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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -3 -20 BOX 14 IN Id r I r' I ■ 14 is - i ,16 4 T J , Is. Ir Wit 01482 PUTNAM COUNTY DEPARTMENT OF HEALTH CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION. PERMIT # P_ 4 - 02- Located at 201 �d�oV� Town or Village pAT�541J Owner /Applicant Name C- 1-tQ�1`, �-64 Tax Map 4 , Block Lot a-0 Formerly Subdivision Name _ Subd. Lot # Mailing Address %E OV t�,ff —1 46 VE P RD P A TrEP -60PJ 1J `y' Zip Date Construction Permit Issued by PCHD 0�_ 1 ° -7 ' 0 2 Separate Sewerage System built by GN WIS 4 4L I W(4-Address W $jam P°L6 W FMV-__'0'J Consisting of 10 0 0 Gallon Septic Tank and �o0 i f' Aft f )A&14 Other Requirements: 6 11 P LL Water Sup"I : Public Supply From or: X Private Supply Drilled by h i Wa D CNLLL W - Building Type Number of Bedrooms Address Address (Olt W'1111 P 40 T + 17'" Has erosion control been completed? Has garbage grinder been installed? Ho I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulation+ of the Putnam Count' Department of Health. Date: rr l y - 0 Certified by (D i n Professional) Address 2oSo(' 'L'L $1✓5 i (L Ny (fl 0q License # P.E. X R.A. 56114 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals pareect to modification or change when, in the judgment of the Public Health Director, such revocationation r change is necessary. 1 By: Title; Date: �s A 1 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: [Lict , _ Town/Village: (``�C"n Tax Grid # Map 34 Block 3 Lot(s) j 0 Well Owner: Name: Chn Address: iJse of Well: 1- primary 2- secondary Residential Business Industrial Public Supply Air cond/heat pump V Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length_ft. Length below grade d6 ft. Diameter 7 in. Weight per foot lb /ft. Materials: Steel _Plastic Other Joints: _ Welded Threaded _ Other Seal: Cement grout Bentonite Other Drive shoe: ' Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield /6 gpm Depth Data Measure from land surface - static (specify ft) During yield testft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve - analyses - -_.__ are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ^ !% If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage T Information Pump Type " �v apacity 6d>a6C. Depth �� 4u Model �1m VD Voltage Jw V HP f1j Tank Type Volume JreSSUt'� Date Well Completed % 5 03 Putnam County Certification No. 007 Date of Report /L/�3 Well Driller (signature) NOT 9: Ijxact location of well with distances to at least two permane t lan arks to be provided on a sepangrsheettplan. Well Driller's Name Xlkct, 11. 1 14 l -1-6_6^;11 :rfiC` Address: AW 1 rs-6 , Signature: Date: 4P White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 Oct 18 04 10:07a TOWN OF PRTTERSO 845- 878 -2019 p.2 OCT -18 -2004 12:27 AM HARRY W MICHOL_S 914 279 4567 P.03 BRUCE It FOLCY LOi181TA MOLINARi R.i't, M.S.N. ' Pn6Rs lkeltA Obsuer• •• •• .. .. •d�toelate hdRe.l�iolrA Qf�tctor,,, .„ , Dkrmar eT rartra &rvfau _„ . .. 1 Oenavl 'Rold Brewster, New YOjk - 10509 " " • •Laireonuiet NuttM (!II)311• /(30 1tx(914)1'It• ?Ott . Memel, t�M�n( it < »91•isSi...W1C(OII)bti•i611 .Flt�ltf(itl•6gfs t.�.lrTlfww'66e'iP11)ylf•i4t� ►rtaioat�lf /11Tt•seri /ee(9H)!7f•d64f B211 ADDRESSMERIETCATION PARM oV4'IV>elzs NAM: G!}p•1S � Kg++7 $c1R4t1� _ :: E911 ADbIi S... �G 6�►• tT Htx .94 AO ,kUTllOvizLZ TQW. K-0.MCL .Lr: (SIgnrturl) . t_.. The Putnaan .Colmt Departmot of Health wilt not issue a . -Ce ' i'l]i2cate -of Consttvalma Compl'iahcaunle9& the about: form U. completed; t.0., N legal E911 • addrtss 13 asstgned by, p authorized town vfiidal. This fot*is to be submitted.-,- _....... with.the appUcation for q Certificate of Construction Compliance: - l` t NORTHEAST LAB ®RAT®RI-ESo INC. 129 MILL STREET - BERLIN, CT 06037 -9990 (Danbury Office and Sample Drop Off Site: 100 Mill Plain Road, Suite 342, Danbury, CT 068111 e� �N AccoRo9 00 6- 7fELEPfON t TOH'Free (in �F-9'O5' (Outside 6T-Y-800-654-T,230" Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 #' Q E -Mail: NELABSCTQAOL.COM www.NortheastLaboratories.com REPORT TO: PAGE 1 OF 1 KELLY BURDICK DATE SAMPLE COLLECTED: 10/04/2005 381 BULLET HOLE ROAD TIME COLLECTED: 8:21AM PATTERSON, NY 12563 COLLECTED BY: KELLY BURDICK DATE DATE RECEIVED @ LAB: 10/04/2005 RESULTS TESTED BY: LAB #11471 STANDARD DATE TESTED: 10/04/2005 – 10/10/2005 BACTERIAL: LAB ID# _ _ _ 0505576_01 REPORT ID# D0505576 REPORT DATE: 10/13/2005 SAMPLE SITE: 201 BULLET HOLE ROAD, PATTERSON, NY 12563 SAMPLE POINT: KITCHEN FAUCET SOURCE: WELL DRINKING WATER TREATMENT: NONE NOTED ml= milliliter mg/L= milligrams per Liter ND =none detected MCL=Maximum Contaminant Level TNTC =Too Numerous To Count —Notification Level ** *Action Level <Q= Analyte detected below quantitation limits data deemed estimated. 3= Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines, however, the underlined results exceed or falls below USPHS recommendations. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: OPOTABLE or ONOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTAB LE WATER) r �, i Approved By: ` ° '=" 'r Laboratory Director CT Cert. #PH -0606 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 MAXIMUM CONTAMINANT TEST PERFORMED LEVEL (MCL) OR DATE TEVIE RESULTS UNITS METHOD # STANDARD TESTED TESTED BACTERIAL: • Total Coliform (Bacteria) ABSENT per 100 ml SM 9223 0 per 100 ml(ABSENT) 10/04/2005 16:00 • E. Coli (Bacteria) NEGATIVE per 100 ml SM 9223 Negative 10/04/2005 16:00 PHYSICALS: • Color (Apparent) 0 mg/L EPA 110.2 15 10/04/2005 16:10 • Odor ND mg/L SM 2150 Not to exceed value of 2 on scale 10/04/2005 16:10 of o -5 • pH 5_5 mg/L ASTM- D1293 -99 64 to 10 Ran¢e 10/04/2005 16:10 • Turbidity 0.38 NTUs EPA 180.1 5 NTUs 10/04/2005 16:10 CHEMISTRY: e Ailcalinity 14 mg/L v SM2320B No defined limits* ~10%10/2005 - -- • Chlorine Residual <0.05 mg/L 4500CIG - - - -- 10/04/2005 16:10 • . Nitrate Nitrogen 0.15 mg/L as N EPA 353.3 10 mg/L 10/06/2005 11:00AM • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 1.0 mg/L 10/04/2005 16:10 Combined limit for Nitrite plus Nitrate = lomg/L as N • Hardness 28 mg/L EPA 130.2 150 mg/L ** 10/07/2005 -- • Lead <0.001 mg/L EPA 239.2 0.015 mg/L* 10/10/2005 - -- • Iron <0.03 mg/L EPA 236.1 0.30 mg/L* 10/05/2005 - -- • Manganese <0.01 mg/L EPA 243.1 0.50 mg/L * ** 10/05/2005 - -- • Sodium. <I.0 mg/L EPA 273.1 20.0 mg/L * *3 10/05/2005 - -- ml= milliliter mg/L= milligrams per Liter ND =none detected MCL=Maximum Contaminant Level TNTC =Too Numerous To Count —Notification Level ** *Action Level <Q= Analyte detected below quantitation limits data deemed estimated. 3= Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines, however, the underlined results exceed or falls below USPHS recommendations. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: OPOTABLE or ONOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTAB LE WATER) r �, i Approved By: ` ° '=" 'r Laboratory Director CT Cert. #PH -0606 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 October 21, 2005 Putnam County Health Department One Geneva Road Brewster, New York 10509 Aft: Mr. Robert Morris Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Email: hnengineer @aol.com Re: Individual SSTS Compliance — Burdick 201 Bullet Hill Road Town of Patterson, NY T.M. # 34. -3 -20 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As Built SSTS," dated 10/15/04. 2. "Certificate of Construction Compliance for Sewage Treatment System," dated 10/10/05. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated - 10/10/05. 4. Laboratory R— eport, dated 10/13/05. f 5. "Well Completion Report," dated 12/17/03. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Department. 7. "E -911 Address Verification Form," dated 10/18/04. If there are ay questions concerning the enclosed. Very my yours, Harry W. N' cls Jr., P.E. HWN:JM :jmm 01- 038.00oct .JNTYDEPARTMENT OF-HE . xtM .... . .... 4_2 7. GUARANTEE OF SUESURFACE SEWAGE TREATMENT S �41 r wil r.-;or Pure Building.. Tax Map_ Blo .,h:as,er of Bu TE� twonstructea by. . TownNillage it '7 1 Subdivision Name-,. BuildintTXpe Subdivision Lot # re' epresent that 1— 611. and Qo' am. h: mpletely responsible for the location, workmarishipi.-mate-- coristructioa' of the treatment system serving"the above - described T y .... constriidted,'a`� s 'oft on the approvo 6 d plan- of appr Cth- oved ameadi en d regulations of the?' tnam.0 ....accpr ancewi :fula4nd u .0unty th 0,4n&�",' t�'Ujjial ere y, gua;an ee to:tk; his s�cces�ors, heirs: "QpeT4tIng-t'Qh diQ or assigns to plaQe7in cio'd, 9. 0 --two: :f e ars n J �y%.�m CQ structed b which Ails to operate fo .'p y r a eri ...0 r. =. teIY:fQ40Wing the date of approval of the "Certificate of ction Coffi p I i Constru repairs mad�e�.by me to.such system,..e `fa i I u r t any. r e t wh�re:th e s.: _�.yhe',willfUa -4uHd u: 'ed -.ne.g-l.i-gen.t-a t�f the-Qccuparit-of thc. Ys m d' h .The,-.yp. ersigne rther -a ees to accept as conclusive ---the determination of the Publi c.-.Hq'a I'th, - Djr`e616r'of the Putaim.Q6unty 1)c' pArtment of Health as to whether or not the" Q167ie f !he's zin" was caused b� the'willful -or negligent act of the occupant of the -.' buildip� til i thej . . . . .. .. Date . . . . . . . . . . . .70 I year e:* M'6nth Day - SigTi.atur. ........... 4 Titi't Corporation -Name-(if.6-6f -i yorat "kddtes S. zip, Stalte-� zi A"4$ AV OP 0 1000 GAL. SEpT'Ir- TANK A Qc tv .0 � "o NO EXIST. WELL 0000 00 PUtam County D .MVISIOU of Enviror. TA Title v� for PCHO Apprc V, DIMENSION CHART (in feet) Number A Z5 Z-7 46 33 3 40 29 4- 47 25. 5 48 a* 6 31 56 35 sG .9 89 113 10 87 113 1 I 19 108 12 175 13 14 so 15 30 %/! 3`DSf G ✓� // PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . .rng -19 %or FINAL SITE INSPECTION Date: o o Inspected by: -Street -Locations G �`i �jo� �a„47) Owner Town ` �,¢ y�G�2r,�,v . Permit # �• TM # 3 Subdivision Lot # -- 1. Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size 1,00 ...:.....1, 250 ......... other ................ b. 'Septic'tank'inst a evel ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 -ft.Original soil between box & trenches e. Junction Box - set .......... ............................... 6. 1'renches properly 1. Length required 3 oe> Length installed 2. Distance to watercourse measured -t-- ► 00Ft.......... 3. Installed according to plan ........ ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot........ ,... 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1112" diameter clean ............... .... : 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped ................... . g. PUMV or Dosed Systems 1. Size of pump chamber ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................................................... 6. C�yycle witnessed by H D estimated flow /cycle .......... M. House4ucildirig IV. Well Well located as per b. Distance_ .( plans . ......:........................ ,,a measured..../_/V2_' easured .... /_/V2_ ' - ft -' - - - - - -- - - - - -a- - - - - - - -- •• - • --- r....,__ ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercoursf g . Footing drains discharge -away from STS are s h -- Surface -water protection- ad-equate... - ................. i. Erosion control provided ............................... I ............ ..... Rev. E102 COMMENTS $c,~ PUTNAM COUNTY DEPARTMENT OF HEALTH DWISION OF ENVIRONMENTAL HEALTH SERVICES j jE,�ZFCR F1NAT, rNSPF.�T1,QN For Fill Date: !I&Q. 1 - &Lt .r, — Trenches -- PCHD Construction Permit # -q -n7 Located: 6a SX A" _ s� (T) M Owner/Applicant Name: „ 49.tsi kcal„ %,)at;XTM 34 Block Lot —Z�0— . Formerly: Subdivision Name; Subdivision Lot # Is 'systeni'fiil completed? Date: It system complete? X14 bate: ZJQ. 11 ley Is system constructed as p.er plans?� Is well drilled? jra Date: _ XAii3. 1A jam_ Is well located as per plans? _ it's Are erosion control measures in plaeu? -- I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and .verified their completion in accordance with the issued PC HD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: �"A�_ 13 IT D► Cerded by: E RA Desi rofessional Address: zags 963 ... Z7 R�, stoma j DS'D9 Lic. Comments: FOR: ❑ADAM ( GENE 0 (N) _. Form FIR-99 lr mt- .111 (TF Ii11N .. n !Ta , fAP" ------ — -- r a LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 January 26, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr..Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — Burdick Bullet Hole Road, (T) Patterson TM# 34. -3 -20, Permit # P -4 -02 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The house must be inspected by this Department upon completion. 2. The well must be inspected by this Department upon completion. Please note that erosion control measures must be installed below the house and well prior to the start of construction. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. GDR: cj Sincerely, iv, Gene D. Reed Sr. Environmental Health Engineering Aide i; SENDING CONFIRMATION DATE • JAN -26 -2004 MON 11:59 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE PAGES START TIME ELAPSED TIME MODE RESULTS : 92794567 : 1�1 : JAN -26 11:58 : 00'41" : G3 : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... �a LOW"A MOLZURI ROBERT 1. BONDI Pa61ee rle4trh 07rrcror Y Coe40, 6xeronMe DEPARTMENT OF HEALTH 1 t3eneva Rued, Browster, New York 10509 C- 11- 1tnratnl ltenro (843)279.6110 Fax (845) 219.7921 . ._ 14mrit" S.-Am (845)278..6558 VAC (945)278 -6679 Fax (845) 278 60115 k" t4terventl -7 —shoot (R45) 278 - 6014 yv (MS) 279 -6648 January 26, 2004 Harry Nichols, PE — Patterson Park, Suite 2050 Route 22 Brewster, New York 10509 Re: Field Inspection — Burdick Bullet Bole Road, (1) Patterson TM# 34. -3 -20, Pormit # P -4.02 Dear W. Nichols: The above referenced separate sewage treatment system can be backFilled. The following comments must be corrected in the field 1. The house must be inspected by this Department upon completion. 2. The well must be inspected by this Department upun completion Please note that erosion control measures must be installed below die house aid well prior to the start of construction. If you have any further questions, please contact me at 845.278 -6130, mtt, 2261. I Sincerely, ((( Gene D. heed ' Sr. Environmental Health Engineering Aide GDR:cj LORETTA yMOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New .York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 February 9, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection — Burdick Bullet Hole Road, (T) Patterson TM# 34. -3 -20, Permit # P -4 -02 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The house must be inspected by this Department upon completion. 2. It appears the well was not installed in the approved location. 3. The well casing needs to be raised up to a minimum of 18 inches above grade. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. GDR: cj Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 . Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 September 10, 2004 Harry Nichols, PE Patterson Park,. Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — Burdick Bullet Hole Road, (T) Patterson TM# 34. -3 -20, Permit # P -4 -02 A re- inspection at the above referenced lot has been completed. Comments are as offered. 1. The house plans in our file do not reflect the construction of the existing residence. Actual house construction plans must be submitted to this Department for review: 2. The driveway retaining wall on the approved plan is dimensioned maximum 3 foot high. Field measurements indicate the wall to be an average of 5 foot high. It is this Departments concern that the 100% expansion area may be compromised. 3. As per my last comment letter dated February 9, 2004, the well casing needs to be raised up to 18 inches.above grade. Please call me to set up an appointment for both of us to meet at the above referenced lot in order to address comment # 2. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj SENDING CONFIRMATION DATE - SEP -10 -2004 FRI 11:32 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE PAGES START TIME ELAPSED TIME MODE RESULTS 92794567 : 1/1 SEP -10 11:31 00'43" G3 OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... LORMA MOLPIARI ROBMtr 1. BONDI P. Wit H-114 d,eerar F C.-ly Ira.vdl- DEPARTMENT OF HEALTH I Oeoeva Read, B —ster, Now Ymk 10309 lta.lmn� l B-Ita (1t11)278.6130 Faa(945)278 -7921 Kar959 9-100 (845)278.6538 •WIC (045)278 -6678 F- (945)279 -us5 barb• lotvrrntbolpraclael (845) 278 6014 F- (845) 274.6648 September 10, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: PieldInspection — Burdick Bullet Hole Road, (n Patterson TWO 34. -3 -20, Permit F P-4 -02 Dear Mr. Nichols: A re- inspection at the above referenced lot has been completed, Comments are as ofrered. 1. The house plans in our file do not reflect the construction of the existing residence. Actual house construction plans must be submitted to this Department for review. 2. The shiveway.rctainio.8 wall on the approved plan Is dimensioned maximum 3 foot high. Field measurements indicate the wall to he an average of 5 foot high. it is this Departments concern that the 100% expansion area may be compromised. 3. As per my last comment letter dated February 9, 2004, the well casing needs to be raised up to 18 inches above grade. Please call me to set up an appointment for both or ,s to meet at the above referenced lot in order to address comment M 2. Tr you have any further questions, please contaet me at 845 -27g -6130. ext. 226 t. Simmully, t(/ . V Gene D. Reed Sr. Environmental Health Fngineering Aide GDR cj i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at 50LLE-r i0Wr-- p4A Eli! hp` Subdivision name Date Subdivision Approved Subd. Lot # wn or Village Pmr ep --6-oV4 Tax Map fb4 ° Block �5 Lot 2-0 Renewal Revision Owner /Applicant Name G14P; 4 V-VLlq WIUi - Date of Previous Approval Mailing Address °'j�l BUU-E1 1i LE WO PAITE L60iA i W-e • Zip 11-6L5 Amount of Fee Enclosed �6 Building Type Lot Area % - � L No. of Bedrooms ?) Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage _System to consist of gallon septic tank and 2 09 L4f A � Other Requirements: (o" To be constructed by 1-N Address Water Supply: Public Supply From Address on_ Private Supply—Drilled-6y Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. A _ Pr P.E. V4-,e 10 R.A. Date i%-1 61 © l License # 5(lkl-i APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified F en nsidered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm' . pprove r discharge of domestic sanitary sewa a only. By: Title: jp�— Date: Z "[ Z— White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 C - PUTNAM' COUNTY DEPARTMENT• OF' HEALTH .l�TYLSIOI ._D :E N ME.NTAL -HEA LTH;SERVICES - DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner — AA -1 Address* Located at Street . gU LLET 4 0LE KO �D Tax Map Block'... Lot %fl t ) (indicate nearest ross street) �1�pL� ���� Municipality .0H Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking 0/2G Date of Percolation Test (o /2710, eR..u` ,fie:' 1 l:'�•) : >; :.... . 1 Pom Q Sumac :.::Starf';s�•tcPJ 11- it Xe kp :.,t:e;; T r 0 I >�•.. Rate: ::Miallacb 2 1,13 10�2q ! 20` 23'' 3'' 'D,3 ' 3 to -��� 20., 2 ✓ (' 4 — i 2 3 2 '' -� ,S 41-'k 5 . 2 3 4. k'n•r•rc. T - -•- L- - - - • .. -, - .v vy svyvosvv o► u uvywl u -11 a},},1vx,ma«iy equal pCrcotauon rates arc obtained at cach percolation-teat hole.. (i.e. s I min for 1 -30 min inch, s 2 min for 31 -60 rTiin%inch) All data to be subrmitted for review, 2. Depth measurements to be made..from top of hole. Indime level at which groundwater is encountered Indicate level at which mottling is -observed. IV O ryE Indicate level to which water level rises after being encountered Deep hole observations made by: GF-N F RU -b D & Dk N k D\-CDNWT Date W27 10 1 Design rrotesstonal Name: Address: ',(,D';Q 9RI WS T �- .y�C� t�SDq Signature Design Professional's Seal �Q Cr x w �No. 561 pgeFESS110 TEST PIT DATA - DESCRIPTION-OF'SOILS ENCOUNTERED IN TEST HOLES .. .11 � ; �•.,:� d Y . -01 _.. ,i;^^iivyip ► ^^�ee�_ T - G.L. _TQ CE o,F TOP olL 1K NU,� 0P 2\L 0.5' ,r ' ,.: ,� = (�� N ... VON .. --- 1.0' )wA Q -oWN i. 5' D1�M�AN - 2.0' G(�RNU- R�INVA -\ P,U - .5' \AW RocyS s L� � GCE ( ow Y.o' SA N\ A. wt� OCR 5.5' 6.0' c=� 6.5' GM, 9 (g` 0' -� 8.0' AM) .10.0' - Indime level at which groundwater is encountered Indicate level at which mottling is -observed. IV O ryE Indicate level to which water level rises after being encountered Deep hole observations made by: GF-N F RU -b D & Dk N k D\-CDNWT Date W27 10 1 Design rrotesstonal Name: Address: ',(,D';Q 9RI WS T �- .y�C� t�SDq Signature Design Professional's Seal �Q Cr x w �No. 561 pgeFESS110 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER W_ ELL ple "ase print or type _ PCHD Permlt #� ` ~— Q Well Location: Street Address: Town/Village Tax Grid # fto ROL-6 kv P/-VV z0`r+ Mapg4l Block `% Lot(s) Well Owner: Name: Address: GAN'4� 14- %J B'J.4 � 1-vpt.6 t�p Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought -, gpm # People Served -� Est. of Daily Usage COO gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No X Name of subdivision Lot No. Water Well Contractor: Q Address: '- Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: -- Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination o be provided on separa shee Jplan. Date: Applicant Signature: V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and 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. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water , e 1 iller certified by Putnam County. Date of Issue �. z— Permit Issuing O i X19 Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 aam Q31Yx0ma- SON NII4 ,Oin(� aBteqDsrp Sup M03 Z81 I£m a SAZ `Os ` T%3/aI0rls ,mO H Z Y Ho ` NNII4 1 ,SZT((—�((� s of CO S<- i � aaNYlsnn myriY 3A0`r3Y 0Y2i AYa I(�n Q3'IIYla(l MtA LId)(---) ('JI3 `3du 3dld) `NI 3Jx O3'IIYi3Q(�(� a3lON 3WI1'IOA 3SO(I /aW l A d 3 %SL 3SOQn( —) S3 N aP aC --)(--) CL33HSA3x) :S.Lt13izlK0:) ScNflOa v saial AI.Ni3doua( )�) s.LSS 3o ,OOZ NUM mass V S'I'I3M( —)C7) SNOI.LYA3'I3 INMUSYa QNY'dOOU HsINI.i Q3SO(1Oxd(---)(7-) " I'd 30 ,m)zHim SQNY'Il3M`S33iri soma `s3sTifIOJumm 30 &,oi vJ0'I( —)c;) 3JN3x333x I nivaC —)7) NOISIA3x ,%a&Yxa 30 3.IyQ( —)(;T) MBAs UUTME-5-d n3AIOHd `SS3xQQY `3AIYN Yx13d `; =IN .I a3xI bU 3I ` %SI OZ Q3QYx03xpn SsMaY aMI4 SHIK - 3TDola 3'I.II.Li —)i,) (- /.OU)�f'VM S.LSS �u laozsc --) . smxvaNnog 3au -nos Yasf1(--)V) / SN (DaY.IUm/ i3LLf !)i0)� oo3( —)(7) o Is im `Mozs 12 AYMI Ixac )(/ 3NI'I Alxaaoxa ol,Si t�l(� .._ _ � -.. _.____.... 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Y I i�0 S II 3Q Q3x1f1 3 \ A. S u-.Ia UI OQ \ A _ a3 �i oJ) rdel�t xYJ i %A P ,/ :a.LYQ jsd ',do lu :Aa as &aLIM :NOUYJOZ 13ms �„ xsi. vo ao 331TYII d i.OI.IJl1 is.KOJ 2T03 I33HS A13LA32I sI43ISAS lil3Iklivaul 30YM3S 3JY3xfTsafis v A'Iddllsx3lYM'IYflaLUGQ HIlY3H'IYL \31CLKOu N3 30 NOISLUQ Hl'IY3H 30 L\314.112TYd3(j Munoz) I1TYNlfld --13RUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETT`A MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 January 3, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: Burdick Bullet Hole Road (T) Patterson, TM# 34 -3 -20 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: -1-. Letter of Authorizatiori has no' t' been signed by the owner (original enclosed). 2. Neighbor Notification to all contiguous property owners is required for this project. 3. Please reduce the number of pipe bends between the septic tank and first drop box or add a cleanout. 4. Fill is to extend 10' horizontally past the ends of all tenches. 5. Provide 20' separation from the foundation to the absorption area. The construction of this sewage disposal system maybe subj ect to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed . by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Since y, SR:tn Shawn Rogan enc. Public Health Technician PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION ..OF--EN,VIR()NMENTA,L- HEALTH SERVICES. .2. LETTER OF AUTHORIZATION RE: -Property -of 4 Located_ ax +Q uc_ TNPAT1_15V61)P T4k Map. # Block Lot Subdivision of Subdivision Lot # Filed Map # ....Date Filed Gentlemen: This letter is to authorize 4W w' R G M L,5 , � PE a,duly.licensed Professional Engineer N or Registered Architect to apply for the required wastewater treatment and/oiwater supply permit(s) to serve the above -noted property in accordance with the standards, rules or-regulations as promulgatc.d.by the Public Health Director of the Putnam County HdAlth-D 'mm' t -and to sign all necessary papers*on.-m behalf in.-connection with ep en -an y matrer and to supervise .-the-tonstty.cdon of said wastewater tretment ahtVOr water supply systems in--,-- f* -1 *5R6d/6f'r47-bf 'the Efiic�Iio' h'kqrls. 0 icle 4 the Public Health Law, and the Putnam Coy - Code. Countersi P.E., R-A, Very truly yours, Signed: (Owner of Property) Mailing Address Mailing Address: o rATT-5"OH- State —Zip State Zip - -. Telephone -( V I o... n .- Teleph e: Form LA-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: 'Property -of L 6 �EU--\tj bop -DIGAL- TN P Tax .Map # Block Lot ZQ Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize Rk W W ' Mt L kO Ly j J�_ PE a.duly licensed Professional Engineer �1 _ or Registered Architect to apply for the required wastewater treatment and/orvwafer supply permit(s) to serve the above-noted-property in accordance with the - standards, rules or.regulations as promulgated.by the Public Health Directbr of the Putnam ............:. County Health - Department- -and to sign all necessary papers'on- my. behalf in connection. with .Sh a:,..... matter and to supervise the construction of said wastewater tretment and/Or w6ter supply systems in _ -,con :wi:th::t ±_.tn,rnvi€ ^� f- ti :-451 xnd/cr 1 � C• taiC uil%,$&W iii La�%J�� the d th o le iie`i Law, and the Putnam CouCCode. .�` V1 ....,.y.rO4 x Countersigned: - P.E., R.A.,# 4p �, Mailing Address 9oF State.. tJ J Zi 0 � O� Telephone: 6 � y - 66 � Very truly yours, Signed: (Owner of Pro rty} Mailing Address: ....... ... . State Zip Telephone: Form LA -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 January 28, 2002 Mr. Shawn Rogan Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Proposed SSTS: Burdick Bullet Hole Road Town of Patterson, TM #34 -3 -20 Dear Shawn: In response to your review letter dated January 3, 2002, we note the following: 1. Signed letter of Authorization is now enclosed. 2. Copies of Neighbor Notification is enclosed. 3. A cleanout has been added to the effluent line. 4. Fill now extends 10' past all trenches. 5. 20' separation distance is shown from the foundation to the septic system. Kindly continue with your review and issuance of the Construction Permit. Very truly yours, �a Harry W. Nichols Jr., P.E. HWN:jm 01-008.00 IU.S. Postall CERTIFIE1 (Domestic Mail C Article Sent To: Ng T &1,4, ,, I Ln Postage 0 80 .': UNIT On C3 rn Certifie'd 'Fee 2,10 "1 ! Postmark ru R6tdrn.Relcelpt Fee Hare > (Endorsement Rpoulred) rq I IM heitricted Dell y Fee ee ver t C3 (Erid&sldnient Required) 4.40 i C3 00 e- & Fees C3 Name (Please efint Clearly) (to be 4 M- i- : 1. M..., I ......... %— Street, Apt. No.; or. Er ............. C3 SW6, ZIP+4 4eted - by-mall6d Pirkir.'ski 1pb,,w,"; ir, NY 10509• Article Sent TO: 4 C C3 rn Certified Fee;, Return 'jjac6lpt R; U ree ent Fequire�j . A G' _, Res{ncted Delivery Fee -(EndojsWmafit. Required) '4 4-8 0 Name (Please Print,cleaV) (to ba,c�Te�t!q by rn rT1 "j- N pt. 4 Sl�.et, 07 Me' Ir np R a I C _C! ; Y 3 State, ZIP PS Forin 3800. JL11Y 1999 Tart k §40 7-1 ,7227 .......... 8UP-DI pJv I N1N� oW►���� ..._._. ._._..........__.......�....,._ ._ _.._... ,.. _ _.. _ ,jai n.,%{iE � ��1:G'- h - - vp►'�i �_ -• — - . J� �' �* 111- GS;�'j• - ... ._...__...----_._ �..._ �.._._.._---._-.___.... _�_._!��..- .....�J'...I��'j't.- _...Fox ¢►iN Go!�t?o1^aHlutl�j, - °. /o {}owtkP-D 4�- P�PLr'�1-1 ..._ - . ........... .___........- ..._.._....__..._. _ 5f NEr.� �oR�: ►-a� I o0�1 d,6 .. A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner &17z njc ,. Address avzz sue- e - Located at (Street) Tax Map 311': Block 3 Lot --2-0 (indicate nearest cross.street) Municipality e�r��7z5d� Watershed MI DDLC— 31Z C_ j../ SOIL PERCOLATION TEST DATA Date of -__-_-.---Date of Percolation Test NOTES: 1. Tests to be repeated at same depth equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 4 :.: .. ..... _ _:._.. 5 . 2 4 3 4 5 NOTES: 1. Tests to be repeated at same depth equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Indicate level at which groundwater is encountered . L-7 $ Indicate level_at which_mottling is_observed!o®y Indicate level to which water level rises after being encountered Deep hole observations made b y: 4:,Z,] T�f 6,c— z;> Date 2 0� Design Professional. Name: Address: Signature:. Design Professional's Seal__ _ _ TEST PIT DATA - - _ 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES- DEPTH HOLE N0. HOLE NO. HOLE NO. G.L. 1.0' 2.0' 25.. < 3.0 .- ie 4,r4 ve/ 45' 5.5' 6.0' Z;to-v mr, Va r: e s 7.5 r 5 8.0' ._. _ w�>2o� k3- 13aulgler,�. 0� AV L ..........._... - -- - -- --- - - - - -- :: - - .. -...._ ..... -- .�._...._.. mil._....... -. •.-.: -. -. _� _:. " q. �. 9.5' 10.0' Indicate level at which groundwater is encountered . L-7 $ Indicate level_at which_mottling is_observed!o®y Indicate level to which water level rises after being encountered Deep hole observations made b y: 4:,Z,] T�f 6,c— z;> Date 2 0� Design Professional. Name: Address: Signature:. Design Professional's Seal__ _ PUTNAM COUNTY DEPARTMENT OF HEALTH - - D��S�ON OF ENVIRONMEXTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A..GENERAL INFORMATION Name of Project BriTZ �!G SM County �y Site Location Aoj og Building construction begun IV c) Extent Is pryrty within NYC Watershed? ................. Yes a No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) I. Hilly _- Rolling _ -- - . Steep slope .......... _... _Gentle slope -- - -_ -Flat -- - - - -- - - -- 2. Evidence of wetlands Q Low area subject to flooding F__J Bodies of water Drainage-ditches Rock outcrops p. dv�nze 3. Property* ro a ity lines or corners evident ....................... .....:......................... Yes No - - 4 :. —Do watery courses exist on or adjoin the property? J.1!©NO..ki-uND . 0 Yes "No .5. Will these affect the design of the sewage system facilities ?............ 0 Yes No 6. —Do watershed regulations apply in this - development ? .:.................... Yes No -- ' ::. 7 —Will extensive grading be necessary ?..:.....::.: .- ` .� --Yes - .-Y - - _ 8. Will extensive fill be necessary for SSTS? . ............................... Yes No =- 9. Do filled areas exist within the SSTS -area lAf .....d... Yes a No _ ?... �. acv 5 . .............. w_. at. is the condition of the fill? saK x- gmve! ... .... __. -._. SECTION C. SOIL OBSE VATIONS,. - - Appearance -of soil: Sand Gravel . Loam , Clay -- Hardpan Mixture - 11. Observed from: F-1 Borings El Barik cut Backhoe excavations 12. Soil borings /excavations observed by 4�,' D_ H, on 61a o 13. Depth to groundwater 6 !�-7 63 on 14. Depth to mottling /✓DNS on 15. Are test holes representative of primary & reserve areas ...... .............. .................. 16. Soil percolation tests made by 7 C e S on 17. Soil percolation tests witnessed by a, 7C' ,e. on SECTION D (on back) on Form ST -1 E 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes E�No 19. Will groundwater or surface drainage require special consideration—? ..................... FD<es F-] No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... FlYes No SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist?:.:::::..:::- :.. ............................... Yes No 23. Additional comments 24. Site observer /inspector and title _ G _ _T�Er_ b 0F. W. T1_ G,. D - t� -- - -- - - 25. Date(s) of observation(s)inspection(s) TEST PIT PROFILES Hole # Lot - Lot # -- Hole # Depth to water Depth to water ... - - - - .. Depth to water - - Depth to mottling _. -. Dop±h to rnottl g- -- - Depth to ottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L. - G.L. :. 0.5 0.5 - ..:... 0.5 .. 1.0 1.0 __.__.. 1.0 2.0 2.0 . . 3.0 3.0 . 3.0 4.0 4.0 4.0 5.0 5.0 W 5.0 6.0 6.0 7.0 7.0 8.0 8.0 M [till] 7.0 8.0 9.0 9.0 10.0 10.0 i,. SEWAGE SYSTEM SHA }( `� .��,[� t"OHSJAUC TYJN DEJ;. j, 9A�]!�.`G 1 ;y�• NEM /OAn" STarE h ANY 516N /iICANr CN X� wRrr JEN dPPROVAL GM'NEA 5N.7LL BE Rr %. ser so AS •ro PRO SYSTEM OR PUMP L 9 2 , _ q��. - �\•, \ ' p Q `.r. j _c .. :. AasoAPr/ON awll V ly Q ASSORPr10N AREA q eN° "•NEC .4 P4i�lR T r� r ;.'1 far Ir ,�'.�y, r b1 1 ! [, / • sA �' 'YiS: ry[ I�JY 3 q 4` ( i^. •b 7 �..ceK" �'. -�,e+� �' { qK�F. , "!V .1�. ! y± ,�, �Ir t +:t s r..:. .E•w, r AM :. a rc'�-�'� �^ �� � �'7s5a 'u e t -4` ..,,,:.I� ...,'�_..��' s.. � � '! ,y�' -,.( "�� _ `^-c. s � ..:;� *`'' x. +,.i- �'l'��"' -;'� a.7���1 t �. - rs i J,x��. a. �uc- �_. -.. �.c -..,.� s�a:� c- ="ir.� p`.. �-- � '��- �-�""^ � �' ". �,.,. .cx. -.�' �- -c. �'c.... -. .w t�' _ _ ,, :. �:_. � � r �, yayr � , 3� �. � -;. �, z rte.• t e-e- ,,, � '': n f - _ < �.. �. ',;,, _ 2 ryY A 'sc .FC t. .r � -' "ter e..x. +LF. � T - -�d _ i.�.. �. x ti 4 ; ; f \ N. -' ... .� �. � re o- _ �. m ,.z _ u ... .�..r �.� vu+e��_ - - - .! .. . - _ .. �. - Ste' .. �.. ,. _. J,x��. a. �uc- �_. -.. �.c -..,.� s�a:� c- ="ir.� p`.. �-- � '��- �-�""^ � �' ". �,.,. .cx. -.�' �- -c. �'c.... -. .w t�' _ _ � � r �, yayr � , 3� �. � -;. �, z rte.• _ MAY - 18-2001 09:13 AM HARRY W NICHOLS BRUCE IL FO1LEY _ - ...... _ . 914 279 4567 DEPARTN&Wr OF HEAD.` 1 Geneva Road Bmwsw, Now York 10509 p.02 LAR87TA MOLMM ILN., M.S.N. Associate Paine Health Director Dlrertor of . Fatfent wines ATTENTION: ® ADAM STIEBELING >(GEM REED All information below roust be 1WLt completed prior to any scheduling. _ BATE: ENGINEER OR FIRM: PHONE 0: REASON: . DEEPS: 6( PERCS: PUMP TEST: ROA6WREET: TOWN: �Ai`���- �J ©i-� TAXbW#: 174 SUBDIVISION: °' LOT#: -�-- OWNER: YES NO a )% Proposed SSTS within the drainage basin of West Branch gr B.vyds Corner Reservoirs. o A Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.. -. o Ql Proposed SST5 within 290 feet of a evatercqur_sar,,s 1911 flow greater than 1000 gallonVday or SPDES Permit required. Proposed SSTS for a Commerical Project. " It is the responsibility of the design processional to provide'the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. It you answered ji to any of the questions, NYCDEP must witness the soft testing. This Department will coordinate a .mutuafty suitable time for Geld testing with the PCDOH, the Design Professional and NYCDEP. It a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP & required to witness the soil testing, it will be the sole responsibility of the design professional to schedule Mwitnessing of the soil testing. with NYCDEP. Pon coua-ry use dray OATS: -- -a12- 6 ®� 'et:►t�� 49 . �.�.&.. :.�..0 ( MLDTEST) --A . . I il 49 Fli 23-2-10 - - - - - - - P/Fi3--2797- 37 1 6.6 jL AC 208.52 4.68 AC. % 2. AC 47 . 35 50 Y n �6 A0 4 t IF, 31 e,-)! 4.92A C. 34 v . V, I- . F .,t 2.32 A 44 0 P L EL77AC: C 55 v IM, I T. 263 I It On AG i AL !JL 26 1, 21 20 1. ea r- As A 38.70 AC. CAL -__o 0 .55 AC 2.95 2.41 54 15. AC 0 14, 33 1.92 Zf 'I% AQ r. 'r # a v 1. 4 AC Is , r Sl ausl 5.51 1.91 At 1.59 143 0 AC. Ac 22 93.76 WS At IL93 44JO AC. 37 38 'V, , jet JE 53 AC. 2.45 Ac. 4.16 AC 25.77 ;C. x CAL. 19.50 AL 41 m :x 21 Ai - 1 9 57., 22 ZI 1.70 A . A. 4as Mr MW MW 1 23 • 171 At &7 AN? NY 5.89 AC. ry. 0- 356 AC. Df m 15 99 2. 66 AC. 44 76 X - * " UT Ar Z 34.84 AC. 69 AC. 45 . . - .r I, 9 I, �14 I - ' Z4 ?0 A 39 30 0 At AL 9 [..j 00 AG 1 0 35.63 AC. v 'S AL P 7 4 re 194 At n6 JL A 3.36 Ac. X 4A 291 5751 346.2950 SA L40 Ar 9 672.72 6.81 AC;i '10 10(l 2.47 AC. AL p7ts Ac 10 AL • &01 At 52 r 333 AG 69. 9 34.13 1.3 At US At 697.% ,P -K 52 4 6Q2 4 1169 3. K JL 5.9; AC. 3 63 - t ./ - 55 3.60 A� 53.51 AC. CAL. tt /34. 17 %46AC. JL JL JL 1.4 ta I JL Na AL 46 21.95AC. 24.42 AC. 541-70 4` 4cl N- 122 4 , 66.90 463AC. A, • b -7 IL PUTNAM COUNTY DEPARTMENT OF HEALTH DMS1ON „0F.J:E � ; 0NMENTAL HEALTH.SERVICES .._ APPLIC-ATYOr4 FOR-APMVAL="DF- PIANS,FOR ... A WASTEWATER TREATMENT SYSTEM - 1. Name and address of a pp licaa .CW-4F-,S . 41 2. Name of project: Iry �D��l,5 3. Location T/V: 4. Design Professional:9- W+ I(. l.S ” Q� 5. Address: 59 ZZ 6. Drainage Basin: 7. Type of Proiect: X PrivateiAesidential ! Food Service Commercial Apartments.,. Institutional Mobile Home Park Office Building Realty Subdivision Other (*pecify) 8. Is this project subjsct to StatevEnviromontal Quality Review (SEQR) ?,... Type Status (cl}eck, one)..;...,_.......; ....... Type..I:. Exempt Type Ii Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... h Q 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N� 1 1. Name of Lead Agency '`l pro cct €r--ah area ender u�� c,�ntrv� or �ocai plaruiing, zoning, or. otfiei__.._._.__ _ officials, ordinancesT .............................:.......................... ............................... . 13. If so, hay; plans been submitted to'such authorities? ::...... ............................. .0. 14: Has preliminaryppo "val been granted by such. authorities?. N ° -Date granted: A 15. Type of Sewage. Treatment System Discharge.......::.:.:::: surface water X groundwater 16. If surface water discharge, what is.the:stream, class designation? :.::::........0..... NA 17. Waters index number i.. ,........................ 18: Is project located near a public water supply system? NO ......: ...................:.....:..... 19. If yes, name ofwater supply ` Nf� ` Distance to water supply N� 20. Is project site neaz a public sewAge.collection or treatment system? ................ MQ 21. Name of sewage system N g Distance to sewage system HA 22. Date test holes observed . r,'I 1101 23. Name of Health Inspector 66l-t5 W 24. Project design flow•(gallons per day) ................................... ........................::...OD 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... �Jo 26. Has SPDES 'Applicatien been submitted to local DEC office? .:................ ...... :... 2 27. Is any port ion of this project located within a designated Town or State wetland? o 28.x: -. W:.e 1. ends• IIa. �ri�: ��::.:.,:. �;:::. ....:.:::....:: �:::::::::::. �o::: �::: :;:::::::.::::::.:........:�.`_ _��=:,.,����, -_ :�, z.., ..�.�. - - -u. 29. Is Wetlands Permit required? .... .........::....:.................. ............................. ... NO Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance. Permit? No 31. Is or was project site used foc agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, �- landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 -feet of existing or abandoned landfill, _ hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? Yes/No DESCRIBE: 3. Is there a local master plan on file with the Town or Village? ......................... , E 5 4. Are community water and/or sewer facilities planned to be developed within. 15 years in or adjacent to project site ? ........................ �o 5. Are any sewage treatment areas in excess of 1.5% slope? .... 6. Tax Map ID Number .......................... ............:.I................ Map ?4t Block Lot 2Q 7. - Approved plans are to be returned --to= _ _ �_pplicatit ^_.. ' - sign:ofessc- = --_- -_- !OTE: All applications for-review and approval of a new SSTS to be located within the NYC .Watershed shal l sent to the Department, and need not be sent in duplicate to the DEP, although-the project may require DEP )proval of the SSTS prior to final approval by the Department. Projects within the watershed may also . quire DEP review and approval of other aspects of a project, such as stormwater plans or the creation of :ipervious surfaces, and the project applicant should obtain the appropriate forms for such activities- from EP and submit those forms to DEP for review .and approval. the application is signed by a person other than the applicant shown in Item l.,the application must accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision ay be grounds for the rejection of any submission.. I hereby affirm, under penalty of perjury, that Information provided on this form Is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant tc GNA T URES & OFFICIAL TITLES: piling Address: .....s:.:,.........., K, 14-16•' WW) --Text 12 PROJECT I.D. NUMBER a, 811.20 SEQ R State Envlrontnintal Quality Review' SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I_PRnJFCT INFORMATION fro be completed by Applloant Or Protect sponeol)' 1. fA6'T'veUq �� i(�� G :. Ira, HON FOAL, J. PROJECT LOCAT101k.P �oN pal- RM Munklpal Co„n 4. PRECISE LOCATION "I address and road 1nt*rwtW&.- pr0min4nt landmarks„ *to, or Provlda map) S. IS PROPOSED ACTIOM' - -- �Ntw ❑ Expanabn ❑ ModllkatloNaltaratlon 6. D`lES''CRIBE PROJECT ORNERY: 7. AMOUNT OF o ECTED: ' � � �I L Ifuuty a" Ulu"taly , , acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXIB'TING LAND USE RESTRICTIONS? ,kY" ❑ No it No, deMVM brletly ` 9. WrA{T 18 PREW LAND 09 IN VICINITY OF PROJECT! -- _ _ - Y_3LR3ls_Lda! Ua1__ -- .L.I1ndLAatft! — 0T4WK*1C!r1 - .I l-ggr:o tu., Gpwwro("VCSpin ipioi _ -- D"odba:5lNEal6 10. DOFF ACTION INVOLVE A PERMIT APPROVAL„ OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Y" *0 II yea, Ilst apaooy(a) and pe mlUapprovaw 11. DOES ANY ASPECT OF TH6 ACTION HAVE A CURRENTLY VALID PERW OR APPROVAL? ❑ Yes. ye?„ Wt WOW name and pwmltlappWAI 12. AS A RESULT OF PROPOSED ACTION. WILL EXISTING PEWIAPpROVAL REQWRE MODIFICATION? . O Ya I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE APPIkanUspmw 'yo 0WAOL-f J M A5 ' P aIt t 5 of S19naturs: 1 ... i/ If the action is In the Coastal Area, and you are a state agency, complete the . Coastal Assessment Form before proceeding with this assessment OVER PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION IXCEEDAN-Y•TYPE I THRESHOLD IN 0 NYCRR, PART 517,4 ?' It yea, coordinale'the. w0w,proase"use the FULLEAF• �.._ ' .. B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 5 NYCRR, PART 017.6? If No, a negative decisraWn� may be superseded by another.inv0lved 494rtoy4 Cl Yes O No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, II legible) C1. Existing air quality, surface br groundwslor. quality or quantity, noloo levels, existing traffic patterns, sold waste production or disposal, potentlal for erosion, . dralru or flooding problem? Explain brlally: C2. AastheUc, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wlldlile species, significant habitats, or threatened or endangered species? Explain bristly: Ca. A community's existing plans or goals sa officlally adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly CS. Growth, subsequent development, or related activities lovely to be Induced by the proposed action? Explain briefly, C8. Long term, short term, oumulativs, or other effects not Identified In C1-05? Explain briefly. C7. Other Impacts (Including changes In use of either quantity or t yp. nl anar gy)? Explain briefly, rte, D. WILL THE PROJECT_HA_VE_AN_IEIPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSM THE E8TAB4l8HMENT -OF A CEJ1? E IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RFLATEb To POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? q�J O Yes O No If Yea, ixpiliIi briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, Important or otherwise significant. Each effect should be aassased In conneotlon with Its (a) setting pee, urban of rural); (b) probability of occyrring, (cl.duration; (d) irreverslbility; (e) geographic loops; and (f) magnitude. If necessary, add attachments crlef /nnoa. supportlng. .msterIk!s. Ensure that explanationtf con ialn`suftlClenI detail to show that all relevant adverse impacts have been Identified and adequately addressed. If Question D of Part II was checked ya, the determination and aignifidance must evaluate the potentlal.impact of the proposed action on the environmental characteristics of the CEA. O Check this box if you have Identified one or'more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration, O Check this box If you'have.deterrnlnedr eased'on t40 Information and analysis W)OVs and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: ame 61 MOT A#VKY Print or Type R—an—w—o7lesponswo ollicer e Uad Apacy Title of Responsible r IVUtuft of es y Wre of Froparer event from respor•s e o icer ate 7 f 4bvf Io:2' /z 480 0 -r. - - BATH 2 _ , I U.fca _w 9. _T vo � ITCHEN BED R�� 1 °' DINING ,, N 00 .O iI N o �. BATH-1 o fn - .8L 1>38 "Flll. QtD - EII$ �.Z-4.1 it 4 =10 I ( v- itI 2'o.; 3'-2i" I -- HALL ' LIG / IN ` `�, cam. BED IRK- 2 f � f 1 (! I r BED,! RM ' 3 ►` �' 'li PUTNAM COUNTY DEPARTMI NT' OE � v H-40 SE PLANS APPROVED FOR BEDROOM,' COUNT 9' I �Zn © © `I nr -L� %4, �- I � •? � ;!' '1 1 ��4�" o � �'- I' /2" 1 © r ���.�. � -� ALL SITE' _ j7-14 ;�d' a ' F 3g' Io C i'•: �.. `O' . n i�LSE IiOU _ x_ �_s 'P 7OQI�z "'. APPROs� �xf iiEw 7 7 . . PLANS h ' 'S 1 _. �3' L I YORK STATE nivtsJn• r -'P ILI SIGNATURE & TITLE i? A TF; Harry W. Nicbols Jr., P.E. Patterson Park, Suite 106 .� . 20SQ Route 22 ^° - Brewster, NY 10509 Telephone (845) 279-4003 Fax (845) 279-4567 December 5, 2001 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Senior Public Health Engineer Re: Individual SSTS - Chris & Kelly Burdick Bullet Hole Road Patterson, New York T.M. # 34. -3 -20 Dear Robert: Enclosed are the following: 1. Five (5) prints of SS -1, `Proposed SSTS," dated 12 -5 -01. 2. "Short EAF," dated 12- 5 -01.. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 12 -5 -01. 6. "Design Data Sheet." _ 7. "Letter of Authorization. 8. Two (2) copies of Residence Floor Plan(s), or `Bedroom Count Only." 9. Review Fee in the amount of $300.00 _ Ib APPLIG�TI.orl_Tp_ _4�M5'fjWcT. A_ .wxrejL NEW. We would appreciate your review, approval and issuance of the Renewal Construction Permit at your earliest convenience. Very truly yours, H arry W. Nic s Jr., P.E. HWN: JM: his 01- 038.00 I - ' ,- PUTNAM .,COUNTY> D AR NE OF HEALTH ;. j UV� Division of Environmental Health Services Carmel N Y 1051-2 y CONSTR'UCTION PERIIAIT .FOR ,SEWAGE ;DISPOSAL SYSTEM, Town or Village Located at Map Block i € Subdivisions Lot Job Owner �J r Address ,!Building, Type�� Lot Area. �'�/ fErJ Number of. Bedrooms rvaG� 9LL 6,t/r 1b.4.f� i Design Flow Total Habitable Space 7S�quare Feet Separate - Sewerage' System .to consist of_�!� - ' Gal Septic Tank' and �� 3�i�t 7 "LE, / /LCD ✓S j T e To_ be constructed by ' Address i `. (Water Supply Public Supply From ;' `• - Private Supply, to be drilletl by s Address ' t Other Requirement - -'' _ I- ,represent that 1 am wholly and completely :responsible for the design?antl location of the proposed systems) "1) that the separate sewage .disposal system �. .. . above described will be.constructed,as shown;bn the approved amendment there to ind.:in accordance with -the- standards rules'an = regula ions,o e u nam a ..: _. ,i County . O,eparimer! of. Health,-; and that on completion thereof a "CerLficate'. of COnstcuctlon Compliance 'satisfactory to the Commissioner of Health'wi11- -be;. "submitted to the Department ,and a writ, en' guarantee will be,furnmshetl.the owner his successors hens or, as i ghi,by the,builder that saidrbwlder' will _. -.pace,.,, in ,good operating .condition: any part of sa9desewage. disposal' system-. durmng the period of two (2) years immediately,followmng thedate'tof the "issu j ance:of the appioval _of -th'e Certificate -of 'ConstrucUOn Compliance of'fhe;origira 'stem -;or any,repair's_;thereto 2) that the "drilled well tlescribed,.above will be..located -as shown':on the approvedplan. and :that said'well will be: installed ,i rdance, with the_ ndards rules and regulaions.: •O: -of, 'the Putnam County Depart enf of ealth = Date Signed `' P E R A � x Address !/ L License APPROVED FOR' CONSTRUCTION: This.a1?0bval expires -one year,:from the date ,issued structidr1 .of the building', has been` undertaken and as, revocable for cause -or maybe amended 'or mqOdjfieo when co_ i ed "ecessar: '.mob .Ahe C m'issio .of Health. Any ,change.`or alteration of. construction requires a hew permd Approved. for disposal no sewa a r w y tU Date .-- By Title zC } r._ a] I " , 7, Gentlemen: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of Howard Burdick Located at 6d1_4-e5Z_ .7-4X A#11,0 -Seei6leh 77 Block Lot This letter is to authorize George A. Haughney a.djjly licensed professional engineer x 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 Commissi6ner of the PLitnam. County Department of Health, and. to sign all necessary papers on my behalf in W-LLfl LILUS MaLLel• allLi to. supervise ine construc-ciuri of said* system or systems in conformity with the provisions of Article 145 or. .147,. Education_.. Law,_ the Public Health La and the Putnam County. _Sani- tary Code. Countersigned: P.E., R.A., Route 52 ress Carmel, New York Very truly yours, Signed �ez.4. Owner of Property Z _� �_ //__1 . AdcIrgss Telephone u (914) 225-9353 DUl I A i A - CO' U e1cr 1 Telephone jN_Qf REALA-U PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES OF' `ICE BUILD -1NG,: - CARMEL,' N:� �....,... 10512'""' •...,. _. u.. _ . - DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner i . 7Z AL-'_ BeleVlCK' Address //oLE k?0,4 4:�1 74x.MAp Located at (Street goe. 77 Block_(Lot 6dicate neares cross street) Municipality Watershed Al SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS ,Hole Number CLOCK TIME PERCOLATION PERCOLATION EM No. Start -Stop Elapse Time Min. Depth to Water From Ground Surface'in Start Stop Inches Inches Water Level Inches Drop in .Inches Soil Rate Min. /in drop 4>5 2'S5 - ¢,'OAS 3aa -�o5 1 3t/ 4a9- 5 x:31 -'ys 4>5 1 2 �i Notes: 1) Tuts 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 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NC ::, G.L. 6" 12„ 18" o 2411 36 if 42" 48„ 5411 66" 72.11. 7811 8411 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED _INDICATE.LEVEL TO WHICH WATER LEVEL_RISES.AFTER -BEING ENCOUNTERED. tJ .... _.. -_. �. _. .. DdL -y�. -7 DESIGN Soil Rate Used bc=/O MirVl "Drop: S.D. Usable Area Provided .6O ©0 No. of Bedrooms ,� Septic Tank Capacity . 00 Gals... Type .AoMj'o1VR -s1 Absorption Area Provided By _3 33 L.F. x24" X width trenc Address ®f/ E 5.2 SEAL Al THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil ' Rate A �° 043 Approved Sq. F`tGalo Checked by r PUTNAP iJZjN Y DEPT ' PUTNAM COUNTY DEPARTMENT OF -HEALTH SEICES DIVISION OF ENVIRONMENTAL °HEALTH RV ALL >COMPLETION REPORT . WeII Location 'Street Address -� age ` - -.`°° fl l �s' G- Ly)'r 1VIap ,3.. Block j' Lots) 1 Well Owner: ; Name Address. �. Use of Will `Residerittal .. Public Supply :; Atr cond/hea,,•pump Irrtgation -1 primary Business.. Farm Test/momtoring Other(specify) '' 2 secondary Industrial Instttuttonal Standby DrilLng; Equipment Rotary "; `.Cable „percussion, Compressed atr percussion Other ( spectfy) , - Well T. a :. yP g ' : p Screened Open, end casirt O en=hole n, bedrock _Other Total length ; ^.;” ft ;1Vlateria_ls .Steel Plasttc =Other Casmg;iDetails Length below:grade., ft Dtameter_in. 'Seal Joints. :` Welded Threaded Other _ ent grout . '. `Bentonite .::Other;; Cem — '; Wetght per foot .�lb /ft Drive shoe: Yes _ No; , Liner.' Diameter.( "in) Slot Stze Lergth(ft)' Depth to Screen (ft) .;- Developed? Screen:Detals First ;' ' _ „: — Yes No Second Hours ' • Well Yield Test Batted : _ Pumped Compressed Atr Hours Yteld .' gpm Depth "?Data = Measure from land surface`ssttator�j(specify ft) During yteld test(ft) Depth of completed well r in feet f Q Well Log. De th= FroTn.Sur "face .: Water Well Formation If more detailed ft ft Bearing Diameter (��) Deser tion p information Land Surface, descriptions or _ steve;anialy�es.M__ - - -- - - - __- are.ava#able, BF- 7 If. as ted Feet Gallons Per Mtnute :Pump /Storage T k:Information at different:dths Pump Type `� apacity ECG , during. drilling, Depth �ju 1VIode1 Qv:� list: Voltage V HP Tank Type Volume r�ssur' - DateWell Completed Putnam County "Certification'No: Date ofRe ort , p Well Driller( signature) 5 03 00 NOT :. xact'location of well with distances to at least two permane' tan arks to be.provided on aupar sheetlplan. Well Drillees Name -' ' �. � z� 1�5 �-• Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97