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BOX 14
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01507
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PUTNAM COUNTY DEPARTMENT OF ,HEALTH
Division of. Environmental Health Services, Carmel, W. Y. 10512
CERTIFICA OF CONSTRUCTION COMPLIANCE FOR SEWAGE 'DISPOSAL SYSTEM Patterson
_ ... Town, 'or Village
Located at McManus 'Road Tax yap 73 Hlgck 3
owner Jefferey & Loretta Adler Tax Map Lot # 4 Subd. #
Separate Sewerage System built_ by 'George .Howell address Terry Hill Rd. -, .Carmel . NY
Consisting of _1,000, Gal.' Septic Tank and 432 L.F. Trenches
Other requirements
Water Supply: Public Supply From `
X _ Private.Supply Drilled By Mill Drilling Inc.
Address Putnam Avenue, Brewster, NY
Building Type • Residence No. of Bedrooms 3 Date Permit Issued 5 -15 -87
Has Erosion Control Been Completed?
I certify that the system(s) as listed.serving the above premises were constructed essentially as shown on the plans,of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regulati in accordance wit iled plan, and,the permit issued by the
Putnam County Department Of Health. -
Date December 2, 1987 Certified.b P.E. X R.A.
Address Route.6, RD. #9, Bre , NY 10509 License No. 55553 -.1
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 sewerage 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 are
subject to modification or change when, in the judgment of .the Commissiner.oi Health, Such rev lion,. modification or change is necessary,
/ # �1 cy 7
Date Title
'- 777 ---
Jeffrey & Loretta Adler
Owner or. urc ase.r oT Building
George D. Howell
Building Construct.ea by
McManus Road
Location - Street. .
3 Dedroom,Residence
Building Type
Patterson
Municipality
73
Section
3
Block
_ 4
Lot
GUARANTY OF SEPARATE SEWAGE SYSTEM a
I represent that 1-am wholly and completely responsible for the,.
location, workmariship,: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 guaranty;to the owner, his.succes-
sors, 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 initial iis'e of the sewage disposal
sy tezn, or ; any repairs .made by me to such system, except where the failure ,
to operate *properly is -caused by the willful or regligent' act of-the occu-
pant.of the.bu lding utilizing the system..
The undersigned further agrees to accept as conclusive . the de-
terminati.ori, of the Director of the Division of vironrrienual - Health Ser-
vices.of the Putnam County Department of Health as to whether or not the
failure. of the system to operate was caused by the willful or negligent.
act
-of the occupant of --the building util,iziizg the system.
Dated this _,4�.S day of .�11 19 Signature
Title -��-•
If corporate . , give name
and addres
THREE (3) COPIES ARE- REQUIRED ..WITH THREE (3) COPIES. OF FINAL ..PLANS BEFORE
CERTIFICATE OF COMP.TTETION WILL BE-:ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST-USE OF .SYSTEM.
Division of Environitrental Health Services, Putnam County .Department of :Health
.__ .
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 Jar-pp-1--y OrI- op&?T /S. Ao�rEe Address 23 SPRin►s S-r to risco.} NY ►o54 >
Located at (Street) gui (_Er HoLr=1ZOAP Sec. 7s Block 3 Lot �{
indica e nearest cross street RECEIVED
Municipality Towel Op BiArTEizsop Water she d_,z "I" NY C. w'yG
.SOIL PERCOLATION TEST DATA.REQUIRED TO BE SUBMITTED WITH APPLICATIONS
... _ .._. 1 AM 20 P T . l
Hole
Number
CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to
Wa er
a er ve
No.
Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.-
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
30
24
2z
2-
15.0
2
1: 5G - Z:7- 30
Z4
22y4
3
Z =27- Z =5-7 30
24
22 %q
13 /Q
17.1
Z 1 30 z z Z 15'.0
3 Z= 33- 3'03. ;,p 24 2z I/z-
4
5
M
3
4
5
FaRC -OL MOW TESTS MADE By JAMF-S J • H"W r-_N4'NS&=tact 31Z5-10-7
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. A11 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 HOIES
DEPTH HOLE NO. I HOLE NO. Z HOLE NO.
G.L.
6"
Amw, A5
1211 # SI�Ty LOAM sNora
18 To. tmpapy,005
2411
30..
3611
42"
4$"
54„
60"
66"
7211
78"
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED Wow&
INDICATE.LEVEL -TO -NCH WATER-LEVEL RISES AFTER BEING ENCOUNTERED' .000a
TESTS MADE BY J. BEM 5oLcKg-rT( + Assoc -. Date
? uc,rE: TE5T Pt-r Data. _rAXGW V£-ZQM "15UmeDiCK Guntil, sumplyloslom M<<n PkGpAmb-u f3Y J. zoeramr Foizm=1 � A
DESIGN
Soil Rate Used 20 Min/1 "Drop: S.D. Usable Area Provided
No. of Bedrooms 3 Septic Tank�' Capacity 1�o Gals. Lpe���c T CoNC,
Absorption Area Pro ded *_4117- L.F. x24"
Address QT �_ D. #k 1 SEAL J, ..,.�• mac,
,o 0555'x. ,• ,
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: ��F S10 - N,
£S -
Soil Rate Approved Sq. Ft /Cal. Checked by _.__ Date
7_7 -,- i —5 .ter;, — — —,— , — --
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Envbronmental Health Services Carmel N Y.1051? Engineer t q,
on CERTIFICATE O PCOMPLIANCE
CONSTRUCTION P FOR SEWAGEZISPOSAL SYSTEM Permit
Patterson
McManus Road _
T own or _v
lllage
S ' ` Burdick" :G1 en` "`10 73 3.
Sabdtylalon Name Subd.•Iof N To Block_" Lot _
Owner /Applicant Name
Jeffrey. & Lo'r`ettaAdler Renewal_o Revision ❑
Date of Pievioas Approval }
" "Ada 23 Spr.i ng Stre'et Tewn zlp�' 10549
g Mt K sCID
Ballding Type ` R P S• 1 d P fl`C e S Ldt Area 1 (1 F R Fill Secdoa Only" Depth Volume
i
'i Nmnber of Bedrooms 3 Design Flow G P D 600 , PCHD Notification is Required When FM to completed
h Separate Sewerage System to rnnalet of 1D OO Gallon Septic Tank and 432 L F: T re n c h e s
' Owner
'. To'be constracted b y _'Addreee
Watei SapPb, Pnbllc Sapply Flom 44 : Address
r'
or: X Private Supply nelued by' Owner _Address
other�'Reoulrements �-
-, I repiesent that I am wholly anC _completely responsible for the des�9n and location of the proposed systemis), .1) that.Me separate sewage disposal system
above Cescribetl, will be constructed as shown on the approved amendment there to,andc in accordance with the,stanpards, rules an regulations o e" Putnam.
County Department, of Health, -and that;on completwn 6iroot a Certilwate <,of Conitruction Compliance' satisfactory to the Cominissioner`of Health will .
be submitted rfo the :Department; and a wntten.9uarantee will be furnished the owner, h�siuceessors Heir .or assigns by the bwlder; that said budder vOill 11 r t
place in good.operatirig condition any pgit o /;.said sewage +tl�sposal.aystem,'durmg the per�otl:of two;(2 ears i mediately following the date of�lhe isw-
ante of the bppr_'oVal "of the CertiUcate't;ot, Construction. ;Compliance ,of .t el syste s trier o; 2).thst the drilled welt described above
• \_ will be located is shown on the appiovetl plan�arid thaViaid-; well -will berl eol in co ce _. the n i , -ruler _and requ a ions of the "Putnam ..
County Department of. Oialtn
• [ o V
Oats" 4� 1587 Sig ed P.E. ^ R A.
1 R 509 055553 1
�.
Address outs "6, RD " #1, ws. r, �i�en :e No
APP,.fiOV,E0 FOR- CONSTRUC .TIDN.This'appro4il'expiies- two yea romthe °:dat -i4 4 d unl s.construct_ion -of the building has been undertaken and is -
revocable for tau a -or may e�amendetl or:modifietl� when consids .net ry liy the' tommission r;of Ith. Any change or alteration of constiuction
requires a newermit p tl for tl3posaf of domestic•.sa ary' aye, a' or t
1/87 .. Date - -. BY - _ Title O/
ADD %t.
-�
Wl:.LL VVl'1LLrjl.L%JV4 1X.u1 VLXi
DEPARTMENT .OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS.
McManus Road
WNIVII I Y TAX GRIO NUMBER
Patterson,. NY BurdzckG7Qods; ?Lot „l0
WELL OWNER
NAME:
Jeffrey Adler
ADDRESS: 25 Spring Street
Mt. Xisco, NY
Q p81VATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
Q RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL - ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5
gpm./NO. PEOPLE SERVED 2 / EST. OF DAILY USAGE 200 gal.
REASON FOR
DRILLING
® NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑ TEST / OBScRVATION
❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 7 6 5
ft.
STATIC WATER LEVEL 40=_ ft.
DATE MEASURED 7/17/87
DRILLING
EQUIPMENT
❑ ROTARY Ca COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. ® OPEN HOLE IN BEDROCK 0 OTHER
CASING
DETAILS
TOTAL LENGTH
32 fL
MATERIALS: Q STEEL O PLASTIC ❑ OTHER
LENGTH.BELOW GRADE
31 ft.
JOINTS: IM WELDED 0 THREADED 0 OTHER
DIAMETER
6 in.
SEAL: ® CEMENT GROUT ❑ BENTONITE ❑ OTHER
WEIGHT
PER FOOT
19 1b. /ft.
I DRIVE SHOE. ® YES O NO
I LINER: O YES ❑ NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND _
.. - - -- - ......._....
...__ .... ....
.r... ..
-
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTN fL
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED 1 tests were done is in-
O COMPRESSED AIR , formation attached?
O BAILED O OTHER ❑YES ❑ NO
WELL LOG ff more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
We11
D'a-
peter
FORMATION DESCRIPTION
COLE,
ft.
tt.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gGm.
Lind
20
no
10
Clay, sitl & loose cobbles
20
.465
yes
6 1
.Hard grey granite
200
1.
-
200
:465
525
6
Pink & white granite
500
1
-
500
1
525
610
6
Black nedim to hard .granite
645
1
-
645
1
610
.765
6
Grey &'black granite
765
6
-
600
5
WATER 91 CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? AYES ❑ NO
ANALYSIS ATTACHED? 1$ YES ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
ILMODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME C DATE2 �H7
MZT�L ARILLING,
ADDRESS Putnam AVe. S
Brewster, NY
r si
S
v
BREWSTER LABORATORIES
_ .. Box 224 --6At STER,
(914) 225 72072
— WATER ANALYSIS REPORT —
SAMPLE NO. 6656
SOURCE:. Jeffrey Adler Lot 10
McManus Rd. Well
Patterson, NY
COLLECTED: August 3, 1987
BY: Mill Drilling, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
August 7, 1987
IV.
V.
om
'A T3nMTnTV 1+
1PT,K17kr SITE INSP
A(Alvol 9 P) A)
3 7 734 .# OR .SUBDIVISION LOT
ECTION Date
Inspected byL-�
OWNER
>7A
...Ym
C7
NO-
DISPOSAL AREA
a. SDS area located as a roved lans
b. Fill section - Date of placement
2:1 barrier. LGTH WIDTH AVG.DPTH
c. Natural soil not striFv�
.1y
d.' _Stone, brush, etc., greater than 151 fran SDS area.
e. 100 ft. fran water course/wetlands.
.SEWAGE DISPOSAL SYSTEM
a. Septic tank size 1,000, 1,250
b. Septic tank instal ,level
c. 101 minimum fran foundation
d. No 90" bends, cleanout within 10 ft. of 45' bend
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
3. Minimum 2 ft. original soil between box and trenches
x
f. JUNCTION BOX - properly set
g. TRENCHES
1. Length required - t-1 2, Length installed --u I/ V
2. Distance to watercourse measured: ft.
. ........ .
3. Installed according to plan
4. Distance center to center
-2
5. Slope of trench acceptable 1/16 - 1/32 "/foot.
6. 10 feet fran property line - 20 feet - foundations
7. Depth of trench <30 inches from surface
8. Roan allowed for expansion, 50%
9. Size of gravel 3/4 - 1j" diameter
10. Depth of gravel in trench 12" minimum
11. Pi• _)e_ ends capped
h.-PUMP OR DOSE SYSTEMS
1. Size of Omp chamber.-
2. Overflow tank
3. Alarm, visual/audio
7 UP
4. Pan p easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health Department
estimated flow per Sycle
.HOUSE
a. House located per approved plans.
b. Number of bedrocms
WELL
a. Well located as per approved plans
b. Distance fran SDS area measured /1)0 ft.
c. Casing lF above grade.
d. Surface drainage around well acceptable.
OVERALL WORKMASHIP
a. Boxes properly grouted
b. All pipes partially backf illed
c. All pipes flush with inside of box
d. Backfill material contains stones < 4" in diameter
'Curtain
e. drain installed according to plan
f. Curtain drain outfall protected & dir.to exist.watercourse
g. Footing drains discharge away from SDS area
h. Surface water 2rotection adequate.
X.
i. Errosion controi provided on slopes greater than 15%.
yr
I
APPENDIX B � kA&-)
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEMM DISPOSAL SYSTEMS
�r
(Name of Owner)
COMMENTS
V
LF trench provided Se
required
60 ft. max.
Parellel to
RWIN
REVIEW SHEET - CONSTRUCTION PERMIT
DATE _ J•(✓-�
BY: -Z7
(Street Location)
YES NO DOCLNENTS T l
Permit Application
-----Corporate Resolution
Plans - Three sets s s-
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc b
Consistent Perc Results (3) Fill
Perc Hole Depth cd
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well 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 & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shoran & Detailed
t House - No. of Bedroans
Wells & SSDS's w /in 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 fill
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. expan)
15' to Drains - Curtain, Leader, Footing
351to catch basin,stormdrain,piped watercourse
10' to Water Line (pits -201)
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
4
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER- CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION. .TO- CONSTRLCT, A WATER. WEL1r,__�
.PCHD PERMIT
WELL LOCATION
Street Address
McManus Road
Town /Village /City Tax Grid Number
73 -3 -4
WELL OWNER
Name
Jeffrey Adler
Address
23 Spring-St.; Mt. Kisco, NY
JOPrivate _
O Public -
USE OF WELL}
1 - primary s� ;, .._
2 - secondary
�F♦C F ENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
C :BUS „ESS+, ❑ FARM ❑ TEST /OBSERVATION
❑'INDUSTRIAL 0 INSTITUTIONAL ❑ STAND -BY
❑ ABANDONED
❑ OTHER (specify
❑
AMOUNT OF 13-SE
qPR 2YIE�5 ; 0UGHT 5 Min. gpm /# PEOPLE SERVED 4 /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
NEW SUPPLY
❑REPLACE EXISTING
❑ PROVIDE ADDITIONAL SUPPLY
SUPPLY ❑DEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED
ODRIVEN
DDUG
FIGRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Burdick Glen
Lot No. 10
WATER.WELL CONTRACTOR: Name
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES. X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO- PROPERTY FROK-NEAREST WATER MAIN.
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON- REAR OF THIS APPLICATION .00 E 0 P E S 1 an )
(date) signs re)
PERMIT
TO CONSTRUCT A WATER YELL
This:permi:t to •construct one water well.as:.Set forth above is granted under -the
provisions of Subpart 5 -2 of Part 5 of the New York State -Sanitary Code, and
provided that within•thirty (30) days of the completion of water well construction,
the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the.Putnam
County Health Department attached to this permit.
3. Submit a Well mpletion Report on a form pr vided by a PutnaWCount
Health Depart nt.
Date of Issue: l 19
Date of Expiration: 19 ermit Is uing Official
Permit is Non - Transferrable
o roe •
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