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BOX 16
19 1
or
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IN
' - 16 ol
1.6
01756
PUTNAM COUNTY DEPARTMENT OF HEALTH x ,
Rev: 3186.
'Division of Environmental Health Se'rvicex, Carmel, N.Y 10512 �
l
'Mu at Provide
CERTIFI -A 0 . ; ONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM / Q tV
a o ? 7"
Located at Q Ta: MBP_ Block Lot
Owner /applicant. Name Formerly_L 'r �al.fti -S i on Nam s bdv,. Lot N
Mullins Address . �P 3 ' - Date' Permit ;Issued
Separate Sewerage System built ,by. V) �-�/ K fi— Address • Q t �7 Ox "! �: Off► Y
Coneleting of - Z, Galion Septlo Tank and
Water Supply: Pobuc Supply From Address
or Imo, Private Supply DiQled by LL;1 Address ►-r c
g� g Has.Eroslon Control Been Completed?
dd ,
Number of Bedrooms '7 Hue•Garbage Geinder'Been InstalledY /��
Other:Regdremente
Z certify :that the system(s) as listed serving the above premises were const tad esaentia4y as shove on the plans of the compl4ed'work'( copies
of which are attached) and in accordance with the standards rules and reg 1 tiona in accordance. with the file la an the permit issued by the
Putnam. County Department ,Of Health
Date'
Cwtifi by - 3.�-�— P E: R.A.
Addreu • icense No�.
Any person occupying premises served by the above, systam(s) sha0. promptly take such actlon as may be nee soery to secure the correction of any unsanitary
contlitions resulting from such usage Approval Oi the- separate= sew99g.- -.system (hall becorne:nuu and void as soon as a pubt': sinitiry sewer. becomes
availat& and the.approval_;of the,pr)vate water supply shall become null and =void ;when a - public - water .supply- beeornes- available. , - Such approvals are
suti)eef to modification .or change when 'in the )u.dgmeni..6f the Commissleaer of Health " eh revoeatlori, modifleit(on or'ehinga is necessary.
Date / 8Y Tine
K.
PUTNAM COUtM DEPAF3II4ERT . OF HEAVIE
ISIW OF ENVIRONMOUI. I, 1�1FAL' �i
SERyCFS-
rl ��,�s l .1 �U 4L ..
Owner or Purchaser of Building
Building Constructed by
TO /�''1�► - /�,yT ���
Location - Street
Section Block Lot
.J-- r- 'e- Al k
Subdivision Name
Municipality. Subdivision Lot #
i� de, L111 LQ.l
Building Type
GUARA =.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 sham 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 .Constructiar.: Compliance" for the sewage-disipos-al systeti,._or
repairs made by me to such 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 utilizin
the system.
Dat a this � day of cl a 19 ?Z
L/-q �/
rev. 9/85
mk
Title
�. I AJ_�4
.:.
See
ess
"I- �Mcn�
WEL_ COMeLETIUN KLruAl Office Use Only
tae
DEPARTMENT OF HEALTH
Division Of Environmental Health=-Services
P.UTNAK..CO1MY _PYF _ AR71. -._J zqEUA]kT
_s TAX GRID HU N
STREET ADDRESS: 7OWNIVILLAULIL11Y Mau- 11 --St Well
WELL LOCATION
Ice Pond View Estates I Farm-to-Market Rd., Patterson, NY�'1471_6
WELL OWNER
NAME. Ice Pond View Estates, ADDRESS:
c/o Eagle River Bldrs., Po Box 970, Carmel, New York 10512
9k PaIVATE
1 0 PUBLIC
USE OF WELL.
-30 RESIDENTIAL ❑ PUBLIC SUPPLY ❑. AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS ❑ FARM ❑ TEST/OBSERVATION 0 OTHER (specify)
2 - secondary
0 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY 0
MOUNT OF USE
YIELD SOUGHT 5 90m:/NO. PEOPLE SERVED 3 to 5 / EST. OF DAILY USAGE gal.
REASON FOR
❑ NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY X3 TESTIOBSERVATION
DRILLING
❑ REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 300 —ft. I
STATIC WATER LEVEL _il_ ft.
DATE MEASURED 1/10/89
DRILLING
❑ ROTARY &k COMPRESSED AIR PERCUSSION ❑ DUG,
EQUIPMENT
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. )51 OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH _72_ ft-
MATERIALS: x&kSfEEL 0 PLASTIC ❑ OTHER
CASING
LENGTH.BELOW GRADE 71_ ft.
JOINTS: OWELDED JaTHREADED OOTHER
DETAILS
DIAMETER in.
SEAL: :aCEMENT GROUT OBENTONITE-0-OTHER
— WEIGHT PER FOOT 19 Ib./ft.
I DRIVE SHOES YES ONO
LINER: 0 YES ❑ No
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
SCREEN
DETAILS
FIRST
0 YES ONO
SECOND
HOURS
64AALi 0ACK
D'Y'S
GRAVEL-
DIAMETER
TOP
BOTTOM
❑ NO
I SIZE:
OF PACK — in.
DEPTH IL
I DEPTH — It.
WELL YIELD TEST If detailed pumping
It more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
METHOD: ❑ PUMPED 1 tests were done is in-
DEPTH FROM
Water
well
)ftCOMPRESSED AIR
formation attached?
SURFACE
I
Sear-
012-
FORMATION DESCRIPTION
C30E
0 8AILlfD 0 OTHER ❑ YES ❑ NO
It.
it.
ing
"ter
In
WELL DEPTH
DURATION
DRAWOOWN
YIELD
Und
Surface
12
Sandy gravel & cobbles.
It.
hr. min.
ft.
9pm.
12
20
Grey hardpan.
200
1
30
200
3
20
30
Hardpacked hardpan.
30
60
Soft fractured bedrock.
300
6
15
250
20
60
300
Medium to. hard a anite.
WATER WCCLEAR
TEMP.
QUALITY 0 CLOUDY
HARDNESS
❑ COLORED ANALYZED? )MES ONO
ANALYSIS ATTACHED? XXYES ❑ NO
STORAGE TANK: TYPE
CAPACITY GAL. —
PUMP IHFORMATIOH
TYPE
CAPACITY
WELL DRIUS NAME MILL DRILL INC. 11 / 8 9
MAKER
DEPTH —
ADDRESS Putnam Avenue
MODEL
VOLTAGE — HP
Brewster, NY Mre eid 'en t
s.4.- ...G BREWSTER .LBi7R�►iil7i�t�
Box 224 - BREWSTER, N.Y.
(914) 279 -4945
- WATER ANALYSIS REPORT -
SAMPLE NO. 7216 WELL
SOURCE: Ice PoAd Estates Lot 13
Patterson, N.Y. 12563
COLLECTED: 1-10-89
BY: Mill Drilling, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
1 -12 -89
0 per 100 ml.
•
Thomas FROM 40 i
Director
Ts
lc: as T:,;-r a,-zrc: EC c a !9 C
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1_ -ac =_ WEZ=
DEPARTMENT OF HEALTH
Division of Environmental Health Services
OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street ddres
'm � .
'� �
o Vi a City Tax Grid Number
� •P/c's o r) o — 5 -- ► 3
WELL OWNER
h=--4
M ilin
S
ddregs,
PO (So x 6T&(4-2.Y
Private
O Public
USE OF WELL
a)- primary
2- secondary
RESIDENTIAL
0 BUSINESS.
D INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
[Q FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED .
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
Rpm /#
PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY
E(NEW SUPPLY N DWELLING
D TEST /OBSERVATION GI ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING,
Ge-
WELL TYPE
ODRILLED -
DRIVEN
[]DUG
OGRAVEL
OOTHER
IS WELL.SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION,.NAME OF SUBDIVISION:
Lot No. I F
WATER WELL CONTRACTOR: Name 4, R Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X- NO
NAME'OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
._._- -.D1STANCE °TO'PROPERTY FROAi NV.REST WATER MkIN: �0- -
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE
MON SEPARATE SHEET
(date) signature
PERMIT 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
thirt3� (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 provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drill perations be contained on this
property and in such amanner as not to degrade or oth wis contaminate surface or groundwater.
//
Date of Issue• !3 19�
Date of Expiration ! 7, 19 3 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
APP—ENDT( 3
aP �y1 CCLT'I'Y %�A_ •` 'T OF I- ALTH - DIV-ISICN OF ENWIRO�ENL'n.L ~S<PLTH SERV?C�
r DO—V .�'?_L Gam' = R SUPPLX & SUPSLaFACE .�..�t ?GE DIS?C r_L Svc' S
C\%-Laer
ZZ
✓�/�V w ' -rte -t/L. BY:
az=ITS
Pew lti t Application
Corporate resolution
Plans - '_ .ree sets
L
:resign Data j'.a t- (DDS)
yep Hole Log
Consistent Parc
Perc Hole Deoth
S/S
S'v_-=v?SION
par`
F i1
cd
House Plans - 'Iwo sets -
Well pe —mut; P %YS l=—
Variance reauast
Legal Subdivision
Subdivision Pooroval Chec:ed
E�c-aoorv,---1 SSJS Pdj . Lots Check-ad
w-etla,nd (TcF,,•:� ,/DBC Permit IR & D)
Data On DDS Plans & Pe_ -mit Sar,,--
R:-:QL�T� DZ.- !=, ON PULNS
Sewage Systzn Plan - (north a=rcw)
Sewage Syste;i Hydraulic P_ o F i l'
F11-1 Profile & D- ::ansi c: s- - Vol:-„
D or J Box;Tre-adn /Caller1 s; ?-V, pit �e�ils
T
Seotic T Lnk - Size,
Wail Detail, Service Line i f over
Const...roction Notes (grin--2isr rate)
Resign Data: _p rc -and -deep- - esalts
1.: i :Gs=rJ
ML, �l i n� tY +�rGp. =s'
Dr_ve ay & Slozes Cut
Footin Gutt_r,C�r ain Dra' s (disc_: v1)
erc & D-zeG 'Holes Located
ep�ase :,'r.tive of pr -,.azy and ex^�ns o1
. j
L-�.ansi on A--rea; shown; gravity size
II ?z med Pit & D Box Sze z & Da _i'__3
Haase - No. of Be roa-s
Wells & SSc)S's wlin 200 i t. of Prooc =-5 Syst--lS
Prooerty eta & Boun^'_s
House Sethac!C _Necessary (Tight lot)
Ho: se Sewer - 1 /4 n/t t. 4"0; ype pi_r
No 3ai ds; 'l.Ji. 32- ndS 45" w /cleF -IoUt
SER_' -_P TION' DIST="N= S_ B2 E = ON
Fields
10' to P.L., Drivewav, age Trees,T- -o of fill
20' to roan`= lion �:a11s
100' to Well; 200' in D.L.O.D, 150' pits
100' to Str a F -,I, k'aterCo: •-Se,
lake (:,c. ea-an)
LG Dr- i -,— :•amain, :r= lei, "oOt: lg-
.15"o CrtCn I"•csin,storitia;n,yit;rd
10' to Water Line (pit - -20')
50' in'u?`mi tellt drain-ace c'y -'r'se
icGti C Tanks .
10' Fran Fo, :5- ---ion; SO' to loll
.J' Well to pr
s
Putnam County Department of Health
Division of Environmental Sanitation
'T T OR—FO— i' OWNER A PPLICA`1`l UN
`. ti Y l`l'i�ci V l l - .L 1 E
FOR PERMIT• APPLICATION SUBMITTED- TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health - In the matter of application for` '
I, __DAVID _ Ct0C.= Go�� Z( ___• represent.
that .I am an offs er or employee of the corporation and am authorised'
-W r A K44 �1 cod
to act for_ _ _ F-X2M_ _ 172)•_ M A. 21e-a7( IF—S-j"A7ir-- 5.
' (name of corporation) — !
f
f having offices at P_-E. 6 SI MPGbAj 120Ap `fin,' 5oX .1'7o
6-A (zNiE, l- N'.`r_ 10.S I12 ,— _ _ _ _ _ _ _Whose officers -are
President C�oC_GO c.V��l-- --_ - -- - - - — — — .—
_
'Name an Address)
Vice - President ��l/`� _aoLt --a(6T
o (Name and Address) -
Secrt tary _ — _ _ O� CL GC.D -
(Name and Address)
Treashrer _ _____'
— ,(Name and Address) _ _
and that I =award w�.11 be individually responsible for, any or all apt¢
1 of. the- corporation with respect to the approval e0ested and•all .sub -
sequeit acts relating - thereto. %
i.
Sworn: to Before me 'this day Signe
._i�Z
Of '!'Y'f %�' � 19 Q� Title L(,� P/l� `� _ �' TA " •
Ilk
Notary Public'
EDWARD J. CRESCPNT.A
Notary Public, state of New yo,
OUGA1140 . in Putnam Coullty
'form November 30, 16•, / .
Corpor4te Seal
• 1
I
I
+ .. 6
Municipal-ity Pi
of Pa7-r Iz►'z J-'
Watershed,
Gr,-o70
F
3
SOIL, PERCOLATION UMT DATA REQUMM TO BE SUBS WITH APPLICATIONS
y
. Dane of Pre - Soaking 5 3 . I. b g - - Date of Percolation Test
_, .. _,•_
S h I b13-
SOLE
141lSER _ "CLACK TIME
Run !Elapse
Depth to Water From
Water Level
xo: ................. . Time
Ground Surface -
In Inches
Soil Rate-
Start-Stop Min.
Start Stop
Drop In
Min/`In Drop
Inches .. _ :..... inches
.._ inches :._
...... ;
-ci 2
P,OLC
I2
4..
1
I
2 to :5? - ll'. I-
3 I1:2'j - 12:03 ; 3G .2A- ZS� Z -
• 1
2
F
3
y
NOTES: 1. Tests to be repeated. at same depth until approximately equal soil rates
are cbtained•at each percolation test hole. All data to'be snbmittla
for review. '
2. Depth measurements to be made from top of hole.
Y
TEST Prl .ATA REQU=,TO BE SUBM h_ .�i APPLICATION
DESCRIPTION OF SOUS ENCOUNTERED IN TEST HOLES
_ ... DEPTH - Hom NO- I EOT2 .rte-... $ME NO.
G.L.
1 .To P.501 L pso 1 L
31
.ii � '; -'.r. tY ;:. its 1.i4.`�. %:; ��'t'1'c' C'•' "Y '�ii :: ?t• ;:•`� % ?'
61
11'
13'
14'
INDICATE LEVEL AT WHICH GRAUNDAAM IS ENCOUNTERED N l�
INDICATE LEVEL TO WHICH W= LEVEL RISES AFTER BEING II3JOUNTERFD
DEEP SOLE OBSERVATIONS MADE BY: LA VL jo-'O-,K P G. D'. o. H.... bAZ'E: 5/1406
DESIGN
Soil Rate Used 2I '3 a Min/1" Drop: o f (a0 S.D. Usable Area Provided .
No. of Bedroams Septic Tank Capacity- 125U gals. Type ,vG
Absorption Area Provided By (a L.F. x '24" width trench
Other
' l �
•t
Name I-AL "T 9MUiAJ6K4z (AJCt �S3 o c PC. Signature 11"'t4T
Address 73 rM m F/ 9t-P D rZi v r- SEAL.
'ant Ci2�
• �h77�t'L3Ut�1 NY• •I ZS(v3 �• �',�`-- __.._ -- ,,P��
THIS SPACE MR USE BY HEALTH DEPAEMEM ONLY:
Soil Rate Approved sq.ft,/gal. Checked by Date
vqr--LL-
0 MA►KET KOAD
AS - BUILT
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