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01738
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PDTNAM COIINTY DEPARTMENT OF HEALTH
Division of Environmental Health'Services. Carmel, N.Y. 10511 Engineer to Provide Permit #
on CERTIF_ ICATE OF COMPLL4NCE.
DISPOSAL
.SYSTEM Permit .#
c
tad st Town or v iliage
. ad�Datyieion l�ieme tib Lo't y < j Taz Map _Block ~Lot —�
�%:1 Renewal_ O Revision ❑
Owner/Applicant Name � ..
Date of Previous Approval
Malting Address A j Town
ZiP.
Ruildiug Typed :N U *of A ea rag 51 -5a*11 r
�— FIII Section Only Depth —volume
C "
Number ef. Bedrooms \1 Des 40 Design Flow G /P /D / PCHD Notification is Required When Fill Is completed
Separate Sewerage System to e6twet 61 Qoo,G Septic Tank .d h 10
N n` T
To he constructed bi N. PEA e-a A IS- �Y r: U Aaareee li 2 lL:rA L-e � /V , .
Water SaPP1J ---- -- c Supply From Address
or. Privyyat��e Supply Drilled by �f L— "ed.t.aaa 4.
Other Requiremea is.
I represent that I am wholly and completely•responsDle for the design and location 'of 'the 'proposed system(s)'� 1)_ that the "separatesewage disposal,.system
above described ,will'be constructeb as shown on the approved,amendnlent there to.and in accordance with the standards, rules and a ions o e. ". u nam
_ County Department of Health, end that on completion thereof a "Cert;f,icate of Construction "Compliance" satisfactory to the Commissioner of liealthwin
be submitted..to the Department, 'and -a written guarantee will be'fur fished the owner, his successors, heirs or assigns by the. builder, that said. builder will
place in good operating condition any part of, ,said sewage disposal system 'during: the period of two (2) years immediately' following thedate of the issu-
ance of 'the approval of the Certificate of Construction Compliance of. the original system or an_y repairs thereto;'2) that the d►illed'well described above
will be located.as. shown on the approved plan anti that said well will be installed in,'.accordance w' gh ye.. standards, rules and - regu aT ons o� f the - Putnam
County Department of Health. - // /J - - n
Date .' .a,� x Signed P.E.J/ RA.-
Address tieense No
APPROVED FOR CO STRUCT O This approval expires one r`ir m tne'. to issued un ss c struction of to building has been undertaken and is
revocable for cause or y be or Modified when conside essary b we - o -mi i e f Health. Any change or alteration of c nstruction
requires 'a new :permC r v or disposal of 'domestic 'sun age, iv o a r s on y. 77 Date BY Title -" rt
Dlvhd6n of]
4T OF 11EALTH:,
Ky. i
is. Carmel, . 0512 Elq
CERMCATE:OFCOMPUA14,
/\�GE DI.W.'O'SAL,�YSTkAt
CONSTRUCTION ?F,�Wr F V.— •
Ta
e�'s6n
't'
Old, "Rou te, :22`:
Located at Town :Village
Apple:
-21 6.4
er/Appuc .at Name Lpft'Corp6r ation /formerly Apple H
Dee of 7'.
Previous Approval .
d..
`MFAI!ng Address Pump House , Road. Town
Brewster, NY ..
Single Family Res,.
'129,553 s
Building Type 5 Lot t - Aress Fill Section Only
Depth Yohim6
=0
74,umber'of Bedrooms Design Flow G/P/D PCH6 Nod6cailh is Required When Fail is 6-mliili4ed
;trend
1.250 553 Iin.:ft:
C
siillilraisp, Sewerage System to consist of Garton So tic Tank aid-L-
P
Tole cidnetraded by Address
Water Supply:' 0Vi6U;c:SF0PjY:Fro.in Address
. . . . . . Ti Son 4 Putnam Aye.,BtOwstor
or�.
Private opply 'Drilled by Address
0 ther Req
I represent that:l am v�hoily.a�nd 'bmp!e lely,rd s`po� nsiblsi for-64 design and loca son of the pro �qieo syste (s); that., t eseparate, sewage disposal system
above clescribed"will,iie cciristiiucted as shown on the approved amendment t'here'to and in accordance with the standards, rule's an d reguiallon f9. �he..- Putnam
County , Departme , nt of ' Heitlih, and -that on.corri'Lleici h Ce 0' �Iiahje., "t,jja_�jo P.. 0
p. n t erecii a " riifidta of Construction c m ry to the Commis sioner f•Heilthwill
60' ssub Department, 'd L, writt n is"h' e 'isili ' t
mitted to the and a sin�guarantee.'%vlll be.�fu'r i the,owner,.his'succe4ors, -heirs or gns.by the builder, Old builder will
the j,66 0
place in. good operating iionjition'any piairt. of .said sewage diip6sal;;.iystsim pe f two (i) years1mirsediately following'theclais of the issu-
ance` of the approval of the"Cert"ificate lo f, Construction -Compliance of the original system or any repalis. thereto; 2') that the drilled- well aeic'ribecl above
A Putnam
will. be. IcscatedL4i'sh_&vn.on the i6piovid'plan and that said well will be installed In a. c! ;o9r �da n e jith thsi.Jta�dards. rule -and reguTa ions. of
County Cie- "t, 1. Health V
PTI 147 9 r A
Date Signed R A
E
Address j0.,GAllo4.ay: Hei s Warwick,
NY 1U9W.
-License N
APPROVED - FOR. . CONSTAPCTIO *N, This approval expires one year from the date issued . unless I construction. of the build I Ing has been 1. undertaken and is
revi;ab1e,*_.1or -use or may be amehded,or modified'when-considsired necei L -Ay. by the; 'Commissioner of Health. � Any changiiii or aneiratiton of construction
requires new permit. Approved for disposal of domestic sanitary sewage, and/' rivate water supply only..
Y
•
3,/86 n Divislon'
>x^°'w• -�'.. �ro.•-�. -Yr ` ;. •.r- "---- '"r --T-? nv- x"T"�,^sr h > s 47771-3i
SAM COUNTY DEPARTMENT OF HEALTH
Envh°onmental Health Servlees; Carmel, N.Y. 10512 .LL
Engineer Must Provlde- P- 41 -86.
P C HD Permit q
OMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Pa.ttPrcnn.
pal
Tax, Lit,
Owner /applicant Name Loft Carpors i n i Formerl}�PP16 Hill Subdivision NamAp'ple Hil'1Snbdv Lotrq 21
Mailing Address P1�FF1� BI�Se $tA�d , R, asrSt2* NY Zip 10509 Date Permit hs'ned 1/L/87-
Separate Sewerage System built by Art Burdick Address . Joes Hill Road, Brewster, . NY
Cdnetstirig;of 1 ? Sn Gallon, Septic Tank and 553 lin. ' ft .. trench
Water. Supply: Public Supply From Address
X Private Supply Dr111ea by Henry Boyd Address Route 52, Carmel, NY
Building I pe Single 'Family Res` Has Erosion Cont of Been Compieto ? Partially
Number of Bedrooms 5 Has Garbage Grinder Been Installed?
no
Other Requirements
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); arid in accordance with the standards rulee and regulations, in accordance with the filed plan, and:the permit issued by the
Putnam County Department Of Health. �� �r
Date 5 -12 -88 ce!lulea by P.E. a:A.
Address 17 'River.'Street .Warwick; NY 10,990. License No 056653
Any, person occupying premises served by the above systems) shall promptly take such action is may be necessary to secure the correction of any'ununitary
conditions resulting from such usage. Approval of, the separate sewerage systiin $hall,beeome null and void as soon as a pubs ?o. unitary 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
sub)ect to modification or change when, in the' Judgment =of the Commissioner of Mee r such revoeati n, motllflution or ehanga It necntary.
Date �� 'Z Y —�- Title
/PUTNAM COUNTY DEPARTMENT OF HEALTH: fivGINEE;R To•PROVinE PERMIT #
ON CERT; FICATE „'OF COMPLIANCE.
Division of Environ inehfal Healih Services Carme% Al. 'Y 10.512 PERMIT;°
Fi�PT•.1.�. a!1
i Ta
...v zutr:i ._��s. .. �:,�a,ri�d� °:i .,d. :�'i. � �.. �? . ���� n✓'�''CS-�s a
. Town or Jlage
Lot
�J1
Located a � �` � Tax Map ', Block
Subdivision `�'�' L Subd. Lot* C : Renewal _ ❑ .. - Revision ❑
owner /Address , � L 1J •ter -O�� Date of Previous Approval
Building Type 5t'/�L. ��M'� -VALot 4rea 5' /iUil sectiodonly ❑
Number of Bedrooms _ Design Plow G /P /D P. C. H. D. Notification Required
Separate Sewerage 'System to consist of Gal:. Septic Tank and
'Q M, — '6
To be .constructed by Address
OFWater Supply:. Public Supply From
Private Supply to be drilled - )
PJV
i•?<
T o
-Addiess r
Other Requirements ^*
1 represent that -l' am wholly . and completely issponsi8le for the design, d locatio of the proposed �system(s) '3) that the separate sewage disposal system
above,tlescrlbetl will be constructedas shown on the approved amendme t•there to d n {accoidancelwi{i the standards, rules an regu•a ions o e u nam
County pepartment .`of 'Health, 'and that,on,complet on thereof a 'Cer `ficate, of o'struction Compliance satisfactory to the Commissioner of Health will
be submitted to the Department,' and a written guarantee will be ,fui ished the o er his -s "cce' ri, :heirs or assigns by the_builtler, that said. builder will
place in good operating condition -any .part of.said` sewage disposal; _. em- during the period: of two.(2) yearsimmetliately following fhedate of the issu-
ance of the approval of the Certificate of .Construction Compliance„ o the original- .system or any repairs thereto; 2) that the drilled, ell described above
will be located as showmon he a'” pproved `plan and that'' "faid well will be insta led ,in accordance., with ahe'staridards, rules a -nd' regu aT%ns, of the Putnam
County Department of ,Heaftth.
Date' t6J —� O 5�9ned P. E. R.A.
o Address t License No, 15 (Q
APPROVED FOR CONSTRUCTION: This approval expires one year from the \ad e ,Issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or' modified when considerep necessarythe Commissioner of Health. Any change or alteration of construction
requires a new permit. Approved for disposal' of domestic sanitary sewage, /or• priJa te';water supply only.
Date gy Title
Rev. 6/85
- W � s ` _ '. COUNTY OF'WEETCNESTER '� ' l
T DEPARTMENT'OF•L`ABCRATORIES ANDNESEAFICN
= 1
E 7 Rev 88
r u •.�: VALW ALL A.;.NEW,YORK 10595;:.
BACTERIAL EXAMINATION OF DRINKING AND TREATED _WATERS;I
fi'v CIA
S- - --•.. .. r.... .. _ u`<; 3 Fw io '1 .,� � ;. £ Bottle No � � .
-T-
L'ab No ENT i DetefColl d%
�I� =OIi. TA1T TITTATT
c� . -!�/ Wr+LL l�Va "aC LrJt iva\ iV.:/r VAl
.: DEPARTMENT OF HEALTH
" = vfsioii °Of' Eiivironrid, al � HiRi
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office use Only. .
WELL LOCATION
STREET ADDRESS: NI I TAX GRIO NUMBE ,
WELL OWNER
NAME. ADDRESS:
-77,
rP8IVATE
USE OF WELL
1- primary
2 - secondary
WRESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT P MP O ABANDONED
O BUSINESS ❑FARM O TEST /OBSERVATION ' .O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
gpm. /N0. PEOPLE SERVED
SOUGHT gal,
�/ EST. AF DAILY USAGE .o?
REASON FOR
DRILLING .
9 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION
O REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
.DEPTH DATA
WELL DEPTH 5 < °ft.
STATIC WATER LEVEL '?o ft.
DATE MEASURED 16'a `
DRILLING
EQUIPMENT
O ROTARY XCOMPRESSED AIR PERCUSSION O DUG
O WELL POINT 'O CABLE- PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING 'OPEN HOLE IN BEDROCK ❑OTHER
CASING
DETAILS
TOTAL LENGTH ft.
MATERIALS: "STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE / ft.
JOINTS: ❑ WELDED "BEADED O OTHER
DIAMETER in.
SEAL: MCEMENT GROUT O BENTONITE OOTHER
WEIGHT
PER FOOT —lb./ft
DRIVE SHOE: M YES ONO
UNER:OYES WO
SCREEN
n S
DIAMETER'(in)
'SLOT SIZE LENGTH
(11)
DEPTH TD SCREEN (n)
DEVELOPED?
FIAST
HOURS _....
SECOND
GRAVEL PACK
o Yo
GRAVEL DIAMETER
SIZE. OF PACK -___ In.
TOP
DEPTH ft.
BOTTOM
DEPTH R.
WELL YIELD TEST It detailed pumping
METHOD: O PUMPED It tests were done is in- t
DrCOMPRESSED AIR formation attached?
O BAILED O OTHER i ❑YES !] NO
A.
1ELL LOG if more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE
Water
Bear-
In9
013'
deter
PoRMATiDN DESCRIPTION
CODE,
tt..
It.
WELL DEPTH
It.
DURATION
hr. min.
ORAWOOWN
It.
YIELD
9Fm-
Land
S
30
3os
ro T,4.A.
/D
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER N�� 04 DATE
ADDRESS SIGfntTURE
J A/Y /OS /oZ/ �ZLI�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISIOiN OF ENVIRONMENTAL HEALTH SERVICES
Loft Corporation
Owner or Purchaser of Building
Loft Corporation
Building Constructed by
Old Route 22
Location - Street
Patterson
Municipality
Single Family Residence
Building Type
69 4 1 6.4
Section Block Lot
Apple Hill Development
Subdivision Name
21
Subdivision Lot $
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
_ r_epai:rs.. mace_: by, . e- to._such_ systE n,._except_where_.the failure :_to...operate.,pr..operly. 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 12 day of May 1988
eral ntra for (Owner) - Signature
Corporation (if Corp.)
o."L, a &5— rc, .
Address
rev. 9/85
mk
Signature
Title
Loft Corporation
Corporation Name (if Corp.)
Pump House Road Brewster NY
Address
_
WELL l.VrirLr. i luiv nc,rVc«
DEPARTMENT OF HEALTH
.Divisicn_ Of - n,vfr.Qnmental ,.Health .$g .; ces_
PUTNAM COUNTY DEPARTMENT OF HEALTH
office Use Only
WELL LOCATION
STREET ADDRESS: TOWNIVICUICLIC111 TAX GRID NUMBER:
WELL OWNER
NAME: e� �� AOOHESS: -2�t %j
� , �p�o
[10(PUBLIC PRIVATE
USE OF WELL
1 - primary
2 - secondary
WRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT P MP ❑ ABANO,ONED
❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING.
9 NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH o ft.
STATIC WATER LEVEL 7 ft.
DATE MEASURED Lb.--7:Z—&Z
DRILLING
EQUIPMENT
O ROTARY COMPRESSED AIR PERCUSSION ❑ DUG
O WELL'POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. g'OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH tL
MATERIALS: )"STEEL ❑ PLASTIC D OTHER
LENGTH .BELOW GRADE ft.
JOINTS: O WELDED CrTHREADED 0 OTHER
DIAMETER in.
SEAL: MCEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER FOOT Ib.Ift.
DRIVE SHOE C'YES O NO I UN ER: O YES RNO
SCREEN
DETAILS .._
-.r.. -
DIAMETER (in)
SLOT SIZE
LENGTH
(It)
DEPTH TO SCREEN #t)
DEVELOPED?
FIRST
...
_...._ ._
❑ YES, O-NO,
HOURS _._. ..._._
SECOND-
_....___._.._
._ .....
_ ._ _ -
- �.
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE..
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH 'It.
WELL YIELD TEST It detailed pumping
METHOD: O PUMPED 1 tests were done is in-
'COMPRESSED AIR ,formation attached?
❑ 8AILE OTHER ❑YES ] NO
It more detailed formation descriptions or sieve analyses
'WELL LOG are available; please attach.
DEPTH FROM
SURFACE
water
8ear-
ing
welt
Dia-
meter
FORMATION DESCRIPTION
poE
It.
It.
WELL DEPTH'
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
9Cm
Land
5urtace
o5
_
S
3o
.305
ro rl4-,4
/D
YfATEB ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? `O YES O NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
WELL DRILLER NAME L/ OATS
�,l(,NAMELC -�`" �����' �c A�
ADDRESS SIGRXTURE
/2 `r
APP -;M- E� C /
FINAL SITS' INSPECTION Date
j /srEr t- _v
Lp TIGN C }9 �i� 1 CWNER
`U4 n OR SL�DIVISiC�1 It7r Tr
SEW-A GE DISPCEAL AREA
a. SDS area lccated as per approver clans
I I I
b.
Fill secticn - Date of placQnent
2:1 barrier LGTH w4 !� i AVG.DP H
I I
c.
Natures soil not strimed
d.
Stcne, br -h, etc., are :tern than 15' from SCS area.
I Al
e.
100 ft. f_.in water course /wet-lar_'
XI
II. SEWAG:, DISPOS?T SYSTEM
a. Sent?c t .*i{ size - 1,000 rl21
I j
b.
S_ct c tariK ins t-=-11led level
JAG I I
c.
i0' min? -li-n f =an fourcaticn
d.
Nc 90° herdis, cleancut within 10 ft. of 45° Eznd
I-�{
e.
DIST"_�T--KT?CN BOX
1. P1_ cutlets at same elevati cn - water t es,µ
I I
I S�LI 1
2. Protected be? cH frost
3. I"linizr,., , 2 ft. cricinal soil he--tNes=n bcx and trenches
f.
JLNCTICN EOX - properly set
c.
'L� z z
Lc ^.c_: `,h install
2. Dist nce to waterccurse m =eaasu re�a ice.
I I I
3. Inst=iled acc.,rainc to plan
4. Distance center to center
5. Slcce cf t --ench accent=-le 1/16 - 1/32 ° /fcGt.
6. 10 fe✓t f_an procerty line - 20 f �t - fcunca
1 De t:h c_ t=ench < 30 inc_^.es from sur-f-ace
S. Ran allcwed for e. \ransicn, 50%
9. Size cf travel 3/_4 - 11" diamet r
10. Devi =: of travel in trench 12" min mur,
11. Pi re e.T:ds cacced
h. M - C.R W— ,
Pr. SYSTEMS
2. Come -r lea tank
3. P.la=, vi sal. /audio
4. P=- m easily accessible mani-ole to crate
5. First box baffled.
6. Cvcl e witnessed by Health De ar ment
estimated flcw per cycle
IV. HOUSE, '
a. House lccated per approved plans.
b. Number of bedrooms
V. wv=
a. Well lccated as per approved plans
b. Distance from SDS area measured ft. G_7
c. Casing 18" above grade.
d. Surface drainage around well acceptable.
VI. OVERALL LyOMSSIETLP
a. Boxes procerly Grouted
b. All pipes partially backfilled
c. All pipes flu=b wit inside of box
d. ill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
f. Curtain drain cutfall protected & dir.to Exist.waterc
c. FcotLiq drains discharge away fran SDS arEr
h. Surface water protection adequate
i. Errosicn controi provided on slopes greater than 15 %.
�9
r
i
PUMM, COUNTY DEPARMM O HEALTH - DIVISION OF ENVIRONMENM HEALTH SERVICES
Y
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
1P1M7TT; T_SHEET CONSTRUCTION. PERMIT:
DATE REVIEWED;. F
BY:
DOCUUMS
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
333
House Plans - Two sets
If PWS - Letter
Variance Request,
REQUIRED DETAILS ON PLANS
Sewage System Plan
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
Design Data
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing /Gutter Curtain Drains
Perc & Deep Holes Located
Representative of Sewage & Expansion Area
`Expansion Area; shy_ pan_ ; gravity. flow, suff . size
If Pumped __ Pit '& fD Box Shown & Detailed
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Property Located
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 110; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
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 Unc. expan)
15' to Drains- Curtain,Storm,Leader,Footing
25' to Catch Basin
10' to Water Line (pits -201)
Septic Tanks
10' from Foundation
50' to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town/DEC Permit R & D)
Data On DDS Plans & Permit Same
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
APPENDIX L
AFFIDAVIT - CORPORATE OWNER APPLICATION
FQk' 'VEMI!i kri:�ftC'A"IT61"t- 5UBj.1-LTT.ED-'0l �,
PUTNA_*i COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
Construction Permit for Sewage Disposal System Lot #21
John Lehman
represent that I am an officer or employee of the -corporation and am authorized
to act for Apple Hill Development Corp.
(Name of Corporation)
having offices at 10 Galloway Heights, Warwick, N. Y. 10990
Whose officers are:
President: . Peter Goertzel 46 Wall St. West Hurlby, N.. Y.
(Name and Address)
Vice-President: Jerome T_ MnnqQrh ' 6n Fast 49nd Street, —N. X 10165
(Name and Address)
Secretary:
John Lehman
(Name and Address)
Treasurer: John Lehman
-and Address)
and that I am and will be individually responsible for any and all acts of the
corporation with respect to the approval requested and all subsequent acts-relating
thereto.
Sworn to before me this 10 day
of July 19 86
Dell Winogrond
Notary Public
WLLW,140d!,0ND
low P011c, stem a NO* Y**
No. Me-eg
w0g,
=11iotan Co
;:W-;W gs AP012,J3
8/84
0
Signed:
a az
Title: /�_� e
corporate -!iea!
PUTNAM COUNTY DEPARTMENT OF. HEALTH
DIVISION OF ENVIRONMENTAL H1�,ALTII SERVICES
O n nA
:'I, I i°v �TTI'T :ri yu a� :S.T
DESIGN DATA SHEET- SEPARATE SE[JAGE DISPOSAL SYSTEM FILE NO. _
Owner_,L_MoM 14 Address pt
Located at (Street C� %-A .- Sec. G,�5 Block ot C
Jndiicate nearest c.ros-, st-r-eet�
Municipality T -Tl gSntd 'ld,a.tershe.d.
SOIL PERCOLATION TEST DATA REQUIRED TO DE SUBMITTED WITH APPLICATIONS
�e
huwl)er 21 CLOCK
T:[t�r
PETIC0L -ATION PERCOI_ATTON
--
"�nzn
EiL�I)se
l°�' Ida laa
� tJai ei° Level
Pao.
`.i':ime
Rrom Ground
Surface in Inches Soil rate
start -Stop
Misr.
Start
Stop . Drop in Min,/in drop
Inches
Inches Inche s
21 A 1 'Z' (. -- :oco
J SZ
71A
2 3/q /?
— __?_o-t - 3 : r ce- ---- 9 - -- '22 -- - -- --� S ---
COY L.oA�1_�1L,�1.1.`� C_q \ -
5
1$ 1 3'.00 20 20 2
3 3:53- 4:20 21 ��� . - 3 4
sr1--T1
5
rl
2
5
Notes: 1) Tests to be repeated at sang; ctepth until approximately equal. soil.
rates are obtained at each percolation test hole. All data to be submitted
for review.-
2) Depth measuren,ents to be ira,de from top of hole.
a
TEST PIT DATA REQUIRED TO BE S1113MITTED WITH APPLICATION
DESCRIPTION OP.. SOILS m.4cbUNT11,I F D IN TEI;T HOLES
G. L.
Ski 1_•l(�Y �OA1�A
12"
18"
2!1"
30�� CLA`( �Ae'N► W�
36"
42"
4811
51�
J _
6011
66"
7211
78 ". .
84"
E=.:��TO.�:.;
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WILICH WATER LEVEL IBISES AI'TLR BEING ENCOUNTERED
TESTS D,
DESIGN
Soil Rate Used yun/l "Drop: S.D. Usable Area Provided S, _
No. of Bedrooms 3_ Septic Tank Capacity 1,00 Gals.
Absorption Area Provided By 3Do L. F'. x24" jb''� width tr en hl.'
> Other
Address_ 10_C. "%QWX,:,e gale�� -c�'S
- 16(ACTIN%Q%t M,Y,
TIIIS SPACE FOR USE BY BEAIR11 DEPARTMENT ONLY:
Soil Rate Approved
Sq . Ft/Cal.
Checked by
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- - l�:� -- ; ts- CAR.
Urr�T%,�iiyi�;`:i�1�;L;
DESIGN DATA SHEET- SEPARATE SEWAGE.DISPOSAL SYSTEM FILE NO.
Owner Apple Hill Development Address
Old Route 22
Located at (Street6dicate Sec. 69 Block_ 4 — Lot 6.4
neares cross s r6et )
Municipality Patterson Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Proposed
Lot #21
Hole
Number CLOCK TIME
PERCOLATION
PERCOLATION
I= Eiapse
Depth to Va-ter
-- �nTaEer
bevel
No. Time
From Ground
Surface
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Min., /in drop
Inches
Inches
Inches
►'� 1x'.56 -3:0(0 1 n
) %i
2.3 0'7 -3' 1(0 R
33;14 -3'a$
a-5 %
3
-3
0—) a" Tc.D�-nj L
1
C-L i4�t Lop�nn
U38)Lr 9gAvE'L
5
3
Q -1 a " T-r) i ri Lo A m LQ h5) LT �pvt L
Q
Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
nVR0DTDMTnAj OF QnTTO !'P;RED IN TEST HOLES
HOLE NO
G.L. L
6 N F-) L r,
1211
In
2411
v
30fl Lr>RM
36"
4211
4811
5411-,
6oll LnL15 If
66
.7211
84111-1
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
-INDICATE LEVEL T0- WHICH WATER LEVEL RISES AFTER=BEING ENCOUNTERED-
DESIGN
Soil Rate Used__q _Ylinll "Drop: S.D. Usable Area ProvidedNo. of Bedrooms Septic Tank Capacity 1,00Q Gals. Typ e
Absorption Area —Provided By L.F.x2411 width h
3b"
Other
j a M M - - Lem M AM. P, C, — Signature.
Addres
WARWMV_4� M.M. %(Ossa
THIS
SPACE FOR USE
BY HEALTH DEPARTMENT
ONLY:
Soil
Rate Approved—
Sq. Ft/Gal.
Checked by
en�M —LA.
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL, SYSTEM FILE NO.
Owner,apg[ /� ej j �a��ress Q (j--) PQ � > /TE c:22 a
Located at ( Street -_Sec. (Block Lot
6dicate neares cross s ee
Municipality, pjg -TE,?�.Jp IV Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Pz2 0 Pas &L Lo
riV1C
Number o CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water r - WaE_er__level
No. Time From Ground Surface in Inches Soil Rate
,Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
3�Z) L( in % n
33:1Q -3as
4
5
1
2
3
5
Notes: 1) Teets to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
j: DE9CRI.PT.IOA ? =-OP-
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L. —T/C�c' n3c )y1 L_ �/
6" p KI J .l -1 l� 1I / 1
12"
18"
2411
30"
36"
42"
48n
5411
60"
66"
72"
7811
8411
=.A' ?�1I3H GROUND:_WATE
INDICATE LEVEL -TO WHICH WATER LEVEL
TESTS MADE BY I -, I
ENCOUNTERED - ...
,S AFT FR
� 4N .E R jDate
llL�1Cr1V -
Soil Rate Used Min/1 "Drop: S.D. Usable Area Provided159 8
No. of Bedrooms '!E� Sept'c Tank Capacity %o� S Gals. Type
Absorption Area Provided By�L.F.x24 '� width trench.
Other
Address
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. F't /Gal Cheek b
't
1
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^
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�.
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.
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L OT 19
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-TF115 iS TO CERTIFY 'i't.>,AT THE SEWAGE
DISPOSAL SYSTEtvI WAS CGW'- ,- T<UCIT=D
AS INDICATED OW THIS PLAN AVID
T1 bz,r 'T"e WAS It•tSFECTED
BY ME BEFORE IT WA,S COVERED
C1ve1z :T "�— E,�r °ST'ETY 'r�ra =- cr�TSS�I�t�t_�ED = -. .
IN ACCORDANCE WITH a±l_L STAl.1DAFeD
RLJLE5 AM> RE:GULC.T10t -tE C,F -T"E
PU -TI,JAM CCAJInY PEF�FZTPnEFiT OF
H'EGLT H .
501L LOG
O� G" 'TOP'SOIL
- ?.4" Sb14CY LO/a.M
24" toCi' CLeK LOtkn W /SIt.-T $ UctnvEl
PERCOL.ATIpF1 RG,Tc
s e epvtaON+ "Ouse
LtN.F'T.1TREti1C" REOO. - 553
LIIJ.FT. TREP1G6t P¢.W1DE0.• 553
2 F1LL REOD.
LOT Z�
Ai[eA- 129,553 SF *-
Putnam County Department of Health
Division of Environmental Health Services
Approved as roteci ^fcrnance wits
applicable Rues and � 5: lat:Lcrs of the
Putnam Count?
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L0CA -T10VA SCII�DULE
F KOM
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Box CRVIR AA
C.RrIR as
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9 5'
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2
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3
719
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05'
i
p4'z(;10 E
I A
! 19
80'
25.16'
2A
122'
35
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2 5'
125'
d9'
i0
4A
128'
5 +'
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SA
131
Z)T'
v
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134
102,
1B
70'
i2'
17'
3B
7 f'
S' ,
j13
77'
57'
58
80,
4,3
66
Bt'
1C
30
-f
2C
46
3c
tl
3i
4c
15
G
�G
16
6#'
-TF115 iS TO CERTIFY 'i't.>,AT THE SEWAGE
DISPOSAL SYSTEtvI WAS CGW'- ,- T<UCIT=D
AS INDICATED OW THIS PLAN AVID
T1 bz,r 'T"e WAS It•tSFECTED
BY ME BEFORE IT WA,S COVERED
C1ve1z :T "�— E,�r °ST'ETY 'r�ra =- cr�TSS�I�t�t_�ED = -. .
IN ACCORDANCE WITH a±l_L STAl.1DAFeD
RLJLE5 AM> RE:GULC.T10t -tE C,F -T"E
PU -TI,JAM CCAJInY PEF�FZTPnEFiT OF
H'EGLT H .
501L LOG
O� G" 'TOP'SOIL
- ?.4" Sb14CY LO/a.M
24" toCi' CLeK LOtkn W /SIt.-T $ UctnvEl
PERCOL.ATIpF1 RG,Tc
s e epvtaON+ "Ouse
LtN.F'T.1TREti1C" REOO. - 553
LIIJ.FT. TREP1G6t P¢.W1DE0.• 553
2 F1LL REOD.
LOT Z�
Ai[eA- 129,553 SF *-
Putnam County Department of Health
Division of Environmental Health Services
Approved as roteci ^fcrnance wits
applicable Rues and � 5: lat:Lcrs of the
Putnam Count?
r :O