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OWNER'S NAME��.0
SITE LOCATION 267&
MAILING ADDRESS �a!/V' X/ L
PHONE
To -3 - 3—
PERSON INTERVIEWED PAID Complaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
REGISTRATION #
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 fram licensed professional engineer or
registered architect.
Inspector's Signature & Title
Proposal Disapproved
roposal approved with the following conditions:
1. Procurement of any Town pewit, 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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as ownekFor r a gent of er agree to the above conditions.
SIGNAZVRE TITLE DATE
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xaitnam County Department.or Nber =_
Qie eion of Enviro tN BlE � R
Approved as noted for conformance
applicable Hu1es and Regula ions of t�®
£ '',•501 Putnam County .Health mart ent.m
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P.O. BOX 644 9iY -9 19--
CARMEL- N.Y. M512 71r4
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN
DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner P . D Address CiST AA7C-1 /
)F�4419
Located at (Street) )W Tax Map Lot
(indicate nearest cr ss street) �/
Municipality — Drainage Basin 1 c
SOIL PERCOLATION TEST DATA
Date of Pre - soaking -11 � I . � Q P 10AI Date of Percolation Test s'/ % / )?'e-
Hole No.
Run No.
Start -Stop
Elan Time
Dipth to Water
rom Ground
Surface Sop)
Water
Level
nches
Percolation
Minn//Inch
1
2
/0
327
30
G
5;
3
ad //0
30
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5
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4
/ ,i d
'30
z
-5
(p
5
2
Aga—
-
3
4
5
1
2
3
4
5
MUTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are oo[amea aL caw,
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole. ,
• L
Form DD-97
STnEtlAUUnG». IUWN /YIILRI,t /WIT.. ►Ax iONUMBUL
ELL LOCATIONJ gg3 Box 312 East Branch Road, Patterson, N.Y: 81- 1 -8'4 -
(
NAME -AD S:
'1ELL OVYNER I Margaret M. Desmond RRJ3 Box 312, F�s-� 'Jranch- Roach. Patterson, NY i PSIV %TE
10 PUBLIC
USE OF WELL RESIDENTIAL - ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary O BUSINESS •D _FARM ❑ TEST /OBSERVATION D OTHER (specify)
2 - secondary p INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY D
.'.MOUNT OF USE; YIELD SOUGHT , 5 1 gpm. /N0. PEOPLE SERVED / EST_ OF DAILY USAGE - 600 cap
REASON FOR CI NEW SUPPLY ❑ PROVIDE LADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLINE ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE DRILLED DRIVEN DUG � GRAVEL D OTHER
?S WELL SITE SUBJECT TO FLOODING? YES :XX N0. .
"7 7Z' WELL IS LOOTED IN A REPI.TY .SUBDIVISION, NAME '.OF _.SUBDIVISION: °
LOT NO
,'j TER WELL CONTRACTOR: Name ° Address. :. ox
PA tiers on ' NY 12563
=S PU=_.IC WATER SUPPLY AVLILP _BLE:-.TO SITEE VES XX ;40
NAME E O: PUBLIC WATER SUPPLY:
... h T. ..) _.
DISTA.NCE_TO_ PROPEP.TY rROM.,;NEAP.=ST -WATER b4AIN .. '
= OC— TION SKETCH a SOURCES OF 'CON T_TMIN-kT ION
_
-•- - _ SEE ATTACHED
(dz e)
PERMIT .
9 - I
C
(signature)
TO CONSTRUCT A WATER WELL
La c. e Of issue:
ermit,, s ing- :Official
a
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES.-_ . , • - .: •._......_.-
DEPT) i HOLE NO. % MOLE INTO. MOLE NO.
G.L.
0.5'
1.0'
1.5'
2.0'
2.5'
3.0'
3.5'
4.0'
4.5' ;.
5.0'
5.5'
6.0'
6.5' n
7.0'
7.5'
8.0'
8.5'
9.5'
10.0'
Indicate level at which groundwater is encountered Al dY'�
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date
Design Professional Name:
Address: Czw lac w
Signature:
Design Professional's Seal
A i
September 25, 1986
Department of Health
Division of Environmental Health Services
2 County Center
Carmel, New York 10512
To Whom It May Concern:
Please find attached a permit request to drill a well on my property
at RR3 Box 312, East Branch Road, Patterson, New York. Along with this
request is a sketch of the existing septics surrounding this property.
If you additional information, please do not hesitate to contact me
at (914) 279 -5223 or (914) 279 -2922.
Very truly yours,
Margare M. Desmond
i
Division Of Environmental Huth Services
TVVO COUNTY CENTER - CARMEL, N.Y. -10512 (914) 225 -3641
APPLICATION TO CONSTRUCT. -A WATER_, WLLL_._: ......
'r
LL LOCATION
SIREEI AUDRESi
Eg3 Box 312
- _ - iUWNinLLAGE /CIIY 1AX (; iU NwbER.
East Branch Road, Patterson, N.Y. 81 -1 -8.4
'1ELL OWNER
Margaret M.
Desmond RR03 Box 312, Eas- 4s Road, Patterson, NY PSIVA.TE
�'0
XX NO
PUBLIC
USE OF WELL
RESIDENTIAL
- ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
1 - primary
❑ BUSINESS
-❑ FARM ❑TEST /OBSERVATION ❑ OTHER (specify)
2 - secondary
❑ INDUSTRIAL
❑ INSTITUTIONAL ❑ STAND -BY ❑
AMOUNT OF USE
YIELD SOUGHT
5 gpm. /N0. PEOPLE SERVED 1 / EST. OF DAILY USAGE * 600 oaI
REASON FOR {
a NEW SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
DRILLING ff
p EEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
WELL TYPE Q DRILLED
a DRIVEN
DUG GRAVEL
F_� OTHER
IS WELL SITE SUBJECT TO
FLOODING? YES
XX NO
2 TELL IS LOCATED IN A
REALTY SUBDIVISION,
NAME OF SUBDIVISION:
Bo.
LOT NO.:
TER WELL CONTRACTOR: Name on s
RR ox
Address: Patterson ' NY
12563
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES XX NO
NAME OF PUBLIC -WATER SUPPLY: - TOWNi /V /C
DISTANCE TO PROPERTY FROM NEAREST WATER-.MAIN.
OCATION -S-KETCH-&- SOURCES - "OF CONTnMINATION .
SEE ATTACHED-
"-'�+a
(date]
.,.. . • i •
signature)
PERMIT
TO CONSTRUCT A WATER WELL
A
l
Date of Issue: ff l9 G
P it Issuing Official
Permit is Non-Transferrable-
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ANDERSON..
;r`• z zPROPOSED WELL LOCATION FOR PROPERTY OF MARGARET DESMOND
Davies'.and Desmond's. septic tanks located by on -site
-`` _inspection; Anderson's fields by engineering and
r as- built plans.
Points located by optical rangefinder and Brunton
transit survey 20 September 1986.
Map scale: l inch = 50 feet. "
James- S.,Mellett, Ph.D.A
Consulting Geologist
.22 Curtis Avenue
New Fairfield, CT 06812