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01743
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER. WELL
.:._.r......, ,.�..,....�...._ � .__.�..� _..�..�...._...�„� _......_ _._:.PCHD PERMIT #. ,'' �•-�.�
WELL LOCATION
Street Address
Old Route 22
Town/Village/City Tax
Patterson, NY 69
Grid Number
WELL OWNER
Name
Loft Corporation
Qgmf eftguse Road, Brewster,NY
Private
O Public
USE OF WELL
1 - primary
2- secondary
URESIDENTIAL
❑ BUSINESS
❑ INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
D ABANDONED
❑ OTHER (specify:
O
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED 5 /EST. OF DAILY USAGE 600 gal
REASON FOR
DRILLING
6NEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
❑ TEST/ OBSERVATION
DETAILED
REASON FOR
DRILLING
New single family
residence
WELL TYPE
UDRILLED
11
DRIVEN
aDUG
OGRAVEL
D
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
AppleHill Development Lot No.
WATER WELL CONTRACTOR: Name Henry Boyd Address :Rt 52 Carmel,NY 10512
IS.PUBLIC WATER SUPPLY AVAILABLE TO SITE: .YES X NO
NAME OF PUBLIC WATER SUPPLY: N/A TOWN /VIL /CITY...
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
4O
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED �, '•`;
[]ON REAR OF THIS APPLICATION ®0 SPA " ">
6 -9 -87 i ��:
(date) sign OA),�o' m
PERMIT SSIO
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
1. Pump'the well until the water is clear..
2. Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on a form provi ed by the Putnam County
Health DeparPAent.
Date of Issue: 19—S-7
Date of Expiration: 19 it ssuing fficial
Permit is Non - Transferrable
I
8/86
APPENDIX H
PUTNAM COUNTY DEPAIM-INP OF HEALTH - DIVISION OF ENVIROMWrn HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET - CONSTRUCTION PERMIT /
DATE
BY:
(Name of Owner (Street Location)
COMMENTS YES NO DOC[]MEN.PS {' .
LF trench provided 5
required --
60 ft. max.
Parellel to
FILL
f ill
new
Permit Application
Corporate Resolution
Plans - Three sets s/s
Engineers, Authorization
Design Data Sheet (DDS) SUBDIVISION
Deep Hole Log Perc
Consistent Perc Results (3) Fill
Perc Hole Depth cd
'7 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
"U REQUIRED DETAn G ON PLANS
12 Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Flow
:onto 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 rotes)
4 = Design Data: perc and deep results - -- - -- -- T
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;shcwn;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
i 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' fran Foundation; 50' to well
15' Well to PL
Loft Corporation 69
Owner'or urc aser of Building Section
Loft Corp. 4
,. +, 'tv'T' -" cr"is:;�S-�`��'.�"�t:•rC�-y.� jr ..... � -. »� - ..., .�� o�''.��. _ _--- _ _ - •_
Old Route 22.
Location - Street
Patterson
.-Munici.pality
6.4
Lot
Apple Hill
Subdivision Name
Single family residence 16
Building Type Subdv. Lot ##
GUARANTEE OF SEPARATE SEWAGE 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 success-
ors, 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 use of the sewage disposal
system, or any repairs made by me to such system, except where the failure
to operate properly is caused by the willful or negligent act of the occu-
pant of the building utilizing-the system.
The undersigned further agrees to accept as conclusive the determin-
ation of the Director of the of Environmental Health Services
of chi -Tutn'enr - County - ' Deparl- lm- a -it-of iieu��.� a� is n*.le�riei or no t�.2 �ail-
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
Dated this 1 day of June 1988 Signature
Title
Loft Corp.
Corporation Name if corp.)
Pump House Road, Brewster
Address
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Division of Environmental Health Services, Putnam County Department of Health
FINAL SITE - INSPECTION Date 57//ol ./�Pe
Inspected by fij
;CATION OWNER._<`��% �P?�
f # %gyp TM # OR SUBDIVISION LOT # tip 9
II,
IV.
V.
UAN
1C
TEAM RAA AREA
a. SDS area located as per approved plans
b. -Fill section - Date of placement
2:1 barrier. LGTH WIDTH AVG.DPTH
c. Natural soil not stripped
d. Stone, brush, etc., greater than 15' fran SDS area.
e. 100 ft. fran water course /wetlands.
SEWAGE DISPOSAL SYSTEM_
a. Septic tank siz = 1,0 1,250
b. Septic tank ins red level
c. 10' minimum fran foundation
d. No 90° bends, cleanout within 10 ft. of 450 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 -- ro 1 set
g, TRENCHES _
1. Len rewired - 3-75 Len h installed ,fit
2. Distance to watercourse measured.. ft.
3. Installed according to plan
4. Distance center to center
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. Pipe ends capped
h. PUMP OR DOSE SYSTEMS
1. Size of -pump chamber
/
2. Overflow tank ,
3. Alarm, visual /audio
4. PLunp easily accessible manhole to grade, /
5. First box baffled /.
6. Cycle witnessed b Health Department
estimated flaw per cycle
HOUSE
a. House located per approved plans.
b. Number of bedroans
WELL
a. Well located as per approved plans
b'. Distance from SDS area measured ft.
C. Casin 1$" above grade.-
d. Surface drainage around well acceptable.
OVERALL WORRMASHIP
a. Boxes properly grouted
b. All pipes partially backfilled
C. All pipes flush with inside of box
d. Backfill 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 from SDS area
.'
h. Surface water Pzotection adequate
i. Errosion controi provided on slopes greater than 15 %.
1C
•-�` PUTNAM COUNTY' DEPARTMENT OF HI7,-ALT11
DIVISION OF ENVIRONMENTAL flMiLT11 S ERVICES
- --
T r r.. r
= -- ;;ia »° =ice: �_ 2
.�_..�_,.,..R. .. _ ..�. �. r;.,:- Imo.
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYS'T'EM PILE NO.
Owner J. Mow►ASCN Address oLA Ro�rcF 22
Located at (Street SPRY y- See . &c3 B] -ock_ 4, Lot C,.4
ndica e nearest cross spree
Afuriicipality pA- t- �t�y���w� Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED IIITI1 APPLICATIONS
FRG3P���D l..C]''C � I[n
oe
Nwnber 1(n CLOCK TI1`41� PERCOIATION PERCOLATION
FZun Elapse Dep 1 E`o T;a_1EeF -Water ve
Ito. Time F'rom Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
1 t(���z- [o•�Z 221 _ 25 4. 2s/4
2 _11.Q4 301
t :310 30 2 3 _�5�2 �!�� 14
4 o- IZ`•'mPSO\� \Z" -'moo" u�a w/ SILT + . GR&Vsx. ,
ifcg 1. :5 - IO:z 0 22 —z 5,zz 3
2
may.
5
IVotes: 1) Tests to be repeated at san,3- depth until app proximatelyy 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.
!" L
r T.11-ST PIT DATA REQUIRED TO ICE SUBMITTED WITH APPLICATION
/ ,DESCRIPTION OF.SOILS ENCOUNTERED IN TEST HOLES
e .
DEPTH__ HOLE4..�N0 . - t� _ }?nT,� <N•0 - - 7 �� .'; u - - . _. ..
G.L.
6" "COPS 1 L
12"
18" SIL`C A !aRwynt-
211"
30
36"
42''
48"
54"
60"
66"
72
78"
8411 V
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO W1EICH WATER I.EYEL RISES- AFTER BEING ENCOUNTERED -
___..__.,.. �_ Z.]' ��►�ie�I���T- - �: -�:�: �:i�4.��ittii.._.._._....__.. 1.�.i."�..e ..1 LI'1 �1 �4
DESIGN
Soil Rate Used 14 Prdn /l "Drop: S. D. Usable Area Provided %pC .
No. of Bedrooms 3 , Septic Tank Capacit --
Absor tion Area Provided " Y oo� r� ��` e
P BY 3'15 L.F.x24' .;;;,�;__£g 0. trench.
name log -Ir` LE- *AyAam. P.C. Signature 7....' . .
Addres Si
THIS SPACE FOR USE BY 11Mk.L'.PH DEPARTMENT ONLY: Ufi� S10 P�
Soil Rate Approved Sq. Ft /Cal. Checked te
Rev. 3/86 PUTNAM.1COUNTY DEPARTMENT OF HEALTH
So Carmel, Division of Environmental Health rvices, el, N.Y. 10512
16:111411neor Must Provide P 6.0_7-87
CE O!ELIAN FOR Patterson'
CATE OF CONSTRUCTION C SEWAGE DISPOSAL SYSTEM Patt'
Town or Village
b
Rout..22 6.4
Located at Ti, map 69� Blod—
A!
Owner/applicant Name* Loft Corp. Formerly Subdivislon Name ANI'. #i-1`kui4v.Lot# 16
Malling,Addiess Pump House Road, Brewster, NY.2,A 1-0509 d 6/16/87:
Date Permit ban
Separa 'Se.werage System bunt by Art Burdi rk. .---Add,,, Joes Hill Rd. Brewster, ,NY
Consisting of 1000 Gano. Sep dc Tank and 380 TA n Ft disposal trench
Water Supply: Pu . We Supply From
Address
or: X Private Supply DrfflM by-, 'Hpriry Myd, Address Rt 52 Carmel, NY
Building Type aJngle I.Pxii)y rt-s Hes Erosion, Control' Been Completed?—
Number of Bedrooms — .3
Has Garbage Grinder Been InstaUed? no
Other Requiremenis
I certify that thfi-syetem(s).as listed serving the above premises were constructed essentially.as shown on the plans':!
.d P
of which are attached), and in accoraahce with the standards, rules and regulations, 'in accordance with the crs
Putnam County r)epartment Of Hefalth. 6�1 88 Certified 'by
DISK
Date 4az lv��
11 �
Address
17 River .Street. Wa-Kick. NY 10990
Any person, occupying promises served by the above systems) shall promptly take such action as may.be necessary to secure the ctlowQV
PU .
all
conditions resulting from such usage. Approval of.AhO'soparate sawerip6.systerri shall become null and void as soon as a Du V rilApry tai
available and the approval of the private water supply shall become nuil,a-nd_ void whin, a public water supply bocol"mmu Iv,'-
subject to modification or change when, in thcjiidgrnent of the Commissioner of4rloalth, such revocation. mod1fication d IN ;'If c"
b
oat Title
- n
En
q SO
on %IrIWI LIP MIA
ONSTRUMONTERMIT'FOWSEWAGE DISPOSAL SYSTEM
P.
Owner Name, -6fpo
:Date of Pieviotis Apvko��
600 'R filr6d
-0 IN spgsd r6rfch
013j. Pi Addrefl�
it
Ps
Date Signe
is
;.Pee
Date ts Title
/�_�\
_a . - --
wnLL IJ
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
-
„-
WELL LOCATION
S REET lufflylVIL0141CIrl TAx GAIO NUMBER:..
_ / ,
L�
WELL OWNER
NA A." aooAESS:
yz; � /L/
J
PRIVATE
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
X RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE d_ n gal.
REASON FOR
DRILLING
ANEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH ft.
STATIC WATER LEVEL __!t63�ft.
DATE MEASURED ._22_7
DRILLING
EQUIPMENT
❑ ROTARY J9 COMPRESSED AIR PERCUSSION O OUG
❑ WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING, MOPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH tL
MATERIALS: P(STEEL O PLASTIC O OTHER
CASING
DETAILS
LENGTH.BELOW GRADE ft.
JOINTS: O WELDED WTHREADED O OTHER
DIAMETER_ in.
SEAL: .CEMENT GROUT O BENTONITE OOTHER
WEIGHT
PER FOOT 12= 1b./ft.
DRIVE SHOE: YES ONO
I LINER: O YES RNO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
O YES ONO
SECOND
HOURS
G.AAVEL_PACK=
O YES
-a iuo`
GRAVEL • '
SIZE
'GIAME7ErZ "
OF PACK In.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST r it detailed pumping
METHOD: O PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER 0 YES O NO
WELL LOG tf more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
Ing
werr
Dia-
Imerer
FORMATION DESCRIPTION
COOS,
it.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft,
YIELD
gpm
Land
Surrace
U-C7
Td rA-._.
WATER ❑ CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES D NO
STORAGE TANK: TYPE
CAPACITY GAL.
WELL DRILLER NAME ^- t / a q OrA#
o?
ADDRESS Ale�z SIGrM
C- ��JEw�z X�. 1111 , 1059
PUMP INFORMATION
TYPE CAPACITY
MAKER DEPTH
MODEL VOLTAGE HP
\\
—,• 1/ // � �� ' / —.\ \ \ \ \ I I 1 t \ \ \ \ \ I \ \ o \ \ \1 I h I I I I \ \ \ \ 1 I I j l � �, ;
l r/ / /// _ 1 I 1 i I 1 I im\ I \�, ►I liii \'1 \ \ 1 \ \ 11 11111 I � )9N �
1000 GALLiN
7///// � -_-�� i// \ \ \\ \ ► ( \ \�\ \ 1 \ 1 \\ 1 1 I 1 111 \ \ � � \ \ �► 11� \I\ \ I J � •-° ErriG TAFlI
�/ / / /____/ v\ \ \\ \ \\ \ \ \\ \ a\ 11 \ \ I II I I \ \ 1 11 \\ \ ► II I. r�
eoxcrvP.)
\
LCS 1 \ \ \' 1\ 1� \11\ Iiljlljl�l\ \` \11 I1 Ill\ I I I I I I I►� °IU I 1"u4 %;
\\\ / 11 1 1 t l\ 1 111 i illl l \\\ \ \\ 1 II I I I ill• � \ `',
\ \\ o\ 1 1 I I 1 III I I I i I I I III I
\\\
/ I I I 1 1 \ \\ \ / / I I I•. I I I \ I I I f I l l l l I I I 1 1 1 IocitN_ a s
EXIST It-IG WELL \ * m
//� I � \ \l /^ � / i �\ \ \� \\ 1 / / // / I• 'i1 / /)lllllllll Ijill II I\I III III \ li \ 1 I II i II I j - -�
/ // )\11 ✓� \ I \ \\ \ \ \ \\ 1 I I(I // /;:) /! / / / /I /1111IIII:IIIIiI II I' \ \ II I I I I
/ /'�. —� \? 11 i � I� i i i l ili\ \.���\ \\ 1\ 1 1 1 a r y l !IIi 1111 11:11 ►III I I I � —__•
, � I i ERVEO I
• iI
1 1 EX \STING WELL
• I
LOT 4t 17
1000 GALLON
15 213 3B
SEI�( IC LOCA -VID" SCJIAEDULE
FROM TO CRNR'AA
TO CRNR 2'06
I 48' -7"
32 -10„
2
4A 510' q
i 4 !08 I"
54'- 5
AREA RES
FOR FUTURE EXPA1SS101,I •�
I ,I
� EXISTIIJC� ;�
1 SEPTIC ;I
i A2EA !I
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9
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ISEE ll
SOIL
O'- 12"
12"-90"
PERC
14 M \T.
3 BE01
LIN.FT.
LIM.. F-T.
LVI 0
AREA'
a
SE
APP I
PATTER
3A
4A 510' q
15
97._�
5fo-S'
28
��p RESERVEp FOR
= U -\'URE ExPANS \Ok 4E 80;_,0
' f
I
JUNCTION �
BOX CT
THIS 1S TO CE-Iz T-e THAT T1.1E SEWAf�E
DISPOSAL S`<5TE-M WAS COf.IS- TRUCTED
AS 1ND1CPTEO C?IJ- Tt-11S >LpM A1,113 .
TNAT THE SYS -n--M WAS \NSPE:GTED
13K ME e>E•FORI�x � 1T WAS C.OVEREO•
OVER.TNE SYSTLM WAS COn1ST4iUL1ED
1N ACCORDANCE! WITH ALL ST•ANDARO
} ':
i .
r
t
!
AREA RES
FOR FUTURE EXPA1SS101,I •�
I ,I
� EXISTIIJC� ;�
1 SEPTIC ;I
i A2EA !I
J')
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9
II .
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ISEE ll
SOIL
O'- 12"
12"-90"
PERC
14 M \T.
3 BE01
LIN.FT.
LIM.. F-T.
LVI 0
AREA'
a
SE
APP I
PATTER