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34. -2 -34
BOX 13
ri
01446
y... '...•— 7k Y"ie 77_77,_ .,E.s.; �_
f�Re v. 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH
b Division of Euvhroumental Health Services, Carmel, N.Y. 10512
Q Engineer Must Provide
�c .. wcc Lq!
CERTIFICATE OF OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL) SYSTEM �4�e/^So`-►
`1.`9l/ / ?G l/Y l f/ e G�� 23^Sovl /V.� .T. Viptdga
Located at e:. Map . Block Lot
Owner /applicant. Name, Formerly Subdivision Name ` ` S% Subdv. Lot'# 30
Mailing Address P :Date Permit �sned I/— / 2
QG1 '71�f P S/2 ^/ If
Separate Sewerage System built by . S, A F S h G SAS - Peru 1i c Address - -ro �. ^ 4.j.
Consletin9 of Z D 4 Gallon Septic Tank and - /
Water Sapplys Public Supply From Address
or: Private Supply Drilled by ii ( �' } h ; 4-12 . � Sn.'Wdress 3 / ( )0/12-, oX j7 / f} t f rsp. l
Building TypeM�od ��'i- Z S' r� �pldn��; �Hsul Eroelon Conh»l Been Completed? \ '{
Number of Bedrooms Has Garbage Grinder'Beeri Installed!
Other Requirements
I certify that the system(s) as listed serving the above premises were c
of which are attached), and in accordance with the standards, rules and
Putnam" County.Diapartment Of Health. .
oste / '7 b Certified bye
essentially as shown on the plans of the completed work ( copies
in.accordan a with the filed plan, and the permit issued by the
,e4— P.E.4 R.A.
Atldress� JS ye-itr "5 .. pf. ^, SVI �C P'% Kb,YI fZ7i'/ kvh,5 'V y Lleense NO. �0
Any person occupying premises served by ,the above systems) shall promptly take such action, as May necessary to secure the correction of any unsanitary
conditions resulting from. such usage. • Approval of,: the "separste'- sewerage . system shall become null'and'void as soon as a pub(': sanitary sewer becomes
availaee and the approval of the private water iupply shall become null okt wean a. public. water supply becomes .available. Such approvals are
subject to modification or change -when, in the judgment- of•the Co lisi er of'Mes14b,`su revocation, modification o► change is necessary.
Data � By Title A
lu
a .. 4
WELL COMPLETIUN KhrUi:cr
DEPARTMENT OF HEALTH
D vis -ic n Of-Environmental Heal>tIn .Services
PUTTIAM COUNTY DEPARTMENT OF HEALTH
Office Use Only.
"
STREET ADDRESS: wNrw� J 1 Y TAX GRIO NUMBER:
WELL LOCATION
WELL OWNER
NAME: ADDRESS:
Cv %.� ,'cam; �Soc�
PRIVATE
p PUBLIC,
USE OF WELL
1 - primary
2 - secondary
YRESIDENTIA'- ❑ PL&IC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS D FARM D TEST /OBSERVATION D OTHER (specify)
'Cl INDUSTRIAL D INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. 1N0. PEOPLE SERVED / EST. OF DAILY USAGE j�Q_0 gal.
REASON FOR
ORILLING
KNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑. TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WEL�bEPTH . '�� ft.
STATIC WATER LEVEL ft.
DATE MEASURED 61 2�
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. 90eOPEN HOLE IN BEDROCK D OTHER
TOTAL LENGTH ft.
MATERIALS: IYSTEEL ❑ PLASTIC D OTHER
CASING
DETAILS
LENGTH.BELOW GRADE � ft.
JOINTS: D WELDED THREADED ❑OTHER
DIAMETER — in.
SEAL: D CEMENT GROUT VBENTONITE ❑ OTHER
WEIGHT PER DOT ___L 7 1b. /ft.
DRIVE SHOE YES D NO
LINER: 0 YES NO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH
(it)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
❑ YES ONO
DETAILS
SECOND
HOURS
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE;
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH tt.
WELL YIELD TEST ; If detailed pumping
yipo0: ❑ PUMPED t tests were done is in-
Rf COMPRESSED AIR ; formation attached?
❑ BAILED ❑ OTHER i ❑ YES ❑ NO
It more detailed formation descriptions or sieve. analyses
WELL LOG are available, please attach ".
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Dia-
offer
FORMATION DESCRIPTION
Calif.
tt.
ft
WELL DEPTH
it.
DURATION
hr, min.
OR
tt.'
YIELD
9Cm.
surface
' -a c 1" baa E rs
S
G ) e
Od
cS
6
�rC)
JUC)
c: <
WATER CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS _
❑ COLORED ANALYZED? ❑ YES ONO
ANALYSIS ATTACHED? ❑ YES ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP WFORMATION
TYPE CAPACITY
MAKER DEP
MODEL VOLTAGE HP
WELL DRILLER NAME DATE
ALBERT M. HYATT & SONS, INC. a�
ADDRESS Well Drilling SIGRATURE
Rte. 311 R. R. 2 Box 171A_
PAT'YERSON; NEW YORK 12563 u
BREWSTER LABORATORIES -
Box 224 - BREWSTER, N.Y.
(914) 279 -4945
- WATER ANALYSIS REPORT
SAMPLE No. 7581
SOURCE: Foley Development Corp.
Windsor Oaks Lot# 30 Fair St.
Carmel, N.Y.,
COLLECTED: 11-28-89
BY: P.F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
WELL
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
11 -31 -89
RECEIVED DE C 2 0 1989
-mam'VAL CC=- OEI�mal
Michael and Maryann Brosnan 30
Lcr-
Colonial Ridge'Associates
Highview Drive
7=t- = - S"=Ser_
Paaterson,, New York
Mrm-i r-+ ----A I jt.y
Modular Two Story Colonial
Smild:L= Tuma
Rosewynd Pond
snjr .v=i= Sam
30
54
who —,1,7 and C=- °LET -7 rzs-
cr =za-tion and of :he sawac-e
that:. it as --howm. ca-
serv=q the above desc---Z p=Pt-7,
IL a amemdment- the_etc, amd is ac=rdanca w-. t FL thf-.
and.
sta-mim-rds, =-Ies a=d. reaga�-atienrls of the Put--22m- C==t:Y Dq=
f to S=d
hi" s=2s5= r he=s' Or as- Sz 9=
cuezat.ina- c-:ntii-�-4=3 any car-t ce said systam cmis-tr=-t bV me vzl= 1-ni. z =e--ta- f= y 1 =qi=q the afte z*_ =22 of the
t:'-'e sewage c= any"
=A- - v zz= Tz5=1, the =ear; r.°
t ct cc- -- -t C:ff
e
r- as mslly-a =2 co-=,
T he
the : -- , - , pur-p-m- co=ty
e
as J wme-- 41,- -tte t= C ---=t? WZ'S
G':-5 ad bv zte -.-i' —I'=L. C-- aea —14,,nr ac- ----,e caild
of tze cc==a J,
the syst;:n-
Datza this day oi--N
(� OL.� =y
N,
.1C._ as �) 2.5�. ,
, Ob I
L
31"Zf
mk
U u LJ
W
Bair TyPe f :. I �L Lot Area m ;J FIIhSeedon
X� Only" . Deptb • Volnmti
Number of Bedtooms ` 1 " Design Flow G P D C) PCHD N_ odficadon is Required Wiliest Fill le completed
Separate Seweeage:Syetem to osnsist of 1i GaDon Tsn L
ll� �pe
To do co iiii i ted by e l Addeetle
Water' SalpPb': PD'bllc Supply From
Address`
'
or. _ • tPrlvate Supply Deified by • 7,' I� Addieee
Otber- Requirements
I repiesent that 1 am wholly and completely responsible for the defi9n antl location of, the proposed 'iyStem(S). 1) that the separate, sewage disposal system
aDOVe tlascribeC will be Constructed as shown on;the approved amendment there to and in accordance with the standards, rules an resu a• ions o e u Ham
County Department of Health,;and that.pn completion the eof a 6ikificate of Constiuotion Compliance satisfactory .to the Commissioner.of Mealthwill
be submitted -to the'Department; and ;a written'yuarantee'will be.4urnish ' tha owner, hissuccessors, heirs or assisn• by the Duittler. that :gitl builder will
place in good, operating condition any part oR: safd sewage'dispo'sal. system. during the period of two (2►,_ ears Imrnerllately following tfieAata Ot;the issu-
ance' of the :approval of the.�6kiffcate'.of do'nitruction .Compliance of `the original system. or.any,re it neret 2) that the drilled well tlesciibed above
will be loutedjs shoavn.on the approved, plan and`that said well wilhbe inst � i cc `rtlance iM t d artl ►ulss and regu a of the Putnam
Co
YHty DAe ►t1lmsnt Of- Mealth -
Pate f1r0�4�; =�. 7 / �,.. -{�.� 5i9n°d V
License No
APPROVED FOR CONSTRUCTIOW T his approval; ex ires•twib Y rs ^fro he `date 'Ass d unless constructs of the building has been undertaken and is
P
revocable for cause or, may be aiiiendetl _or modiiied when consi redo sary,by- th._ • . mmissio I 'Any change or alteration of construction
requires a e permit App for di3posal�Of domerilc- t sewage, and/ t ly
87 Date BY Title'
W
�Q�►Si � Go' 0 � WA'f�v . JT�t� Jys ��-- .
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PuTNAm CCUNTY DEPARnMM OF HEALTH DIVISIM GF R4VIRCNMENML :E Y: SERVicES
INDIVIDUAL WAY01• SUPPLY & SUBSURFACE `f . /• !S DISPOSAL SYSIM
(Name of Owner)
COM14ENTS
LF trench provided
required
60 ft. max.
Parellel tr.
FILL SY TEMS
clavt4rrier
10 ft.
f i1V notes
nea saec.
depth gauges
100 vr. flood elev.
O :1�1 i• • i'� • • �1'
DATE REEiTIEMiF..D
BY: /
(Street
iOS
NO
Location) TT
DOC94EMS �-
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) S'JHDIVISION
Deep Hole Log Pe_.rc 2c�-
Consistent Perc Results (3) Fill
Perc Hole Depth cd
House Plans - Two sets
Well ------permit; P S letter
Variance Request
('F NFRAT
Lecai Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Pennit R & D)
Data On DDS Plans & Pennit Same
REQUIRED DETAT_LS, ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
0-epultic Profile & Dimensions - Volume
J Box;Trench /Gallery; Pm1p Pit details
Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes (grinder notes)
Design Data: perc and deep results
Two-Foot Contours Existing & Proposes
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge oK >`.I
Perc & Deen Holes Located
Representative. of primary and expansion
Expansion Area; shown; gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's Win 200 ft. of Proposed Systems
Property Metes & Bounds .
House Setback Necessary (Tight lot)
House Seger - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /clearout
SEP.WMCN DISTANCES SPECIFIED ON P:.AN
Fields
10' to P.L., Driveway, Large Trees,Top of fil
20' to Foundation Walls
100' to Well;. 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. e pan
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stormdrain, piped waterco_urs
LI
1,
F
i
%
_
`l;
'
l'
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10�Foundation; 50' to well
15' Well to PL
n
PUTNAM COUNTY DEPARTMENT OF HEALTH
DiviAcin -of"EnVironmental --He-ilth
A)FFIDAVIT - CORPORATE OWNER APPLICATION
17OR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of applic'ation for:
represent that I am an officer or employee of the corporation and am authorized
to act for
(Name of Corporation)
having offices at 4,kj 7" e
Whose officers are:
Ntj
President: k,*,CL,0 -7
(Name and Address)
Vice - President:
(Name and Address)'
Secretary:
(Name and Address)
Treasurer:
(Name and Address)
and that I am and will be individually responsible for any and all acts of the
corporation with respe,:t to the approval requested and all subsequent acts relating
thereto. I'll
Sworn to before me this day Signed:
of / lqt� Title:
C Iv-
Notary Public
woof ork
k
�Ik 8/84
Corporate Seal
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET- SEPA�IRA-T,E SEWAGE DISPOSAL SYSTEM -�7 FILE NO.
Owner(�b\tAi .;k; '/ � -_ Address 4 \��vn � Ct.r �r►a��� 1� t )� 4
Located at (Street ALjLjja,, ,Block Lot 14
IndIcate nearest cross ss ree j
Municipality is Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION - PERCOLATION.
Run E`iaap e DeptE to Aa er water eve .
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start .Stop Drop in Min. /in drop
Inches Inches Inches.
Cz
3 Ae-)
C
Z 1 C)
5
1
2
3
5
l -.
tj . I ! i
'L 1
Notes: 1) Tests to be repeated at same depth until approximatelyy 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.
TEST PIT DATI, REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIP`1'ION. OF SOTIA`j• - i�NOUN�I'RF.D:, IN. TEST�.:HOLES F ^ _
DEPTH HOLE NO. f HOLE NO. HOLE NO.
G.L.
6"
12 "� �A _
18
24" �l
30" it
3611
42" ti
48"
54rr
6011..
66"
72rr � _
78" ei
841
LEVEL.AT WIEFCH GROUND WATER IS ENCOUNTERED
INDICATE- -LEVEL- -TO WfP:CH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY<77>- _ � �• Date c3 C \
"Drop: IGN
Soil Rate Used ZL-� 1�in/1 Drop: S. D. Usable Area Provided C) O �- Y�
No. of Bedrooms - Septic Tank Capacity l Gals. Type
Absorption Area Prov:�ded By (�C�ZL. F. x24" s� jG width enc .
o�
Name . ✓!r1 e.�o.�. .�, Y. Signature
o
Address SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved_ Sq. Ft /Cal. Checked by
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
treet Address Town/Village/City Tax
Grid Number
WELL OWNER
Name Mai - ng Address
'7 G
Q7 Private
O Public
USE OF' WELL
1 - primary
2- secondary
0-RESIDENTIAL O PUBLIC SUPPLY
O BUSINESS 0. FARM
13 INDUSTRIAL O INSTITUTIONAL
❑ AIR /COND /HEAT PUMP
❑ TEST /OBSERVATION
O STAND -BY
O ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE
SERVED_ /EST. OF
DAILY USAGE !Odgal
REASON FOR
DRILLING
SUPPLY ❑PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
OTEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
c�
WELL TYPE
D.BRILLED
DRIVEN
DUG D GRAVEL OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ENO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_
Lot No.
WATER WELL CONTRACTOR: Name �', Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES C -fi%
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: c
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION [C�01� TES ET
(date) (s i e _
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 permi
3. Submit a Well Completion Report on a form .pro e y e Putn o ty
Health Department.
Date of Issue: ,-- �-�
Date of Expiration. 19
rmit I suing ffi
i
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 Orange copy: Well Driller
NO
DISTRIBUTION
1250 GAL. SEP77C TANK
N 9.3833" E /50.00
HIGH VIEW DRI VE
I
TERALS AT AVERAGE
7H OF 54 =3"
THIS IS TO CERT /FY 77•JAT 7HE SEWAGE DISPOSAL SYSTEM WAS
MEASURED BY ME ON DEC. 14, 1989 AND APPEARS TO BED
C01VS7RUCTED IN ACCORDANCE W 17H ALL STANDARD RULES
AND REGULA77O1VS OF 771E PCHD 8 NYSDM
DESIGN INFORMA77O1V
FROM FILED MAP)
4 BEDROOM HOUSE
PERC RATE - 24 MIN, //NCH
LA7E AL LENGTH - 667 LF
GENERAL NO TES
OI ALL SURVEY 1NFORMA77ON TAKEN FROM SURVEY PREPARED BY
ROBERT M BERGENDORFF, L. S, BREWS TER, N Y.
O AS- BUILT "MEASUREMENTS 7AKENI2114189'
BY S7E'VEN ✓ HYM4,% P.E.
LATERAL ENDS LOCA7E 0 BY LOCA77NG ✓UNCTION BOXES FROM
O REAR HOUSE CORNERS AND THEN SMKING EACH LATERAL
AND MEASURING LENGrh
Y
CQk�QL POINT
N792928 "W
20.00
PT. "A "'' :: PT.-B"
_ S 10 3O32_W _
—
DRAINAGE 150.02
DISTRIBUTION BOX
EASEMENT
50' -0"
N1O 3032 "E
61-0 ",
56' -0"
b
b
LOT AREA
60' -0"
® 442O0SS.F.
N
N 9.3833" E /50.00
HIGH VIEW DRI VE
I
TERALS AT AVERAGE
7H OF 54 =3"
THIS IS TO CERT /FY 77•JAT 7HE SEWAGE DISPOSAL SYSTEM WAS
MEASURED BY ME ON DEC. 14, 1989 AND APPEARS TO BED
C01VS7RUCTED IN ACCORDANCE W 17H ALL STANDARD RULES
AND REGULA77O1VS OF 771E PCHD 8 NYSDM
DESIGN INFORMA77O1V
FROM FILED MAP)
4 BEDROOM HOUSE
PERC RATE - 24 MIN, //NCH
LA7E AL LENGTH - 667 LF
GENERAL NO TES
OI ALL SURVEY 1NFORMA77ON TAKEN FROM SURVEY PREPARED BY
ROBERT M BERGENDORFF, L. S, BREWS TER, N Y.
O AS- BUILT "MEASUREMENTS 7AKENI2114189'
BY S7E'VEN ✓ HYM4,% P.E.
LATERAL ENDS LOCA7E 0 BY LOCA77NG ✓UNCTION BOXES FROM
O REAR HOUSE CORNERS AND THEN SMKING EACH LATERAL
AND MEASURING LENGrh
Y
avision of Environmental Health Servic.'
.pproved as noted for conformance with
1pplicable Rules and Regulations of the
'u County Health Department.
.if. 30 to .
11anaturp A• T14! O .1+
a F ILED MAP 0 2/94, F ILED 12/2/86
CQk�QL POINT
STRUCTURE
PT. "A "'' :: PT.-B"
SEPTIC TANK
33' -8"
49' -0"
DISTRIBUTION BOX
41' -6`
50' -0"
JUNCTION BOX 1
61-0 ",
56' -0"
JUNCTION BOX 2
67' -9 "-•
60' -0"
JUNCTION BOX 3
74' -6'..;
64' -4"
JUNCTION BOX 4
81'-6"
68' -3"
JUNCTION BOX 5
88' -5'
72' -8'
JUNCTION BOX 6
95' -3'.
77' -6"
avision of Environmental Health Servic.'
.pproved as noted for conformance with
1pplicable Rules and Regulations of the
'u County Health Department.
.if. 30 to .
11anaturp A• T14! O .1+
a F ILED MAP 0 2/94, F ILED 12/2/86
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5 IO° 30''32" W
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NIGH VIEW Di21VE
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FZEPATtED FOtZ.
COL.OI JIAL. RIDc2s Q560CIATE5 , IQC..
LDT Q0. 30
AS '5HOWti ON
FAIR, STREET 5UBD'VI -5IO►.! FILED MAP# 2CH FILED I2 -Z -$fo
TOWN OF PATTERSOoJ PuTtiIAM CO. NIN.
sd oc-To ®ER I'4, 1481
MAN -I, 198a `
cKo 1L 4Tiot -+)
% AtJ 3, 1984
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