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HomeMy WebLinkAbout1826DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35.06 -1 -3 BOX 16 titi j - ;1 go Ap imr... min . ,, Is f r A. 01826 WhLL UU1V1rLLiwLUA rkzrual DEPARTMENT OF. HEALTH Div-is.io.n-...Qt.--giiyironmental Health Services- PUTNAM COUNTY DEPARTMENT OF HEALTH office Use Only WELL LOCATION STREET ADDRESS: 76WN/VI[LAWCIIy,* TAX GRID NUMBER* Apple Hill- Development Patterson, New York / 61 0 Y WELL OWNER NAME: ADDRESS: Italo LeDonne 17 Lakeview Avenue, Valhalla, NY RBIVATE Q PUBLIC USE OF WELL 1 - primary 2 - secondary aAESIDENTIAL 0 PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP 0 ABANDONED ❑ BUSINESS ❑ FARM 0 TEST/ OBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT 5 gpm.1NO- PEOPLE SERVED EST. OF DAILY USAGE gal. REASON FOR DRILLING a NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY 0 TEST/OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 365 ft. STATIC WATER LEVEL - 20 ft DATE MEASURED 5/10/88 DRILLING EQUIPMENT 0 ROTARY -0:iCOMPRESSED AIR PERCUSSION CIDUG 0 WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASINQ . SPEN HOLE IN BEDROCK ❑ OTHER TOTAL LENGTH 65 ft MATERIALS: x-OSTEEL ❑ PLASTIC 0 OTHER CASING DETAILS LENGTH.BELOW GRADE 64 ft. JOINTS: OWELDED filf-IREADED OOTHER 6 DIAMETER —in. SEA004CEMENT GROUT OBENTONITE OOTHER WEIGHT PER FOOT 19 Ilb./ft. I DRIVE SHOrkZkYES 0 NO I LINER: OYES ❑ NO SCREEN DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (it) DEVELOPED? FIRST . - 0 YES ONO -.. -. . SEC . ONO * .. ...... ......... "HOURS GRAVEL PACK 0 YES 0 NO GRAVEL SIZE: DIAMETER OF PACK Top DEPTH —ft. BOTTOM DEPTH ft. WELL YIELD TEST It If detailed pumping I METHOD: 0 PUMPED 1 tests were done is in- �COMPRESSED AIR fo* rmation attached? 0 BAILED 0 YES 0 NO 0 OTHER It more detailed formation descriptions or sieve analyses VELL LOG are available, please attach. DEPTH FROM SURFACE Water Bear- ing Well Di3- meter In FORMATION DESCRIPTION C00E. ft. ft. WELL DEPTH ft. DURATION hr. min. DRAWDOWN ft. YIEL D gprn. d Sur Lanlace 2 no 6 Hardpan, clay & boulders. 28 45 no 6 Soft weathered bedrock. 300 1 30 300 3-3/4 45 285 no 6 Hard grey & black granite. 365 6 - 300 12 285 317 yes Black & white granite. 317 365 yes Pink & grey granite. E= WATER CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? XIAYES ONO ANALYSIS ATTACHED?XXYES ONO H STORAGE TANK: TYPE ,Diaphragm CAPACITY 62 GAL. 17 PUMP INFORMATION TYPE suhmi-rSibICIAPACITY 10 MAKER Goulds _ DEPTH 300 OEJ07412 2 3 Omp 4 MODEL VOLTAGE WELL DRILLER NAME MILL DRILL IN , C. I DA ffl/12/88 IG ADDRESS Putnam Avenue I i R Brewster, NY i Ro M1 1, Pr Wsi ent �. ELLIS A. TARLTO -N LABORATORY • DIVISION OF ELLIS A. TARLTON, ENGINEERS, INC. CHEMICAL 34 PLEASANT STREET DANBURY, CONN. 06813 -2328 WATER - WASTEWATER PHYSICAL METHODOLOGY BIOLOGICAL P.O. BOX 2328 203 - 748 -7903 APHA - EPA - ASTM REPORT OF BACTERIOLOGICAL AND CHEMICAL EXAMINATION OF WATER NAME AND ADDRESS OF PERSON TO RECEIVE REPORT Mill Drilling, Inc. Putnam Ave SOURCE OF SAMPLE Water Supply, LeDonne'C_Res. Apple Hill Subdivision Patterson, N.Y. Brewster, N.Y. 10509 DATE OF COLLECTION May 12 1988 DATA COLLECTED BY Mill Drilling Hydrogen ion COLOR TURBIDITY - ODOR CORROSION INDEX DISSOLVED SOLIDS Concentration LANGELIER (pH) RYZNAR NTU Mg /L Alkalinity as CaCO3. Fluoride (F) Bicarbonate Nitrite Mg /L Mg /L Mg /L Alkalinity as CaCO3 Chlorine Residual NITROGEN CONSTITUENTS Nitrate Mg /L Carbonate Mg /L Mg /L AS Total Hardness Conductivity NITROGEN (N) as CaCO 3 Ammonia Mg /L Mg /L Micromohos /cm Mg /L Iron as Fe Mg /L Mg /L Chlorides as CL Mg /L Manganese as Mn Mg /L Mg /L Detergent as MBAS Mg /L Sulfate as SO4 Mg /L Mg /L The arithmetic mean of:-all- standard samples" examined' per'month using the membrane filter technique 'slirrnot, exceed. °' MEMBRANE FILTER TEST - _ - -- , . �- - --• — • - -_-. .... _.... - -- . -- -. Colifd M-Colonies7100ML' one colony per 't00mI. ColitorIn colonies Der stantlard sample shall not exceed 3/50ml, 4 /100ml, 7/200ml, or 13/500ml in: (a) Two consecutive samples; (b) More than one standard sample when less than 20 are examined per month; or (C) 0 More than five per cent of the samples when 20 or more are examined per month. AT THE TIME THE SAMPLE WAS SUBMITTED: ® 1. The results of the analysis of this sample were satisfactory and met requirements for a potable water. 2. The results of the analysis of this sample were satisfactory for a potable water but certain of the chemical or physical constituents were high. These are as follows: E] 3. This sample was not satisfactory since It did not meet the bacterial requirements for potable water. The presence of organisms of the collform group In a sample of potable water is undersirable and, while not necessarily Indicating the presence of any disease - producing organisms, does Indicate that such contamination might survive to the same extent. The presence of organisms of the coliform group may also Indicate that the treatment was not adequate at the time the sample was collected. F14. This sample was unsatisfactory as a potable water because certain chemical or physical constituents, were above acceptable limits. These are as follows: COMMENTS The bacterial analysis showed no organisms of the coliform group at the time the.sample was collected which indicates the water potable. `-� C �� PUTNAM COUNTY DEPARr2AERT OF HEALTH DIVISION OF FaNVIRUIZ IAL HEALTH Owner or Purchaser of Building Buildin Constructed by Location - Street Section Block Lot Tax 1map Number Subdivision Nacre Municipality Subdivision Lot n Aj Building Type / GUARANI= OF SUBSURFACE SEWAGE DISPOSAL, SYSTR4 I represent that I am wholly and completely responsible for the , worananshio, material, construction and drainage of the sewage disposal system serving the above described property, and that it has teen constructed as shccv-,i cn th apu oved plan or aporoved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam, County Departnent 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 per -icd of two years immediately following the date of approval of the --- ._.. "Certificate of Construction - Compliance "'-_ fox.._-_ the -:sewage- disposs--syst�n, or any �dsuch`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 Enviromental Health Services of the Putnam County Department of Health as to whether or not the failure of the syst m t operate was caused by the willful or negligent act of the occupant Lhebui!ldi�q utilizing the system. - m` Dated this /]I of vtA4 19 $ Signature Title -eneral Contractor (Owner) -- Signature �'� �`N Corporation Name (if Corp.) Corporation Name (if Corp.) Address rev. 9/85 mk I-) A CK "'V'4 0 a P ess It --- II. IV. m VI. ...� I FINAL SITE INSPECTION Date Inspected by ;CATION /G' S S �� G .� ,� OWNER !-" e M/ d -1,07 .,r $ TM # OR STTRDTVTST(-N TnT # -- 1`. _Size of _ _ chamber 2. Overflow tank 3. Alarm., visual /audio 4. Pum p easily accessible manhole to grade, 5. First box baffled 6. Cycle witnessed by Health Department estimated flow cle HOUSE ' a. House located per approved Pi ams .o- b. Number of bedrooms c e G 4ELL ell, a. Well located as per approved plans b. Distance from SDS area measured ft. C. Casing 18" above grade . d. Surface drainage around well acceptable. OV&2AU WOP MASHIP a. Boxes properly grouted b. All pipes partially backfilled c. All ]2ipes flush with inside of box d. Bad1fill 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 frcan SDS area .2 h. Surface water rotection adequate i. Errosion controi provided on slopes greater than 15 %. 1C t Nd C COMMENTS SEWAGE DISPOSAL AREA a. SDS area located as per approved plans b. Fill section - Date of placement 2:1 barrier- 2LGTH —WIDTH -- AVG.DPTH c. Natural soil not stripped d. Stone, brush, etc., greater than 15' from SDS area. e. 100 ft. fran water course /wetlands. SUZ GE DISPOSAL SYSTEM --� a. Septic tank size - 1,000 b. Seotic tank installed 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. TRENCHFS 1. Len required - Lenqth installed 2. Distance to waterco se 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 prcperty line - 20 feet - foundations 7. Depth of trench < 30 inches fran surface 8. Roam allowed for expansion, 50% 9. Size of gravel 3/4 - 11" diameter 10. Depth of gravel in trench 12" minimum 11. Pipe ends canned h. PUMP OR LOSE SYSTEMS 1C t 101 N 011 V1 Kkei r:YI- 'Ji ill • :I li: p • • a D wffi r • ' n ID Z 0 L.1 M :I 01' M�. r t• rr r• r• �. • • • •+ a r a � • •� • � � RL'UT._EW (Name of Owner) - COMMENTS SHEF]rw-..= CONSTRUCTION.. PERMIT DATE REVIEWED- Location) Docum rS 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 = �r�✓' Perc Hole Depth cd . lans - Two sets el permit; PWS letter ariance 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 REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D orr ;Trench/Gallery; Pump pit details Septic Tank - Size, Detail /C� Well Detail, Service Line if over Construction Notes (grinder no -- Design..Data:_. perc- �de��`r - - s _ �..__.._ . - -• -- .._ _ �. _._ 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;shown;gravity flow,suff. size If Pumped Pit & D Box = & Detailed House - No. of Bedr Wells & SSDS's w /in 20 kf 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 f (5treet YES NO ' ' 4-71 !� f7 LF trench provided rewired �2 ft. max. Parellel to contours q - f FILL 13YSTEMS clatrbarrier ,- 10 t. fill notes new Sid 4 de gauges 100 yr. flood elev. ` -�s 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL n DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ... .... ..... ......._ APPLICATION 'TO"-CONS'T'RUCT A'_WATE'R` WELL- PCHD PERMIT # WELL LOCATION Street Address Town Vil -lage City Tax Grid Number — 1 2 WELL OWNER Name iv1 L Mailing Address O i�,q i-1 (� , _e,0 8 3 Private O Public USE OF WELL 1 - primary 2 - secondary ®,RfSIDENTIAL ® BUSINESS ® INDUSTRIAL OPUBLIC SUPPLY OAIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY ®ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT 15— gpm /# PEOPLE SERVED (, /EST. OF DAILY USAGE �j gal REASON FOR DRILLING UR0 SUPPLY O REP ACE EXI TING SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED ODRIVEN ODUG ®GRAVEL C1 OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ,,:F- C� i Lot No. % WATER WELL CONTRACTOR: Name j o �Fj , ) Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L--'NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY .DISTANCE - TO' PROPERTY FROM-NEAREST WATER "MAIN :.. _.... _.. LOCATION SKETCH &.SOURCES OF CONTAMINATION PROVIDED ` I []ON REAR OF THIS APPLICATION N SARAT (date) SE (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 s.hall: 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: 19 =�=- ��"'"� 11 Date of Expiration: r 1g - - =? ermit Issuin fi Permit is Non - Transferrable 2/87 White copy: H. D. File Yellow copy: Building Inspector Pink Copy: Owner Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Services AFFIDAVIT - CORPORATE OG7NER' -AP PLICA7T0f4'" FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health In the matter of application for: I, represent that I am an officer or employee of the corporation and am authorized to act for fV\( l- N C . (Name of Corpo ation)) ` having offices at �� �-�� (%� j'�� i�1�� Whose officers are: President: Vice - President: Secrd'tary : Treasurer: Name and Address) Name and Address) ame and Address) Name and Address QC WSIZ 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 day Signed: of 19 Title: a KEVIN 4 WRIGHT tjobry Public, State of K." York AAftp Qualified in Putnam CcuntY Commission Expires 8/84 Corporate Seal APPENDIX B kV1tzM COUNZY DEPARMVENT OF HEALTH DIVISION OF /' • ' 1 tf• HEALTH SERVJ INDIVIDUAL V/• E!• SUPPLY & SUBSURFACE P h DISPOSAL REVUW SHEET CONSTRUCTION PERMIT. ai/I /' - ali I ion DOC[A+MS Permit Application Corporate Resolution Plans - Three sets s/s - Engineers Authorization Design Data Sheet (DDS) SUBDI' Deep Hole Log Perc Consistent Perc Results (3) --Fill Perc Hole Depth' cd Houses - Two sets Well permit; FWS 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 REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit detail Septic Tank - Size, Detail Well Detail, Service ine i ver Construction Notes inder -- notes) Design Data: perc and TWOFoot . contoursr'Ex sting & Proposed Driveway & Slopes Cut Footing /Gutter,Curtain Drains (discharge OK Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. siz If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Sys 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 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. e 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped waterc 10' to Water Line (pits -201) 50' intezmittent drainage course ,Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL r� NOAM MM MM LF trench provid .• required. 60 ft. Parell to - MM MM WM MM .. =01M �+ =MMM .- MM - .- M� ion DOC[A+MS Permit Application Corporate Resolution Plans - Three sets s/s - Engineers Authorization Design Data Sheet (DDS) SUBDI' Deep Hole Log Perc Consistent Perc Results (3) --Fill Perc Hole Depth' cd Houses - Two sets Well permit; FWS 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 REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit detail Septic Tank - Size, Detail Well Detail, Service ine i ver Construction Notes inder -- notes) Design Data: perc and TWOFoot . contoursr'Ex sting & Proposed Driveway & Slopes Cut Footing /Gutter,Curtain Drains (discharge OK Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. siz If Pumped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Sys 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 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. e 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped waterc 10' to Water Line (pits -201) 50' intezmittent drainage course ,Septic Tanks 10' fran Foundation; 50' to well 15' Well to PL p.i R. TOLEY Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 PROPOSED ADDITION APPLICATION (RESIDENTIAL ONLY) STREET 6105 5 hn 6`9 TOWN y 7l ,e X MAP # ' (& -e/- NAME L , ,/Ij)AV PHONE07f Z/ CHD # saK 7? MAILING ADDRESS DESCRIPTION OF ADDITION)' P1 alt; 41)m. NUMBER OF EXISTING BEDROOMS 3 PROPOSED # OF BEDROOMS (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) *Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 4 Geneva Rd., Brewster, NY 10509, Phone 278 -6130. 1. Certified check or money order for $100.00 2. Sketches of existing floor plan (drawn to scale, all living area including basement) * Non - professional sketches are acceptable 3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #) * Non - professional sketches are. acceptable 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Cert. of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling., OFFICE USE Comments Feb 98 l f DEPARTMENT OF HEALTH J Division of Environmental Health Services ` TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATI.ON TO CONSTRUCT. PCHD PERMIT # V� WELL LOCATION Street Address Old Route 22 Town/Village/City Tax Patterson,_ NY Grid Number 69 WELL OWNER Name Loft Corporation Address Pump House Road Brewster, NY XlPrivate p Public USE OF WELL 1 - primary 2 - secondary (IRESIDENTIAL ❑ BUSINESS ❑ INDUSTRIAL []PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION 0 INSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify. 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 O REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL ❑ TEST /OBSERVATION DETAILED REASON FOR DRILLING New single family residence WELL TYPE DRILLED DRIVEN ®DUG '®GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF A W L J,S1 $CAT?l IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: pple i eve opment Lot No. i2 WATER WELL CONTRACTOR: Name Henry Boyd Address :Route 52 Carmel, NY 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: _' ,N. /A.. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 4/13/87 ® ON REAR OF THIS APPLICATION 0 SEPAP 4TE,SHEET e (date) (s griature) 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 t Putnam County Health Dep rtment. J Date of Issue: Date of Expiration: 19 Pe rmit Issuing Official Permit is Non - Transferrable DEPARTMENT OF HEALTH Division of Environmental Health ,Services 4 Geneva Road Brewster, New York 10509 TeL (914) 278-6130 Fax (914) 278-7921 December 15, 1998 Deborah and Italo LeDonne 15 Blossom Lane Brewster NY 10509 Re: .Addition - LeDonne, Blossom Lane No Increase in Number of Bedrooms (T) Patterson, TM# 35.6 -1 -3 Dear Mr. and Mrs. LeDonne: BRUCE _ R. FOLEY . w. `Pu61ic 'Health--` Director I have received and reviewed the plans for the proposed addition to the above mentioned residence. The proposal for the addition has been approved as per plans bearing the latest revision date of December 11, 1998 and this Department's approval stamp. Based on the information submitted, the above mentioned addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. J. All plumbing fixtures must be updated with water saving devices, i.e., new low flush toilets, restructures for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Very truly yours, William Hedges Sr. Public Health Sanitarian WH:tn cc: BI (T) r DEPARTMENT OF HEALTH Division ; Of Environmental Health Services 4 Geneva!' eneva ' Road, Brewster, New York 10509 (914) 278 -6130 Putnam County Dept. of Health 4 Geneva Road Brewster, NY 10509 Gentlemen: BRUCE R. FOLEY, R.S. Acting Public .Health Director Re: Residence TaxMap ,3:�5, /_,3 Town_ l �r According to records maintained by the Town, the above noted dwelling _ IS _ IS NOT in compliance with ToNNm code and the total number of bedrooms on record is This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: A�v 11 2 Building Inspector Y � 11 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITIONIREPAIR FORM SECTION A: GENERAL INFORMATION L--TM# Name of Project j S io 5 S ° "^ ✓L�(T)(V) Year of Construction . Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. 011MXYDRolling MISZteep Slope ®entle Slope ®lat 2. ❑Evidence of wetland Clow area subject to flooding ®Bodies of water ��ggr' ❑Drainage ditches Clock outcrop YES N 3. Property lines evident? - " 4. Water courses exist on, or adjacent to parcel: 5. Existing individual wells within 200ft of the existing SSTS? D SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. ®Level ❑Gentle Slope Steep slope _ B. ❑Well drained LJModerately well drained ❑Somewhat poorly drained Poorly drained C. Area available for SSTS. (Primary & Reserve) ® .( Extremely limited U� Somewhat limited ®Adequate ft x ft F D. INSPECTION Date 12— 1 111inspector 1314o evidence of failure ®Evidence of failure ®Evidence of seasonal failure -------------------=-=----------------=---------- - - - - -- �--=-- --- -------------------- : - - - -- (Indicate North) i y �- HOUSE r f ------------------------------------------- - - - - -% ---------------------- - - - - -= (1) Indicate location of SSTS A. Size and type of septic tank' v O Gallons Metal l�Concrete OPlastic B. Type of absorption area 1. Fields �'f S �a ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front sireet, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING WATER SUPPLY MPWS ID Shared well 91ndividual well L `�Drilled 0Dug I Casing above ground COMMENTS: we (( REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: . -- Inspector: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE,BUILDING CALM, Y. - - .'10512 , DESIGN IIATA SHEET - SEPARATE SEWAGE DISPOSAL SYS'T'EM FILL N0. owner j, Mo )AA,115CN Address OLD Rc�1rcE Z2 Located at ( Street SPR,� Lq%C% Sec. �9 Block 4 Lot X0.4 �n ica�ares� cross street) Municipality pA- t- T�RSQw� Watershed SOIL PERCOUTION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS PROPOSED LOS � 12 Hole Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water a ter ,ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1. 11'.33-`2:03 30 223/4 24/2 13/4 _ 2 ►z:o4 -_1 ;34 30 23 247% 1��8 3 12:35 - 1'.O 30 Z3��4 243/4_ 1 ��i 20 4 O - 6�TnPSO1L g��- 30� SAND`( C.L1�Y ►�nnn Vy�SAIIA�L STO►.1ES 1 4 5 2 5 6 Notes: 1) Tests to be repeated at sap:: depth until -a'JD-roximately equal soil rates are obtained at each percolation test hole. Al,_l data to be submitted for review. 2) Depth measurements to be made from + -op of "hole. TEST PIT DATA MIQUIRED TO BE SUBMITTI,D WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN `.PEST HOLES DEPTH HOLE. NO,_ i �, HOLE N0. �_.x_..nv�a: Ii0h1; N0. a., .. __ G. L. L� 611 3A N.nV I _(, rPM u ) 12" 18" 24" 30" 3611 42211 11811 54" 60" 66" 7211 7811 8411 7 INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO W111CII WATER LEVEL RISES AFTER DE'ING ENCOUNTERED .TESTS - MADE BY ^ . as en�ti "r ... d. S • �- ��PAA.N Date. DESIGN Soil Rate Used 20 MiVl "Drop: S. 1). Usable Area Provided S.CK)o Ido* of Bedrooms 3 Septic Tank Capacity 1.000 Cals . Type CONCP_M_TP-6 Absorption Area, Provided 1212 By L.F.x24" ��' p, width Trench. her Address_,jnjAM LEUhAe&APC.. THIS SPACE FOR USE BY IEA.D.PH DEPARTMENT ONLY: Soil Rate Approved _ S'q`. R /Cal. Checked by i� te�� FUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING ^ARMEL, . N. -Y. -10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYS'T'EM FILE, NO. Owner ,i. M�p�SC►� Address OLD nou- M z2 Located at (Street SPIZi LAAKE Sec. <,-b Block 4,---Lot �.4 n ica�aresTcross street Municipality pq-rTn n" Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS PROP05EU LO.� � 1Z- Hole+ Number CLOCK TIME PERCOLATION PERCOLATION Run Elapse No. Time Start -Stop Min. Depth o a er From Ground Surface Start Stop Inches Inches Water lovel in Inches Drop in Inches Soil Rate Min. /in drop. 1. Iva - %-`2:03 30 22��4 Z4,/2 13/4 2 12:o4- 12:34 3o 23 24 -,/g 12/8 3 %Z:3s- 1:05 3o Z3��4 2434 l��z 20 O - a?(�PS01L g- 30 SAND`S CLt�Y LU1�.M W�SAIIA�.t STO?�ES 5 1 1 . Notes: 1) Tests to be repeated at sam3 depth until appyroximatelyy equal soil rates are obtained at each percolation test hole. Al� data to be submitted for review. 2) Depth measurements to be made from top of hole. TEST PIT DATA P,PQUIR ,D TO BE SUBMITTLD WITI'.I APPLICATION DESCRIPTION OP' SOTLS ENCOUNTERED IN '.PEST HOLES DEPTH HOLE ....NO.,. �, HOLE Mn :..; _IIOLE:.NO. _ G.L. -To es:0 611 s J � tq 12" — - 18" 24" JOn 36" 4211 w I18 n ` 60" 66" 7211 7$n 84" INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AF`1'E13 BEUNG ENCOUNTERED . _�., TESTS _..Mt1DE_.BY..R.��ort�,uES'� J• Le�M�t��_ - -Date_..2_Z� -a5 DESIGN — Soil Rate Used 20 A1In/1 "Drop: S.D. Usable Area Provided 5.o00 Ivo. of Bedrooms 3 Septic Tank Capacity 1 °000 Gals. Type Absorption Area Provided By L.F.x24" -jam"- width trench. Other Address���L •Eti.��,s,� P.C. THIS S SPACE FOR USE BY I I.tEA.1 ;.VH DEPARTMENT O ONLY: R PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES � .. ...:...... ....COUNTY- OFFICE BUILDING . ^APAM, U. DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYS'T'EM FILL' NO. Owner �l. Mo►.tp c►a Address o�T ROU-cE 22 Located at (Street SPRY 1-,AK Sec. C,9 Block 4 Lot �.4 finndica�areb cross street) Municipality Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS PRoPOSEO Lq't' � IZ Hole Number CLOCK TIME PERCOLATION PERCOLATION Fun Elapse Depth to Water a er ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 1. 11'.33 -i L.0 S 3o 223/4 24'/2 INA 2 ►z:o4- j2:34 30 3 12:35. 1:0 5 3o Z3,4 4 O - 6 "-Tce=%I - 8i ,- 30' SAND`C C tIK I�A.M W ISMAX.L STOt.IES 1 3 1 .. 2 ifi'4V7r'. k { y �� '�• � .ii ., 41;44 s; „ , :, Notes: 1) Tests to be repeated at san:: depth until agroximatelyy 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. a TEST PIT DATA PTQKRED TO BL +' SUBMIT'.1'L'D W]m.[ APPLICATION DESCRIPTION OF SOILS PeNCOUNr[ERED IN 'VEST HOLES DEPTH HOSE NQ . HOLE; G.L. - PSO/ L 6" nA Af ,V I r rn IA )1 12" L - 18" 24" 3011 '36" 42" W 60'r 66" 72�� _ 78•• 84" � �► INDICATE LEVEL AT WMCH GROUND WATER IS ENCOUNTERED INDICATE LEVEL TO WIFICH WATER LEVEL RISES AFTER IB fNG ENCOUNTERED TESTS_.MADE..BY. DEBIG14 Soil Rate Used 20 MliV1 "Drop: S.D. Usable Area Provided S,GOo Wo. of Bedrooms 3 Septic Tank Capacity I,00O Cals. Type GpNCRS-« Absorption Area Provided By L.F.x24" width drench. Other IJame /// J o h , ai natuurre 1, d Address_jDjdN Lr =M_ &A& p.C" SF,A THIS SPACE. FOR USE BY HEALTH DEPARTMENT 014LY: Soil Rate Approved Sq. Ft /Cal. Checked 1 F oF NEG►� O 3 to PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owner =�`� =�t� Address "cox -7 Located at (Street ��,�yi Block Lot .indicate nearest cross s reet Municipality Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME -X PERCOLATION - PERCOLATION Run Elapse —67a- ter . water Level No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 4. 5 1 2 3 5 Notes: 1) 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 measurements to be made from top of hole. Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by_ Date TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF- SOILS ENCOU.NT ;TEST.:HOLES DEPTH HOLE NO. i HOLE NO. 7- HOLE NO. G.L. 6" 18" 24 ►� � 3011 „ ►� 3611 42" 8" ,, it 541 60" ►, 66" 7211 7 84" - INDICATE LEVEL AT WHICH GROUND WATER IS. ENCOUNTERED INDICA'T'E `WA`rER ­IEVEL- RISES AFTER °BEING ENCOUNTERED TESTS MADE BY Date, =�_3 L9 DESIGN Soil Rate Used ��Min/1 "Drop: S.D. Usable Area Provided ».`zed�jyy -No. of Bedrooms D Septic Tank Capacity \0 ' Gals. Type �. Absorption Area Pro Ned By � L.F.xRa width trench. l?hhan Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved Sq. Ft /Gal. Checked by_ Date ; M. I It. .?3Yz" q „ 1:p" 10':gYL° A" -:IO,l- IQYi ". -.:_: -.. ;.'qr 9'_pMt"� �. 17' -Qn_ i;, a . .p `1 ® - -- TV. JACK ............ ....... I T 7 P110NE I Lj �� ��+30' 4 C 10-kre DCF4R- PMbNT{DF HEED 'V! ; JAL'Y. m:� C K -- II �:. 3` L65E,T fit}U.c FLaf15 APPiOVFD FOR i I66I i . 3!c BEDROOM Grp;!` T ;30VE NOOK ��Q(�- v' CYUTEI: i AT ISKYLITEi r ;.,;. �rDR I DINING ` . @ xm �, aEDROo s 3 cnnl`RED" p F } I ►.. `I }sr Lav :.v,>o3n W ' Jl �' I s 13 ii3J MD; m Signature E Title In MASTER o 1 � as•Lav DD J I SLQITCI.4 FOR-' , i cu: t� -- N C caw /ua+l KITCHEN tiwu to _ r Q - I�+irs i II i- SIG _ 9 L _ rV._Af ace c . ` 13 BATH vWi; 11 L U., W4 ZADSV- K m u O O 6POTUGHr LLJCATI0N v �SIIGtIT/ �jK GUEST ` O/ . U �" PHONE JACK L4S0{30 �IME2� ® Q I - - T.Y: JALK H ON NAT UOkTb _ ® - A LS FSIUA 1 FOR SW FOR SFi�TULHT PH JACK L---- 1 — -0 / ULHT' 6UP' WIZE FOK FUTURE s 5LUMH AND CUD LOCATION FOR p HALL ®. X TKA-K ULITTIN4 G�S� :I A! BASFJIIENT 31�1 LIVING RM ®CATA. CEILINLA � WTUR6 FAN /LILHT 7 Q 0 p-1 r - -1 BED.-RM 3 BED -RM 2 ro I _ .Q o v ±: TV, JACK ti T °STUA60VENO�W� iWlu CW- x' bu _ _.ZZ'= Q3/4'� QD 4+ fD' -5 y4" q'. 13,_p i 4l4" Z.- pyc• gio a Iq _0 - i 30 2Ak� : 4:1r I o E�o l-w-C ✓ p (j FLOOR PLAN 07 SCALE Iiq " -ILQ" i PX Cti't�A��3Slo-I-3 �2 A�r✓P = 1►�6�11 �.� r90 f, w EI-t- Np 55pA WITNIH IOo � o t 1 A I \\ f; nog GO¢�� 0 r DRAIn� � M,N �\ \\�\ o \ ti �nc,•fl on \ \ \ \,0 \ 'I \0 az (TYI') d/ 1000 Get, MA50NKY �\ \ Ss -Pf1� TANK \' S \ S, ID =MIN. 1 0 I� i —o 0 0 I� iNlh Ih fo. G EK -fNA'( l0t� Sr WA t�1hPU`�AI Sys f�M �A`i lvr, <, Gr JG "e..; GN fNlh BEAN f){Ar fOr 5yh'frM WAS INSPr,G'(rD 8Y M5 >35 �� �: If w }L, • fN�' `7Y`�TFiM'`, CUNi'fKUGf�D IN AGGOKp�,nc� wl`d ALL ::'fA:�;.;•��C' R4. , "' A• REI�I%VAfIG'Nh -> iNr- PufnAM GoUnTY D�r'ARrM�Nf A, OF" ✓E•�t,TN ANi7 :ar: Nt:.. ox. ,r �QARiMEN( �iAIiN. Fi j, , +• e - C.I. AT l+ 9pPE 01-9f: FROM N0lJ '2f; 60MPONEN'( LOGA•(ION Nt� /BORN fZ -,r //o tirg 5�ffl0 TANK Zv n� NW 6PKNgK 36- 1' 17'- 5" 56f'Ql -TANK 9r GoKNFK hEYfp9 TANK SW GORN� -K -96'- o„ 2' tM MX III Gr- ti %1Z 35- 10" 50'- 2 21'- 8" 28'- 0, v-`9f tOX 42 v wia (,Wt�r 610f5R d0' I' 33,8' 17I5j. t3oX �9 G �-NTr-R G0 64--l" ,,W, 2„ 78 O, `2 ,5WIO r- C NW 601znR h,wrlo 5r- 6/09 N6K i 1 2'- 6" h�rfle, rI� II, v SW GoKtIEK r90 f, w EI-t- Np 55pA WITNIH IOo � o t 1 A I \\ f; nog GO¢�� 0 r DRAIn� � M,N �\ \\�\ o \ ti �nc,•fl on \ \ \ \,0 \ 'I \0 az (TYI') d/ 1000 Get, MA50NKY �\ \ Ss -Pf1� TANK \' S \ S, ID =MIN. 1 0 I� i —o 0 0 I� iNlh Ih fo. G EK -fNA'( l0t� Sr WA t�1hPU`�AI Sys f�M �A`i lvr, <, Gr JG "e..; GN fNlh BEAN f){Ar fOr 5yh'frM WAS INSPr,G'(rD 8Y M5 >35 �� �: If w }L, • fN�' `7Y`�TFiM'`, CUNi'fKUGf�D IN AGGOKp�,nc� wl`d ALL ::'fA:�;.;•��C' R4. , "' A• REI�I%VAfIG'Nh -> iNr- PufnAM GoUnTY D�r'ARrM�Nf A, OF" ✓E•�t,TN ANi7 :ar: Nt:.. ox. ,r �QARiMEN( �iAIiN. Fi j, , +• e - C.I. AT l+ 9pPE -r-, 10 5s, vAk— ""--V-- lull Iml .4- 2-5, PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM.COUNT ONLY, BEDROOMS IN Z Signature & Title Dat t It j.15 I � � !��i +:1 V, Lq L-3 lips PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY: PUTNAM COUNTY DEPARTMENT OF HEALTH Engineer to Provide - Permit q Division of Environmental Health Services. Carmel. N.Y. 10512' on CERTIFICATE OF COMP CONS ON PERMIT FOR SEWAGE DISPOSAL SYSTEM Permit k Patterson Located at Old Route 22 _ Town or Village Subdivision Name Apple Hill Subd. Lot M 12 Tax Map 69 Block 4 Lot 64 Owner /AppllcantName Loft Corporation Pump House Road, Brewster, NY Mailing Address Renewal_ ❑ Revision - 0 Date of Previous Approval Town Zip Building Type Single family Epp Bence 117,641 S.F. [FMSecdonOnly Depth Volume Number of Bedrooms 3 Design Flow G P D 600 PCHD Notification Is Required When Fill is completed_ Separate Sewerage System to consist of 1 QQQ _Gallon Septic Tank and 440 Lin. Ft. Disposal Trench To be constructed by Art Burdick Address Joes Hill Road Water Supply: Public Supply From Address or: X Private Supply Drilled by Henry .Boyd Address Route 52, Carmel, NY Other Requirements 1 represent that I am wholly and completely responsible for the design and location of the proposed systern(s): 1) that the separate sewage disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regulations o o Putnam County Department of Health, and that on completion thereof. a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill be submitted to the Department, and a written guarantee will be furnished 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 the date of the issu- ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above will be located as shown on the approved plan and that said well will be installed in accordane ith the standards, rules and regula ,—ions of the Putnam County Department of Health. Date 4/13/87 Signetl P.E. R.A. Address 10 Galloway Heig is Warwick, NY 10990 License Nd o� C3 APPROVED FOR CONSTRUCTION: This approval expire It a y s from he pate issuetl unless construction of the building has been undertaken and is revocable for cause or may be amended or motlifietl when riside d from y y he Co s' her of Health. Any change or alteration of construction requires a new p it. D ved for disposal of dome i sa ary sew e, d r ri� ter s my - ev._ 187 data •y Title i PUTNAM COUNTY' DEPARTMENT OF HEALTH 'ENGINEER TO PROVIDE PERMIT ON Division of Environmental Health Services, Carmel, N.- Y. 10512 PERMITT), LIANC f}FICAT OF C P . CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM Located at l56-10550M G44G , 1 ?"Mnae�V �. 1 / • Subdivision. /'i!��ryJ��yf� suba, lot t 12 Ovner/Addeess Building Type 12E� /D�NiIAz Lot Area Number of Bedrooms 3 Design Fla.. a /P/D ��������� Seoarate Sewerage System to consist of Gal. Septic Tank *To be constructed by�F��A Water Supply: Public Supply From Private S Address Other Requirements y, own or village 1 *Tax Map Block Lot D 41teneval .�� vision IF Date Of Previous Approval Fill Section only ❑ Y)/� P.C. H. 6.. Noti: \� PUTNAM COUNTY DEPARTMENT OF REACTS Realib Services, Carmel. N.Y. 10512 Enower to Provide Permit N v( �RoAreamtmtal � on CERTIFICATE OF CO CE CONSTRUCTION FOR SEWAGE DISPOSAL SYSTEM 3s tj(ci - Peemlt # T S© - Ldd at BLOSSOM LAN E7 tate dw. or m.Qe _. - 5zrbdlvis6 Plaines -ippa_ Lt__' shd. lot # J2 TA, MAP `2050 Bla Lot 1,2-. Owner /Appikaat Name T A Lo veeal E L-C •DONN C-_ Renewal—❑ Revldoa ❑ Date of Previous Approval Address 1 I L AKEVIEW AVE. Tow. 04044 Q_ F3 zip BWMWS Type SjhQt,6 fAtAiLY i% C Tat Area _L�-1 6¢1 `'P Fill SetdonOnly Depth Vohtmo Number of.Bedroomr J Design Flow G P D (O ©p PC® Nod adm Is Required When Fill is completed Separate Sewe:roge System to comw ore- �-LOCO—Gallo. Sep& Tank To be eaoliftu tell by 1• YF7� .�' ��`�'� �.'� Water Supply. 4 PdWU1c Supply From Addreta ort PrlvaUe Supply Drilled by _Addms Other ReguImmenq 1 represent that I am wholly and completely responsible for the design and location of the proposed system($); 11 that the separate sewage dis oral system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an rag u a ions o • u nam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Haulthwill b• submitted to the Department, and a written guarantee will be furnished the owner, his succauoes, 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) yea►s.immedistely following thedate of the issu- ance of the approval of the Certificate of Construction Compliance of the o► • al syst m or firs thereto; 2) that the drilled well described above will be located as shown on tha approved plan and that said well will be install n rd as ith andards, rules and r•gu out of the Putnam County O rt ` ht of Health. 1/ Date �j Signed P.E.! R.A. r T — Address v12 C f License No 41-00 z 2- APPROVED FOR CONSTRUCTION: This aPPIOVaI expires two years from the date issued unless construction of the building #has been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any Change or alteration of construction requires a npw permiij Approved for disposal of domestic sanitary %swag%, and �p►iveto water supply Only. A 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH 1 Division of Environmental Health Services. Carmel. N.Y. 10512 Engineer to Provide Penult # t cor&RucrioN PERMrl' FOR SEWAGE DISPOSAL SYSTEM LL- 0 MM Snbd. Lot # on CERTIFICATE OF COMPLIANCE �Jj _V -Z # Town or Village t Lot Z Ter: Map &C Block �_. (� Renewal_ ❑ Revislon ❑ Owner /Applicant Name 1 `� O t�h 9 4A rya LLB Date of Previous Approval Malling Addreae -RtCxC '183 d� y6p P/3 — Town Zip Building Type _FOr,ta_-b1_C-t tit- Lot Area ��'� '�C`� Fill Section Only Depth - Volume Number of Bedrooms 3 Design Flow G /P /D (0 c PCHD Notification Is Required When Fill to completed Separate Sewerage System to consist of Gabon Septic Tank a. 4-3o �1 to � [ �_ [..sue i I —0) c- (.l j To be constructed by --r', -C) . Address 1 Water Supply; Pdblic Supply From Address or: Private Supply Drilled by 0--Address )ther Requirements 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 bove described will be constructed at shown on the approved amendment there to and in accordance with the standards, rules ;od regulations of e Putnam ounty Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill e submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will lace in good operating condition any part of said sewage disposal system during the period of two (A) immediately following thedate of the issu. ue Of the approval Of the Certificate Of Construction Compliance of the Original sys m Or any re i s thereto; 2) that the drilled well described above ill be located as shown on the approved plan and that said well will be in led in ccord co wit he st ntlards, rules and regu a� o� ns of the Putnam aunty Depart vent Health. :te / Signs / P.E. R.A , / Address license No 'PROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless constructeo Of the building has been undertaken and is ocable for cause or may be amended or modified when con siderej by the missioner of Health. Any change or alteration of construction tyres a ew permit. Approve for d• o of damesti�„sanita sewage ,vale wate!—pop l only. e� �' � 9Y ��,�%