.UNTYy DEPARTMENT �OF HEALTH ON cERT F I c,aT OF' 6OMP I CE ` r sfon of E-nwronmen 05 tal Heal[h Services Carmel N Y 1.12 RM I T PE. yi _- CONSTRUC 1 PERMIT FOR: SEWAG E DISPOSAL SYSTEM r I I 4 w _ mown ► T/I lage Located .at �'^ ��� Y j ' ,Tax wMaP� aElock 1Y r SUbdiVisi011r�a�m r��u�� r 1 SubdLot N10��`,'3 Renewal Its, Revision y(]. r P Owner /Address OffPrevious Approval t -•L" Buildrn Type' �F+� �+� 11 � ! ` `, �� '`i� Fil'1 Section Onl L 9 Ype r r {Lot Area T�. { y Number of Bedrooms ._°�_ Design�Flow G /P /D. �"TC�CJrr2 a P C tH D Noti'Lication Required �� x ` k ,•., Y cX ^ i j> f . t b . {7d i A — '= 'sue- ?r x— 'l. -�1 `G._�I %A��' 5'eparate 5eweragexSystem . to consist of 1 Gal SepticFTank antl "!� Ll�t �'` 0 To De ,constructed by To o y n Address �(� F �.c�'_"f axe � %,,, x T {'h r` .," 9 �:. > r �.. � � t � � j 4 �d � ��� �� t`•.� � Ln '+ � 2 r Wat_r S' upply ' Publics SupplygFrom Pnvate ,buppty fo be dulled by � • - tom." t '�•:-AddreSS , Other Requvemen'ts .L -.•?'t i- rp ry. . �� y t. •.` i, -�, vrepresent that 1 am wholly antl completely,responslble for the design and location of ;the proposed systems) 1) that the separate sewage;.disposal system - 5bove:descr�beA will be constructed =as shown on the approved amandmentkthe/e.`to and'`in accordance with the stanGartls rules and re a_ ions o. e " .u, nam ti;County-;Departmerit fof 'Wealth, and that'on completion hereof a Certificate of Construction Compliance satisfactory,to ' th'e Commissioner ofrHealthw{II - �t3o asubmittetl to`ahe Department,antl a,wi�tten guarantee :will be furnished.` +the owner hiswccessoc; °hetrs'or bssignsby the•builder_ that said`,tiuilder will, ,4 r.: „'',place 'm good operating`;condition' any part ofF said sewage disposal system, during ,the perioG of two'(2) years immediately. following the date, of; the . issu - ance of ,the approval of ;the ,Cerfificate of;. Cor,structron Co`mpliance Of the.bng {naf system or,any repairs thereto; 2). hit the drilled well described ,'above ti 'will be' located as[ "showno`n +the approved,plari�antl that said wellfwill beinstalted fin accordance with the'ystantlards "r s'bn 'regu aT oirns,'of Pufnain County'D "epartmentiof Health it n .,l r t F tsxtiY$ t k t r OSte �_y`�• -Y � � J � � L Signed � y ` P E / R. �+` lt� Address License,No. APPROYVED FOR;CONSTR. UCTION This:;approvaP,exp�les one year from the. date i' s copstruct�on' of the: .budding- has1been, +urideitaken and -ii Y. �.� ..., n .. t.., .vY'_... _ onstruction, . revocable for rouse or ma be `amendetl or modified whe sidered necessar by a Commiss nor of Health.", Any " alteration of c• requ'►es a new per rt Approv or disposalfof do stic� n wry appt�'oftty- .. ,• Date By It R Title F, - y {' 5c L v- va �. 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Y 5.w A» "n -g �r .^^^' a ^ rte"^ .'° ^ ^" 5 w, rt n* .-. "`4: =N _ •3--- __. P. y .f 4 i Y eat y } 4k x i 4 4. f t'r" k h L 4 i ... I Y `L. `' i r t ¢ �. r _- __•_,- --�}_ i ;, i + �_+ , . �7 iM' �, i { i- -'mss _.,4 s . 't ,,. _""` °�"„ -" _ 5 .N {. 3 '4 r _' : PUTNAM COUNTY DEPARTMENT OF HEALTH NO. 0,5-1 G COMPLAINT OR SERVICE". REQUEST RECORD �{dN PATTERS ON -y 'Date 7/22%86 Time REFERRED TO TAKEN BY J S H TELEPHONE CALL XX IN PERSON LETTER CONFIDENTIAL REQUEST FROM RICHARD MORGENTHALER TELEPHONE 279 -8818 ADDRESS ENVIRONMENTAL HEALTH: Home Sewage XX Rodents Refuse Public Water Food Service Migrant Camp Other COMPLAINT OR REQUEST SEPARATION BETWEEN PROPOSED WELL AND EXISTING-SEWAGE DISPOSAL SYSTEM ON PARCEL ON 4 JAVA ROAD APPEARS TO BE LESS.THAN 1001. PERMIT P 8- 86,.TM.57 -1 -8, PUTNAM LAKE LOTS 7066 -7073 TO BE APPRISED OF, STATUS, JAVA ROAD AT GARFIELD. r FOLLOW UP INSPECTION (S). .. _• -DATE- _ . _ FINDINGS _.. _ .:._, ..._.... -_.._. __......... - -. _ DATE FINDINGS PROBLEM ABATED DATE PERSON NOTIFIED ESTIMATED TOTAL MAN HOURS SPENT ACTION TAKEN BY 7 - Z - 't _' _ A LY FINDINGS ,dtlt�,tQ dint dt. (� �S E I.o [►�.dAJ+1/1� r FOLLOW UP INSPECTION (S). .. _• -DATE- _ . _ FINDINGS _.. _ .:._, ..._.... -_.._. __......... - -. _ DATE FINDINGS PROBLEM ABATED DATE PERSON NOTIFIED ESTIMATED TOTAL MAN HOURS SPENT :. x <PUTNAM COUNT --T DEPARTMENT �W Yp4 DIVISION: OF ENVIR&NMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health = FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME MoDVLAR cousI'WOOA/ cam cgjn§ 0.Xw Orig. Routine Orig. Complain ADDRESS two PAItesnN Orig. Request No. ", Street Municipality, (T)(V) (C -) Compliance Complaint Comp MAILING ADDRESS Final P.O. Box Post- Office Zip, Code, Group Illness Construction TELEPHONE Re inspection PERSON IN CHARGE-, Field, Sampling Only OR INTERVIEWED,` MR. gpR',( mb-MA-w- . .' __ Field Conference Name and T�t'le k 7 DATE O 014 j�'to ° . `^ TYPE FACILITY r Other TIME ARRIVED 40 TIME LEFT;: 16 , Explain - FINDINGS : a�,d l} roast /Z tj'r. �r- Nolan �.,� ". -hP . ,,� /' t ac g �p �o SRlrVevc„r 6 C ,blds.T r da�,g cue kAt� P.L� .PUTNAM 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 (Street, /y��. be-e -. "L Block L Lot 48 Indicate neares cross s ree Municipality h3 Watershed Pt-A, SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME; PERCOLATION - PERCOLATION No. Start -Stop Elapse Time Min: Depth wo Wa er a er bevel From Ground Surface in Inches Start. Stop Drop in Inches Inches Inches Soil Rate Min. /in drop _1 2 e0_ �a 1 3 0- lip i 0 19- �� l o- +� ►� -- 7 13 ?i 2 3 4 5 Notes: 1) Tests to be repeated at same depth until a roximately 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. PROFESS \0 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by Date TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS 1ENCOUNTERED IN TEST HOLES DEPTH HOLE. NO. HOLE N0. HOLE NO. G. L. l l� 0?!5d u_ 6" 12" N _ 18" C 24" t' `Z`1 drbd 3011 36�t 42" d �t 4811 " Y 60" 66" 7211 of 7811 � ,r 8411 44. CATS LEVEL AT WHICH GROUND WATER IS ENCOUNTERED P•�� k XCGZ, �J -- -- INDICATE - LEVEL TO- WfLICH WATER.. -LEVEL .RISES._ AFSER_. BEING--ENCOUNTERED- TESTS TESTS --�. Date e� MADE BY 7i DESIGN Soil Rate Used6"_'S�_ MirVl "Drop: S.D. Usable Area Provided -.*V, i.0eXqIt No. of Bedrooms Septic Tank Capacity e;O Gals. Ty Absorption Area Provided By L.F.x2411 �'bj - wid c G�{� L� to �- o •� �' sc4 � j,— pr�.C.i -� � �C� �l�.t�i..�`C� o� � Name_ P r-k ze:. Ac, 32!SZ -C P,; = Signature Address T3Cj k a -3 SEAL . a PROFESS \0 THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Cal. Checked by Date John M. Simmons,,M.D. ;ION OF 'ENVIRONMENTAL'HEALTH. SERVICES _... _. - ra. r �. s ......' - t :brig.., Rou[ine • �— � �(. Orig. Complain � (/ /� /! ADDRESS / p P Orig. Request No. Street Municipality (T)(V)(C) Compliance Complaint Comp MAILING ADDRESS Final P.O. Box Post Office Zip Code Group Illness Construction TELEPHONE _ Reinspection' PERSON IN CHARGE Field, Sampling Only' OR INTERVIEWED Field Conference• S Name and Title DATE TYPE FACILITY ._Other TIME• •ARRIVED ��% TIME LEFT - G�G�j Explain FINDINGS: S/ 11 Ss'? INSPECTOR:�� ll Signa a and: ' le PERSON IN CHARGE OR INTERVIEWED: I acknowledge receipt of a copy of this Field Activity Report....... ......... SIGNATURE: TITLE: TELEPHONE: i I I �. \o„ Tom 1U tD®.'r'1- F'cJT�,� c�•i GO, 1.1. y. M,o.Y ! D, 1986 \ JULY ZZ, 1515t (VIE) T1Gicd,7lo�lh IUDICATEC, WE E01.J 51�►.11G -r T1 n+t"i 'G`( 1ClAh FFEP:vGn IQ Al�L1eQ41.4 -ZE I[ M4 "111E r1..IG CryE_ cF { IC.E Cot L.A,uC� 9J vF-lK, Acoprer> !IE UE1L! -(OW 'S� A44C)CJ&nClI„J Cr ES51O/.J4L I SU>TlE.'`lOYh. gAic> CE2vTFjCAnok* SMALL OuQ oI.1LY E PEZ6oQ FC>= WW OM IW- S_ 014e�( l5 QED AJUD '"' eEJ-IA.LF -TO -D*- 7M-F- COMR&j} ( A/,-tc> L EQC>j (-., T- LMC>.J LISTED HEIX3=4 -1. cEZng IC- tT(oltS AEL UCSr ADDrn01..(,4(_ 11.lSiTt ClTio►,15 02 ;F- 1L)E./JT- cAdkiez's. uk44LM1400j7 AI- E.ZQT1oQ 0E Acomotit -toi�{I�j SU.C'IEY f4 A \(IOLATIOQ o� SE-C.TlO j 4- -72ag oG 71}fE. Qekj - (o1?1C SIAM E— MX�fnCkJ LAIJ. SrM-C TUZS- - IFAI�K, I.KSr 51 lO�clt`1, AL-L- CEZFIFICA -noQ,i HEPEoQ Aom \j FL72 7 4K? 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