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BOX 17
01843
191
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01843
E � Sri
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state Sewerage cte7rj
i4juni c z �Ditvr "'
qtr �- .tea,.-•.
'RAT 'PION. PERMIT
` P, �xW, � "AD Section Biock
a � w•"'? Gr itY1' -�4�C i�l�Jpu'N /��t�1�d 1s�V _ Lot Job ����� f-��1+
Are
is lip
4 L
'ota]. Babituab"Le Spac'W..._.µ., %CZ����._.���.
.Sy!stem to consist, Of f X,,0 Gal s
t `_Oil 4
i ,Ti�Gi'L1Cf;d k::
" "1C i1C ",7% i i
Y
lrlent i3 r3 Fr/ _; , �::.� ! �. �f'�'/�
�: ," Yi Y1 d _ C'-1. iJed. T��.. 11 be ;Un t :.'C', t,F� ? t...
r A,4 7 YL\ , _ )•urn '- y yr
'.i ( { 1
_x{�IY7 (1., ..�.''',L` i. 'r tryfaf _. 2 G£i o C _ 'f
�t { {
.pa' t cr., ' t1:.4 1ti' +' +�,' ._ nSi' +sif..i. s'"_' _i.. ..,f 1' _ 1L i:J �_ .'t �^i ?. �. �. ,. ?. ?,_. - 1 _. :
i:La a nt c., wl.? 1 �-; f.0 ,iiShE i% ?.;C<: _.
S rj iJ T the J a , :a`. ii ." g t 3h.a. 1. d i' 1)• ._, .. t +!
ticr ! ors "wt:, i. `:1. 8
n Z3
e .�� �� _ Af',13� - St:��:U �;,_ s ,._ � ,..'..i:�..iJ .�� r7.;.. - q T • � „s, - �t C: ..
b y
• •V" .. � �j ���`- _ _ � Y ice.,"(. �'��'1� r •.. -�.. -.
Da•tc.:
t
INITIAL SIDE INSPECTION e
Yes
No
CcTrtrents .
,'?, operty lines or corr_ers found e
Can estimate house location ... . .
_
Room alloyed for exy;ar_si or_ trenches
- .-Over. .SC: ft . _. from swa.mp,.,•ratercour se .. ,_.._.... -e- .. a-- ... =...
_
-Natural soil not st= ip_ned or SDS area
_
Will driveway reed cut .
2Q ft. from house . . e . . . . . . . .
Must .trees be removed -note these . '.
etc. follows ula.n . . . a
Is deep hole representative of entire SDS area
Additional deep 'roles needed. . . . . . .
Stones; brush, stumps, rubble, etc. greater
'
than 15 ft from near-st trench . . . . e
15 Ft. of peripheral soil horizontally from
'.
trench
_
Sufficient SDS area available considering
driveway cut,house to cation, separation
Could surface run off from drive - :ay, roads,
ground surface, etc.., channel near SDS
area
• distances, etc.
e . . a . .
Does lot drainage annear '0. in area of. SDS - -
:.
DEEP ji0 r,, DATA .
' Dapth :
Water elevation: =
Rock elevation:
'
- Soils descritition:
Date r
FINAL SITE 1�1SPECT L Inso. by:
House located where shown on approved plank
_
w•0 I .
'OF f' t 6i'ed e
/ .
!
Width of trench average
_._?
Slope of the line and trend a�table
_
Room alloyed for exy;ar_si or_ trenches
- .-Over. .SC: ft . _. from swa.mp,.,•ratercour se .. ,_.._.... -e- .. a-- ... =...
__
-Natural soil not st= ip_ned or SDS area
unnecessarily graded . . . . . . . . .
10 Ft. mainta.ir_e frog: nroD.line and
2Q ft. from house . . e . . . . . . . .
S .-paration of trench fron house, well
etc. follows ula.n . . . a
Number of bedrooms -checks . . . . .
Stones; brush, stumps, rubble, etc. greater
'
than 15 ft from near-st trench . . . . e
15 Ft. of peripheral soil horizontally from
'.
trench
. . . . . . 0 * . . . . . . . 4, 6 a
Junction box *qs prope_Ily set
Could surface run off from drive - :ay, roads,
ground surface, etc.., channel near SDS
area
e . . a . .
Does lot drainage annear '0. in area of. SDS - -
--
FIPU'lI, GRADING OF SITE ACCEPTABLE
0
.i •
wr. c;i 11jrc rase.: of L.uild ug
Municipality
lc i�id Cun�tructe l,y. .. Section •
atiu - Street' - block
ldi 1`yPe Lot..
-GUARANTY OP,'SEPEIRa'1'F, ST :,7A0E SYSTE'tI
I
represent that I ,am wholly and completely responsible for ..the lceation;.
kmanship, material', construction .and draina e of the sewage - disposal sys :=em
vino the above described property, and that it ha'S "been, constructed. as shorn on '
approved plan or approved: amendment-. thereto, and in accorc:Mnce With Lhe stanc4r.':s.
2s and rep lations of the Putnam. County Department. of Heal;:h, and `.hereby gua ran *w
the •own.er; , his successors, heirs or assigns, t0' place In - ocod. op�r�:tina conciy tiGa
.part oz-'said system constructed by me .Which fails to. onerFte for 'a period of � -:o
os im -iedia -ely follc:� ina' the. date of initial use of they stwc'e disposal, s }s nr or
.repairs made }�y me to such = system; except c:here the failure to� o.perate prcperly'
NiU.iCU _i.�v lile W111lul . ul >>ekii <�e:i L. ac L: U.L . 1-le ' oL: L: U. P- C1i, L. Of L14 "LA-J_ . -.- /Jb +•+ +:•0
The undersigned further agrees to- accept as conclusive the,determinntion
the"• Director- of the Division oi-.Environ,.,ental .Ilealt;r Services of the Ratri :r. COL, 1-..L,
zrtment of Health as to whether. or not> the Failure of the, system, to operate c.7as
;ed by. the willful or necrligent act .of the occupant of the Luilding utilizirj ttre
Lem. • .. - -
�d this �_ day of •19 Signature. ZLA
.. Title i iZzwiZ
• `(if corporation6 a�ve na► � and.. ad`rc s;
:E (3) COPIES ARE REQliIRED 1 ITH THREE (3). COPIES OF FINAL PLANS. BE1 ORE Cr1:TIFI•C��TE,
:OLMPLETIONI WILL BE ISSUED
Z1 \TOR TS RFOUI RT D TO FILE ;NOTICE OF DATE or •FIRST USF. _ OF SYSTEM.
_- - - - - ---------------------------------------------- --------- - - -- - - - -_
:Sion of Environmental }Iealth Services, Ritnam.. County Department of Health .
WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH
3/71 Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL, NEW YORK
This report is to be-completed by well driller and su!�:-.;itted to County Health Department together with laboratory report of
analysts of` water'sarnpte "in'Lficating water is of sati0tictor -i b6cteri51 quality before certificate of'c6ristruction compliance is issued.
REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION
OWNER
NAME
�•'I
Ihotnas ► ors
DRESS CYte&C OW 4 Q l'.
. 0-0 atl'-'- .3iZ
LOCATION
OF WELL
t(No. d Street) (Town) (Lot Number)
0. CSo n 16 f IL
PROPOSED
USE OF
WELL
BUSINESS
LfJ' DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
SUPP Y ❑ INDUSTRIAL ❑ CONDITIONING ❑ OTHER )
EQUIPMENT
� ROTARY El A COMPRESSED . CABLE R PERCUSSION ❑ PERCUSSION ❑ OTHER )
CASING
DETAILS
LENGTH ,(feet)
p
I DIAMETER(inches) WEIGHT
PER FOOT
i �b s ® THREADED . ❑ WELDED
DRIVE SHOE
23 YES ❑ NO
VVAS A ING GROUTED?
❑ YES ® NO
YIELD
TEST
❑ BAILED El PUMPED
HOURS G.P.M.
� COMPRESSED AIR 3 J-1—
YIELD (G.P.M.)
5
WATER
LEVEL
-ft FROM LAND SURFACE —STATIC (Speclly feet)
/ o v e,f 3o t
1
DURING YIELD TEST (Jeet)
Depth of Completed Well
feet below land surface:
SCREEN
MAKE
v
LENGTH OPEN TO AQUIFER (feet)
Non �✓
DETAILS
SLOT SIZE
No V1 e,
DIAMETER (Inches)
rte,
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (inches):
GRAVEL SIZE (Inches)
t\' (- o Y1 'e—
FROM (feet)
TO (toot)
DEPTH FROM LAND SURFACE!
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
Fc'eT to icci
tD
ra
If yield was tested at different. depths.during drilling, list below
FEET
GALLONS PER MINUTE
DATE WELL COMPLETED
Ci I11 by
DATE OF REPORT
i2I % - I- I-)q
WELL DRILLER (Signature)
V�
If
BREWSTER LABORATORIES
Box 224 - BREWSTER,
WATER ANALYSIS REPORT
SAMPLE N03349
SOURCE: Tom Dillon - faucet well supply
Meadow Ridge Road
Patterson
i, New York
COLLECTED: Deci 9.i. 19P4
BY: Philip L Gapra
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 ml.
This result
indicates the
source of
the sample was
of satisfactory sanitary
quality- when
thi sample
was collected.
sec. 10P 1974
V45-.4 (161,
Bickwit P. E.
Dtrectar
iY,,5,...Ft1'.✓.7"i ,k,``h`."7.'i'Sa�y"`W .a =.k1..
APP OVER,
9 74
rv- •:s,.. Y �l, iti.Y7w'S S r�Y.�e �,� �a '4-, v-�} `l.C�. .'F.; rF4,3 tt
}
,UTP�A COON DEP
'1Y T. OF t,•
.... t .. ..DIVISION
a _ _-
e.mPnNMENTAI HEACTN SEM'+
....8. `V
. "rig . ft, Er r-
`� ` Fl�
z
[]] (ar(� }, dry .[/vgyp) �:,\ \l A -es ,tr €� IV b.P. , � 14:1
oll-V
Fe c. 1 �I' ,.�•.xt 7'j� � i l .r `^ 'i�.l '1� 7-A� �' li ` �� '• j X d',je , , �fJ�` �, +
s
t�
� � ��, � ?� � L,, �.� �- � "�� ';�:�. Ate,. •
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL. SYSTEM REPAIR
OFFICIAL USE ONLY
TM# J15, 6 r 0
PHONE
SITE LOCATION 3 r% Meadow Koke-
OVNER'S NAME i e
MAILING ADDRESS R r e vl s, +e,v- A
PERSON INTERVIEWED PCHD Complaint #
J Name & Relationship i.e., owner, tenant, etc.
DATE % I 1()1 TYPE FACILITY rc
PROPOSED INSTALLER
ADDRESS
PHONE yr Z cI ^ La q
REGISTRATION# 93
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
may require submittal of proposal from licensed professional engineer or registered architect.
C,
C
J;-as-owner; or reported agent of owner agree to the conditions stated on•this form.
SIGNATURE TITLE DATE 7 b3
Proposal v conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. - System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
ye e
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NIL
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DWjVM DIVISION Of
— — — — —
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i PUTN", COUNT'S
Division of. Environmental l
'GERTiFICATE`OF Cf;P�S U, CT10)V Ni�'tiAiV FOR; S
Located
i O:wner ��
Separate ewerage System! built by
Consisting of Gal Septic Tank
Other = requirements
l
Water Supply Public Supply;)From
Pnvate Supply Drilled
w Atldressc
11 3 r
Building Type
i
Has
Erosion.. Cdntrol Been
Completed
r
1- certify that the•system(s) as listed serving the above prem ises, were constn
attachedj; and ,n accordance w t the stare" rds rules and;'regulat,ons, p
Date ! 4
t ertifie-
Any person Noccupying premises served by the above`System(sj; shall prom)
( coriditions resulting from such usage � Approval of -the separate sewers
f available and .the approval of the private water supply shall'become null
t _subject to`motl�f� cation or change:^when-*,n; the _jud`gment "of the Comn
} Date
r "PJTnNA1VI C(
� f - � -� _ s.. D►vlsfon of Env�r
� , CpNSTR'UCTION- '•PERMIT FO� /R /) SEWAGE 'DISPO:
Located at
Bujld�ng Type" %lA1/V�7
Number `<of`Bedrooms m
k 9
.Separate Sewerage System 't "o consist
To be constructed by
j SWater Supply .' Public Sup
i •� Private Su
i � I represent that 1 am whollyar
above! described will be conttr-u
County 'Department of Fieall
be submitted to_ "4'he Depaftm
Jplace in good ':operatmg tort
ante of the approval of the_ -
will be located as sho wn on';the
Countys Department of Health
RO
w Date
PiPPROVED FOR CONST.—
' - •_ < -- ,.� „« r,r'mav tie
Z
�7 -
DEPk IE.NT; OF HEALTH
lea /th Serlii "ces, CaPme/ N Y fU512
D
iilAGE D):SPOSA_L SYSTEi1i1
FTOI r village
Section Block, t
Address- +C�- �1r11/ {
s T
lineal' Feet XK width trench
aa-
t
rL
No of Bedrooms Date Permit Issued
cted,esse as shown on *the plans'of the,completed;work(copies of which are .
ass fil the perm sii _ y t utnam County Department of eaa
i,
- t
t
E
E. RA
' L,cense No
tly, take such actwn as may be necessary tojsecuie the correction of an unsani ar:
ie system shall become null ahci vo,d,,as soon as a ` ? r. y' t ' y
and void when a Putitic sanitary - sewer' becomes
putilIc water supply.'`becomes available Such. approvals are
ussioner of ,Health such revocation modrf� cation or change 'is °necessary,
y
Title, -
., ��ri' rt ,,ia►T'r',:,r1�'k�lt7it±�s`�li TN.;��. x, , ..� ':.s..r.; -.�. � -�c .� , ,,.. , ._.
:s z 'Town or Village
t K��
Lot -I :f Job
�3 M }
,
Sq(jare „F,eet
Gal Septic Tali ny lineal feetrXr 4� width trench
0001, Address �” $� z
From � m,
-moo ,�� /Z�7'�i2 .... �
to' bey drilled by{ ,
-,:... ., .. r . o
:IySresponsi6le for the desigrtand. location of the proposed systems) l'')lthat the separate sewage disposal system
ved = amendment thereto and m accordance w�tli the standards rules an regu a ions:
o ,t a u. Warn
can on the approy - d _
t on;thereof a Certificate`\ of Constructi*- w-ComPhance satisfactory to the`ComrTlissloner of Health'wil' 11, t on comple
tee:w�ll be furrnshed; the owner h�ssuccessors; heirs or,assigns:by the,bUll er, -fiat said builder w l_
i ;written guaran
,'e disposaf system: dunng •the period of two (2)ryears lmmedlately following the date. of the issu-
part of 'said sewag:
of.'Construction`Compl�anceyof tFe original system 'or any repairs thereto,.2)'that the.dril'led well described above
plan and that sa d well wdl be installed ac cordance w the, Bards rules and [egulatwn; of the Putnam
, R.A. -
Signed g PGA
�,� rtrtv�� L � / k "fir- -ti - x 1 ., j t A -,Mx � ' ex'ir es one year. -from Stiete issued,�un uction of the` h�sapproval, P .. .. r �r`modified`'when considered necessary the,, Comm Health. Any - -� a- •.»e�+�c sanitary sewage, /or� private ply'.only c � �
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
,. . ,w...
COUNTY OFFICE BUILDING, CARMEL,Y N. Y. ~10512
DESIGN DATA
Owner
SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Address
Located at (Street -��f~ ec . Block Lot
Indicate ea s cro ss street)
Municipality C��cG�l 'Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED ITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water Water Levei
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
2V/6
1
m
W
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.
1
m
W
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.
DEPTH
G.L.
.61t
1211
18"
24"
30"
36"
4211
48"
5411
6011
M
7211
78"
84 fl
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. HOLE NO. HOLE NO.
,Si /V//--,) X,
z
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED 6"
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED,
TESTS MADE BY Date
... .... DESIGN
Soil Rate Used /- 1"Drop: S.D. Usable Area Provided
No. of Bedrooms -,-3 Septic Tank Capacity '30c-> Gals. Type IV4,3014�
Y-909e L. F. x241 x� width trench. Absorption Area Provided' a 3b"
z s- - Other
Name � a-c> 1Z E- A -V A6 69 r4 cir Signature
Address c 2 SEAL � 4
T�IMEL
4+
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: 41, `
�-.PE OA
Soil Rate Approved Sq. Ft/Cal. Checked b q. jig te
COUNTY OF WMMHNMR DEPARTMENT OF HEALTH Division of Enviromental Sanitation
DESIGN-' DATA SHEET". SEPARATE' SERME SV -ft= - No
Owe D6 51 tFJP—V j Address t�o PC LA�Jiz� S014 gFizS
Owen PC-4- - '
UC
Located At (Street) UEADOW Block Lot 3A2
—
..Undicate nearest cross street)
Municipality.-- MuFosarj Watershed orLtd &n e. 1.
SOIL PERCOLATION TEST DATA REQUIRED + TO BE SUBM TIED' I4ITH APPLICATION
3
2) Tests to be repeated at moo depth until approximately equal soil rates* we
obtained at each percolation test hole. All data to Be m1bmi for revieve
2) Depth meawnvments to be made from top, of hole
Hole.
Number
CLOCK Tng--
PERCOLATION
PERCOLATION
Mil
Elapse
Depth to Wkter
-Water Level
No*
Time
From Ground Surfam in Inchew Soil Rate
Start
Stop
Mine,
Start Stop.
Drop in Mn/in.d!rop
Inches Inches
Inches
1, .3
2
24F
3:/*
2- z
/X
3
-70/0
3172
Z Z
ZL
f-f
331
3 3
3
-Z 3. z
3
2) Tests to be repeated at moo depth until approximately equal soil rates* we
obtained at each percolation test hole. All data to Be m1bmi for revieve
2) Depth meawnvments to be made from top, of hole
Soil Rate Approved, Fto /Galo Checked by D
S.D`o 2706 (Rev® 5- 24-66) (February 18,9 1969)
i