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631- 589 -8100
35. -5 -15
BOX 16
01801
Rev )3/86
ZZ
Located at —" E
Owner /applicant. Name P
MaWng Address 11
Brew
PUTNAM CpUNTYDEPABIMENT OF HEALTH
Division of Environmental Healtb Servicex, Carmel, N Y 10512.
z Engineer Must Provide P _ ?4- 88
D Pe mltq
I tUCiIOPLCOMPWAN E.FOR_S WAGE DISPOSAL SYSTEM, Patterson
own oi, Village . _ ......._. ,. ,
Branch Road T, "Map 69 Block 2 Lot 19.\
Batchelor Formerly- <'. Sibdivtsloo `Name = Sha�1T0 Sabdv. Lot p�-
; .
rfield Drive ]5n9 . Date Permit Issaed '4 05= 88
t by
Monet International ;C�rp. aaareaa13. Hillview Dr New Fairfield, Ct
n0 Gaon' ptic Tank and 400 +/- L: F PPVC Fields
_Pab11c Supply From Addre`as
j'. .. _-
rkt 61 Aj &r i i�'Ray/ lL'1��A ddress
or = , P rlyate Supply DrWed by
a - RA`c. i runt i a l_. Aad.Eroelou Congol Been Completed? NA.
tially.,s'. hoym ` s.of the completed, work ( copies
f' =plan, and the'peruiit issued by the
E. k— R.A.
BTeIn�SteT Llcsnsa'NO.
tion as maybe ecessary to secure the correction of any unsanitary
mcorns null and' void. as soon as a pub;': sanitary sewer becomes
public.watei supply becorimei ivailabhx. Such' approvals are
Iff,: such revocation, modification or change Is .necessary.
TItIs i
TLL COMPLETION REPORT PUTNAM COUNTY DEVAt1Tl'.SGNT OF 1tEALTlt
)t Division tit EnvhonmanWl licatth Vnrvlces
u ' COUNTY OFFICC EIUILOING - CARMEL• NEW YOt1K
Thic repo. t is to be completed by v.'c,ll driller and :o County licilth. Depirtment to ^ether With laboratory report of
analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance Is issued.
CkiEf?OI.T:a.7UST BE SIJ(:'.7 {1'TED CiFT11111 30 D.1YS OF t'E'LL CO.Si'L[TIOJJ
OWNER
_
ttAx.E
Monet International
ADDRESS
13 Hillview Dr. New Fairfield, CT
LO,'ATION
OF WELL
(No. 6 Sffool) (Toym) (tot Vvrrt.or)
E. Branch Road Patterson, NY
PRO ?OSED
USE OF
YiELL
BUSINESS
cmtESTIC ❑ ESTAEIISHMENT ❑ FARM ❑ TEST Y /ELL
PUELIC AI, ^ ^, OTHER
E] SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Speci(y)
DRILLING
EQUIPMENT
1:1 POTARY El [T j COMPRESSED CABLE OTHER
AIP. PERCUSSION ❑ PERCUSSION ❑ fsp:;; {yJ
CASING
DETAILS
LENGTH (leer)
1.00
I DIAAIETEF:(inches)
7
VrEIGHT PER FOOT
24 � THREADED ❑ WELDED
Vi:VE SHOE((���
- EIYES - [_-JNC
((t�' n]]5 CASIhG C "•_� T
- -l` yo
TEST ill
TEST
HOURS G.Fem.
EI CAILED ❑ PUMPED U COMPRESSED AIR
1
YIELD (G.F.Af.)
2
l')ATE^
LEVEL
MEASURE FRO)A LAND SURFACE— SfATIC(Speeily feet) DURING YIELD TEST (feet)
3
Depth of Complefed Well
in feet below land surface: 300
SCREEN
MAKE
_ '
LENGTH OPEN TO AQUIFER (feet)_
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF Gr ^.AVEL
P)1CKED:..
Diorneler of well including
grovel pock ( inches):
GRAVEL SIZE (inches) FROM ()oat) 10 0-0
I I
Tit FPOII IAKD SJOACEJ
FORMATION DESCRIPTION
Fill & Soil
Ckotch exact loca:;on of well with cosfonces, To at loss(
two ^fmonenf landmarks.
____
v 90
90 300
Pwvaw>tY
�fG t
61 T a OIL
;zi iiwK
Bedrock
_.
If Tisld was tested of d;fTerenl depths during dr;ll ;nj, list below
FEET
GALLONS PER MINUTE
t VrIEE cuwLLTED
DATE OF HLI'OHT
.a
WELL E)!! LL C Slgnsturc)
13
..BREWSTER LAB ORAT ORIES_
Box 224 - BREWSTER, N.Y.
(914) 225-2072
- WATER ANALYSIS REPORT -
SAMPLE NO. 7085
SOURCE: Walter Batchelor
East Branch Road
Patterson, NY
COLLECTED: September 19 * 1988
BY: Rider Fuel
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
hose bibb-well
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
September 23 1988
G
Roy Bic it P.E.
Dirtctor
0 per 100 ml.
PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
ENID L. CARRUTH, M.P.H.
Public Health Director
JOHN SIMMONS, M.D.
Deputy Commissioner
JOHN KARELL Jr., P.E.
Director
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310 September 28, 1988
Mr. John C:albo, Building Inspector
Town of Patterson
Route 311 & 164
Patterson, New York 12563
RE: Batchelor SSDS /Well East Branch Road
(T) Patterson TM 69 -2 -19 - Permit #P24 -88
Dear Mr. Calbo:
The house on the above- mentioned lot was not located in the same location
as ;indicated on the approved plans dated April 15, 1988.
As you know, house location is a function of zoning and required setbacks
set forth by the Town. The proposed location must be shown on Health
Department plans 'to insure adequate separation distances and elevations
for the sewage disposal system can be maintained. As John Eberle of
Baldwin and Cornelius is aware, as well as other engineers submitting
designs to our Department for review and approval, revisions for revised
house locations must be submitted for approval if the revised location
.affect the approved sewage disposal.area or well location.
On May 31, 1988, John Eberle questioned me concerning whether a revised
:plan.- needed•- to--b•e ._submitted on the above -me- ntioned lot because. t-he -
location of the house was to be moved to the northeast. A review of the
plans indicated that relocation of the house would not affect.the well
and septic location previously approved, and, therefore, resubmission was
not required. Mr. Eberle was told to note the location on the final
survey and "as- built" plans for the issuance of the Certificate of
Construction Compliance. The Construction Compliance was issued by me on
September 23, 1988, and the sewage disposal system and well location meet
all rules and regulations of the Putnam County Health Department in
effect at that time. If the plans had been revised, or the original
plans had indicated that the residence was to be constructed in the area
indicated on the final survey, the plans would have been approved by this
Department.
If you have any questions concerning this matter, please contact me at
your convenience.
Very truly yours,
William Hedges, Jr.
Sr. Environmental Health Sanitarian
WH:mk
cc: Baldwin & Cornelius, John Eberle
JK
ELC
APPENDIX I
PUrNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMEN'T'AL HEALTH SERVICES
Owner or Pchaser of Building Section Block Lot
Building AM RT�IFIMMWI "M
by
Location - Street
11.Q. ."t3 \�L b3
Municipality
�M-
lmvrewfy r, •-
Tax Map Number
Subdivision Name
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
by- me._to. -such system, except where_ t -he- 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 1914cp Signature - e
Title
General Co ctor (Owner) - Signature
+(Vo ail C
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Corporation Name (if Co .)
r
Address
c
16
W
11.
IV.
V.
V1.
F= SITE INSPECTION Date
2e I qZ��Iby
Cov.MER,,, eC,
�,
:E qm a nTz -qrTRnTV1STCN LOT
NO
DfslDosar
a- S-us area located as per approved plans
b. Fill section - Date of placement
2:1 barrier. IGIH WIDTH AVG.DPTH
c. Natural soil not stripped
d. Stone, brush, etc., greater than 151 fran SDS area.
e. 100 ft- fran water course /wetlands.
SETP& =-- DISPOSAL SYSTEM
a. Sentic tank size - 1,000 1,250
b. Sentic tank installed level
c. 10' minimum from foundation
d. No 90' bends, cleanout within 10 ft. of 450 be,-,.d
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tesJC�3
2. Protected below frost
3. Minimum 2 f-;--. original soil between box and trenches
f. J=ION BOX --prct>----lv set
g. Mai= le, � ins
1. Leen�-- mired Lemath- tall ed44W
2. Distance to watercourse measured. ft.
3. Installed according to plan
4. Distance center to, center
5. Slone of t--er.ch acceptable 1/16 - 1/32 "/-EcOt.
A4--
1
6. 10 feet fran prap---ty line - 20 feet - foundations
7. Depth of trar.ch < 30 inches fran surface
8. Rocm allawed for exnansion, 50%
9. Size of gravel 3/4 - 1 " diameter
10. Depth of gravel in trench 1211 minimLm
L. Pine: ends capped
h. FUMED OR DOSE SYSTEMS
2. Overflow tank
3. Alarm, visual /audio
4. Pump easily accessible manhole to grade,
5. First box baffled
6. gycle witnessed by Health Denar`�.menrt
estimated flew per cycle
HOUSE
a. Hcuse located per approved plans.
b. DL-Ttioes of bedroaus
WEIL
a. Well located as per- approved plans
b. Distance fran SDS area measured ft. --7-<
c. Casing 18" above grade.
d. Surface drainage around well acceptable.
-Y
OVE?,AJ-:-L WORMIMSHIP
a. Bcxes properly grouted
b. ALI pipes Bally pax-I backfilled
c. A121 pices flush with inside of box 17
d. R-a-r-k-fill, material contains stones < 4" in\djaxe;b-!5r
e. Cartain drain installed according to plan
f. C—,r-;u-ain drain cutfall protected & dir.to exist.w-atex-ccurs
g. Fcoting drains discharge away from SDS area
h. SLrface water 2r2- ection ademmte
i- lion -control' Provided on slopes greater than 15-%.
-b I
Y '–"d NY'105121 EiIY F 111—
CATEOFC_0 _CE.
Ifiivfliellli iitl Heilth SiM6" C m
NB
Onhdr FOR SEWAGE DISPOSAL SYMM 77 iY
---------- i— /00
j 7'
Loaded at :'East Brandh.Road 'XTown-, or 'VIUM6.
Sabaivldon o S-U 2
Shapij� W -, " 9� '.
Name R111111A. Lot #_ Tax I".
Renewid-
Pam Batchelor, C]
Oii� A" Revision ❑
7
Date of 16vious Ap"_
112 . lairfi Id -Dtiv6 Town . .B . rews ter 509
c6lordal .6.6 AC Fm Section On1Y Type • Lot 'Ares Depih voattpe
800*
4 W- G P D_ PCHRNodfleadon is Roquhvd When F
Nuimber d.Bed itlits— DesIV Flo' Is atuphited
Separate, SgyeiaSe, System to consist oC 1200- Gaigoilit Septic Tack and 400 L.F. PPVC,
'To determined Andreae 'Y'
Water ita M
SLUPPyb. _M'jk"S`
"P, Address
idet, Supply . Del O: by To lie determin
Other
I re0roserit-In-t I am wholly and _ro4piit.ly isiporilbli for tne fieiiin and location of the proposed System(s); that the separate sewage disposal system
abovi"ikribid whi be constructed ai-shiiwh approve;a arne'IdW!nien f t here to and in accordance the standards, rules and regulations of. the Putnam
County Departmant' u
94 14*ikh 'ih1146at;6n cd6ipliItion thereof a " �;Crtili of- Construction j:ompiiance'! satisfactory to the cornmissi.oner,of kealth will
mi tod to' .the C?�jpartrKe'nt,'La id_�&` be fur hiirs.oui ions by tho'builder;,that said builder will
04-,sub It -4;uarikie Will ni thi,owner. his successors, $5
place' to it-�if'sdid: disp'' A p . erlo I d of. two j2j years Irnmed oII0*Inj the date of. the issu-
j��doperating_'condlt,lo, , lately f
"._-sewage, lip" syst?rq� dui
ance"bf •thie,�approyal.Jof :the',' C'ehif icite of - Construction Compliance of at system or. i the drilled well described above
!, th� airs' ato; 2) that
that::" Well will,be,inStall_ co
will r r and r"u a o,ns -,of the Putnam
County n.
tiipirtiriini 6f.
IuM0h.,0
&140 S igned A.
Address icense No
APPROVED FOR CONSTRUCT-i f a constructid of the building has been undertake and is
expires from the issue unIess. Or t
issue I -�Xplre
.f ... rnml�
rev'd' rib i O,r, or may be B!ren, approval When d H
C!"'or.. �onsl �re It
_��sar the mmissioner ny change or alteration of. construction
JA t
.e
d/or e r y
�v App la%AdjMr, -1. "domestic` san "and /or at r
C,
require
Rev.
1/87 oat Title
PUTNAM COUNTY DEPARTMENT OF HEALTH NO.
COMPLAINT OR SERVICE REQUEST RECOR
TOWN Patterson DATE 6/30/88 REFERRED TO P-A
TAKEN BY WH TELEPHONE CALL IN PERSON x LETTER
CONFIDENTIAL -
REQUEST FROM William Paragine TELEPHONE 279 -4553
ADDRESS c/o Joseph Bigou, East Branch Rd., Patterson
ENVIRONMENTAL HEALTH: Home Sewage x Rodents Refuse Public Water Food Service
Migrant Camp Other
COMPLAINT OR REQUEST House under construction, mislocated by 100' to Permit # P24 -88
Fact Branch Road, Patterson - Pam Butchelor Shapiro Subdivision-#2
�
ACTION TAKEN BY f
FINDINGS ���' ° ^'7 S /o-,r G/l •r-�J` �4 .D i �•G� �ca ,c�
�'"� ��• �-a_ Cam...- �� /���✓ ..�!y�-' -G' - G ���_� d� .✓��� -���. _
S 5 )0
FOLLOW UP INSPECTION (s) /
DATE FINDINGS
._.......�.�_� CJ� ....�/1 ✓a. �_.._... ��/ d�eca�%�r,... rY�C ..._..C/ v71.__. 5..'04 C.t
)ATE FINDINGS
ESTIMATED TOTAL MAN HOURS SPENT
'ROBLEM ABATED
)ATE s _
�V4+2ERSON NOTIFIED
/
ESTIMATED TOTAL MAN HOURS SPENT
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. .10512 (914) 225 -3641
APPL'ICATION'TO'CONSTRUCT A WATER WELL
PCHD PERMIT # /
WELL LOCATION
Street Address
East Branch Road
Town/Village/City Tax
Patterson
Grid Number
69 -2 -19
WELL OWNER
Name
Pam Batchelor
Mailing Address
112 Fairfield Drive, Brewster, NY 10509
QPrivate
O Public
USE OF WELL
1 - primary
2- secondary
® RESIDENTIAL
O BUSINESS
O INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED 6 /EST. OF DAILY USAGE 360 gal
REASON FOR
DRILLING
®NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY 0DEEPEN-EXISTING WELL
❑TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
New supp y or propose d 4-bedroom home
WELL TYPE
®DRILLED
DRIVEN
ODUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _ —NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Shapiro Subdivision Lot No. 2
WATER WELL CONTRACTOR: Name To be determined Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE*TO PROPERTY YROW NEAREST WATER'MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
OON REAR OF THIS APPLICATION ,' 0 S SHE
� 23 $�
(d te) (signature)
PERMI
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 ompletion Repor on a,,.form provi d b the P to m C y
Health Depart ent.
Date of Issue: 19
Date of Expiration: 19 Pe Wit Issuing Official
White copy: H.D. File
Permit is Non - Transferrable
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
V ��
PM ,M COUNTY DEMR24EM OF HEALTH - DIVISION OF ENVIROIMWAL HEALTH S----RV-ICES
INDIVIDUAL WATER SUPPLY & S"JHSURFACE SEWAG=E DISPOSAL SYSME
V �
(Name of Owner)
REVIEW SHEET - CONSTRICTION PERNLIT
DATE ;ED:
3Y • C—
(Sheet Location)
CCMMMS
YES
1
I
LF trench provided
required Q (/
60 ft. max.
Parallel to corn o s
1.00% exp.
j
---
....... . -.._ .... .. ..__ ........._ .. rte. - .. _
J .�.
..
t
FILL SYSTEMS
clavbarri
10 ft.
fill note
new soec.
death ga tes
100 vr, flood el�v.
200 ft. reservoir, etc.
150 ft, trigall /ga11.
s
1
P
ti
I
TCCOMRM
Permit Anplication �
rporate Resolution
Plans - Three sets s/s
Engineers Authorization
Design Data Sheet (DDS) Su=DIVISION
Deep Hole Lcg Par`
Consistent Perc Results (3) Fill Perc..-dole Depth cam
House Plans - Two sets
Well �Ipe=t; Pr/v-s letter
Variance Reauest
Q kL r
Legal Subdivision
Subdivision Aooroval Checked
Ex- approval SSDS-Adj. Lots Chec'
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Pe?,nit Sarra
REQUIRED DETASi..S ON PLANS
Swage System Plan - (north arrow)
Sewage System Hydraulic Profile - G_avi_y Flow
Fill Profile & Dimensions - Volira
D or J Box;Trrncz /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Derail, Service Line if over.
Coristniction - Notes (grinder rat')
Design'Data: Perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes Cut
Footing/Gutte_r,Curtain Drains (dis0:arge Oil)
Perc & Deep Holes Located
Representative of primary and expans on
Egpansion Area; shown; gravity flow,suff. size
If Pmwed Pit & D Box Shown & Det=_iled
House - No. of Bedrooms
Wells & SSDS's w /in 200 ft. of Proposed Systems
Prorty M —etes & Bounds
House Setback Necessary (Tight lot)
House SL=,wer - 1 /4 " /ft. 4 "0; Type pica
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, large Tre s,Too of fil
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake tine. exPan
15' to Drains - Curtain, Leader, Footing
35'to catch basin,stormdrain,nired watercours
.10' to Water Line (pits -20')
50' intermittent drainacTe course
Seotic Tanks
10' fro.n Foundation; 50' to well
1:Z I W�l 1 +-- rnr
TEST PIT DATA UQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOiRRIERF:D IN TEST HOLES
._'HOtk ix3.-1 °- DT 1
G. L.
1' TOPSOIL
2' DARK BROWN
HOLE NO. �DT 2l HOLE NO.
TOPSOIL
DARK BROWN
3' SANDY LOAM SANDY LOAM
4' DARK BROWN DARK BROWN
5' LOAM LOAM
61 J r
7' LOAM /CLAY LIGHT BROWN
8' SANDY LOAM
9' NO ROCK NO ROCK
10'
11'
12'
13'
INDICATE I= AT WHICH GROONI7WATER IS ENOaJNTERM N/A
INDICATE LEVM TO WHICH WATER LEVEL RISES AFTER BEING ENOOUN'Iat D N/A
DEEP HOLE OBSERVATIONS MADE BY: Terry Smith DATE: 5/12/87
DESIGN
Soil Rate Used 7 Mir/1" Drop: S.D. Usable Area Provided 4800 S.F.
No. of Bedroans l$ Septic Tank Capacity 12 5 0 gals. Type Ma s o n r y
Absorption Area Provided By 400 L.F. x 24" width trench
Other
Name Baldwin & Ccrnelius, P.C.
Address RD 6, Route 22
Brewster, NY 10509
SPACE FOR USE BY HEALTH DEPAR'Il`TM ONLY:
Signature
mv SEAL
Soil Rate Approved sq.ft/gal. Checked by Date
pUiyAm CO(WrY DEPAR19a�T OF HEALTH
DScTISION OF HEALTE SERSiICES
DESIGN DATA. SI iEE— SUBSUFACE SSE. DISPOSAL SXSTfM FILE 140.
Owner PAM BATCHELOR_ Ad&ess112 •Fairfield Avenue, Brewster, NY 10509
Located at (Street) East Branch Road Sec. '69 Block 2 Lot
(indicate nearest cross street)
ftjn cina t ; ty
Patterson
Watershed Croton i
SOIL PEROOLATION TEST DATA RDQUIRED TO BE SUBMI= WIM APPLICATIONS
Date of Pre- Soaking 5 / 12 / 8 7 Date of Percolation Test 5/12/87
HOLE
Na,mm c= TIME
PERCOLATION
PEttCOLATION
Run Elapse
Depth to Water From
Water Level
No: Tim
Ground Surface
In Inches Soil Rate
Start-Stop Min.
Start Stop
Drop In Min/In Drop
Inches Inches
Inches
A 1 1:30 -1:38 8
21 24
3.0 2.7
2 1:41 -1:59 18 21 24 3.0 6.0
3 1:59 -2:19 20 21 24. 3.0 6..7
4 2 :19 -2:39 20 21 24 3.0 6.7
5
B 1'1:30 -1:40 10 21' 24 3.0 3.3
2 1:42 -1:55 13 21 24 3.0 4.3
3 1:56 -2:11 15 21 24 3.0 5..0
4 2:17 -2:31. 14 21 24 3.0 x 4.7
5 .
1
2
•fit. -_ y,,
NC7I'ES: l_ Tests to be repeated' at sate depth until approximate) equal p _�
are obtained at each peroolation test hole. All data to' be subcnt
for review.
2. Depth irnasurements to be made from top of hole.
rev_ 9/85
' APPLICATION FOR PUBLIC ACCESS TO RECORDS
TO:....: RECORDS _ P__CCESS OFFICER
�Fironmenta He nth Serview
I @► dl's Rt. 6 'qtr - Bldg $
DATE:
Cx
OSE_ L_ PELOSO, JR., PUBLIC,
• INFORMATION OFFICER
I HEREBY APPLY TO INSPECT THE FOLLOWING RE(
01'6�A &ZLA ) T1
�- L/ - 9-p
I IM 1 MM6, 4
C�
i (7
Date-
_ � ;•t1 -"`
Reoresentina
Mailing P_cc=ess
FOR AGE`CY L:E ONLY
L P?PROViD
DENI_.D I V
Record of which this acency i egal Custocian cannot be found.
Record is not rnaintained by this Agencv
Signature Title, Date
NOTICE: YOU HAVE A RIG --:-T TO APPEAL A DENIAL OF THIS APPLICATION TO THE.
PUTNz• +. COL ITY:•EXECUT_VE .
Name Y siness Add_.ess
I -
WHO MUST FULLY EXPLAIN HIS F.EASO *IS FGR SUCH DE`1IAL IN WRITING SEVEN DAYS
i OF R C IPT• OF PSI IA?PEA -L.
I HERESY AP--PEAL:
Sicnatu=e %, Date
--,-; •� ... tirrrivli.1x r
- bivision Of Environmental Health Services
r•
TWO COUNTY CENTER — - CARMEL, N.Y.. 10512 (914) 225 -3641
: AP,PLICATJON
PLEASE PRINT OR TYPE
SIRW AUUHUS.
IIELL LOCATION I East Branch Road-
NA -
ME.. WELL OWNER Pam Batchelor
WELL TYPE DF.ILLED
DEPTH DATA I WELL DEPTH
USE OF WELL
1 - primary
2 -secondary
® RESIDENTIAL
❑ BUSINESS
❑ INDUSTRIAL
TO_ ..ABANGOiV••�A-- •- W-AT£R':.W£LL `.r,�i � �4
1UWNiV1LLA(kX111 -
terson, NY
ADDRESS.
112 Fairfield Drive
1.=z GRIU hUmaEH
69 -2 -19
0 PSIVATE
Brewster 1 0 JUBLIC
L DUG GGR.VEL ODRI J TE= R
ft. STATIC WATER LEVEL ft. DATE MEASURED
❑ PUBLIC SUPPLY ❑ AIR /COND. /LIEAT-PIIMP ❑ ABANDONED
❑ _FARM ❑ TEST /ORSSERVATION : ❑ IOTHER (specify)
❑ INSTITUTIONAL ..❑ STAND/BY ❑
WATER WELL Name: .4ddress :
CONTRACTOR: 440Z A _ iN 644CK 417__Z>A� <::� --i
REASON FOR Existing well was found to be non conforming to PCHD Standards
P3ANDONMENI.:as regards a separation to property* lines ( 15') Applicant proposes
DESCRIPTION OF WORN to. drill a new well in order to conform..
TO BE PERFORMED::
oesi " a (nck& c AeT �6 iN
lie
.:.
d te) -
PERM 1 -•
This permit to abandon one water well as set forth above is
.granted under.provisions - of Subpart 5 -2 of'Part 5 of the
New''York State Sanitary Code and provided that: Within 30
days of the completion of the abandonment-of the water well,
the applicant shall submit to the Department a certified
statement that the information delineated on the application
for this permit has been completed-..
Date of Issue:
:Permit .Issuing .Official 23
BALDWIN & CORNELIUS, P.C.
Putnam Business Park
RD 6 Rte. 22
BREWSTER, NEW YORK 10509
(914) 279 -7115 .. , LL ,.__ ............ _ , , ..... . _ . .
TO ZL I1- &14M CuL)A//_Y ' 4714
dG i7 G�c�y f Ct uicrc_
LIEUTEa @[F MUSEDUML
DATE
JOB NO.
ATTENTION -
i� r�cr7Gr`S .
RE:
WE ARE SENDING YOU XAttached ❑ Under separate cover via the following items:
❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications
❑ Copy of letter ❑ Change order ❑
COPIES
DATE
NO.
DESCRIPTION
THESE ARE TRANSMITTED as checked below:
XFor approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
REMARKS
❑ As requested
❑ For review and comment
❑ FOR BIDS DUE
❑ Returned for corrections
❑ol
19
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
_ lfR,Ot 'It 'itJL FZ17 4 d ClU ?CA4)1I'f 'Tv X "47'``F4's ✓�7`
COPY TO
SIGNED:
If enclosures are not as noted, kindly noti us a once.
��
WO C NTY
DEPARTMENT OF HEALTH
Division of Environmental Health Services
CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
�.j APPLICATION TO CONSTRUCT A�WATER WELL
PCHD PERMIT #�
WELL LOCATION
Street Address
East Branch Road
Town/Village/City Tax Grid Number
Patterson NY 69 -2 -19
_
WELL OWNER
Name Mailing
Pam Batchelor 112 Fairfield
Address
Drive Brewster NY
QPrivate
O Public
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
0 BUSINESS ❑ FARM O TEST /OBSERVATION
® INDUSTRIAL b INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT 5 gpm /#
PEOPLE SERVED 6 /EST. OF DAILY USAGE 360 gal
REASON FOR
DRILLING
NEW SUPPLY
OREPLACE EXISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
0DEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
Well t
15' t0
property line)
WELL TYPE
IDDRILLED
ODRIVEN
ODUG OGRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES °X NO
IF WELL IS LOCATED IN .A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Shapiro Subdivision Lot No. 2
WATER WELL CONTRACTOR: Name 4*4V?_fA1 Address • toi4TbIV, G7:'
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES X NO
NAME OF PUBLIC WATER SUPPLY: -- TOWN /VIL /CITY --
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: NA
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
O ON REAR OF THIS APPLICATION ®ON SEP RATE SHEET
7 -27 -88
(date)
a '
(si n ture)
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 thirty (30) days of the completion of water well construction,
the applicant shall:
1. Pump the well
2. Disinfect the
County Health
3. Submit a Well
Health Depa
Date of Issue:
Date of Expiration:
until the water is clear.
well in accordance with the requ
Department attached to this per
ompletion Repo t on a form pro
n
19
77 E 19 '
t.
d
is of the Putnam
t Issuing Ufficia.
Permit is Non - Transferrable Whi te copy: H.D. File
Yellow copy: Building Inspector
2/87
Pink Copy: Owner
Orange copy: Well Driller
0
,I Q WELL
c
M .
LOCATION
CHA2T
A -G
36
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05
A- D
14-G
E5-P;
153.5
A -E
t4+5
E5-E
153.5
A -F'
)44
13 -F.4
. 159'-• -
A-G
143
13-G
155.5
A -H
142
F -H :
157
A -I
14x.5
r--5 -I
t59
A -T
l4t.5
e T
16i
17-L
85.5
M - T
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31
D-T
17
l-1 -A
57.5
W -K.
35.5
CF,: 1 REVISIONS. , ?