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BOX 16
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PUTNAM COUNTY DEPARTMENT OiligALTH
ReV 3/ 8 Division of Environmental Health Services, Carmel, N:Y 10512
r ° Eaglneer Maet Provlde�j
P C.H D Penmlt # —�
CERTiFI OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM
Located it "C vY1 . Ta: Map ock Lot
Owner /appllcant_Neme �. ,e / ! n eF rmeily Subdivision Name
�1 _ a !� `e Sabdv. Lot.# f
Mailing Address . P Date Permit leaned
Separate Sewerage System, built by �' L11 Address
Consisting of f. ' ! � Gallow Septic Tank and L. .aOr r
,Water, Supply Public Supply From G Address _1
or. J✓ ' ' Prlvatef Supply Drilled by �r �EA � /;k . I�CAddr"i Q Ux i�� r "� , W/ e_
Building Type �-
ai.Gll'1�1 Gil Has Erosion Control Been CompletedY
Number of Bedrooms Has Garbage;Grinder. Been Installed?
d`.
Other Asti emente
I certify that the systems) as listed serving the above, premises were ;constructed essentially as shown 'on the ana of the completed ;work ( copies
of which are .attached), and in acoordance w th_tfie atandarda rules ` tione, aecoidance with th le plan, a +the .permit. ssued by the
Putnam County Department 0f l,iaimith
Date w Certifletl b PE. -R.A.
J
Address
.Any parson - occupying..premises served by. the a'do
conditions.resultiny from such ;usage, 4'pproval,
available and the .ipproval of the. ;private'Witer. su
.subject', to modification or change when,- in the
Date ' q D
By
License No. '
I y'y ke suCh,aCti011 of may be necessary t0 secure the correction 'of any unsanitary
psystsm shell become null end void as soon as a pub;': sanitary sawer'becomes
nd void 'when a public *Water supply bicomes available. Such approvals are
stoner of .Health, such revocation, modification or change Is necessary.
Title DOL
�1 .l
PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
February 15, 1990
Mr. Randolph Laurent, P. E.
73 Fairfield Drive
Patterson, New York 12563
Re: Proposed SSDS:
Certificate of Construction
Peragine
(T) Patterson, TM #69 -2 -16.1
Dear Mr. Laurent:
JOHN KARELL Jr., P.E.
Director
Review of plans and other supporting documents submitted at this time relative to
the above - captioned project has been completed. Comments are offered as follows:
A water analysis report and a well log was submitted for the above - captioned lot
under the name Franklyn Williams. I informed your office this was not acceptable
and it was required that your office submit the required documents under the
owners name, Peragine. At this time I am in receipt of an acceptable well log,
._the..ter_ anal.ysi s . repo:ct- has-been -altered.-
-
Certificate of Construction Compliance will not be issued until a new water
analysis report is submitted indicating satisfactory sanitary quality.
Upon receipt of a submission, revised to reflect the above comments, this
application will be considered further.
Very truly yours,
o", b&! 77 0
Robert Morris
Assistant Public Health Engineer
RM /jp
PUTNAM MUN`I'Y DEPARTMENT OF HEALTH '
DIVISION OF ENVIRONMEWAL HEALTH SERVICES _
Owner or Purchaser of Building Section.. ,Block Lot
Building Constructed by
.;
Location Street Subdivision Name
oi�
Municipality Subdivision.Lot -# '
c a�fen
AJ
i
Building Type
GUARAN= 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 thei .
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 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 detemination of.
the Director. of the Division of Environinental Health Services.,-of . the 'Putnam County
r .
Department of Health as to whethe or not the failure of th system to operate was
caused by the willful or negligent act of the occupant of the bu�'ldin utilizing
the system.
Dated this day of 19% Signature
.�
NI I
Title
Corporation Name (if Corp.)
rev. 9/85 .
mk
Corporation Name (if Corp.)
BREWSTER LABORATORIES
_ --
Box 224:- BREWSFER= -N:':� -
(914) 279 -4945
- WATER ANALYSIS REPORT -
SAMPLE NO. 7593 WELL
SOURCE: William Peragine
East Branch Rd.
Patterson, N.Y.
COLLECTED: 12-14-89,
BY: P.F. Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method p per 100 ml.
12- 17 -89.
WhLL UUrirL1111un rUlruAl
DEPARTMENT OF HEALTH
--• -. •� -. Division: Of-r- Erivr- ori�ienta °T�ffeale•'irwSer`vices� �
(� -X0 PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
��
WELL LOCATION
STREET ADDRESS: WNIVI TAX GRID NUMBER:
East Branch Rd. Patterson, NY Tax Map 6g,B1.2,Lot16.
WELL OWNER
NAME: ADDRESS.
William. Pera ine SAME
❑ PRIVATE
1 O PUBLIC
.USE OF WELL
1 - primary
2 - secondary
JO RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /CONO. /HEAT PUMP O ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
QREPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY
]UNEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 605 ft.
STATIC WATER LEVEL 40 ft.
DATE MEASURED 1/5/89
DRILLING
EQUIPMENT
IS] ROTARY I2 COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT O .CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING aOPEN HOLE IN BEDROCK O OTHER
CASING
TOTAL LENGTH - 112 ft
MATERIALS: 9I STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE 111 ft_
JOINTS: ❑ WELDED W THREADED ❑ OTHER
DETAILS
DIAMETER 6 in.
SEAL: 2 CEMENT GROUT O BENTONITE O OTHER
WEIGHT
PER FOOT 19 Ib. /ft.
I DRIVE SHOE: ® YES ❑ NO I LINER: ❑ YES C3NO
SCREEN
DETAILS
DIAMETER (in)
SL07 SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
HOURS
SECOND—
`_ �.:_ .._ ". -:
_
,. -.
_..
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH tt
BOTTOM
DEPTH It.
WELL YIELD TEST If detailed pumping
METHfD: O PUMPED ; tests were done is in-
�ONPRESSED AIR , formation attached?
O BAILED ❑OTHER i ❑ YES ❑ NO
WALL LOG !f more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
Welt
OIa'
In
FORMATION DESCRIPTION
pot
ft.
it.
WELL DEPTH
ft.
DURATION
hr. min.
DRAM /DOWN
ft.
YIELD
g)rm.
surface
Drilling
in overburden clay & bld
s .
H't
iFock
at 95,
6o5
6
585
5
112
D
i Aing
in rock set casing,grout
d.
112
60
Drilling
in rock granite.
WATER O CLEAR TEMP.
QUALI -n ❑ CLOUDY HARDNESS
O COLORED ANALYZED? ❑ YES ❑ NO
AIALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE Well Xtrol 251
CAPACITY 62 GAL.
'PUMP XFOHMATION
'-.,TYPE Submersible CAPACITY
i MAKER Gould DEPTH 560'
i ,;
MODEL jES10 •12 VOLTAGE 230HP 1
WELLORILLERNAME P.F.. Beal & Sons c T /8/90
aooaess PO Box B slGrnfiUR
Brewster,NY 10509
II
IV.
V.
VI
FINAL SITE INSPECTION Date
Inspected by
;G�iTION = G ST .,� � �c� CWNER
:a �J °� 'iYd (7R _SiTADNISIGY1 LGT `�� .
-... - - - • , -- - -
•iE►�'1.
NQ
- - 1 • ��7 ..
�.�
,. `_.'- �`�' -- .
,_ 12�iE'�i• AREA
a. SUS area located as per approved plans
b. F4 11 section - Date of placement
2:1 barrier. hGTfi W1D`L'H AVG_DPTE
-"
c. 'Natural soil nct sari ped
d. Stone, brush, etc., greater than 15' fran SDS area_
e_ 100 ft_ frcm water course /wetlands.
S'r r&-G DISPPOSAL SYSTEM
a. Septic tank size 'l,OW 1,250
b_ Seotic tank inst level
c. 10' minimum from foundation
d. Nc 90° bends, cleanout within 10 ft_ of 450 bend
e. DISTRIBL"TICN FAX
1. ALL outlets at same elevation - water tested
2. Protected ice? cw frost
3. Minim= 2 ft. original sail bet=Neez box and trenches
f. JUNCTION ECX = roperly set
g.
1. Lend' h recnired Iaancth installedc- li
2. Distance to watercourse measured. �
xl
.
3. Installed- acc—.rdinQ to plan
4 Distance can-ter—to canter
5..Slcre of t_encz, acceota ble 1116 - 1/32 " /fcot.
6. 10 fe=t f_en prcr.,erty_ line - 20 feet - fcur- :aticns
7. Depth cf t_- cn < 30 inches fran surface
8. Roan allcwed fer e-xr nsicn, 50%
9. Size of cravel 3/4 - 1�" dizzamete'
10 . DEDt:*l cf c_ rave in trench 12" minimum
CC
111. Pine ends ccced ,
h. PLC OR DOSE TZSTEM.-S _
1. Size: of- ptmm cza-iber
2. Overflcw tank
3. Alan, vim,;;;. /audio
4. Puma easily accessible manhole to grade
S. First box baffled
6. Cycle witnessed by Health De=e nt j
est mated flcw per cycle
HOUSE '
a. Hcuse located perr approved plans.
b. of bedroans
I
WALL
a. Well located as per approved plans
� I
b_ Distance fran SDS arm. measured ft. I
c. Casing 18" abcve grade.
d_ Surface drainace arcund well acceptable.
OVERA-1-1, WOR&%4A.S-dLZ
a. E-,xes rOop —r1v arcuted
I
j
b. All pipes - 4ially backfilled
c. All pipes fitu-1 with inside of box
I
d. B-ackfi11 mate-ial contains stones < 4" in diameter
e_ Carttain drain installed according to plan
E. Crr`,-ain drain cutfall protectea & dir.to exist_waterccurs
�
g. F -etinq drains d, sc -;=Te awav fran SDS area
(
••
h_ S� =ace watt rotection adequate
i_ E_=osion control provided on slopes gre?tE--- than 15 %. IA
PUTNAM COUNTY DEPARTMENT OF�HEALTH,
3186 Divlilon of Etiviroumeutal Health Services Carmel N.Y:1051Z RTIFICA �jRoe'V. o- CE TEf
CONShRUCTION PERMIT FOR SEW ISPOSAL SYSTEM - Permit p
W.
IMPLIANCE l � Q�
Located at 9;N S7c Town es -
�. r• -•.. r= �rlr - +i.� ....L..r ....�..�..r..v. �.�.e�.r �...ra...ea...aa�� -.� .� -.-. .• -_�.. r�� rr.�.e =� _ rrr�.aurt+�.r..�..e�.
r Subdivision Name Sub& Lot q Tax Map Block • Lot
Renewal-0 Revision --❑
Owner /Applicant Name�pylI
Date of Previous Approval
Mailing Address town"' Mz:fs,�1 tV Y Zip
Building Type _ � N-�l Let Area C : Fill Section Oul
B Y Depth _ Volume
Number of Bedrooms Design; Flow G /P /D : 60C� PCHD NotlHcadon is Regnired When Fill Is completed
Separate Sewerage System to consist of GaDon Septic Tank and
-
To W constructed b
Y Address
Water Supply: Pdblio Supply From _Address
or: Private Supply Drilled by 1Addreai '
Other Requirements
1 represent that 1 am wholly and completely responsible for the design and location of the proposed, system(s);- 1), that the separate- sewage disposal system
above described will be constructed as shownon the approved. a mend mint thereto and in accordance with the standards; rules and .regu a ions of e Putnam
County' Department of Heikh;; antl thii-"on completion thereof a "Certsf;cate" of Constructton.Comp ! iance'1 to the Commiisioner of Healthwill
De submitted to .,the - Department; pnd, a 'wrdten•guerantee - will• be furnished the owner;'his wccessois, heirs or assigns Dy ,the builder; that said builder will
place in good operating condition' any part of sa.id sewage disDOSaI system during the period 'of two (2) years lminediately,foliowing the date of the issu-
ante of the approval of ,the Certificate 'ot, Construct�on-Compl ` f tho,oOginil- systern or any repairs they ) that the drilled well described above
. ..,.. . .. ,..
will tie, located as shown on the approved 'plan and that said well w�l De °insta m scc ante with the s s, r les and regu a ions of. 'the '.'Putnam
Count / Department of Health -
Date T7, l $ 5;9ned P.E. r! _ R A.
uO�lI
Address 1s b� License No.
APPROVED FOR CONSTRUCTION: Tnif approval,,expues ooe year from the Cate issued unless. construction of the Duiltling hss been undertaken and is
revocable for cause or :may be• amended' or•. modified when considered necessary by the Eommfss ner of Health. .Any change or alteration of construction
requires aoFfw permit. 4pprovod forclisposal domestic sanitary sewage,'sd%o I_ w
le
A COUNTy DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH " 8EkVICE9'-
. • °"(Name' " "bf bw
COMMENTS
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET - CONSTRUCTION PERMIT -
_on 11 oe DATE REVIEWED:
BY
) �° Str- eet••Location....�.- ._ <.x_._ � -. , . ,
I YES I NO I DOCUMENTS
ix trencn proviaea _
required _
60 ft. max.
Parellel tic
V
Permit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
Consistent Perc Results
Perc Hole Depth
s/s
(3)
ns - Two sets_..
_ permit; PWS
Request
SUBDIVISION
Perc
Fill -
cd
letter
cE24ERAL i
legal Subdivision
ivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arrow)
Sewage System Hydraulic Profile - Gravity Floe
Fill Ale &Dimensions - Volume
D oxr2� ;Trench /Gallery; Pump'.pit details
Ce-maize, Detail
l Det ail, ice Line if over
s coon Notes
Design Data: perc and deep results
Two -Foot Contours Existing & Proposed
Driveway & Slopes_Cut
-Footing /�3utter;C'urta- n -Drains- (discharge -OK)
Perc & Deep Holes Located
Representative of primary and expansion 1'
Expansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
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 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of HE
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, Leader, Footing
35'to catch basin,stormdrain,piped watercourse
10' to Water Line (pits -20')
50' intermittent drainage course
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL
9
10
PU11MM COUN'T'Y DEPARIl4FM OF HEALTH
DIVISION OF ENVIROMMM HEALTH SERVICES*
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE -NO.
Owner V V 1 t-1-i�M (4 6jSe jj Address C�.V Z0 - ( Y
Located at (Street) PU Sec. Block Lot
(indicate nearest cross street)
Municipality t [ZS Watershed (3MD --ro t,-C
SOLI, PERCOLATION TEST DATA RDQu= TO BE SIIBMITID7 WITH APPLICATIONS
9
Date of pre - Soaking "] iI e5-7 Date of Percolation Test `7111 / 87
HOLE
MM CLOCK TIME PERCO=CN PERCOLATION
t EY Water Le el
Run
No.
Elapse=
Time �-
Depth to. Wa er om
Ground Surface
v
In Inches
Soil Rate
start-Stop Min.
'_
Start,
Stop
Drop In
Min /In Drop
Inches
Inches
Inches
1
iz o(0- l
z2
3
1
2
IZ:5Z- Z:lo
'78
- 3
Z :1I - 3 :3a
87
Z4
Z�
3
4
3' �i
3� -' O
qD
Z d
2Z-7
�J
5
21- �� -3.d�
q0 -- Z7 3 3°
3 3 ,1-1 ^ Q7 q0 Z-7
4
... 1
2
3
4
: NOTES: 10 Tests -to be repeated'at same depth until approximately equal soil rates
are obtained at each percolation test hole. All data to' be. submitted
for review.
2. Depth reasurements,to be made from top of hole.
TEST PIT DATA REQUIRED TO BE
.. 1LtifR]TTYi7Tn *l 11L cATTe L'/.1
r
DEP'T'H HOLE NO. HOLE NO. Z HOLE NO.
(� s i cry cw3w1 V\)/ -- -t6,
>,cS cU,Y �6S of et.�Y
.21
3'
'41
T
g'
.110 -
12°
13'
14'
INDICATE LEVEL AT WHICH GROUNDM= IS, ENOOUN'I�RED ►`( j� .
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER. BEING M=UNTEM t`l
DEEP .HOLE OBSERVATIONS MADE BY: Z \A1 L,),U MG-, DATE: Z-7d 8-7
t L1:+.71Vi\
Soil Rate Used Tj---:�,C> Min/1" Drop: S.D. Usable Area Provided 5
No. of Bedrooms 3 Septic Tank Capacity lei gals. Type
Absorption Area Provided By 60�D L.F. x 24" width trench
Other
N&v-- 0�0f'Ll.(J, L_�C
1���- Signat
- Address % ��r�.��G�
17Ct1 SEAL `i rn s
� ,y -o ;
rn w r
KAY L2�63
NQ. p49�0
THIS SPACE FOR USE BY HEALTH DEPT ONLY:
Soil Rate Approved
sq.ft /gal. Checked by
Date
DEPARTMENT OF HEALTH
Division of Environmental Health Services
rWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL Q
PCHD PERMIT # �o
WELL LOCATION
Street Address
own illage City Tax Grid Number
*A 3
WELL OWNER
Name
Mailing Address
rivate
Public
USE OF' WELL
1 - primary
2- secondary
RESIDENTIAL
0 BUSINESS
0 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
6 9pm1#
PEOPLE SERVED 3 -S /EST . OF DAILY USAGE_pagal
REASON FOR
DRILLING
UNEW SUPPLY
O REPLACE EX_ ISTING SUPPLY
O PROVIDE ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
[jDUG
GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 'NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name -Vb 13G. A06- 1t5CMA,-( -G0 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES e/ NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION 0 SEP T E
-7- 1'7-69-7
(date) A (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 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 provided by the Putnam County.
Health Department.
Date of Issue:
Date of Expiration• 19 Permit Issuing is
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
2/87 Pink Copy: Owner
Orange copy: Well Driller
�U�tGtlOrl din �t•(P)
Iv
e II L.P 6A Ih
L-lo 6p
"ac tq 41 IA
]•6�1 IpfJO DAL
�JEP'fIG TANK �UµG710N 60X
ex Iot. N
WELL
�jt A T
5l.AIX :
1"
4;P�.2'
g8'O"
FIU. Flt✓.EIEV.
2
3
1259"
12'(r'7"
113' 1►"
7
�
tl2'8"
dap
5
128'11"
111'0"
r
11OW,
dJ
(OA
132'4"
110'G"
75'O"
4S5
sCJataE
8
78O"
10
lOH`0"
112'5
II
80'0"
,48p
11.1. ✓.
-7FgNT
12
t7T9°
I(o5'6°
X81.45
Moat IT (-CY??�
13
t000°
-r=1i
IGJ
t$Z'D"
1(04(0,
1000 GAL-
�U1FuaW ,
L
1b
I(v�j8
475
C'f1y1Y
A" 40 50Lic> -P.vc.
f
-470
4" d Seta
d
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