HomeMy WebLinkAbout1148DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.56 -1 -72
BOX 11
�' -
,4','`
t�r
Rev.. 3186.
AA
RTIFICAT
Name
Mailing
.7
.'PUTNAM-COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health:Servlces, C"el, N.Y. 1051:2
� ; .Engineer Mast Provide � �` .
'D.
F-CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
T--
144UI L, A&D Tax Map Block--/ —, t 7
1 VL
116,7/ dillign "L �Cb(
Forme Subdivision N!Lme—Subdv. Lot #—
zip" Date Permit' Issded
f5' I?--
Ik 1/7 4addlz
Separate Sewerage built by 4r —
Mile ystem —Addiress-
Conal sting of Galion Septic Tank and
Z�lt
Water Supply: Public Supply From Address
vats Supoly Drilled by
or: Pri Address
]Building Type Has Erosion Control Been'Completed
Number of Bedrooms 111 Has Garbage Grinder Been Installed?
Other Requirements CL11
I certify that the system(s) as listed serving the above premises were consi
of which are attached), and in accordance with the standards, rules and re . qu
Putnam County D partment,.Of Health.
• Date —71;/ -7/11 -7 C rtiff " by
X. ea 1. MjkAV7, U114
Address 1 ti.-1%06441 w
Any person occupying promises served by the abbve system(s) shall promptly
condItions resulting from such usage. Approval of the separate sewerage /
aval lable (and the approval of the private water supply shall become null d
subject to mods ?cello P or change when,' In the judgment of the,Cdrn
Date 4 8y
0
-a" bu6iic.i
A A the completed work ( copies
P &no the permit issued by the
P.E. R.A.
Zis
nse INO.—
49 correction Il a correction of any unsanitary
r a C'�
sanitary A pp.W- unitary sewer becomes
is available. Such approvals are
Ion or change lsAtcaswry.
Title
4
� f,.
_ ..__ --,
I
,�
:�
M C -
a' a WILL UUr1r1jL11vly r%E1rU�1
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
_
WELL LOCATION
STREET AOURESS; TowillultacKlElly TAX GRID NUMBER'.
Laconia & Haviland Drive Patterson, NY
WELL OWNER
NAME: ADDRESS:
Richard & Nan Schult, 24 Rte. 37, New Fairfield, CT
P61VATE
p )SIVAT
USE 'OF WELL
1 - primary
2- secondary
&RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND.IHEAT PUMP O ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
p INDUSTRIAL O INSTITUTIONAL O STAND -BY 0
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 2 to 4/ EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY []TEST /OBSERVATION []ADDITIONAL SUPPLY
XEINEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 2 8 5 ft.
STATIC WATER LEVEL 25 ft.
DATE MEASURED 6/10/97
DRILLING
EQUIPMENT
❑ ROTARY x COMPRESSED AIR PERCUSSION O DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED O OPEN END CASING 10�7PEN HOLE IN REDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 41 _ fL
MATERIALS: X X2 STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE 0 ft.
JOINTS: O WELDED X OTHREADED O OTHER
DIAMETER 6 in.
SEALx59EMENT GROUT O BENTONITE ❑OTHER
WEIGHT
PER FOOT 1 9 1b./ft.
DRIVE SHOE_fkYES O NO
I LINER: GYES O NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS ._ .
SECOND
_ _ ..
__ . _ . _.
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK In
TOP
DEPTH ft.
BOTTOM
DEPTH It.
WELL YIELD TEST pumping
If detailed
METHOD: O PUMPED I tests were done is in-
QCOMPRESSED AIR , ormation attached?
O BAILED O OTHER ❑ YES ❑ NO
�IELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACF.
Water
Bear-
Inu
Well
Ota-
meter
FORMATION DESCRIPTION
coat
tt.
tl
WELL DEPTH
It.
DURATION
hr. min.
DRAWDOWN
ft,
YIELD
gpm.
Surface
15
Sandy grave W cob es
15
285
Black & white granite .w /pink felds lar
285
6 -
150
60
WATER >Z3 CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? X3YES ONO
ANALYSIS ATTACHEDXX2 YES O NO
STORAGE TANK: TYPE Diaphragm
CAPACITY 86 GAI.. 2
WELL DRILLER NAME MILL DRILL .: , C 0
Putnam Avenue / 7
ADDRESS GPdA �
Brewster, NY R r , ill, 'P e i den
PUMP INFORMATION
TYPE submersible CAPACITY 13
MAKER GOULDS DEPTH 60'
MODEL 13GS10412 VOLTAGE230 HP 1
s1 uy
a
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Owner or Purchaser of Building
Building Constructed by
cam-► � �112 n,O-
Location - Street
Municipality
Building Type
Section Block Lot
Subdivision Name
Subdivision Lot #
GUARAJIM 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 19�-L
General ntracto Owner) Signature
Corporation Name (if Corp.)
G I✓ ('
Address
rev. 9/85
mk
Signature
Title ,e�5 c%e //�►-�
Co ration Name (if Corp.)
OM 4)A)ec Fi= C,!AK eK V y
Address
v - _ • Date OF u
Ad8!en 4 TOMM.
FPP.
a 011118 .. '{.fiL � t," Aran Pm Secdois * . VaIO�
Number at Bmhmi�e (� Desiv Fbw G P D PC® NoMatb6 b Ye4dmd Whoa FW b eiimpNbed
SepMM Sewelow Sydm to Comm dJ
Gabor Saptic T�IdI )
Ti be'end�a�ed Address
Wader Sappy Ftim
Addten
DflBed by - s &M.
at
owr Via.
II represent that 1 am wholly and completely rssponsible forthe design and location of the proposed. systems) 1) , that the aparatt .saw di vi s stem
above described wiil•be'oonstructed ,as'shown on, the approved amendment there to and in accordance with the standards. rules a repo ns O ruinam
County Department of�'Flealth. and that on completion .thsreof;a''•Csrtifiate of .constructlonixompliana' milsfacto►y to the Commissioner of MMKhwill
aloe of the sppfwal of the Csrtif icke of Construction. COmplienCe of the_ orpihit' an NS o, 2) that the drilled .wet said builder will
he submitted to the pepartment and a written guarantee will ba. furnished the owner his swtcasson, MI►s aao » end ; builder. date Of the qau-
Pine in good ope►atinp cohONion My part 01 said sewage disposal system tluring tM of,t' (2) immedietsly following tM
s described above
wiN be located as shown on the approvsq plan and that said well will be installed st s, p f 'the Putnam
County apartment of N eth.
Date SMn
P.E .A.
;�' Addna license No
A PRO,VEO FOR CONSTRUCT14
MIOcable for cause or may be am
►quires new permit. ApWOV4
Rev. . +�
10/88 Dace
M
:.ObTkAM COIIIPI'Y DEPARTIM P OF DEALTS
. to Proylde Fteaodt�� �.
.. �� :.. Dbrlw ae Healtfi Seevkes,. Cat®el. N.Y.1�SU .'
=CERTIFICATE
Fetdt
N FBIIMd' FOR SEWAGE DEAL SYSTM .
7�fflm' air
R u i ij W `ice : i« r _ _ .. i,= zrao ioi �r
o...� x eb %2 (L/f/ /i%�!✓ S }UL-T eel_o
Obi p i ?i Date d Frevlooe Almwi l
M. .. 7-`i 4-Vk 37,A&1AJA1Agdd C'f 1 Town ZIP
Date Subdivision ""roved Fee Enclosed[] Amniinr
BWk%,g Type VJ COT) FiR4M4 Lot Area Fm Secdoo 0* Lj peps Vol"M
Noober a[ He�eoma // Deai@t Flow G V D D ��^^ YC® Nelt&atloo b Begahed When Flo b completed
Sq"reft SOWfa W System to Comm d GaDoa Sepdc T"k Ma 2199 L,J W/
To bwensin6ted byM2 A. 10 Addma
iV.tar soPpb: F11e4 F `q ,,.1"7/�rt/7L.
et: PAvata Stipple Deed by
1 represent -that 1 am wholly and, completely ►efponsible for the design and location of the proposed t
above described will be constructed as shown on the approved amendment there to,and in accordance w
County Departmant of Health, and that on completion thereof a " Certificite of Construction Com
be submitted to the Department, and a written guarantee will be furnished the owner, his succe
plane in pod operatinb condition any part of sold sawage disposal system during the iod b
enie of tM approval of the Certificate of Construction Compile nce o1'tM q 1 sY or a
will M located:as shown on the approved pun and that aid well will be
Irt IQ in" ccoM N. t
County Detract rat of Health.
Date men.
Address OA �lr�/� •!J - ��-
APPROVED FOR CONSTRUCTION: This approval expires two l's *fr' date ed unless -co
revocable for cause or may amended or modltied.when con reeulres a new pare for disposal of. domestk an / r i to water
Rev.
10/88 Date BY
Title
sslener of Healthwill
that saki bulkier will
the date of the usu-
well described above
of the Putnam
E. ) l RA.
!I been undertaken and is
alteration of construction
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD
PERMIT #
WELL LOCATION
Street Address
Town/Village/City Tax Grid Number
WELL OWNER
Name
Sc4qfJZT
Mailing Address
lXrivate
O Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
® BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
® ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT S° gpm /4E PEOPLE SERVED /EST. OF DAILY USAGE CIO al
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION GI ADDITIONAL SUPPLY
ANEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
17eal #a- Gf-c_-
WELL TYPE
;DRILLED
ODRIVEN
ODUG OGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: UI-A,1,4M L..'e4-14_p_
Lot No.
WATER WELL CONTRACTOR: Name l Address: 9i8Wjj4e4—
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY:
%---- TOWN /VIL /CITY r__
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: rr,
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON SEPARATE SHEET
( ate (s gnature)
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
thirt3, (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
any and all water or waste products from such well dril .
property and in such manner as not to degrade or of er,,
Date of Issue• 194-1— X
Date of Expiration '2-1 Permit
take appropriate action to assure that
g operations be contained on this
a se °L contam' to surface or groundwater.
^�
Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date 67
�cNU� l
Re: Property,of
Located
kii
(T) Section �Block . Lotj
&J,-A/
Subdivision of, k
Subdv. Lot .# Filed Map # Date
Gentlemen:
This letter is to authorize J-DA
a duly licensed professional engineer X or ct
(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 provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
P.E.,
Aaares�sj4 ` q /
0/y- ZZ f--17-
Telephone
Very truly yours,
Signed
Owner of Property
-2 V A 3 7
Address
Town
,10 3.. -7 391
Telephone
PC -1
PUT NAM COUNTY DEPARTMENT OF H EA LT H
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: -5 C.14 UL,'f
2. Name of Project: _SS ��I LAM, L 3. Location T /V /C: Ai' i<s
4. Project Engineer:"'Fola y\ )"-Zkre-a ly 5. Address: PO 60k oy
COP-nyel �uy /OPa'
License Number: �3Z- ?� Phone: 2-
6. Type of Project:
7` Private /Residential Food Service Commercial
Apartment's Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject to State Environmental.Quality Review (SEAR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted -1<11_
8. Is a Draft Environmental Impact Statement (DEIS) required? ............. AJ 6
9. Has DEIS been completed and found acceptable by Lead Agency?
10. Name of Lead Agency
1t. Is th.is...projec _ n..an.area, under.the cont.ro.l- .of__: Iocal..plann.i.ng;. zoning,._ ..
orother officials, ordinances? .......... ...............................
12. If so, have plans been submitted to such authorities? ..................
13. Has preliminary approval been granted by such authorities? Date Granted:
14. Type of Sewage Disposal System Discharge...... Surface Water `Ground Waters
15. If surface water discharge, what is the stream class designation ?........
6. Waters index number (surface) .....
17. Is project located near a public water supply system? ............:..... AV 0
18. If yes, name of water supply
Distance to water supply �"e1
19. Is project site. near a public sewage collection or disposal system ?..... rho
20. Name of sewage system Distance to sewage system mkf
21. Date test holes observed: 22. Name of Health Inspector: X /j/ // �-J
i , f 'rte &? 1 1�0 G
23. Project design flow (gallons per day) ................. ...............
11/93
elq
24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?..
25. Has SPDES Application been submitted to local DEC Office? ................
26. Is any portion of this project located within a designated Town or State 6
wetland? ...... ............................... ...........................
27. Wetland ID Number .......................................................
28. Is Wetland Permit required? . ........... ............................... k? a
Has application been made to Town or Local DEC Office? ..................
29. Does project require a DEC Stream Disturbance Permit? ................... 1? 0
30. Is or was project site used for agricultural activity involving application
of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ..... .. YES or NO y
31. Is project located within 1,000 feet of existence of abandoned landfill, v
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? ..............YES or NO
DESCRIBE:
32. Is there a local master plan or file with the Town or Village? 2 f
33. Are community water, sewer facilities planned to be developed within 15 years?
34. Are any sewage disposal areas in excess of 15% slope? ........................ d
35. Tax Map ID Number .. ............... .... ...............................
36. Approved Plans are to be returned to: ................ _ Applicant Engineer
If the application is signed by a person other than the applicant shown in Item 1, the
application must be accompanied by a Letter of Authorization. Failure to comply with this
provision may be grounds for the rejection of any submission.
� of Nib r
I hereby. affirm, under penalty of perjury, tha ,� �ri4 1 O Wed on this
form is true to the best of my knowledge and nts made
herein are punishable as a Class A Misdemeano r t;.;`, c 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
MAILING ADDRESS:
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 SC Hut-7- Address
G.A -coat/ /� 4 07N I LIM
Located at ( Street 0 ILl V (__S Sec. `( Block ( Lot , Z--
n ca e nearest— cross 's ree
Municipalit A / Watershed (,
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run apse Depth to Water Water Levei
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop -Drop in Min. /in drop
Inches Inches Inches
2
4
3
5 '
Notes: 1) T(�Rts 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.
DEPTH
G.L.
611
1211
1811
2411
3011
361
4211
4811
5411
6011
6611
7211
7811
8411
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
-- DESCRIPTION OF SOILE, ENCOUNTERED IN TEST HOLES
HOLE NO. HOLE NO. HOLE NO.
I
9
InM
INDICATE LEVEL AT W'HICH -GROUND WATER IS ENCOUNTERED
WHICH WATER LE-V-EL-, RISES .AFTER BEING ENCOUNTERED
TESTS MADE BY -t- r\ 0 M � - Date
DESIGN
Soil.Rate Used�PUn/l"Drop:.. S.D. Usable Area
No. of Bedrooms Septic Tank Cape citym�6) PRE
-4' ch.
Absorption Area Provided Byl:L10L.F.J2
e
Fam — --- -- Signature-11K V1,445MANVIA-50
Address S
THIS -SPACE FORUSE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved , Sq. Ft/Gal. Checked by
Date
LE
m1p im
AIL.
EX. WELL
00,
xt,fi
rvicat
ith
the
1LDING NALL
51-7°50'40 "W
550 43.55'
N12 Oq"t 11N 5
�O\\ 9
t� 4" PV 4" I. I/4
1/8" / T. IN. \
1000 G. MA5. I BEDRC
SEPTIC TANK
i
512001'
207
LA
ai
FRI, JUN -20 -97 8:08AM TOWN OF CARMEL 914 628 2087 P:02
Lu
' r
OL
a
tr a9 i Z
de
Saga
rA
.001, 060m
1
c
o
Mw ®� �SotIS®
TOTAL P.02
FR I, JUN -20-97 8 :08AM TOIAJ OF, CARMEL 914_628 2087
ci
� 3
p ,.3
o.
F `
i
P.02
Y I
Lu
1
� 0000000•• R � /
Epir
r
a
milph psams\
TOTAL P.02
Z-
� Q
J �
;) W
h -72 °09'20 "W
IC
�N
Z H SILT FENGE, TYP.
p r
LDR 8 FTG O
DRN D150H. Z
Pi ---
3ED (2) ioo;
PROP. WELL
10 NO 55D5 WITHIN 100'
PROP. I.
0 E:
0 N A � R I Y E PROPERTY LINE
(TYPICAL)
PLAN
5C-,,ALE 1 " = 20'
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York. 10509
(914) 278 -6130
° APPLICATION TO CONSTRUCT A WATER WELL-
OA jL n
PCHD PERMIT #w
WELL LOCATION
Street Addr ss To Village City Tax Grid Number
o.--.1—
WELL OWNER
Name Mailing Address
ty." gau a"a:Z2
ivate
D Public
9 OF WELL
primary
2- secondary
SIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
D BUSINESS O FARM O TEST /OBSERVATION
D INDUSTRIAL D INSTITUTIONAL O STAND -BY
D ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT_ �� gpm /# PEOPLE SERVED /EST. OF DAILY USAGE tD gal
REASON FOR
DRILLING
❑ RYLPLACE EXISTING SUPPLY O TEST /OBSERVATION 13-ADDITIONAL SUPPLY
M4EW §UPPLY (NEW DWELLING D DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
O
DRIVEN
ODUG
0
GRAVEL.
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
F WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISI
Lot No.
WATER WELL CONTRACTOR: Name --roe--p> rp Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L*00"' NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY-FROM NEAREST WATER MAIN:
LOCATION SKETCH OURCES OF CONTAMINATION PROVIDED
WJ53P E SHEET
(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
thirt -y (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 conta ce or groundwate7
e
Date of Issue: iI/� / 19
Date of Expiration 19 !Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Dr!
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Re: Property o
Located at
(T)
Date y�_ /� 7
-,
S
Subdivision of
Section Block Lot ;7cZ
Subdv. Lots# S / D Filed Map # / 1s /`7( I"/,j o Date P"7 ,)j-&4,Zr�,
Fa � -
Gentlemen: T' DUCHAEL DALY, P.E.
CONSULTING ENC-- jNEEfj
This letter is to authorize.
i'. 0. BOX Z43
v r Jim
a duly licensed professional engineer or reg'
(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 r1ecessary papers on my behalf in
connection with this matter and to supervise the construc-tion 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.
Very truly yours,
ILI
LiLll Signed
Countersig �. Owner of Property
r} 2 `% 0?, de :3
P.E. , R.A. , # `-t�rY
Address
IIL�i1 0 11.1. Town
Address A ��EE
®�iifL ;Y,
Telephone
e)--? '- 7,11-1vz—
Telephone
` Daalp YYw G iP ! ' )eNo
m
MD l biu m Y
a.rw:�1.�a■e.'s.wa Zt 9 Z �l n! F-'T� b �' -4' x�1'7,r� L4- t✓ '� S
N Cp1l�ktely nlpoafieN fp tM d�fi�n aMf,beatlon',o/ tM p000Md syftmNol l) that-Ahs'• rate �{ H1 ; ftem
iete0 af`ihairn Oe.tM aopovee ameii�riwit tMn to 110 in 4tepidanOe with the, ftaepwvl.,rum own wwu ...
m -OIN tow "'P P MOOaMrset a''"CMt{tkiN of :Cohlti6dw n C~ls t ntleaet.6ry to the Comm' 11 '01 multhwim
n!M aN ya •lwltfyt� Mi►aMaa wlu M Iue�f�IwN tM owwar hl� fuooaneif� hNn or iulm �y, M'twNNr, mat qIN• WNM wIN ,
NIIM;awy, e• nIN't.wn. f� fal/tan .awinj+tM:oMbN ot'twe y!r� Mmmi/IatMY,loNOirN» tMMtrof tM Ie1ur
OgtMkato of Cehetnretle Ca�ililMuoa oY'tM 0►1ji1N1 fyateww ahy r f "Ot the,* we11 flaetlNlM aioro
i aMrMirN Nkn am ttrtpN i� in weN;wxt:he hua11e0 rAaw wlt� ►u1" awt♦ r f the huts
'TIO"I'V b aNMOw.I orN!aa twe y!wf'tro�n tM Aat� "IfNUA ue1Ma eoirftruet of M twiWln! leaf Oaan'urNMt�k6n aM if • . f.
atMOY/ a.i o�MIM'rrlNn eomlNrnO na Y tM CornnNatenM
of "Unk ;AOy,drnp &;Ntwatloe of eevafructloe
fM Nktonl of Nowak nn a/oi Orlwto; water nroofy oi►ty
P P
PUMAM overrTDa toi�.ia ;5
Haal�laeflaa�.�laufel.�I1T l�Slt <rhlwWlrslt•
°r
i.
• afYY lfa.. 5
5�Z 1 32,ti , r' s
DL.N a
Dili of
S»hdiviinri''AnD "rove E
E
,"�"' _
`
r � ��' ,: .��i ,
%1� AlY �.W �� N+ C..�c �
�i� -� `
m
MD l biu m Y
a.rw:�1.�a■e.'s.wa Zt 9 Z �l n! F-'T� b �' -4' x�1'7,r� L4- t✓ '� S
N Cp1l�ktely nlpoafieN fp tM d�fi�n aMf,beatlon',o/ tM p000Md syftmNol l) that-Ahs'• rate �{ H1 ; ftem
iete0 af`ihairn Oe.tM aopovee ameii�riwit tMn to 110 in 4tepidanOe with the, ftaepwvl.,rum own wwu ...
m -OIN tow "'P P MOOaMrset a''"CMt{tkiN of :Cohlti6dw n C~ls t ntleaet.6ry to the Comm' 11 '01 multhwim
n!M aN ya •lwltfyt� Mi►aMaa wlu M Iue�f�IwN tM owwar hl� fuooaneif� hNn or iulm �y, M'twNNr, mat qIN• WNM wIN ,
NIIM;awy, e• nIN't.wn. f� fal/tan .awinj+tM:oMbN ot'twe y!r� Mmmi/IatMY,loNOirN» tMMtrof tM Ie1ur
OgtMkato of Cehetnretle Ca�ililMuoa oY'tM 0►1ji1N1 fyateww ahy r f "Ot the,* we11 flaetlNlM aioro
i aMrMirN Nkn am ttrtpN i� in weN;wxt:he hua11e0 rAaw wlt� ►u1" awt♦ r f the huts
'TIO"I'V b aNMOw.I orN!aa twe y!wf'tro�n tM Aat� "IfNUA ue1Ma eoirftruet of M twiWln! leaf Oaan'urNMt�k6n aM if • . f.
atMOY/ a.i o�MIM'rrlNn eomlNrnO na Y tM CornnNatenM
of "Unk ;AOy,drnp &;Ntwatloe of eevafructloe
fM Nktonl of Nowak nn a/oi Orlwto; water nroofy oi►ty
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130
APPLICATIGN-TO CONSTRUCT A WATER WELL
PCHD
PERMIT 4 P-44 Af
WELL LOCATION
Street Ad ress
p.0 It r
o Village City T x Grid Number
Aj — -°
WELL OWNER
Name
-"
Mailing Address
.v' 0
Private
0 Public \
USE OF WELL
�] - primary
2- secondary
�=M-Hd'SIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
M INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT_ gpm/ #
0 R LACE EXISTING SUPPLY
MfEW SUPPLY NEW WELLING
PEOPLE SERVED_ /EST. OF DAILY USAGE 600 Sal
0 TEST/ OBSERVATION 13 ADDITIONAL SUPPLY
-13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
-T
WELL TYPE
GRILLED
DRIVEN
EIDUG
GRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 4--'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: u—t C
Lot No. !�aZ
WATER WELL CONTRACTOR: Name 7--m Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE-TO PROPERTY FROM-NEAREST WATER MAIN:
LOCATION RETCH & SOURCES OF CONTAMINATION PROVIDED
SEPARATE SHEET
(date) ( gnature
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
thirti, (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 contaminate surface or groundwater.
Date of Issue:
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy.: Bldg. Insp. Orange copy: Well Driller
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
- DIVIS-ION -OF ENVIRONMENTAL HEALTH SERVICES - - - -
Re: Property o
Located at
Section Block Lot
Subdivision of
Date M& -A 14,) 94
Subdv. Lot .=)2 Filed Map ,#
Date
T. MICHAEL DALY, P.E.
Gentlemen: CONSULTING ENGINEER
P. 0. BOX 243
This letter .is to authorize SHENOROCLN.L 10567
a'duly licensed professional engineer or
(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
. - . conne .ction:.with_..th.is ... matt.er and to . supervise • the._ con.structi.on.,of..s.aid
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.
Countersign
P.E. , R.A. ,- ## qez* V
T. MICHAEL DALY, P.E.
Address eoNsut
P. 0. BOX 243
SHENOROCK, N. Y. 10587
9i�-��
Telephone
Very truly yours,
Signed
CKqner of Property
Address
Town
Telephone
03
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
Street.Address
Town/Village/City
Tax Grid umber
tq1 -1 — iZ p�-D
WELL OWNER
Name
Mail ' ng Address
pfrivate
O Public
USE OF WELL
.primary
2- secondary
G- I&SIDENTIAL
0 BUSINESS
D INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT— 6- PEOPLE SERVED 8 /EST. OF DAILY USAGE 600 gal
Q REPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY
LZKEW S PLY (NEW DWELLING D DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
06ILLED
]DRIVEN
[]DUG
GRAVEL.
]
OTHER'
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: O AfA VAV4----'
Lot No.
'WATER WELL CONTRACTOR: Name �� Address:
IS PUBLIC WATER SUPPLY - AVAILABLE TO SITE: YES L--'NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
I (34 SEPARATE SHEET
i
(date) ( ignature
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 su ,ph a manner as not to degrade or otherwise contaminate s�,face or groundwater.
Date of Issue: &gE:z �:�z % 19 T -2
Date of Exp" ation / 19 V1 r Permit Issuing Offic
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
J a
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES'--'-- - --
Re: Pro
Loc
(T)
Subdivision of ----P0TUA -»\ "Ig�
Subdv. Lot # 6, �i 2 � --�1737-y fled Map. # Date
Date
T. MICHAEL DALY, P.E.
Gentlemen: CONSULTING ENGINEER
P. 0. FOX 243
This letter is to authorize SHENOROCK, N. Y. 10587
a duly licensed professional engineer 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 'superdi"s6- the cans true- tion—o.f_- 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.
Very truly yours,
Countersigned
P. E. , R.A.
, -MICHAEL DALY
Address CONSULTING ENGINEER
P. 0. BOX 243
SHENOOROCK, N. Y. 10597
91`41- Z- P- 0 =S-Zy -7 - -
Telephone
Signed
Owner of o ty
S
t�2 2� c �P/ 73
Telephone
C
Zt
Rev PUTNAMCO DEPARTIKE
tai OE
of HEALTH 3 'x w, ?
3/8 Divlelon Envi nmen Health Se vfcee Carmel N:Y 1051? �.• F BTI C eer;to Provide Penult q
COMPLIANCE
on CE \�
Permit q
CONSTRUCTION PERMfl FOR ti AGE'DiSPOSAL SYSTEM
Located at Town or ,VWage
1
Sbbdivision Name' F Sabd: Lot N 5�2�� 3 ZTak Mapes Block Lot
wal, ❑ Revielon
Rene ❑
Ownei6Appllcant Name1C
Date of Previone•Approval
r Town � Z' � 4:a MaWn Addess .
Bdildhig Type �i�7w I4L Lot Area .. FID $eMlon Ody Depth Volume'
Number. of Bedrooms ` Deslgn Flow G /P /D 8� d pCHD Notiflcatlon la Required When Fill bti completed
t.. f
Separate Sewerage• Sys tem. to rnnsi'st of LTI"D Gallon Septic Tank end Z . L11 To be conetracted by �o
• Address
Water•Su Address
orr '✓ Prldate 3apply:Drilled by Z o • 1 - Addreea,
,
Other f ii iirementa .,:.
1 represent that 1. am wholly and .completely responsible for the design'and location of,- the proposed system(s); 1) that the separate sewage disposal i stem
above described_ will' be c am
County Department of- oHealth eand,that on c mpleton the'
hereofeaaCert,fycate tofaconstructlonaCompl ance standards, the Commisslo er of Healtnwill.
'be submitted to the Departmdnt, ;and a wr{tten,'guarantee' will be ,furnished %the owner, hif'fuctessors, heirs or assigns by the builder, that said bui)derwill
place .in good ,operating condition any part of said sewage'- disposal system,,dur{ng the Period of two (2) years immedi y' following the date of the issue
ante. of the approval of, the, Certificate' of �Conitructi6n Compliance of the original system or„ any .. epairs then to; 2) • at the d ed well described above
will be located as'shown on the approved -plan and -that said well will. be;instelled in 's cords a wit he Stan ru s a r ons, ;of the '`Putnam Y
County Depart ant .of Health. . L
Date
,, Signed P.E. -%- .R.A.
Address License No ■
APPROVED FOR CONSTRUCTION This approval expues'one year from the date issued unless construction. of the building has been undertaken and Is
revocable for cause or may, be amended or modified <when considered n'eees ry:Dy th`e :Commissioner .of, Health. Any Change or alteration of construction
requires a new, permit. Approveedd for -d` Sal of domestic sanitary sew ge,'an /or pr ater ply only. //L'
s. Date `"�C� _,.,"_•' .^r'�Title
In
t
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES'
D'a t e MArl 0'6
Re: Property of Y--
Located at L4C.OkYA, N 40 6_u_trJ n -0 iZ y(_7
(T) Block 1 Lot i
Subdivision of Px_13 n. �A
Subdv. Lot # 6-I2I -513a Filed Map # (Q� �jC-� Date .
T
Gentlemen:
This letter is to authorize MI0 f-= ' AL
a duly licensed professional engineer or registered architect
( Indicate
to apply fora Construction Permit for a separate sewage system, to'
serve the above noted property im ac.c:ordance, 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.lprovisions of Article 145...6r
147, Education Law,.the Public.Health Law, and the Putnam County Sani-
tary Code.
CountersUned:
P.E., R.A., #
_PO 30 _7
Address
Q l 4 %Z (2) -oscn
Telephone
.Very truly yours,
Signed.
0 e Jf
es
Town
Telephone
It
PA
- Division Of Environmental H%aj h. Services
TWO COUNTY CENTER - CARMEL, N.Y-05:1- 1 (914) 225. -3641
"APPLICATION TO CONSTRUCT A'WATER WELL
IS WELL SITE SUBJECT TO FLOODING? YES 0
IF WELL IS LOCATED 'IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 1`��7 ►�'ar+.l -n.k
LOT NO. .y -1 51 3i
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES d0
NAMIE OF PUBLIC -WATER SUPPLY: TOWN /V /C
DISTANCE TO PROPERTY FROM NEAREST WATER• -MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION
( ate) i (signature) _
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well asset 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
2. Disinfect the
of the Putnam
permit.
3. Submit a Well
the Putnam Col
until the water is clear.
well in accordance with the requirements
County Health Department attached to this
Completion Report on•a form provided by
anty Health Department.
Date of Issue: �� 5� 19 S,�'"��._.'_= e>i_ -'-� -
�;/ Permit Issuing Official-- -
Permit is Non =Transferrable•
STAEci AUNESS.
i09Nrv1LIAG ,! Y lax VW NUMbER.
WELL LOCATION
WELL OWNER
NAniE. •
AOORESS: '
�
�IVATL
,v
USE OF WELL
3 RESIDENTIAL
❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS
O _FARM ❑ TEST /OBSERVATION O OTHER (specify)
2 - secondary
❑ jNOUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT
— gpm. /N0. PEOPLE SERVED �_/ EST: OF DAILY USAGE 00 gal.
REASON FOR
"EW SUPPLY
O PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
ORILLING
❑ $EPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE
a -tRILLED
El DRIVEN El DUG GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 0
IF WELL IS LOCATED 'IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 1`��7 ►�'ar+.l -n.k
LOT NO. .y -1 51 3i
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES d0
NAMIE OF PUBLIC -WATER SUPPLY: TOWN /V /C
DISTANCE TO PROPERTY FROM NEAREST WATER• -MAIN
LOCATION SKETCH & SOURCES OF CONTAMINATION
( ate) i (signature) _
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well asset 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
2. Disinfect the
of the Putnam
permit.
3. Submit a Well
the Putnam Col
until the water is clear.
well in accordance with the requirements
County Health Department attached to this
Completion Report on•a form provided by
anty Health Department.
Date of Issue: �� 5� 19 S,�'"��._.'_= e>i_ -'-� -
�;/ Permit Issuing Official-- -
Permit is Non =Transferrable•
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
FIELD I�NSPECTI�ON REPORT DATE: 7/X 0/
INSP. BY: :sue b
(Name of Owner) (Street Location)
:.:INITIAL SITE INSPECTION NO
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.. .. .....O./� .....
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells /septics ............................
D.H. 1 Lot D.H: 2 Lot
Depth to G. W. Depth to G. W.
Depth to rock Depth to rock
Soil Descri tion
0/ft.
,t
3 ft.
6 ft.
9 ft.
12 ft.
V M21�i
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 Lot
Depth to. G.W.
Depth to rock
Soil Descri tion
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
DATE:
FINAL SITE INSPECTION INSP.BY:
Soil Descriptio n
°
CONVENTS
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 ....................
Natural soil not stripped or SDS area
unnecessarly graded.............................
10 ft. maintained fran 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 from driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
FINAL GRADNG OF SITE ACCEPTABLE..
rte f er
3 ft.
�-ra U
6 ft.
"''a�;e4. c
9 ft.
12 ft.
Soil Descri tion
0/ft.
,t
3 ft.
6 ft.
9 ft.
12 ft.
V M21�i
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 Lot
Depth to. G.W.
Depth to rock
Soil Descri tion
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
CONVENTS
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 ....................
Natural soil not stripped or SDS area
unnecessarly graded.............................
10 ft. maintained fran 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 from driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
FINAL GRADNG OF SITE ACCEPTABLE..
L
__
. '.'_.yj•f.iar.r. Y -}ry. �..ywM-a•v WrwlL.Mrw. n.�.YU•v �'`�' ^^ � •J.
•I•@J vfl.vi •<.u•KY l)1.. - .. - .- t M1�q -. .Yh . ...t �� '
._ �.� «'.��riu..F•. "� �uwY rr ,��� ? —� vY....w�AY.�I. 4.h -� -�wV -. ..
C-..D
- p COUr7I'Y DEPAF�iT OF HEALTH DIVISION - Oil ENVIROUMML BEP,I,TS .SERVICES ...
INDIVMYJAL WATER SUPPLY & SUBSURFXM .MODE DISPC .SYSTEMS
` r
REVI�T
SHEET��= M==N PERMIT
✓' � t'',� � -.���:.�%� �- BY:
REVD -� ��
(Name of Owner)"' (S treet Location)
CCYwENTS YES NO DCCUKaM -
Permit Application
- corporate,Resolution
Plans - Three • sets .
Engineers Authorization
�.- Design -Data Sheet (DDS)
�'
i
Ie__ �_e�-
Other
House Plans - Twn sets
If--M - Letter
ence Request
REQUIRED DETAIIS ON PLANS
Sewage System Plan
sewage System Hydraulic Profile - Gravity Flcw
Fill Profile & Dimensions - Volure
W D -or J Box;Trench /Gallery; PmV pit details
Septic Tank - Size, Detail
- Well Detail, Service Line if over
~,Construction Notes
_Design Data
Two -Foot Contours Existing & Proposed
,.Driveway & Slopes Cut
.Footing/Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
epanSion Area'; shown; gr-avi ty flow, stiff .' si'ie _ .` ......_. .
If'Pumped Pit & D Box Shcwn & Detailed
House - No. of Bedroaas
Wells & SSDS's w /in 200 ft, of Proper--ty Loc_ted
Property Metes & Bounds
House Setback Necessary (Tight lot)
House'Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Fends 45° w /cleanout
5F-PARATION DISTANCES SPEX; IED ON PLAN
10 to P.L. , Driveway, Large Trees
20' to Foundation Walls
100' to Well; 200' in D.L.O_D, 150' pits
100' to Stream, Watercourse, Lake ( inc. ex-man).
15' to Drains -C rtain,Storm,Leader,Footing
25' to Catch Basin
" 10' to Water Line (pits -201)
-- Sei)tic Tanks
10' f roan Foundation
50' to Well
15' Well to PL
COAL
Iegal'Subdivision
Subdivision Approval Checked
Ex approval SSDS Adj. Lots Checked
lietland- (Toam/DEc Permit R & D)
. Data On DDS Plans & Permit Same
`
PUTN�M CO(JNTY DEPARIMrrrl ur
•
SSDS/WS REVIEW 5HEET - DETAILS
a. SEP= MM D=
,:
cL WALL IEIgLTL
1.
Ot1Prt 2" bA inlet -
-1.
Ztp of caring 1811 - - _
2.
Minirrm 3" bad of pea gavel
2.
itp d 0'13 2' above F,,L cr wtectidfit
3-
yl-L in cf J#d& 4' -
3.
Minimm 20' casing of steel cc Ott irm.
4.
Ta)gf-h - tnLmmm twice width to rmx3mm fog
4• .
10' minimzn gout into rack,
tkas width. 1
5.
C1*let 4' hO cw O.G. Iran.
5.
MEcd=12" air.
6.
si tary rah -
6.
I=ticn sWce-
.7.
Gcni3 grzdEd a ay b= X11. .
7•
btftl e - qmrli rxg - mffi rnrn 20" in suer
dinta iaL _
e- aMm ESPM LEIpiIIS
8.
n--fn ecteid 20% cf liclid abate 1 gEd
1-
OX3filI to allcw fcr s`trlirr,: 4 "•-6" _.
level WF4,, b=1011, 6:51,b -12 ")-
2.
6" -12" natural soil bxdcfiL.
9 few -�5��}
3-
U tt�tsl b+�igaljdu �'-
�(9�.
1.0.
LIf,.,1,,,�,,.,'yh�,GG.T.
(p2�c//z� {n�ents1.�'�
1`'i1nlHllrl ark �ty 1.WO E0 .r +200
4.
,�{�.�
i" to 11" dj-=n gzve cr: st l i p.
ga , h�kc=134 co bam;161 cf/4 b2 m
5.
1-fin. 4" pedmtEd giFe.
11.
Baltic acating fcr minfamd fie.
6.
Pip kweLt 6'_ cEf bottaiL
12.
Inlet e 1E' bely flew hie
7.
18" - 24" wide bzrh.
13.
Ctiklet to J, e 28" bElcw flan 1ir-_
8.
Lath mate.
14
zniet pipe slcpe :" p= foot nnn. (2%) .
9.
sepm ucn from SMS arta 15' min.
15.
M- Pf- piFe cast i=, 4'Yri.n.
f- a: P CR aN3'ICN B33 rE=
16.
O±let pipe slrpe 1/8" p= foot min. (1 %) .
1.
Femvz e bac cover.
17.
� j:� fcr EFc taq te~s-
2.
0==tcr n*lr+ la" aba21at 1 a ==
11fyi• 1: R / :/ 13if•
1. Inlet invert ndn. 2" above at et kwert
2_ PJ.1 cutlets at s e1'vatim
3. O1_.s 1" to 5" above tank hCttcrn.
4. Minimm 12" be33i.ng clean s?rxi cr p�a c mva-
5. Inlet ale-
6. N Ddr 12" ate.
7. Feeble cater ftr ate.
8- s�1 ;�i pire jou (as�altu.c cr eg$l)
9. Slop` Qt ets at 3,/8 -irvft (1 %)
10. FYcst p rtecticru.
_- - VVVIO 1•i9 • •119•
1. Slr e 1/16 in./ft. to 1132 in_ (0.5% to 0.25%)
2. 3/4" to 11" canliEd stcre cr gravel
te-
3. 4" mini= lat moral di.areter-
4. 2" mir±= aggragte aver lat aal.
5. 6' zriinim n aggaM- to tx-B'-r late. -al..
6. u- balding parer cr 2" .ef straw ewer
Ate-
7. . 6" ndnirrun, 12" MmLInm eari-h Yeddi11-
8. cvErM to allcw fcr settling, 4" --C'.
9. 2'nanirrun faun t ru h bott'.cm to rater- 'Sft.gc-a�
10. 5'mtn -fran t rerrh bottan to irTEEvirazs
7 ft. gme-
11. Mimrh spcingman.6'O.0 (24 "tcen:7) .
12. tizrsrn:br=d lateral arts mst be pltxggEi.
13. Fill. - 2:1 slc�
win. 10' balmd trerh.
dEpth:31'mc.c v r xock +,- 2'uax -air Vate*
3. iatEmis fi,� with bod=n. _
4. TiG�tpipEs behem -b=es-
P[TE M COUN'T'Y DEPARZ4W OF HEALTH
DIVISION .OF HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE S&gAGE,DISPOSAL SYSTEM FILE NO.
Omer 'F-AZ�.��� Address
Located at (street) AA.e1 ` y Sec:. Block �_ lotZ
(indicate-nearest cross street)
Municipality ��- ,,y Watershed 11-PCT1j^n- \.
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMIT= WITH APPLICATIONS
Date of Pre- Soaking Date of Peroolation Test i�5 1 Z G
HOLE
N_ (BIDER C= TIME S 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
2
3
4
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 subnitted
for review.
2.. Depth measurements to be made fran top of hole.
rev. 9/85
2 o
IZ
t 3
-Zo
.
4 _
t `� 1 �'
t'1
7-0
-_5
'Zp
-t, 10
I ... ..
aft
�o
��
? -. 3 O .
I S�-.b
2540 -
t5 .. L S -.....
1
2
3
4
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 subnitted
for review.
2.. Depth measurements to be made fran top of hole.
rev. 9/85
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. LL
21
3'
41
71 c E Lf
81:
91 f Vf
10,
121
13'
INDICATE LEVEL AT WYIC9 GROUNMNTER IS S ENCOUNTER . ED �n (/ �
INDICATE LEVEL TO WHICH WATER LEVEL RISES M= BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: o DATE: TUW
DESIGN
Soil Rate Used ( Min/1". Drop: S.D. Usable Area Provided - tb'c) VJA
No. of Bedrooms 4- Septic Tank Capacity I gals. Type
Absorption Area Provided By. 2 r 1—
. - Other -OWIFIC
Name 77 Signature
Address
1 o2a?
THIS SPACE FOR USE BY HEALTH -DEPAR24EM I ONLY:.
Soil Rate Approved sq.ft/gal.
SEAL M lk
Checked by , Date
� 517 °SO'go "W
3
a
0
w:
PLAN
zo
A
o q' 2.d' w
L AC-ONA OZJVE�
Cam•
a
7
S -
"This is to certify that
Lhe sewage disposal syst--n was constructed as indicated-ch this plan and
that the system 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 New York
State Department of Health." 97"
I
4W AWW%
0
3
lqilc-lp
en Ue alt
6f
h
emm
80 ,,jg
Al
5i-722: 5725 S
06
' 5772
010 tj
1 4 too, 051 0
33 W
s \ -05
9-7750
910
CONC' 5`0#4- X77 QED
77f7VX-
729
\
2- 6 00 , \7 A16' 5726
t
5727
_4
�t 5725 - ( , .
SCA% V� LACXAIIIiIIJA Plow
.5-L/4 V-4- Y
�4CIIV5
AS-BUILT -
MEASUREMENTS
NO
A
B- C
-Z Z.-
T
5C)
3-7 q1
3
2-&.
9T
(a q i 5R
IT-
(,o 7-
.5 Ll
5 -70 (0
5c 74 r�rr
P)Z--'mA,*-Y
W'- F-6LO -z- 10
L-f- P9" -Z, 2.,2- *
",45 -eolz-7-
55D
g14YACa
IdL
EX. WELL
x 6,
0c
I �- ---
DING WALL
58 0
510
It 100% EXPANSION AREA
% '-NO WELL WITHIN 100-
PROP. 5505
1000 G. MA5.
SEPTIC TANK
I Pfzopo9Erl> (2)
BEDROOM
9
_ W \
PROP. WELL
NO 55D5 WITHIN 100
PROF. i
20
LACONA L,)Rl-\,/E. PROPERTY LIKE
(TYPICAL)
FLAN
SC-,ALE 1 20'
FENCE, TY-F.
Z_SILT
Ln
LDR 4 FT&
r:>F;ZN D 15CH.
411 FV:1
4" .►. 1/4",/FT.
/
jj /T
1/5 T.
IN.\ i
1000 G. MA5.
SEPTIC TANK
I Pfzopo9Erl> (2)
BEDROOM
9
_ W \
PROP. WELL
NO 55D5 WITHIN 100
PROF. i
20
LACONA L,)Rl-\,/E. PROPERTY LIKE
(TYPICAL)
FLAN
SC-,ALE 1 20'
p\IL
580 8.55' I
N-12'Og r2�2 "W
5-70
80.00' 1 `• Z
i
N12 °09'20 "W
LDING WALL
i
FLAN
SCALE 1 " = 20'
SILT FENCE, TYP.
Ex. WELL
�r
m/
LDR E FTG O
@ DRN DI5CH. x
Q
i 4" PV
w PI
4" .I. 1 /4 "/FT.
1
iOO
1000 G. MA5.
EDROOM
SEPTIC TANK
i
6
MIN.
PROP. WELL
NO 55D5 WITHIN 100'
__-
PROP.
i ' �►.
+ 5 -72 °09'20 "E
AO �A
RIVE E PROPERT( LINE
(TYPICAL)'
LDING WALL
i
FLAN
SCALE 1 " = 20'
:?E
UL
EX. WELL
1,00,
I � -:: --
DING WALL
550
SI7 °50'40 "W
N-7 -) -Oci 2010q
-7
80.00'
100% EXPANSION AREA
"NO WELL WITHIN 100'
PROF. 5505
1000 G. MA5.
SEPTIC TANK
PROP09ED, (2)
BEDROOM
V
O
W \
PROF. WELL Ica,'
NO 5505 WITHIN
PROF. i
WE
LAC.,ONA DR I VE PROPERTY LINE
(TYPICAL)
FLAN
SCALE Ill.= 20'
DH SILT FENCE, TYP.
-LIN
LVIR S FT&
4" PV'
115" T.
Pi
4" I. 1/41/FT.
1000 G. MA5.
SEPTIC TANK
PROP09ED, (2)
BEDROOM
V
O
W \
PROF. WELL Ica,'
NO 5505 WITHIN
PROF. i
WE
LAC.,ONA DR I VE PROPERTY LINE
(TYPICAL)
FLAN
SCALE Ill.= 20'
55742 57*1 97140
A - 00141199l
R : 6m
. "Jo9 020A�a
7jo,
''
61
5770 _ t
5129
JIA,%b 57128 it
VW. V0572-7
5721!
A You.
Maw
5L;RW!Y0 PROMM-.-
rREPAW12 FOR
MCFAW L... & NM P. 5CHU,r
� NOS. X110 -5115a
A5 %iOM ON
15-4+" MW OF FIA!'" LAKE. FSXV MW NO. 1496, F"V 3 -20-31
511UNM N
TIOWN Or- PA1 R5M PUTNAM CO., N.Y.
5C&F': I" -- 40' JUNF, 25, Iii
CCF'dacz`lf @ 1997 TeWY KRaWORPF COU.M, &I, W" M%k-vW
CWW&GATICA,6 lWr-ATVt7 HMON SIGNIFY 145
9"Y WA5 PFEFAREV N ACCOWNsICE WtlH 1W
l!)(151N6 GODS OF MACfla FOR LAW 5WRY5
ADOPTED BY 1W NEW YORK %Alt A550CLATION
OF PROM551C*M LAND %WvtYOI?5, INC.
aWTVICA11ON5 901-L KN OWY'110 ilf MR50N
FOR WHOM 1HS 51JEWY WA5 PWPARW AW ON
H5 MKALF'110 *E TITLE CO. AND LZNI?M IN9n-
111roN L.151W W-WZN.
CWMIC-AnON5 AM NOr MAR5FMAME '110 APM-
110R& -IN5fmjn0N5 M 505MBW OWNW5.
irdWY !t30-hVe7kr-F rjOU-IKK
IW ALTERATION OF 9JMY MAIR5 DY M
OrHeR TKAN IM OWNM PIMPAMR 15 h
LeAmz, cow1.54w *v Nor N im a
WELFARE NV PeNfftr OF 1W PUPLIC.
L-MIN15W LAW %MY017-5 5KALL NOr o
51. wy MW5, %RVF-Y PLANS OR %mly
PIMPA00 DY ofw55.
1.14AUMORVet? &SRA110W OR APPI1110N
5LIMY 6 A VkXAIION OF 5ECIION * 7
IW NEW YOM 9rAlt ePLIC-AlION LAW.
1W LOCA110N OF UNPERCROLS-V IMPlag
OR eNCWACHACW5, IF ANY M54 OR AF
FMON, AM NOr CIMMEV. -
ALL aVffIGAYI0N5 ICON AM VALID f
MAP NW COM5 IHMM47 ONLY IF 5AV
COPIF5 MAR THE IAAFRR5%t2 5F& OF TH
5UMYOR W40% 51a4AIM AFMAR5 4
f
6482'
A - 00141199l
R : 6m
. "Jo9 020A�a
7jo,
''
61
5770 _ t
5129
JIA,%b 57128 it
VW. V0572-7
5721!
A You.
Maw
5L;RW!Y0 PROMM-.-
rREPAW12 FOR
MCFAW L... & NM P. 5CHU,r
� NOS. X110 -5115a
A5 %iOM ON
15-4+" MW OF FIA!'" LAKE. FSXV MW NO. 1496, F"V 3 -20-31
511UNM N
TIOWN Or- PA1 R5M PUTNAM CO., N.Y.
5C&F': I" -- 40' JUNF, 25, Iii
CCF'dacz`lf @ 1997 TeWY KRaWORPF COU.M, &I, W" M%k-vW
CWW&GATICA,6 lWr-ATVt7 HMON SIGNIFY 145
9"Y WA5 PFEFAREV N ACCOWNsICE WtlH 1W
l!)(151N6 GODS OF MACfla FOR LAW 5WRY5
ADOPTED BY 1W NEW YORK %Alt A550CLATION
OF PROM551C*M LAND %WvtYOI?5, INC.
aWTVICA11ON5 901-L KN OWY'110 ilf MR50N
FOR WHOM 1HS 51JEWY WA5 PWPARW AW ON
H5 MKALF'110 *E TITLE CO. AND LZNI?M IN9n-
111roN L.151W W-WZN.
CWMIC-AnON5 AM NOr MAR5FMAME '110 APM-
110R& -IN5fmjn0N5 M 505MBW OWNW5.
irdWY !t30-hVe7kr-F rjOU-IKK
IW ALTERATION OF 9JMY MAIR5 DY M
OrHeR TKAN IM OWNM PIMPAMR 15 h
LeAmz, cow1.54w *v Nor N im a
WELFARE NV PeNfftr OF 1W PUPLIC.
L-MIN15W LAW %MY017-5 5KALL NOr o
51. wy MW5, %RVF-Y PLANS OR %mly
PIMPA00 DY ofw55.
1.14AUMORVet? &SRA110W OR APPI1110N
5LIMY 6 A VkXAIION OF 5ECIION * 7
IW NEW YOM 9rAlt ePLIC-AlION LAW.
1W LOCA110N OF UNPERCROLS-V IMPlag
OR eNCWACHACW5, IF ANY M54 OR AF
FMON, AM NOr CIMMEV. -
ALL aVffIGAYI0N5 ICON AM VALID f
MAP NW COM5 IHMM47 ONLY IF 5AV
COPIF5 MAR THE IAAFRR5%t2 5F& OF TH
5UMYOR W40% 51a4AIM AFMAR5 4
L Or2t6 (7iZADl
_ . 92 l e OF x 4 ZsAI LAYS
DISt2t?>tJ ?IJN E'Ox 5L;,—, LbVBL UN c
_.. 'JEL-D tv f, <DyT 9 s f
I°120F LZ-- DIA,(aleAMAT
WBIV
10-1 ?1 ', aGAI ttO(Zr I "' 2OI
J '
.P
J
Y
AaBA' = 0.4 0 A[.M
D' (MINj
` 1259 MA�ri ; T 5r iG 7A,NK
._. _._ - •_^' _" -mss :r •.
Ir' MIN)
i9 No lN,TH `I IQ7
.1� -
�
At D
y� �
i
m1