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631- 589 -8100
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DEPARTMENT OF HEALTH
Division Of Environinental I!ealrh Services -
• �� Y O PUTNA,' t COUNTY DEPARTMENT OF HEALTH
STREET AOURESS: WN /Vt TAX GRID NUwIEA:
_ WELL LOCATION a t a 6 Ke, A I-re rs,
WELL OWNER
NAME ADDRESS:
C'
IY PBIVATt:
O PUBLIC
USE OF WELL
1 - primary
2- secondary
Rl RESIDENTIAL O PUBLIC SUPPLY O AIR /CONDAEAT PUMP ❑ ABANDONED
❑ BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify)
O INDUSTRIAL O INSTITUTidNAL O STAND -BY O
MOUNT OF USE
YIELD SOUGHT ___,5_ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
YEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL 3S ft.
DATE MEASURED
DRILLING
EQUIPMENT
O ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT ❑ CABLE PERCUSSION 11 OTHER (specify):
WELL TYPE
.ti
/
❑ SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH _ ft-
MATERIALS: STEEL ❑ PLASTIC O OTHER
CASING
LENGTH BELOW GRADE ft.
JOINTS: O WELDED YTHREADED O OTHER
DETAILS
DIAMETER in.
SEAL: O CEMENT GROUT AENTONITE ❑ 0TH
WEIGHT
PER FOOT 1"S' 1b./ft.
DRIVE SHOE YES O NO
LINER:OYES IdNO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH ((t)
DEPVAO SCREEN (ft)
DEVELOPED?
FIRST
A A
A
S ONO
HOU _
SECOND.
_... _
GRAVEL PACK
° ' s
❑ NO
GRA E
SIZE
DIAMEV
OF PACK in.
TOP V
DEPTH tL
eorT
DEPTH ft.
WELL YIELD TEST I( detailed pumping
METHOO: O PUMPED 1 tests were done is in-
I ✓COMPRESSED AIR , ` ormation attached?
❑ 8AILE0 ❑ OTHER 0 YES O NO
WELL LOG If more detailed formation descriptions or Sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ina
well
Dia'
Ineier
FCRMATION DESCRIPTION
cNE
tt
ft
WELL DEPTH
ft.
DURATION
hr, min.
DRAWDO`NN
It.
YIELD
Lund Surtuc
76
6
WATER CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? O YES O NO
ANALYSIS ATTACHED? O YES ❑ NO
STORAGE TANK: TYPE C(�lf �'fr-t, %,` CO
CAPACITY DMa:r� -„' GAS.. FO
PUMP IHFD NATION. ��r�� ��,�,.
TYPE �% CAPACITY __L_ /Q
MAKER uh Z5 DEPTH _
MODEL �S ❑s' 9 VOLTAGE ��OHP_�6—
WELL DRILLER NAME DATE 1! ,
Ao ERT M. HYAIT .& S6N5, s1N&,rURE O
Well Drilling
Rte. 311 ' R.R. 2 Box 171A
a/ o7 rm i t nrcoUw, ivwv T Urcr\ LcUoa :/
m
PtTPNAM COUNTY'DEPA OF HEALTH
DIVISION OF ENVIRONMERrAL HEALTH SERVICES
Jerome Smith & Bridget Kearns 66 6 1,2, &3
Owner or Purchaser of Building Section Block Lot
D.E.W. Construction Inc.
Building Constructed by
Hazel Drive
Location - Street
Health Department
Municipality
Hbuse
Building Type
Subdivision Name
Subdivision Lot #
GUARADPM 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 2 8 day of June 19 94
eral ntrac (Owner) - Signature
D.E.W. Construction Inc.
Corporation Name (if Corp.)
• :•. 1 - ••
rev. 9/85
mk
Signature
Title Vice Pre ent
D.E.W. Construction Inc.
Corporation Name (if Corp.)
P.O. Box 420 Patterson N.Y.
ess 12563
YML ENVIRONMENTAL SERVICES
321 Kear Street l
Yorktown Heights, `NeYo 1
_ . 598
24 00 T.
i _� 914`D .� _5 29 h
Al bert H. Padovtni ,,,Director y4
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PO 'BOX X420 F,.:,��d,1 F- ST DAT'E /TY��tEC ,D =:'06/24/94 44 00-
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DATE FLAG - PROCEDURE RESULTf�ORMP,L RANQE
06/27/94 MF'T. COLIFORM ABSENT /100 ML 'ABSENT,
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DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Summons, M.D.
Deputy Canmissioner of Health - FIELD ACTIVITY REPORT - Sheet of
INSPECTION
NAME Orig. Routine
Orig. Canplain
ADDRESS Orig. Request
o. St t Tm Canpliance
N ie
/6f� _ Canplaint Comp
MAILING ADDRESS Final
P.O. Boat Post Office Z p Code _ Group Illness
Construction
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE TYPE FACILITY
TIME
t
FINDINGS:
TIME LEFT
Signature ana -rice
PERSON IN CHARGE OR INTERVIEWID:
I acknowledge this Field Activity Report. SIGNATURE:
Z.
TITLE:
Reinspection
Field, Sampling Only
Field Conference
Other
3 '*� dP
Explain
mm
y.. d
Ell, i
bA0
S40mb s wy 'sj is Comm d
y �. b
� .`• <' 1►ijrNallt tnif t inl who11Y aitd- ewnlrNt!h! t„OonfieNifor tM AisiCn and ?N
aboso daieritNO will -bo- condrvdoi�ss thii6n'" Ae spC►owO:sii4 ritilm
t cadotti . DaMtrtamovi N "not ft. am that on.caholatloriaherso/ a - COitlfw
• ° , ,. M wiMrNetM to.;tffo Wt♦MtslwM, and a wrNtsn �IiafMltN' wN1�tN lurnhh
poici iR'99 .NMMYN` etiMNktn inY tti►f' M aide sow— `fMloal "sy t:
so" N tlii aMrwiN M.IM CertMkale el Cewstrudlat Comfaliina of i
tfo.boM�d N t�tayrw M tM at ►MiM taNh aM that soW wNl wNl tfe 61IM!
C�rntn wMt. ►IdtR • � -
Af MOVCO FOR CC)f' M lCTION:ThI/
i bisrN for'CaYM or." M afuotw a
r
follow" • . taermM. AMrwM .hr d
��Q�By Oi1b
n
rtsn of �on�itilc
lon:; of thi' ;prOpOfW. fyttern(flj 1
to, 804 M,04mAinCe WR.Wthe.ftan
.Qw construetlon CornWwww. all
tlietownM. MisuoiaMOn. 11eMs w
dwNN tlii.prtod.o} two:(!) yaw,
aljinal *ft- - or, any iMtis t11M
'wish eta
that t" se wits swr o dl al a stem
rats, rules a q
ru
Sdory �to the Commialorw of t♦rQhwin
y the Wilder. that pl/ .bm"w win
M-2 tNy folkrwlno tMMta N the Mw
t) the drilled wNl•deWI M 06*m
ru _ a r"Gur" f, lh� putoom .
..� E //• ICA-
A��,rjLrtaceiar wo 'HX
Nis tonR�uetfon oft buildkq leas tlMn undartiken and is
Ismoloor of Maalth.• y Chang. or altsglion of. ConttruttN¢.
watts supply , only
TRN
/"��� \/ lVlflwl[ COUIfti DElAlif�fi 0F0EALY8 M �iwW PON*
,� s Defltlr t[O�wnaYl BNB Sf=fYss; dlwofi. !1 Y 1519
w C�ID7GlS O1r O�Q11AlICi
lO�.l l�1► Or40•iL SYS1�Il
lrslt /
•
'lie
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: .. 4 ;i 'f ,��' $ x .-� �S�CY r?.. _ Y � .1 �.«
nArp 'St,hdiv` -iwibn Approved t" Fee. Enclosed®
Y
D�a1�rF)nr G � 'D Nf�nflfa "YSigi�M Wrw F� Y.as�MIN
ui �prw�nt +� Mt�l wholly aW eanWitNy rofoefi®N io► tM AMi4e indaloution of tM propofwrd syitom(gi 1) tMt tM ato Al tiU
"' a0a±oo dne+Nlod will;,a'o0hftroet09 of hourh,a,' M �pprowd •inor,dniorit tR n to <an0 M NtWidtino� with RM ftandNdf. ruNS,a u �� ow �Tkw
=' ebway ,WOwtwt of `W"k. pld ",fhs1H on tOlhyMtiOli thgwt a 'Cwtifiyft� of CoiatruOt Con,Wtfha" ntiffactory: to the Comm! of FIMKhwlq.:: thiiuww' "No aid ba"mr, -mil
s MKy in"ped`MNaW tCOMMIM o1raW f!MrMo d— wf fNr? dwNi� tM ha! f•(s YMrI ioMl tNy lOMiy» tMdNe et MtiNw
M01 'oi 'tM Oink "tIN CNtMit�b M. Cepetreetiai Cbw101bhp of "tM orpNwi fyit or Y rNf6f f_ i 2) t, tM°drMW :wadi dito►Md atioM`
fnNl N to �tsd M,ilinfrs df, tMe irk 6" tMt tithl wNl vrNl'N Inftal M _ wit tM u, ft0 rNYii f of tM hRwfni
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' ;NllC grThb ajpvowl �xOk f, troan',tM'dit isfuid`,unlnf =wnftrYetWwrr';01 t ulldby h�f hoM, LodwtiikM and'i{
rorOpdN f01 CWp 0► fM tl W nNtoA whori Y t1Y 'tM oenniflioiNr Ot FIMKh; ny d,n,�f aKwfitloe of eoiutrwKion
,', ftIf111MM • iNw ti'f►111 AfpoirW for dh�oml df WONb oh�Y
pNt�•�wltM � '�'
- ''VD�. k.:We. -° +.+- _.,'w 1v „•;�' ,•,�y3.- �++��r-�sw< �r "-''`�'... v x '"�� Vi``'?`.��'.�� -•�� .. ,. � .�,.- r ,. .. , .• - .„. 1
7
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
-7 Y !Z T
WATER WELL CONTRACTOR: Name '1 i�� 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 SKETCH: &�OURCES OF CONTAMINATION PROVIDED
4-31 *815k SEPARATE SHEET
L
(d te)
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�� (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
Department attached to this.permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
1 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---mntaSj,.qate surface or groundwater.
Date of Issue:- 19
1 �te of Expiration 19 Permit Issuing Off cial
+t Non-Transferrable White co : HD File Pink copy: Owner
is copy: py
Yellow copy: Bldg. Insp. Orange copy: Well Driller
P•
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
PC1HD PERMIT
# P -7,5--Bb
WELL LOCATION
Street Address
Town/Village/City Tax
Grid 'Number
WELL OWNER
.�. Name.
,� � l" A
Mailing
S Z
Address
ivate
O Public
USE OF WELL
primary
- secondary
SIDENTIAL
® BUSINESS
® INDUSTRIAL
' ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM 0 TEST /OBSERVATION
O INSTITUTIONAL 0 STAND -BY
.O ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT gpm /46
PEOPLE SERVED__ /EST. OF DRYLY. USAGE_ W0 gal
REASON FOR
'DRILLING*
® PLACE EXISTING SUPPLY
W S PLY (NEW DWELLING
0 TEST /OBSERVATION 12. ADDITIONAL SUPPLY
® DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILI,ING
.
WELL TYPE
RILLED
DRIVEN
ODUG
O
GRAVEL
O
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES N0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ► 0T?JAron
Lot No
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC.WATER SUPPLY AVAILABLE TO SITE: YES t/NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATI N SKETCH & SOURCES OF CONTAMINATION PROVIDED
N SEPARATE 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
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 dril g operations be.contained on this
property and in such a manner as not to degrade or of erw se contamin to surface or groundwater.
Date of Issue: 19�.
Date of Expiration 19 12- Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner .
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
C.. f RJ�.11. tw.s S.:YS
` ` P)UTNAM COUNTY�DEPARTMENYOF HEALTH
t sion o nm �tal'Health Se Carm 1
® Dlvi f Eaviro en rvloee e N Y 10512 ; Engineer to Provlde'Perssilt lY
1 P x on CERT�[CATE.OF COMPLIANCE -
Y / f , L a Y.i i� { "f V .r 'Permlt N .� •/ `/ }�
CONSTRU N PERMIT FOR SEWAGE,DISPOSAL SYSTEM �� LjJ` y
a 1 r
a-rel .
Llicsted at�'L TJ� \`` L F Town of VU -e
Sabdlvisloa Nrame��(Tl.11kl�l' LAS Sabd'.Lot IY +81''i Y1'4'a' Ta= MeP �D�C7 " 'Block tint.
. A
Owoer /Applicant Name "G"I�^'�1 eID�I ' LiCJCflAA1:�
Revision ❑
`Date of Previons'Approval
Ballding TypeiQcLy Lot Area o FW Secdon Only Doptlt_��Volame
Number of Bedrooms t i_� Design Elow �G P D , PCHD Notiticstlon.le Regdred When FIII le completed
i -•♦
" Sepaite Sewe age System to consist of 1 �, Galloa'Septic TaaltYiad Z�J d' �� I co' •1..''11 .��
rr
To 6o cbastracted by Address'
Water Sappy. Public It apply From - �Addreas
' r
ors' +�Privite Sapply'DrWed 6y; ��''r Addreee5`
s
s Other; Reoaireeteats t
t
s I iepresent,that<l am Wholly antl• completely responsible for the design a d location df '_the proposed°fystem(s) ,i)'that h separate sewage disposal ^system
;above'describetl w�ILbe.consfructed as shown on.theapD,ro4etl amendment theie',to and in ••accordance w�th.the standaitls- .,iules'an regu a ions o e u nam
i;y� County �gepal;finent ,;of Health,' •and that on completion thereof a .- f>erhMcate �., 'CO, Con ;Cructlon•Compluhce sat{s}actory to the Commisslone�:o1 Health will:
;.
�• , .,- ba,'wbmtted:,to thel'Dapartinent and a written.quararitee:w�ll,be "•furnished' the ownei his wccesfori heirs or ss�gns by'fhe builder, thai said builder Will
r Dote- �n good operating condition any'-part of ,said .*sewage tlisoosii iyste wdurmq! the periodtof.two (2{ y r immediately following the:gata of the lau•
l _
,, • • °erica• of, the.,'a.Pprovai, di ,the !Ce'rhi,catev of ConstrucLOn Compliance of tns „orig,nalRsystem or,any reps' her to )that; the drilled well tlescriboo 'above' '.
•. -
.,:,will be louted�asshdsrvn:on thespproved Dlan antl•'tnat sa�d.wefl wJl tie = installed °'in �aecor ace th 'they der s, les-and requ actions f :the .Putnam
County Depa "r,` an of ;Health.; r. t"
.r
_ r
r_
` Adtlress t License No
APPRObED?FOR CONSTRUCT ION, This approval: expues; two years •-fromxthe, date issued unless const” ctio of the buil0ing he been urideitaken antl is
ievocaDle foi cause or.;may De amended ormoditied when'considered ' necessa % y:by the'COmm {ssioner of 'H fi.' `Any change of alteration`of construction
4F iiequ�!es a new permit,-:'Approvetl /for diiippbssaal /of;tlomestic,sandary sewag rwate water supply only - , ,,:• h.
/1 87 Oate ��G� 7/e / Z5 +vim' Ry Title
K
DEPARTMENT OF HEALTH'
.Division of.Environmental Health Services.
TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL �4 _
PCHD PERMIT # d '?g
WELL LOCATION
Street Address
Town/Village/City Tax . Grid Number
WELL OWNER
Name
Mailing Addre @?rivat
Public
USE OF' WELL
1 - primary
2 - secondary
9MSIDENTIA
O BUSINESS
® INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ABANDONED
O FARM O TEST /OBSERVATION O OTHER .(specify
C31NSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD. SOUGHT
gpm /# PEOPLE .SERVED /EST. OF DAILY USAGESe® gal
REASON FOR
DRILLING
aw4fW SUPPLY
O,REP14CE &XIS
OPROVIDE ADDITIONAL SUPPLY. OTEST /OBSERVATION
NG SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
CoG
WELL TYPE
RILLED
[]DRIVEN ODUG OGRAVEL ®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IN A.REALTY SUBDIVISION, NAME OF SUBDIVISION:.: 't'o
Lot No.
WATER WELL CONTRACTOR: Name _71 _F0, lam. 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 SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION �N S E S ET
(date) (signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
I. 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 ssuing f Ta
Permit is Non- Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
T. MICHAEL „IC HAEL DAL , P. Loa
(914) 628 -0507
BOX 243
' SHENOROCK, NEW YORK 10587
December 24, 1988
Putnam County Department of Health
Division of Environmental Health Services
110 Old Route Six Center
Carmel, New York 10512
Att: Mr. William Hedges
Ref: Well & Septic Application, Ackerman, Town of Patterson"
TM 66 -6 -1,2,3
Dear Mr. Hedges,
Pursuant to your request, the above mentioned septic system
layout has been revised.
The following items are enclosed:
(3) copies of the revised septic system layout
(1) highlighted copy of the revised septic system layout
Town of Patterson sewage application #191.(TM 66- 1 -2,3)
Town of Patterson sewage application #192 (TM 65 -1 -1)
Copy of "As Built" Dwg. TM 66 -1 -1)
_.. _.._.._ _. ..--If- y..o.u... h.a v e..: a n y.,....q -u.e s_t i.o n s ,.... o.r x.e q u.i r e -additional. .......... _.. .
information, do not hesitate to contact me.
Very truly ours,
. Mi bl Daly, P. E
cc: Peter Ackerman
~
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BOX 243
oyEmonouc. NEW YORK 10587
October 7, 1988
The Putnam County Health Department
110 Old Route 6 Center
Carmel, New York 10512
Attention: Mr. William Hedges
Ref: Well & Septic Permit Application
Town of Patterson
TM 66-6-1,2,3
Peter & Mindy Ackerman
Dear Mr. Hedges:
Enclosed please'find the following:
a) Certified Check for $100.00 -
b) Septic System Permit Application
c> Well permit application
d) Letter of Authorization
e) Design Date Sheet
f) (3) Copies of Septic System Layout (10/5/88)
g) (2) Copies of House Plans
The soil testing which was done on the property, was
.-witnessed by a representative of-yaur- office, on'Jqne-30, 1988i'
If you have any questions, or require additional
information, l d t hesitate to contact me
ease o p no .
TMD:bh
CC:Peter Ackerman
/
/
.. . ,
Re:
PUTNAM-COUNTY DEPARTMENT OF HEALTH'-.
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Property of
Located at G (7
(T) Section Block Lo t'
Subdivision o f
Subdv. Lot #(3144G'-Pjj464 Filed Map Date`&
Gentlemen: I
This letter is to authorize
a duly licensed professional engineer
(IndicateT— or , re � e 6re �ar chi t - 6 -6't
to apply for a Construction Permit for a separate sewage system, to
serve, the labove noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department o�-6Health, and to sign all necessary papers on my behalf in
66hfi&c-tiolf with t1il . s" .Wit t . e . r -'a-n"d to " s'- u" p"' e" i'v1 's"e'- the ie 6 o'n's t- 'r"" u .. c . t i . o n - 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 trul
Signed
C o un t e r s i
P.E. #
Town
C��
aN
dress
Telephone
0 61
Telephone
DESIGN DATA- SHEET SURSUFACE,. SEWAGE DISPOSAL SYSTEM..:._ . _..,...... .FILE NO...
Owner Address
Loted at -(Street) t sec: Block B1Block �� Lot
ca i "ZJ
( indicate nearest cross . street)
Municipality Watershe
SOIL PERCOLATION TES'P DATA R3QUI1M TO BE SUBMIT= WITH APPLICATIONS
Date of Pre- Soaking 6c i (98� Date of Percolation Test elDczj- 4 i c)8 V
HOLE
Ng-MER C= -TIME PERC0 ATION 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
3
NMM: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole.. All data to•be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
�9
5
Z
2
0 _
3
6 _ 150 110
4
o- So -3
(9114
2' 4
i3
2 2
2 3
O ^.. 3C?
.1
3
NMM: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole.. All data to•be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
5
.1
3
NMM: 1. Tests to be repeated at same depth until approximately equal soil rates
are obtained at each percolation test hole.. All data to•be submitted
for review.
2. Depth measurements to be made fran top of hole.
rev. 9/85
TEST PIZZATA. REQUIRED- TO BE SMUTTED WITH APPLICATION
DESCRIPTION OF'SOILS ENCOUNTERED IN TEST . •
DEPTH HOLE NO. ( HOLE NO. HOLE NO.
9'
10'
12°
14'
INDICATE LEVEL AT WHICH GROUNDWATER. IS ENCOUNTERED1'
INDICATE LEVEL TO-WHICH WATER LEVEL RISES AFTER BEING EN100UNTERED
DEEP HOLE OBSERVATIONS MADE BY: l o���c� DATE:
DESIGN
Soil Rate. Used Min /1" Drop: S.D. Usable Area Provided Lfack iWOVA
No. of Bedrooms _ Septic Tank Capacity gals. Type
Absorption Area Provided By 7-SE) L.F. x 24'° width trench
�7 OF N�
Other, %� ....00 , � �- W-L, 4 GZ) `�� 5 M � ` tia� o I/1'
��^ ','�ti -'tom► r �
Name _7_7 pV \t L1� �: • , ate- �,� Signature
Address ��3C �'� SEAL
U� �0, -77 �F553Gi'tA��
THIS SPACE FOR, USE BY HEALTH DEPARTMW ONLY:
Soil Rate Approved sq.ft/gal• Checked by' Date
P[Ti'NAM COUNTY DEPAR'324M. OF HEALTH
DIVISION OF ENVIRONMENTAL AEALTH'SERVICES 30
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner s K ail' �� Address /7 0, Z -'e'- 1 _S-� - aC.(+ [ -a-
Located at (Street) Sec. Block Lot
(indicate nearest cross street)
municipality Watershed
■ ■ . x * 201 ko ■,
Date of Pre- Soaking
Date of Percolation Test .
5
HOLE
NUMBER CLOCK TIME
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
4
5
1
2
3
n
5
NOTES: 1. Tests to be repeated at.same depth until approximately equal soil rates
are obtained.at each'percolation test hole. All data to'be submitted
for review.
2. Depth measurements to be made from top of hole.
rev. 9/85
TEST PIT DATA RDQUIRED`TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNI'F' M IN TEST HOLES
DEPM HOLE M. HOLE NOa - HOLE -NO.
G.L.
1° a asp
21 Cam.
3°
4°
5°
6°
7°
8°
9°
10°
11°
12°
13°
14°
INDICATE LEVEL AT WHICH GROUNUKATER.IS ENCOUNTERED t' GL 5
INDICATE LEVEL, TO WHICH WATER LE VET, RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY :�L�(L� „y�i�C,� DATE: (�
- DESIGN
Soil Rate Used Min /1” Drop: S.D. Usable Area Provided
No. of Bedroans Septic Tank Capacity gals. Type.
Absorption Area Provided By L.F. x 24" width trench
Other
Name Signature
Address SEAL
THIS SPACE FOR USE BY HEALTH DEPARTHM ONLY:
Soil Rate Approved sgoft /gal. Checked by Date
'. I I � T� � i i.
35,
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r2 w
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Date*.,* ........................................................................... N?I( .192,
TOWN OF PATTERSON
PUTNAM COUNTY, N. Y.
Application -for Installation of S'ewag*e Disposal Facilities
Fee of $7.50.must, accompany Application
. ne undersigned hereby makes pplication for approval'of and a certificate of occupancy
for the installation of Septic Tank Cesspool ❑ Chemical Toilet ❑ Privy ❑ on the property
described below.
Location of Property .............................................. ............. . Street . . .. . .. or ... . .....Avenue . .. ... ...... ..............
Village Subdivision .............................. 5, ";,d,
.......... ........
Block No. Lot No. Size Of Lot
Character of building Dwelling Garage' ❑ Store p or other ❑
No. of Occupants..... .. e ......... Bedrooms....' .......... Baths...... r............ . Extra Showers ......................
Garbage Disposal Sink .............................................. Automatic Laundry Washer ......................................
Source of Water Supply Public 0 Drilled Well l� Dug Well ❑ Spring ❑ Ground ❑
Name of Owner. IV/
............................................................. Address ................................................................
Diagram showing location of proposed installation on property. (Show distance from
adjoining property line and distance from nearest water, watercourse or source of water supply,
within 200 feet. Also show location of dwelling or building to be served).
to
Corrections. if -7, to be made by Inspector In red.
General Contractor ............... : .................................. Subcontractor .............................................
(sign) (sign)
Address ........ I N
........................................ I ..................... Address ........................................... .............
Certificate 'd'f'0cc'u'pa'ncy
I certify that I have inspected.t14 facilities called for in the foregoing application and find that the
same are installed as shown in the diagram thereon with the changes noted, and find that the same
comply with the sewage regulations of the Town Board of Health of the Town of Patterson and do
hereby grant this CERTIFICATE OF OCCUPANCY.
Premises were inspected on the following dates
First......................... ................................................ Date Issued .............................................. :* ......
Last ....... t..'.!....' � ! / Q / ./
...............................-
.......................
Other* .................................................. ..................... .......................................
Sanitary ... &;pe,��r,
I-W M3 /•9 `2- AS-.4.e
Percolation
Test
Time - In Min.
Inches
it
Tank Cap.
Linear ft. of
in 0als.
Trench
Corrections. if -7, to be made by Inspector In red.
General Contractor ............... : .................................. Subcontractor .............................................
(sign) (sign)
Address ........ I N
........................................ I ..................... Address ........................................... .............
Certificate 'd'f'0cc'u'pa'ncy
I certify that I have inspected.t14 facilities called for in the foregoing application and find that the
same are installed as shown in the diagram thereon with the changes noted, and find that the same
comply with the sewage regulations of the Town Board of Health of the Town of Patterson and do
hereby grant this CERTIFICATE OF OCCUPANCY.
Premises were inspected on the following dates
First......................... ................................................ Date Issued .............................................. :* ......
Last ....... t..'.!....' � ! / Q / ./
...............................-
.......................
Other* .................................................. ..................... .......................................
Sanitary ... &;pe,��r,
I-W M3 /•9 `2- AS-.4.e
I
:743
Date.-J.' .......... ............... .. . . . ............
TOW W;'OF: PATTERSON eA,
PUTNAM 'COUNTY, N. Y. [ A
Applitati 09r.-Installati6, of Sewage Disposal facilities
Fee of $7.50 must accompany Application
The undersigned hereby makes ication for' and a certificate . of occupancy
for the installation of Septic Tank;te Chemical Toilet ❑ Privy ❑ on the property
described below. 11.il ..--
&.4
Locationof Property ...................... .................................................. . . .......... C.-e ............................................
village Street or Avenue.
Subdivision ................................ 3 .14
. ............. !tn ..... ...................... ............
Block No. Lot -NO. size of Lot
Character of building Dwelling E Garage 0 Store 0 or other ❑
No. of Occupants...A—.41 ........... Bedrooms..:.: ................. Baths...................... Extra Showers......................
Garbage Disposal Sink ............. ` ............................. Automatic Laundry Washer._ .................................
Source of Water Supply 'Public L] Drilled Well In/ Dug Well ❑ Spring C] Ground C3
'Address .................................. .............................
Name of Owner _ ...... . .......... ..................... . .........
Diagram showing location of proposed installation on property. (Show ' distance from
adjoining proPeitYline -and distance from nearest water, watercourse or's6urce of water supply,
within 200 feet. Also show location of dwelling or building to be served).
V %
Percolation Tut
Time In MW. Inches
Corrections, if any, to be made by'Dispector In red.
General Contractor ........................... ........................ Subcontractor .......................................... ..............
(sign) (sign)
Address....... . .............................................................. . Address .................................................... ...............
ca 6-6f.0tcupancy
Certifi 't"',
I certify that I have Inspected the fcMti' called . a. P c . for In the foregoing app on and find that the
same are lAkt-Red as shown In the diagram thereon with the changes noted, and find that the same
Ijl comply with the sewage regulations of the Town Board of Health of the Town of Patterson and do
hereby giant this CERTU70ATE OF OCCUPANCY.
Premises were inspected on the following dates
First 10 ............. ... Date Issued ... . ..............................
Last..... . .....................................................................
Other.................................................. : ........
Sanitary Inspector
14 M4
Tank Cap.
Linear ft. of
in oafs.
Trench
70o
Corrections, if any, to be made by'Dispector In red.
General Contractor ........................... ........................ Subcontractor .......................................... ..............
(sign) (sign)
Address....... . .............................................................. . Address .................................................... ...............
ca 6-6f.0tcupancy
Certifi 't"',
I certify that I have Inspected the fcMti' called . a. P c . for In the foregoing app on and find that the
same are lAkt-Red as shown In the diagram thereon with the changes noted, and find that the same
Ijl comply with the sewage regulations of the Town Board of Health of the Town of Patterson and do
hereby giant this CERTU70ATE OF OCCUPANCY.
Premises were inspected on the following dates
First 10 ............. ... Date Issued ... . ..............................
Last..... . .....................................................................
Other.................................................. : ........
Sanitary Inspector
14 M4
C-, L
........................
••5
's LOC
CODalat�
ro
';Water S6pply: +
�. lk
°NDD1118t' �Oi BeII[OOm
Dt6
0t6r RBgil 'eM8
r�,.I cart fy ith# tho,
of Mhich' are attacfi
,•Putnam County D;pai
t
Any person oeeupyi
t aconditionit►esultln9y
'�avallabl�. and tfie��p
wb)aet t difiea
AM'
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a '
•(.
1 't
l
;tied work"( copies
ermit '- iaeued' by, "th'e
E. R'.A.
.ry „aWar f,,
WO ala ark
F"ury
J �
YES N
PUTNAM COUNTY'HEALTH DEPARTMENT
DIVISION -OF ENVIRONMENTAL. HEALTH SERVICES
Internal Use Oniv
SYSTEM REPAIt'
❑ � Repair Permit Issued in IasC'S years �t in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION M #
, i , 3
OWNER'S NAME cTr'r a,,.,,o �'rl} PHONE. #
MAILING ADDRESS I #c,,ze) Or.'Pa,Cf'cSoY1 , ✓� G
APPLICANT
Name & Relationship (Le., owner, tenant, contractor)
DATE LO FACILITY TYPE PCHD COMPLAINT # Pc 3-I
PROPOSED INSTALLER �, �, �%, ro PHONE #y.
ADDRESS 8Q. REGISTRATION /LICENSE # -AG LJ 3
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed. trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
V -.I- ,[ / / _ ,I
I, as owner, or re ed ag owner agree to the conditions stated on this form
SIGNATURE TITLE,Q ,
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed inoctordance with the
above proposal and condition .
Proposal Approved Proposal Denied
��J...
!Inspector's Signature & � Title Date It
COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE Z 6) (3
r
10 FA MA
Sheet _of_�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION`OF-ENVIRONMENTAL`HEATLH SERVICES
FIELD ACTIVITY REPORT
AnDRFCR. A"e4 77r, Pa
Street Town . State Zip
PERSON IN CHARGE
OR TNTFRVTFWET): UE�/ Co�Sfr�c.�.:►e T)atP_ /'O�2- %�bF�.
Name and Title
TYPE OF FACILITY:
FINDINGS:
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Signature and Title
RFP-f1RT RPrF.TVFT) RV:
I acknowledge receipt of this report: SIGNATURE;
02/96 Title;
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