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APPENDIX I
PUTNAM COUN'T'Y DEPARTMENT OF HEALTH .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
9jch8gD t Joba I YIq�IOk)E 73. 6 5
Owner or Purchaser of Building Section Block Lot
DN S 73
Building Constructed by Tax Map Number
64,6t Burdick Woods Subdivision
Location - Street Subdivision Name
i�A1RS� , �j �( 1663 Lot #1
Municipalitppy_ Subdivision Lot #
J�RIS�.P
Building Type,
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I.am wholly and completely responsible for the location,
workmanship, material, construction and drainage of the sewage'disposal system
serving the above. described property,,and that it has been constructed.as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee.to the owner, his successors, heirs or assigns, to place- in good
operating condition any part of'said system constructed by me which -fails to
:operate for a period of.two. years immediately following the date of approval of the
-- "Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made by m—e to ' sddh' system, except where the failure to operate properly -is
caused by the willful or. negligent act of the occupant of the building utilizing
the system.
The undersigned further. agrees to, accept as conclusive the determination of
the Director of the Division of 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 the building utilizing
the system.
Dated this day of d�-l� 19'_V Signatureb�
ope� , m -
Title
eral Co tractor (Owner) - Signature.
Corporation Name (if Corp.)
Address
,F I ..,.
.Ore.- /
rev. 9/85 16
mk
WELL COMPLETION REPORT.
DEPARTMENT OF HEALTH
_.Division— Of..Environmental Health.Services
PUTNAM COUNTY.DEPARTMENT OF HEALTH
Office Use Only
MOUNT OF USE YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 4 7 EST. OF DAILY USAGE 350 gal.
REASON FOR aNEW SUPPLY ❑ .PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
DRILLING O REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA . WELL DEPTH. 300 ft. STATIC WATER LEVEL 30 ft: DATE MEASURED 919187
DRILLING ❑ ROTARY ECOMPRESSED.AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE ❑ SCREENED ❑ OPEN END CASING. ®OPEN HOLE IN BEDROCK O OTHER
STREET ADDRESS:
TOWN/VILLAGIICIIY
TAX GRID NUMBER:
NELL LOCATION
Bullet Hole Road Patterson, New York
40 ft.
NAME:
DETAILS
ADDRES S:
�flIVATE
WELL OWNER
Richard
Viglione
lA Ib. /ft.
❑ PUBLIC
USE OF WELL
QRESIDENTIAL
❑ PUBLIC SUPPLY
O AIR /COND.IHEAT PUMP. ❑ ABANDONED
1 = primary
O BUSINESS
O FARM
O TEST /OBSERVATION ❑ OTHER (specify)
2 - secondary
❑ INDUSTRIAL
O INSTITUTIONAL
O STAND -BY O
MOUNT OF USE YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 4 7 EST. OF DAILY USAGE 350 gal.
REASON FOR aNEW SUPPLY ❑ .PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
DRILLING O REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA . WELL DEPTH. 300 ft. STATIC WATER LEVEL 30 ft: DATE MEASURED 919187
DRILLING ❑ ROTARY ECOMPRESSED.AIR PERCUSSION ❑ DUG
EQUIPMENT ❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE ❑ SCREENED ❑ OPEN END CASING. ®OPEN HOLE IN BEDROCK O OTHER
WATER 09LEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? )MES ONO
ANALYSIS ATTACHED? MMES O NO
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME
MILL DRILAN01, INC..'
ADDRESS
Putnam Ave.
Brewster. NY
DATE
to
TOTAL LENGTH
-4 i ft.
MATERIALS: BSTEEL ❑ PLASTIC ❑ OTHER
CASING
LENGTH.BELOW GRADE
40 ft.
JOINTS: ❑ WELDED EMHREADED ❑ OTHER
DETAILS
DIAMETER
6. in.
SEAL: UOEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT
lA Ib. /ft.
DRIVE SHOE: 94ES ONO LINER_ ❑YES ❑ NO
DIAMETER (in)
SLOT SIZE
LENGTH
(Iq
DEPTH TO SCREEN, (11)
DEVELOPED?
SCREEN
DETAILS
FIRST
o YES ONO
SECOND
HOURS
GRAVEL PACK
O YES
GRAVEL
DIAMETER
TOP
BOTTOM
O NO
SIZE
OF PACK
in.
DEPTH ft.
DEPTH It.
WELL YIELD TEST It detailed pumping
P. P 9
WELL LOG If more detailed formation descriptions or sieve analyses
are available, please attach.
METHOD: O PUMPED
i tests were done is in-
formation attached?
DEPTH FROM
SURFACE
Water
Weil
DIa-
O COMPRESSED AIR ,
YES ONO
Bear-
1n9
"ter
FORMATION DESCRIPTION
CODE,
O BAILED O OTHER
tt,
it
WELL DEPTH
DURATION
DRAWOOWN
YIELD
Surface
3
no..
6
Soft. silt, clay & loose ledg
It.
hr. min.
It.
gpm.
200
2
30
200
3h
e i m to hard grey & white-9ran
300
6
15
.250
20
WATER 09LEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? )MES ONO
ANALYSIS ATTACHED? MMES O NO
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME
MILL DRILAN01, INC..'
ADDRESS
Putnam Ave.
Brewster. NY
DATE
to
Box 224 - BREWSTER, N.V.
(994) 225 -2072
WATER ANALYSIS REPORT
well
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
October 3, 1987
oy Bickwh P.E.
Director
0 per 100 mi.
:7
.a
IV.
V.
Vi.
APPENDIX C
FINAL SITE INSPECTION
-Ole
GWNER
TH OR.SUBDIVISION U)T 4
Date
Inspec4ed
gEWAGE DISPOSAL AREA
a. SDS area located as per epproved plans
b. Fill section - Date of placEmnt-
2*.--1 barrier. LGTH WIDTH AVG. DMye:,�::%P
c. Natural soil not stripped
d. 'Stone, brush, etc., greater than 15' from SDS area.
e. 100 ft. frm water course/wetlands.
Or
SEkaGE DISPOSAL SYSTEM
a. Septic tank siz5=, OG-,,? 1,250
b. tic tank ins evel
c. 101 minimun frcm foundation
d. No 900 bends, cleanout within 10 ft. of 453 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
f. JUNCTION BOX - properly set
g. TRENCHES
1. Length required -7S,- 7 Sr installedZ�/e
2. Distance to watercourse measured*
3. installed according to plan
4. Distance center to center
5. Slope of trench acc2atable 1/16 - 1/32 -/foot.
6. 10 feet from property line - 20 feet - foundations
0
7. Depth of trench < 30 inches from surface
8. Roan allowed for Sion, 50%
9. Size of gravel 3/4 - 11" diameter
10. Depth of gravel in trench 12" ndnimun
11. Pi' -- ends capped
h.. PUMP. OR_ DOSE - SYSTEMS
1. Size . of pump chamber
ti
2. Overflow tank
3. Alarm, visual/audio
4. Pump easily accessible manhole to grade
5. First box baffled
6. Cycle witnessed by Health De ent
estimated flow per cycle
HOUSE
a. House located per Lipproved plans.
b. Number of bedrocms
WELL
a. Well located as per approved plans
b. Distance f ran SDS area measured ft.
C. Casln�glV above grade.
d. Surface drainage around well acceptable.
OVERALL WORKMASHIP
a. Boxes properly Eouted
'
b. All pipes partially backf illed
C. All pipes flush with inside of box
4—
d. 'BEckf ill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain outfall protected & dir.to exist.watercours
g. Footing drains discharge away fran SDS area
h. Surface water protection adequate
i. -Erosion control provided on slopes greater than 15%.
4TEST PIT DATA REQUIRED.TO ME 'SUBMITTED VITN APPLICATIOI1
DESCRIPTION OP' SOILS II' TEST 11OLC
DEPTH - 119Li _.- IJO....- ..._A __ _._.- ..„UOiAE hD.._ B..'- _
1101A...140..._.._ .0
G.L.
6.. • Topsoil Top oil
Tops it
12" San y
1131 Loam Sandy Loam
Sandy Loam
2.1111 w /rocks 2' -3' 0 N stones 4" -1' 0
,O"
3611 Flock Q 30"
11211
111311 Roc 45"
51l,i
Rock @ 48"
6ci"
66"
72"
I hUICATC ILL AT I•liIICH GROUND WATER IS ENCOUNTERED N/A
INDICATE LEVEL TO W1LICII WATER LEVEL RISES AFTER BEING ENCOUNTERED N/A
TESTS I•IADPS• - -gy- John E b e r l e Date_ 4'1-31 1 8 6
DESIGN
Soil Rate Used 1.3 Min/1 "Drop: S.D. Usable Area
Provided 3500 SF
Ito. of Bedroom3 3 Septic Tank Capacity. Gals.
7)rpe Masonry
Absorption Area Provided By 375 L.P.x2411 X '—
width Erench.
& CORN
F'' +.,,,
O
r�
3.5 Fill Required A% .......
I
lame - "
;-
v
Addre.ss w Z r- , L
:..,
{.
s =
1980
MIS SPACE FOR USE BY I1=r1i DEPARTMENT ONLY'r. ••.•
itlf,,
,gir1Yj�
SSICNf \'
Boil Rate Approved. Sq. Ft /Gal. Checi- "'\\
Date
-6
' TEST PIT DATA REQUIRED TO PE
DESCRIPTION OP' SOILS ,?1111COUP
11ITH APPL•ICATIO11
11 TEST HODS
DEPTH D ^HOLE�NO 11OLE NO.
G. L.
6)` • Top oil
1211
113" S81ndy -
211" Loam
X011 w /stones
3611
112"
11811 Rock ® 42"
51111
6o"
66"
72"
71311
INDICATE LEVEL AT WIIICII GROUND WATER IS ENCOUNTERED
I1.IDICATE LEVEL TO WHICIi WATER LEVEL RISES AFTER BEING ENCOUNTERED
Date
DESIGN
Soil Rate Used �Min/l "Drop: - S.D. Usable Area Provided 3500 SF
No. of Bedrooms 3 � Septic Tank Capacity 0 CA3.q��-,,,,,,,_ Type Masonry
Absorption Area rov a By375' L.F.x2411 X ,,'Cr��`cCORN— �Afi��, ti renc
�4aRA l c3' her
3.5 Fill Re uire
1a me gna
&a-eeAA1&z1aS A/C A,
Address 1CML 1980
NEWY,, OP .
T11I3 SPACE FOR USE BY HEALTIi DEPARTMENT ONLY: essicN
Soil Raise Approved Sq. Ft/Gal. Checkod by Date
UIVISIUH OF LIIYIIiUNMLIITAL 1_ML'1'11 SERVICES
CUUII''Y OFFICE 13UILD111U, CAItMLL;: H. Y. 10512
LESIUU VA'1'A Sl U -S 1MAIUIJE SL'WAUE ]DISPOSAL SYSTEM VIM IIU.
UN1io1 SKY VIEW MEADOWS :DEV .'CORP.Address c/o HEELAN REALTY CORP.
Located at (Street BULLET HOLE RD. Sec- 73_ Mock $ .Let i
WRcate nearer, arose c reaq
fluidelpality, PATTERSON Watershed CROTON
SUlb 111101DIA'1'101I TEST DATA REQUIRM) '1'0 1313, SUBMIT= WITH A11'L1CA'1'1U113
llul.e
11unil,e1• CLUCK TIMB,
MWI
'11111fe
iitalt -stop I11u.
111311 OIAT10H
WPUII U WaLet181.6i; Level
From Urowid'. Surface 1.11 11 0,811
Start Stu I)rol) JLi1
Inches I1Mile� luclfen
I'EIICUTATIU11
Bull WILD
I,I111. /iu droll
P1 1
1017
1047
'30
21
24
3.0
10 _
2
1047
1117
30'
21
24
3.0
10 -
3
1117
1147
30
21
24
3.0
10
Il
P2 1
.1018
1048
30
'21
23.25
2.25
13.3
2
1018
1118
30
•21
23.25
2.25
13.3
1118
1148
30
21
23.25
2.25
13.3
r
,
3
-
II
• f'
110M, 1) 11'este to be repeated at sams depth uift-il n > ITA11"ately egiu0.1 V0
• rt1 es are obtailfed at each peraplptioll test 110180 All data to be submltte
. •!'or rev -10W.
2) Wptll measurements to be made from top of hole.
PUTNAM COUNTY DEPARnmu OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEnT SHEET - CONSTRUCTION PERMIT
UAT
OoLr_ BY- j�11
Name of Owner) (Street Location)
COMMENTS YES NO DOCUMIIUS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
- Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
House Plans - Two sets
PWS - Letter
iriance Request
7QUIRED DETAILS ON PLANS
-wage System Plan
-wage System Hydraulic Profile - Gravity Flow
.11 Profile & Dimensions - Volume
or J Box;Trench /Gallery; Pump pit details
:ptic Tank - Size, Detail
11 Detail, Service Line if over
)nstruction Notes
:sign Data
io -Foot Contours Existing & Proposed
�iveway & Slopes Cut
)oting /Gutter Curtain Drains
arc & Deep Holes Located
Representative of Sewage & Expansion Area
Tension Area;shown;gravity flow;suff. size,
If..Pumped_Pit & D Box-- Shawn__ &_ Mailed - - -- - - --
)use - No. of Bedrooms
11s & SSDS's w /in 200 ft. of Property Located
-operty Metes & Bounds
)use Setback Necessary (Tight lot)
)use Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 450 w /cleanout
1PARATION DISTANCES SPECIFIED ON PLAN
.elds
10' to P.L., Driveway, Large Trees
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,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
!ptic Tanks
10' from Foundation
50' to Well
i' Well to PL
ZERAL
.gal Subdivision
bdi.vision Approval Checked
approval SSDS Adj. Lots Checked
�tland (Town/DEC Permit R & D)
Lta On DDS Plans & Permit Same
i
l
3
f
TA 5
� X '
GRAVEL DRIVE
y
A
3 BEDROOM
DWELLING^
/ W !
P 0
M M
m L 1
n K
� M �
� B
i
io
J
H
� C
F 0
E � ,
1000 GAL.
SEPTIC TANK
M a DISTRIBUTION BOX (TYP.)
M _
U M
T ro
S R rMn
0
DISTAN E: C' :RT
POINTS
C
D
E
F
G
H
I
K
L
M
N
0
P
Q
R
'4utnam County Department of health S
VTv1sion of Environmental Health Services T'
Approved as noted for conformance with 0
applicable �'7ules and regulations of the
Putnam County healt Department.: v
Y
3URDIOK WOODS.
UBDIVISIONi LOT 1
A
59.0
61.5
61 ..5
59.5
58.0
56.5
56.0
56.5
30.0
26.5
25.0
24.0
23.5
26:5
95.0
93.0
92.0
90.5
90.5
89.0
B
43.5
41.5
56.5
60.0
63.5
68.0.
72.0
77.0
41.0
46.0
52.5
58.0
63.5
69.0 "
83.0
85.0
87.0
90.0
93.5
96.0
SCALE: As SNoWN
DATE: i i /Z-/87
JOB NO. 7(,,?-0!6