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02112
61011
_ CE ATE.OF. C
Located at
UTN
Diylafon of AM COUNTY DEPARTMENT OPHEALTH G
Euvbionmental Health Sevices, Carmel, NY 10512 a
Engineer
de
Moat Provi -�
P C.H D Permit N
ISTRUCTION COMPLIANCE FOR SEWAGE✓ DISPOSAL.SYSTEM
.� . Town or village
Ta: Map 3'p Block 3 Lot _ � � 7
Owner/applIcka - Name Ic t L S ]- CEO RE Formerly L M Subdivision Name Sabdv. Lot N v
Ats" Address - fi � E12as.1l�oi� ZIP Date Penmit Issued
- A
Separate. Sewerage, System built by P Ad�dr1ess
tlng Gallon Septic Tali and —T
' Cousie � of 1- b G� li
Water Supply: : Public Supply From_ Address
or: Supply Drilled by' -1C � Address - 1 e.i.0 s'T`g -►2_ 1�}
gogd .q tag' P'r4+M a Has EroslaW; ontrol Beea�Complete ?
Number of Bedrooms Has Garbage Grinder Been blstalledY
Other Reguiremente
I Cortffy,that'alie syatea(s) as 3lsted seivinq' the above;premiaes were conetrucCed;'e ti 1 as on eras of the completed work `G copies
Y
of which are, attached),., and in'accordance with, the standards,'rples'an elation' rdan with " e' i d -plan',' and the permit 'i'ssued by the
Putnam County Deparittment -'OP Health .
Dite; '1 Certifi6e! by , ' 0 v R.A.
A'ddiess Llpnse NO. ` V IQ
Any person oecupYine Premises ss►ved 16*', -the above system(. shall_ promptly take tueti.aetiort:as may ba`neCetpry'to'seeure the eor►eetbn .of any unsanitary
conditlons 9esultinq from such `ufaye ,Approval ot• the:. 'separate'sewera9e system shell beco e- hLiwand. void as aoon°as a pub�i_ sanitary sewer becomes
avaltable and- the appro`val of the'.privale water supply shall become null and ,v Id when a public wsfar supply becomes available. Such approvals are
subject .to`.modifintlon. "o eharipe -when; in tlie: judgment °of ttie `Corti r of H eh ievoutlon, modification or change It n�eeles/J1t /aJOriyS�
Oats BY r Title
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i
r- ,BREWSTEW- LA130RAT- -OF1fES ._.___
Box 224 - BREWSTER, N.Y.
(914) 279 -4945 .
WATER ANALYSIS REPORT -
SAMPLE NO. 7660 TEST WELL
SOURCE: A.J. Builders (R.I.C. CONSTRUCTION)
Lafayette Rd.
Patterson, N.Y. 12563
COLLECTED: 4-10-90
BY: Mill Drilling, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
0 per 100 ml.
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
4 -13 -90
U
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health
In the matter of application for:
C •
represent that I am an officer or employee of the corporation and am authorized
to act for
Name of Corporation
having offices at
Whose officers are:
President: JC11i41� Parr�luk) L a-p -U-cob I
-- (Name and Address)
Vice — President:
Name and Address)
Secretary:
(Name and Address)
Treasurer:
Name and Address)
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 Sig
ne
of 19_ Title: F-
Notary Public
8/84
Corporate Seal
PUTNAM COUYfY DEPARTMEW OF HEALTH
DIVISION OF ENVIRONMEWAL HEALTH SERVICES
1 C, C�cisT' r-n,e42
Owner or Purchaser of Buildiilg
91TC,
Building Constructed by
N1ES��Z_ u�A�t� -T;�- ,mss
Location Street
Municipality
Building Type
6a 3 64"7
Section Block Lot
P')""' �" '_
Subdivision Name
Subdivision Lot #
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 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. Consttuction.'Cbmp aq or the -sewage disposal systsn, 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 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 20 day of TLip 19 ?0 Signature
Q_
. &I
Titlei��
General Contractor (Owner) - Signature
Corporation Name (if CoAp.)
Corporation Name (if Corp.)
Address
Address
rev. 9/85
mk
A k Cq/'
WLLL U1J1'1rLZ!11Jn A-EXUA! office Use Only
DEPARTMENT OF HEALTH
PUTNAM COUNTY DEPARTMENT OF HEALTH
STREET ADDRESS: WNW t TAX GRID NUMBER:
WELL LOCATION Lafayette & Wes ley Road Patterson, NY --=,— ---S - 4 f I
WELL OWNER
NAME: ADDRESS:
R.I.C. Construction,, c/o John Petrillo,, Brewster, NY
)aPRIVATE
xc
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
)Iff RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANDONED
0 BUSINESS ❑ FARM 0 TEST/OBSERVATION ❑ OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY 0
AMOUNT OF USE
YIELD SOUGHT 5 gpm./NO. PEOPLE SERVED '3 to 5
EST. OF DAILY USAGE— gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ❑TEST/OBSERVATION [l ADDITIONAL SUPPLY
BNEW SUPPLY (NEW DWELLING) .[]DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 285 ft.
STATIC WATER LEVEL 20 —.ft.1
DATE MEASURED 4/10/90.
DRILLING
EQUIPMENT
0 ROTARY AN COMPRESSED AIR PERCUSSION 0 DUG
0 WELL POINT ❑ CABLE PERCUSSION 0 OTHER (specify):
WELL TYPE
0 SCREENED ❑ OPEN END CASING )90PEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH fL
MATERIALS: MSTEEL OPLASTIC OOTHER
LENGTH BELOW GRADE 94 ft.
JOINTS: 0 WELDED 191 THREADED 0 OTHER
DIAMETER b in.
SEAL: Q CEMENT GROUT ❑ BENTONITE 0 OTHER
WEIGHT
PER FOOT Ib./ft.
t DRIVE SHOE JR YES ❑ NO
I LINER: 0 YES 0 NO
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
DETAILS
FIRST
0 YES ONO
HOURS
SECOND
GRAVEL PACK
1
0 YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK — in. I
TOP
OEM tL
BOTTOM
OEM — It.
WELL YIELD TEST tIf detailed urnping
I P
wmoo: 0 PUMPED tests were done is in-
X) COMPRESSED AIR formation attached?
0 BAILED ❑ OTHER 0 YES 0 NO
"If more detailed formation descriptions or sieve analyses
WELL LOG are available. please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
well
Dia-
meter
In
FORMATION DESCRIPTION
CODE
ft .
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
it.
YIELD
99m_
Land
surface
80
Hardpan, silt, sand & cobblds.
8C
285
Medium to ard granite.
285
6
-
200
30
T
WATER (X CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? IXYES ONO
ANALYSIS ATTACHED? OYES 0 No
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL _
CAPACITY
DEPTH —
VOLTAGE — HIP
WELL DRILLER NAME MILL .DRILL INC . V17/90
ADDRESS OC
Putnam Avenue
Brewster, NY 0 it Pr
a esideq
i/ tsy
John M. Simmons, M.D.
PUTNAM COUNTY-HEALTH DEPARTMENT
.. .. ..... - ----
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Deputy Camnissioner of Health FIELD ACTIVITY REPORT Sheet — of
INSPECTION
NAME Orig. Routine
ADDRESS z—, /--, --
TM No.
MAILING ADDRESS
P.O. Box Post Office Zip Code
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE
TIME
FINDINGS:
TYPE FACILITY
TIME LEFT
Orig. Cunjilain
Orig. Request
Canpliance
Complaint Canp
Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
940 1 141= MA-WK, 4-
INSPECTOR:
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE:
'P,
A
OF
....... H 6! v�"Cmm& M10517
N
DMdon
an CERT[Q+ICATE OF
0
At
Sabdttlon Name abd Lot N39 "1 —`i0 ' 12
-m; .'. SL
snow
-2-
V.
[j Block Lot
Ov��ZA 001kalif Name, .
Date of Pt4l
WouvA
Approval 7'
Taiwis
5F Blilldbtg Type rye)' �"-� .lot Area �j F01'Secdon Only
'�.."Depth 'i�'
,
I Nvusibor of'Bedreom_:L� !4p
Li
separate _1- rim
Water ppw
A re"Pres-b-' 0!1-- IV responsible f6rAhi.'iiWiijr�.an'ii w sawageFAisposA "i iin
resent '�.Polged systerfi(s).
f�rn -i'thiie,,'ib ind ih.accordainco:wi M
'c6p - 4 odTiehariiih as shown ._avo
' completion there i6alon'dc
o!"
County; .' - "I ;�' . " ,, - '-_
Department
k be
if - , _ " - .- is by the buiidii..ttCat,iiidb'ijildir,*IlI o the _ �'� r'
I�OA4 (2j'
�qbddj'operati Ine GaWaymi �i' su
perati i I sw
re welt described above
anee otythe^app ► oval of the Cert�fiuteot Construction Compliance 'of the o�.iginal I that j0p,drilled,
WITT!'; or any
will be 10 n a 0
In IA aif vuxnam
0
A
map-
9,01;
11, that so
C
icen
APPROVED FOR CONSTRUCTION Th�sapproval expires two years tr°om i6o- claii issued unless construction. 0 the building
' fiisb n 'dn�eit�
�'Gn4nd is
rev ca 6w f or tiusa,6r_niy-b dOd f Commissioner �i- 46h* A ny.chan e or ij of;-: onaijction
&to w'a,ter S-6ii0ly
D'ate
10
7'
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL_.
PCHD PERMIT
WELL LOCATION
Street Addre s
Town Village/City Tax Grid Number
F� 4.) — -Co
WELL OWNER
Nam4
MAO
Ma' ling Address
0 Z-Z „�
CtPfivafe
O Public
USE OF WELL
1 - primary
2 - secondary
CESIDENTIAL
❑ BUSINESS
13 INDUSTRIAL
❑PUBLIC SUPPLY
O FARM
CIINSTITUTIONAL
QAIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
E3 ABANDONED
0 OTHER (specify,
AMOUNT OF. USE
YIELD SOUGHT_ gpm /# PEOPLE
SERVED 4 /EST. OF DAILY USAGE-300 gal
REASON FOR
DRILLING
EW SUPPLY O PROVIDE ADDITIONAL SUPPLY
❑REPLACE XISTINq SUPPLY ❑DEEPEN EXISTING WELL
® TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
RILLED
13DRIVEN
EIDUG ® GRAVEL
® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L "NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ,-
Lot No.
WATER WELL CONTRACTOR: Name �� �,� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 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- BiQ� S
(date) (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 0 19
Permit
Date of Expiration: 19 Issuing ff a
�
Permit is Non - Transferrable White copy: H.D. File
Yellow oo Py B g uildin InspectAr
•
Pink Copy: Owner
287 Orange copy: Well Driller
PDEPARTA IMTOMEALTH Pr
PYITPIAM COUNTYRealth Servkerl. Cgemei. N Y: Y®Sl? • ; me®r to ProvWe; - eemlt a
1 nlYlelon of Enehenmen
- ..om cESMtcATE oFco _
CONSTi ll M n YIOR SEWAGE PWgSAL SYSTEM E
_ _ Losete¢ et `� �• ' Ord 7 A.0 ovrn or VIOage K
r.•. \ ^. S1 �, � at .y :1h R »Y'v v—. ,. • .f f � 4s : a. .� —._.
Subdivlelon IdROIe�^ SObd Iota `� �3� jblep'� Bleelc =� Ipt
Owner/
Applicant Ne®te t� - e tuZ3:
Re ea O Revision p
id
' ° 1 �V
- APP
MilltDg Ad/h®ee; , as �N iii trJ �
Bandung Type-. I Lai
Area Fu1 Soctlon only Depti� Volume y
Des Flow,G P< PCND,Nofl9txtlon ili;Redtalieeol When Flll le completed
Nu>mrb®r of lied�oo ®s / _
sepaeat® Setvee�ge System ro cdtnelet ceuon sepne �'
01 oaastracted by ,:• 7 Addesae
Wate>< SuPP F; Pabllc'Sopply Fliom Address
arr- Private BaPPiY 1)etDed by w
other Roviairements 1 ��
I represent that.l amwholly anticompletely,responsi. e(o the#1 gngnd locatioh of- the.,Droposed syriem(s) 1►.,t,at the 'separatesewage disposOlsystem
above :dascnDsd will be eonstructetl. as shown on the aDDrov adment there to antl in accordanee with the stantla'rgs, rules and requ s •tons o e u nam
....:. ,.
County Department of "'Health and that;on eomplehon the ''Cer`ti(�ute of Construction Compliance' satisfactory to the :Cornmissionmof Healthwill
De wDmdted..to the Department, - antl 's wntten`quprantee _ JI be furnished the owner, his successors;'hefrs or assgni tiy.the Duildei 'tMt said'bu,ltler will
pkce in good ;operatntg,tongdion any pert of said sewage disposal :system, tluruy,the,perrod of two.(2)' years 1 "' teiy f011owiny thetlate -ol the ifsu
Once ;ot the eDproval of the Certif�uterof Construetiori. Cdinpliance "of the original system or any repbir$ thereto;' t at ttie drilled "well 641! eA itbove
will be'loutod`as fh non the aDProved plan and that said well will be,lnstalled. i' cc`rdan with a Stan rds, 'r les Ono `r u a, t-T•f n of the Putnam
County Oepa merit Of Health
Date + J. Signed P E-
Address X I'i nse No �
Z
APPROVED'FOR CONSTRUCTION This approval'expues; two years -from the Cate issued unless conriruetion, of
't e' building has' been undertaken and is P I
. revocable for cause or;may be amontletl or;motliLetl `when- ,eonsitlered naeessery;by the CO m' ssioner of'MeaIM.. Any change or alteration of construction
requires a new permit., '-ADDrovetl for d ot';ddmeri'iu`sanitar.y' sewage, :and /or Jprfvate water su: ly only:'
!�ev.
i7 Oete. BY Title
0
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- OFFICE` BUILDING,--- CARMEL,- R. -Y. -10512 -�
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Address .1 c{ MAAj, -,ic s ei �N W
Located at ( Street XjE�a � -,See � Block 53 Lot-
�indica e neare cross street)
Municipality '7-REB -717 AJ Watershed ` � ;,�,.�,,„�„ ",-.-
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK
TIME
PERCOLATION
0--o
PERCOLATION
No.
.. -Start -Stop
Elapse
Time
Min.
Depth to Water
From Ground Surface
Start Stop
Inches Inches
Ater: Eevel.
in Inches
Drop in
Inches
Soil Rate
Min./in drop
r^ 2
5
_
4
" 5
l
Notes: 1) Tests to be repeated at same depth until approximatelyy 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.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESORIPTION OF _ENCOUNTERED IN TEST HOLES
DEPTH HOLE NCO. HOLE NO. HOLE NO.
G.L. Zx,70
611
18'►
2411
301 �r o
3611
42' i
48"
7T It ° !'
I .
60 ".. ➢ ��
6611.
70
7 811 °
4"
,CATE _LE`IEL. AT WHICH GROUND WATER IS ENCOUNTERED ��o uj
INDICATE-- TO WHICH -WATER -LEVEL RISES.-AFTER BEING ENCOUNTERED" ; s
TESTS MADE BY i ; Date �g
DESIGN
Soil Rate Used (O•-7 Min/l "Drop: S.D. Usable Area Provided l
No. of Bedrooms Septic Tank Capacity ' Gals. TypeS> K
Absorption Area Prov de By L.F.x2411 h trench.
ro�ti
i T:T � —4—x4 G,�,z a.� t ; �'O r� � • �, c
Address yccd-
THIS SPACE FOR USE BY HEALTH DEPARTIMT ONLY:
Soil Rage Approved Sq. Ft /Gal. Checked by
0
Date
BRUCE R. ,FOLEY, R.S.
Acting Public Health DirectCr
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
PROPOSED ADDITION APPLICATION - (RESIDENTIAL ONLY jp,5 rl - _C
STREET: r I Lq-Ae� ' C, Red, TOWN � " TX MAP #
� t o
NAME: 0 �'2 �' PHONE' f PCHO PERMIT #
MAILING ADDRESS - / � ,s A ., e y j e
Description of Addition X 6 t An, e b
.Number of existing bedrooms _ Proposed number of bedrooms
from Certificate 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 DEPARTMENT,
4 GENEVA ROAD, BREWSTER, NY 10509, Phone 278 -6130 with the following information.
1. Certified Check for $100.00.
2..Sketch of existing floor plan (all living area including basement, if any)
Non- professional drawing is acceptable.
3. Sketch of proposed floor plan.
Non professional drawing is acceptable.
4. Copy of survey showing well and septic location, to the best of your
knowledge. Include date of installation if known.
Include all wells and septic systems within 200 feet of property line. Any
questions please contact this office.
5. Copy of Certificate of Occupancy from Town or Certification from Building
Department of legal bedroom count of dwelling.
OFFICE USE
Comments and /or conditions
d
application
August 1995
July 1996 (Revised)
DEPARTMENT OF HEALTH.
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
Re:
Residence
Tax Map
ToNNm
BRUCE R: FOLEY• R.S.
Acting Public Health Director
Gentlemen:
According to records maintained by the Town, the above noted dwelling
�i
IS
IS NOT
in compliance with To%Nm code and the total number of bedrooms on record
i
is
This information has been obtained from:
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:
OTHER I
Building Inspector
x
REF: "MAP OF PUTRAM LAKE" � ' Out
MAP No. 149 I I n4z
Q Wn
LOT 347 i LOT 396
. I
N89 °51' 4 0 "E 100.00'
- _ ... P. 346 397
N N
- -398 '
I o
345 b Well O I
444
343
i�
0
m
O
N
20
� `I Fr.
J I OECK
36.0'
DRIVEWAY
N
O
N
34.2 399
I Sty. Fr- 400
R. RoncA
Otto.
Pore It
In
M
M I
I �
I•
I
c 1.
' 0.37 n
Ac.
_ A
\ ,o
\ o
\
\ A
O
I r z
00 1 0
20.07'.. I I
LP
set N85 0140$0 "W
WESLEY
-1 HEREBY CERTIFY TO —
'AWLING SAVINGS BANK
THIS SURVEY IS ACCURATE
AND CORRECT BYt
GERALD L. LYNN
WAPPINGERS FALLS / N.Y.
N.Y. REG. SURVEYOR
ROAD
3
N
OD
O
0
N
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TOWN OF PATTERSON
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