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BOX 13
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01455
PUTNAM COUNTY DEPARTMENT OF HEALTH' v
Re 3186 Dlvlslon o(Envira:nmental Health Servkres, Carmel, N.Y:10512
�! EngineeiMastProvlde
CE ATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM a ..YrSQ�j
-
_ T r Village
"led at Vvo Tom` p Block _Lot '%
� / `� Sdbdv, Lot N
Owner /applicant Name Formerly Subdivision NameQ __
Melling Address �a &&y ,' �°-' Zlp Q � Date Permit Issued L( �' O
Separate - Sewerage System built by . �: �. � y°h�� / Address
Consisting of Gallon Septic Tank and
Water Snpplyq. Public Supply From Address _
i or: Private Supply Drilled by Address 194 as 2
Building Type_ es Erosion Control Been Completed?
Number of Bedrooms Has Garbage Grinder Been Installed?
Other Requirements
I ee ;tify'.thit the system(s) as listed serving the above premises were constructed essentially as shown on th 1 ns.of the completed. work ( copies
of which are attached), and in accordance with the standards, rules and re tions, i d e w the a pla and -the permit issued by the
Putnam County O rtme t of Healthc ,,
Dats
Certified by-
0.E.l_ R.A.
Address License No
Any person occupying premises served by the.above.system(s) shall promptly.take such action as maybe nece ►y to ss la the correction of any unsanitary
conditions resulting, from such usage.. Approval of the separate sewerage system shall become hull and void as soon as' a pupa: sanitary ewer becomes
atvallal:4 and the approval of'the private water supply _shall become null and void when a "public water supply becomes availabW Such approvals are
subject to modifkation or change when; in the judgment of..the. Commissloner of Health, Alan revocation, moAllfication _or change Is neces sary.
j y
Date k4 4 a
a .e
WLLjL UUrirLr.liUiv nr.rvni
DEPARTMENT OF HEALTH
'Division 'Of'- Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
/.,�
'7.h (-
WELL LOCATION
STREET ADDRESS: wNIvIL I TAX GRID NUMBER:
a 0
WELL OWNER
NAME: ADDRESS:
�.. � �,' e�
PRIVATE
0 PUBLIC
USE OF WELL
1- primary
2 - secondary
9RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /NEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM - ❑ TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL "❑ STAND -BY ❑
MOUNT OF USE
. YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
VNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST/OBSERVATION
❑ REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH / ft.
STATIC WATER LEVEL Z:5�ft.
DATE MEASURED
DRILLING
EQUIPMENT
❑ ROTARY COMPRESSED AIR, PERCUSSION ❑ DUG
0 WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
/
❑ SCREENED ❑ OPEN END CASING. 6 OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH YL ft.
MATERIALS: df STEEL 0 PLASTIC 0 OTHER
CASING
DETAILS
LENGTH.BELOW GRADE f 07 tL
JOINTS: ❑ WELDED THREADED 0 OTHER
- —DIAMETER' –7 —in.
SEAL: ❑ CEMENT GROUT YBENTONITE 00TH
WEIGHT PER FOOT Ib. /ft.
DRIVE SHOE. MIES ❑ NO
LIN ER: 0YES NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE'
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
❑YES ❑ NO
HOURS
SECOND
GRAVEL PACK
O YES
❑ NO
GRAVEL
SIZE.
DIAMETER
OF PACK in.
TOP
DEPTH tL
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED tests were done is in-
'COMPRESSED AIR formation attached?
O BAILED ❑ OTHER ❑YES ❑ NO
It LOG ff more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
Well
D'a-
meter
FORMATION DESCRIPTION
CODE,
ft.
fL
WELL DEPTH
It:
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
ggm.
Land
Surface
nn O
b�
dCJ
6
S
o C,
96
o
e r, e, 0
WATER O CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
❑ COLORED ANALYZED? ❑ YES ❑ NO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
WE�ILRff "VE HYATT & SONS, INC. DATEr
ADDRESS F{ I 1IVVII Well Drilling SlGrrkTURE
Rte. 311 R. R. 2 Box 171A ,°��►
PATTERSON, NEW YORK 12563 ,//
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
PUTNAM COUi11'Y DEPARTMENT OF HEALTH
DIVISIOIN OF ENVIRONMENTAL HEALTH SERVICES
7Z
Owner or Purchaser Of Building SectiCn Block Lot
1
Building Constructed by
ICAAv1l/�� STIc°. t j
Location - Street Subdivision Name
/%��7�r�SGv�
Municipality Subdivision Lot #
� es�` � � a /
Building Type
GUARARM OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
,I represent that I am wholly and completely responsible fox,. 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 faiTur2'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 Environmental 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 th bull ing iliz'
the system. ss YY'' 2, Dated this �_ day of 19 Signat
/1 w
Title
General ntractor (Ownery - Signature,, J
Corporation Name (if Corp.)
rev. 9/85
mk
Corporation Name (if Corp.)
?o• �
Mdress
C v--oSs & # v£ r
4
LoIr 181
II.
IV.
V.
VI.
21DDV&TnTV 0
FINAL SITE INSPECTION Date
Inspected by
OWNER is -G /lJ 7 / /l / % (r ✓c • -�
r
# -/6j1- C� % TM # OR SUBDIVISION LOT # ' % / ,
I
-
SEWAGE DISPOSAL AREA
a. SDS area located as per approved plans
b. Fill section - Date of placement
2:1 barrier: LGTH WIDTH AVG.DPTH
c. Natural soil not stripped
d. Stone, brush, etc., greater than 15' fran SDS area.
e., .100 ft. fran water course /wetlands.
SEWAGE DISPOSAL SYSTEM
a. Septic tank size - 1,000 1,250
b. Septic tank installed level
c. 10' minimum fran foundation
d. No 900 bends, cleanout within 10 ft. of 45° bend
e. DISTRIBUTION BOX
1. All ,outlets at same elevations - r test
2. Protected below frost
3. Minimum 2 ft. original soil between box.and trenches
f.- JUNCTION BOX - ro 1 set
g. TRENCHES
� - - --
2. Distance to watercourse measured- ft.
3. Installed according to plan
4. Distance center to center
1<
5. Slone of trench acceptable 1/16 - 1/32 " /foot.
tC
6. 10 feet fran property line - 20 feet - foundations
7. De th -of trench < 30 inches fran surface
8. Roan allowed for expansion, 50%
9. Size of gravel 3/4 - 11" diameter
10. Depth of gravel in trench 12" minimum
11. Pipe ends capped
h. PUMP OR DOSE SYSTEMS
1. Size of chamber
2. Overflcw tank
3. Alarm, visual /audio
4. Pump easily accessible manhole to grade,
5. First box baffled
6. Cycle witnessed by Health Department
estimated flow per cycle
HOUSE
a. House located per approved plans. C�
b. Number of bedroans
WELL
a. Well located as per approved plans
r
b. Distance fran SDS area measured ft.
C. Casing 18" above grade.
_
d. Surface drainage around well acceptable.
0MRALL WORKMASHIP
a. Boxes properly grouted
}C
b. All pipes partially backfilled
c. All pipes flush with inside of box
d. Backfill material contains stones < 4" in diameter
7
e. Curtain drain installed according to plan
A
f. Curtain drain outfall protected & dir.to exist.watercours
A
g. Footing drains discharge away fran SDS area
�--
h. Surface water 2rotection adequate
f-
i. Errosion control provided on slopes greater than 15 %.
I
?*^ .m¢ -n _ '..+— ar'�- +�T'.'T.ar fi..,F'.r• \ 9,rye R" 7'_"'xi^n aY"+" f�^ «+1 Rk"E e4?`NC'� - e –...e' �.' '.y,._� ).a. '" "'_i „^"a'T' „ , .i':�,
'41D 1', PUTNAM COUPITY DEPARTAUNT OF HEALTH
, _ .
..
Dlvlelon of pavlrcomentet SeWtb Servkws Cormel. N:Y lOSl? to ProvWe:Petmlt N
'
0
„ ' :P CERTIFI TE OF COLIANCE.,
CONSTRU PEIiMPT
,'6C
FOB SEWAGE- DISPOSAL SYSTEM
Located at
µTo:
•• tH' Sabdlvlebn Name V.. abd. Lot # �L ` ••
Map Lot�'�
�/''
'
j . .. Itonewol_ ❑ Bevielon ❑
f-0 `,
Owner /Applicant Na®efJ
[J 1 /,..� t`�l �• dG ;
F�/v
Date of. Previous Approval'
A
MaWog Address. '
I g�
`� O�-yY1 � � L� . 1-1� trY) U 1J _ Town / '� i' yV� 0/�3i� Zip C)
13ailding Type : s�
7 - i P
�„ Lot Aron FW Secdori Only De tb Volame
Number of Be me Design Flow .13 _ P D PCHD Nouncatlon to Begalred When Ffll is oompteted
Ii."in its Sewerage System to consist of J1G Gallon Septic Tank and_
a
To be contracted by 1 ..tom Address
Water, Supply' Public Supply, From . ^' Address
fi ors Frigate' Supply: Drilled by ..ir��'�
F.
Otber; Req�tilrements.
I represont,thgt'I am wholly an
antll „completely rospon'sible for the design d location of the' proposed systom(sj; 1). that the separate. sewage disposal system
4; above described will be constructed as shown On the.approved amendment there ito and in accordance with the standards, rules an regu, a ions o e• :u nam
u :. ..., -
County Department of,;' HeaRh,'.and that on completion thereof a -6f; Construction,t:onipliance satisfactory to ths,Commissiorw of Health will
be' submitted .to the 0pparfinerit, and -b,.written;guarantea�wrll be- furnished tha owner; his successors;horso'r s+ssgnsDy the,builtler; that.said 'builis r will
place' in good:: operating "eondition, any _ part of., said, sewage disposal system auring,thi period of'two (2p years madiatety following theaate "of the .tssu-
ante Of the ap0►oval Otthe
„ will D4, ocated' s shown''on the
County be ment of .Health
k Date
APP'.ROVED FOR,CONSTRUC
reyocable for cause or maybe
1 reQuires a riew per Appr
z Date
In
BY
�y rs Yrom a date ss ed unl
d nec y by Commis
r_ any Opairs th et ;, 2) that the drilled well described above
rith n'e sta ds; . ules an / repu sT ro of : gene 'Putnam
P.E._ R.A._
License No 49<
ass coristructroh 'the building has. been undertaken, and is
ii er f - edt Any change or alteration of c instruction
a I nly.
Title
B' T
0oxaAdated 7ec14rNo&##., 9mc.
..., ......... -�_ : ,. _ ......_- ....__ry . -
P.O. BOX 261 • MT.- KISCO. NEW YORK_ 10549- (91.4) 591- .9010• -, __
May 6. 1988
Colonial Ridge.Associated Inc.
c/o Weinstein Pharmacy
101 Katonah Avenue
Katonah, New York 10536
Re: Water Sample
Lot 21 Jennifer Lane
Town of Patterson, NY
5/3/88 5:30pm from kitchen sink
76 -1 -43
Dear Sir:
Following is the result of a bacteriological analysis
performed on a sample of water received on May 4, 1988:
Analysis Result Remark
Total Coliform Bacteria *LT 1 *LT
Counts/100-ml Less Than
This sample _ meets _Drinkin Water Standards for
bacterial purity.
JPM:es
cc: Weinstein Pharmacy
Very truly yours,
Consolidated Technology, Inc.
al
John P. McGuire. P.E.
APPENDIX
PUTNAM CCUNTY DEMAR24M OF :1 k: DMISIM OF ENVIRCNMERML HEALTH 'M rati
INDIVIDUAL WAYaJ• / • • SUBSURFACE P !! DISPOSAL SYSY8
■ aal <i0 �C ii•JI�OI • ' al'
J
(Wf-
(Street Location)_.�,j
DOCOMENM L-67
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
PeTc Hole Depth
s/s
S MIVISION
P°+rCZ_
(3) Fill
cd
House P - Two sets
Well pe-rmit; PWS letter
Variance Request
-- C'F:tJFRAT. -
Leaa -l. Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Pemdt Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sne,rage System Hydraulic Profile - Gravity Flow
Profile & Dimensions - Volume
o ' J Box;Trench /Gallery; Pump pit details
Se c Tank - Size, Detail
1 Detail, Service Line if over
Construction Notes (grinder notes)
_.Design Data: , perc -and deep ,results
Two-Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutter,Curtain Drains (discharge OK)
Perc & Deeo 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 & SSDSIs Win 200 ft. of Proposed Systems
Property Metes & Bounds .
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type Pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
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 Unc. e`cpan
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stormdrain, piped watercours
10' to Water Line (pits 720')
50' interntittent drainage course
Septic ranks
10' fran Foundation; 50' to well
15' Well to PL
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
___ LIGATION TO CONSTRUCT -A "WATER' WELL
0 r
PrRD PP'PMT'P 4 ) I It)
WELL LOCATION
Street Address.
Town/Village/City Tax
Grid Num
er
WELL .OWNER
Name
Mailing
Address ,
rivate
O Public
USE OF WELL
1 -,primary
2 - secondary
EIIE'SIDENTIAL
D BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
11 FARM .O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
ABANDONED
0 OTHER (specify
AMOUNT OF USE
YIELD SOUGHT gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE Ogal
REASON FOR
DRILLING
GKEW SUPPLY
OREPL CE EXI
TING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
0DEEPEN EXISTING -WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
LLJDRILLED
DRIVEN
ODUG ®GRAVEL
®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES0
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name oa j�,� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES JX NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCR TO PROPERTY FROM NEAREST WATER MAIN:.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION EET
,A( C { 0�
(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 thi//;ermit it.
3. Submit a Well Completion Report on a fori by he Pu a unty
Health Depa tment.
Date of Issue: — 19
Date of Expiration: 19 Issuing ffici
t\` Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
i
287 Orange copy: Well Driller
4
PUTNAM COUNTY DEPARTMENT OF HEALTH
`Division of Environmental Health
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO :- Commissioner of Health
In the matter of application for:
represent that I am an officer or employee of the corporation and am authorized
to act for
ame of Corporation
having offices at 1��d�t✓►J i.-,-
Whose officers are:
President:
?'ri ny ii�
(Name and Address
Vice - President:
(Name" and Address)'
h
Secretary:
(Name and Address)
*r
Treasurer:.
(Name and Address)
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts relating
thereto.
Sworn to before me this day Signed:
of 19V Title:
Notary Public
f 6MAS 1.. APNTJNECCHIA,
York
;a n;,. COLSh4;
1VI1rajt1 rittl W Eii ,.t ... ..
!Y1twNksion EX"I'r.` �J
8/84
Corporate Seal
a
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 ^0C Address -4-' �oZm
.� i2 �- ,�czr.;►� ,.c�, ®Sn�
Located at (Street 7 (_o Block Lot 14 j 2. 1
Indicate nearest cross street)
Municipality Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME - PERCOLATION PERCOLATION .
apse Dept iF— water a er lievel ...
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches. Inches Inches
5
1
2
3
4
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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
- DES'CRIPTION OF SO-T. . <= IdCOUN'l`ERFD� IN TEST-HOLES-
DEPTH HOLE NO. l HOLE NO. HOLE N0.
G.L. L
611.
12"
i
1011
2411
30"
i .r
3611 t
42" �r
481 li
5411 r
60"
66'1. fir.
7211
78"
1� 11.
�Cr
t,
KATE .LEVEL AT WHICH'- GROUND WATER IS ENCOUNTERED—
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED`
TESTS MADE BY -Date i
DESIGN
Soil Rate Used `-- .Tcwn/1 "Drop: S.D. Usable Area Provided— &--X 4: i J�
Lt . �`°
No. of Bedrooms - Septic Tank Capacity Z Gals . Absorption Area Prodded L. F. x24" 0c,
Name !C. Signature
�.
Address SEAL
�Q 0,4
P hl�
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved 'Sq. Ft /Cal. Checked by Date
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-R= 25.00
n. LW 1I' y3.,
_ L= 2A.4r
m
'SUiZVEN�( OF PQOPEZ -TY
Fl ZEPAZED FOR
CC)LC)K lt-\L RIPcaE A5.,0GIATE50 IKJC..
LOT IUO. 21
AS 6HOWU ON
FAIR 5TREET `5UBDIVISIOh.I FILEb NAP 3k ZIg4 FILED
7 —DW114 OF PATTEIZ'SOKj PUTWAM GO. N.Y.
5cALE I" = 5p' O(,T�BER 14. 98�
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