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02119
{ k - PUTNAM COIINTY DEPARTMENT OF HEALTH
'Re V . '3/ 6 Division of Environmental Health Servlcex, Carmel, N Y 10512 ' r
Engineer,, ,,, Pro vide -±
P C. D Permit M
f
WELL COMYLETIUDI ruxuxi
* * DEPARTMENT OF HEALTH
" Division Of Env ironme ntal 'Health- "Se°rvices
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET AOURESS: WNW i TA% GRID NUMBER:
ZIwg�R Rto, Brewster, New York
WELL OWNER
NAME: ADDRESS:
Randolph Laurent, Zimmer Road, Brewster, New York
BIVATE
o PUBLIC
USE`OF WELL
1 - primary
2 - secondary
xgJcRESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY O
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 3 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ®ADDITIONAL SUPPLY
xgNEW SUPPLY (NEW DWELLING) ® DEEPEN EXISTING WELL
DEPTH DATA
365
WELL DEPTH ft.
75
STATIC WATER LEVEL ft.
7112196
DATE MEASURED
DRILLING
EQUIPMENT
O ROTARY x&COMPRESSED AIR PERCUSSION ❑ DUG
O WELL POINT 0 CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED O OPEN END CASING x&cOPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH 35 fL
MATERIALS: - 41STEEL O PLASTIC ❑ OTHER
LENGTH BELOW GRADE ft.
JOINTS: O WELDED xQcTHREADED ❑ OTHER
DIAMETER 6 in.
SEAL:QCEMENT GROUT ❑ BENTONITE ❑OTHER
WEIGHT PER FOOT i9 Ib. /ft.
I DRIVE SHOEQ YES ONO
I LINER: DYES ONO
SCREEN
_ . _DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (It)
DEVELOPED?
FIRST
O YES ONO
SECOND
- _
-
- y
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
-OF PACK in.
TOP
DEPTH ft.
BOTTOAS
DEPTH ft°
WELL YIELD TEST If detailed pumping
P P 9
METHOD: O PUMPED i tests were done is in-
OMPRESSED AIR , ! ormation attached?
O BAILED O OTHER ❑ YES O NO
WELL LOG It more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFABear-
ino
Wei
Dia'
meter
FORMATION DESCRIPTION ^
coat
ti.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gCm.
Surface
6
1
Sandy loam & cobbles
6
365
& white granite,
Hard e e
300
2 30
300
4
365
6 —
150
75.
WATER xAWCLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? x:QcYES ONO
ANALYSIS ATTACHED? DES O NO
STORAGE TANK: TYPE tjanhMam
CAPACITY 86 GAT,. 23
INFORMATION
TYPE submersible CAPACITY 10
MAKER Goulds DEPTH 200
MODEL 1=— 104.1 VOLTAGE 22301P _L_
WELL DRILLER NAME MILL rnzuLl , / 25196
ADDRESS Putnam GN RE --�
Ave. tive .
Brewster, N(, Robert ,'bt. 1Ni 1 l Pr it
J /bV
PUMPM C OC N DEPATMaD7Z ` OF HEAMH
DIVISION OF ENVIRO�LVrP.L fiEn1,TH SERVIQ S
Owner or Puxcbaser of Building
Building Constructed by
Location — Street
b%nicipality
Building 1
.3
Section Block Lot
Subdivision Nam✓
Sah.divis.ion Lot
GO- i�RAI,7 LF OF SL�T_SU Fr.(ti Sa'tAGEE DISFCL�r, SXS r •i
I represent that I am.. wholly. and co.�pletely responsible for the lccaticn,
wor }a�ariship,
material, construction and drainage of the sewage "disposal system
serving the above described property, and. that it has -been constructed as sham on
the aooroved -plaft or aoprov.ed amendment. thereto,:.. a-nd 'in accordance with the
staneards, rules and regulations 'of: the .Putrani County D`parl riant of Health, and
,hereby gua.La:ter to the a ner, his successors, heirs or assigns, to place in goed
operating condition any part of said system, constructed by me which fails to
operate for a period of t _=, v..
two years iediately following the date of approval of the
" ertificate of Construction Comno! lance" for the sewage cusposal system, or any
repairs : ade by .r,y-- to such system, except where the failure to operate . properly is
caused by the willfu'1 or negligent act or= the cccupant.of the building utilizing
the .,
The undersigned further agrees to zccept as conclusive the dete_mLIPa.tion or
t)e Director of the Division of Fnviron:er.L -_J_ Health. Services of the Putnam County
Derartr.ent o= Bealth as.. to w�,,etherr or not the failure of the system to o�aerate was
caused by the willful or neglicent act o_ the occueant t= -. e building utilizing
the system.
Iktcd this . 1-991 , Sicna tur
e
of-
Title
C- r'ne.ra�_ Contractor (Cwnex) - Szgnatare
Corroraticn (1% Cora. )
Corporation tie (ii- Corp.)
eSS --
t� ' ess
Mj ej S { j65 a�
r e %r . O/O 5
i� l_
..:: ,.. TARLTON ENVIRONMENTAL LABORATORY, INC.
A Division of Northeast Laboratories, Inc.. _ - .. _ .__ . cT Cert: PH -0404
DANBURY: 39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 and PH -0606
BERLIN: 129 MILL STREET - BERLIN, CT 06037 NY Cert: 11471
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING, INC.
PUTNAM AVENUE
BREWSTER, N.Y. 10509
DATE SAMPLE COLLECTED:
TIME COLLECTED:
COLLECTED BY:
DATE RECEIVED @ LAB:
DATE(S) TESTED:
TESTED BY:
REPORT DATE:
11/19/96
9:30 A.M.
RUSS
11/19/96
11/19/96
LAB #11471
11/21/96
SAMPLE SITE: LAURA.NT, ZBEVIER RD, PATTERSON, N.Y.
SAMPLING POINT: BOTTOM OF TANK
SOURCE: WELL -NEW
TREATMENT: NONE
TEST PERFORMED RESULT:.. RECOMMENDED LIMIT
BACTERIAL:
Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml
CHEMISTRY:
Chlorine Residual ND mg/L - - - --
m1= milliliter
mg/L = milligrams per Liter
ND = none detected
RESULTS BASED ON SAMPLES SUBMTTTED:11 /19/96
SAMPLE, AS TESTED ABOVE: MOTABLE or F— POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
0
Laboratory Director
CT: DANBURYAREA (203) 748 -7903 - FAX (203) 748 -0652 - CT: NEWBRITAIN/HARTFORDAREA (860) 828 -9787 - FAX (860) 829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 - OUTSIDE CT: 800 - 654 -1230
I j
TE O OOABIIANC�
.jam" J� .. •- �
�IiON PElbQP FOB SEWAM DWW" SYSTEM
T- t¢`%%iPSOA/ Y
LjtiMd �t - %A�LANY iii4LG: �� ar- vSlaae.
af,rPna m ca49:'pot # /s �3cf Y
- _
aeoe
o.,ri
t ❑
— R ❑
S Dae.or Prevoas Appoal
MEN" 11AYALN T _ R�=
Town & qum a --/ IA-0 wp
Date Subdivision Approved Fee Enclosed ® Amnrmt
•
lot Area Fm s«t 0, DeP& vdbore
Nubie of Hed<000a y Delon, F)ow G P D PCHD Nedecitim 4 Qeip i When AS )s d
Sepa1131s Sewee Sq*c Tank S g� lat t D
To 6e aednKted b� 7`t�17 Address
Wetter Sttpp�/.
PWWIC St4PI7 Ptm Addren
Girt k Prkate Sim* Deed by
1 ripresent .'tries 1 am wholly ang eompMtaty r.ipons�ble for the tlssgn and'tocation . Of, the proposed system(s); 1) that the separate sewage disposiU s stem
above described wilfge constructed as shown the approved irneritlrnent there to and in. accordance with the standards, rules a ►egu ens o nam
County on rtinent of IIa1itQ and that on complatiOn themof i •'Certificate of Cor structlon Compliance" atisfactory to the .Commis now' of Meaithwill
till s"Ol ted to. tM Department .arW;a writteh;quarantea'will pe,.furnisfib the owner; his successor; Mfrs or angns by'the pulkMr. that sif0 Oui1Mr will
Otaee i11 goia operating 'it IN ahy'part� of aid wwaga:dispoal system duri p the period of two (2) yearsimmediately folbwing.thadateof` the ism-
of n h orginil system W any NW INS thwet0:,2)'that the drillid well'deser*44 above
wN a Ibtatetl -'s thawn' dot{ tM �pOr ed PNn aela N�ttai0 Compliance
M instat in' accordance with the nilar
WHO Olaf Oapattmint of. Mwftti. s, ubs 'antl r.yu ons of tM Putnam
oat• ���. 9_s Sioneq_ .
APPROVED FOR CONSTRUCTIDN..This approval expires two years if
revocable for cause or -may Oe_ amerWlA;or;modifiad when confidired,na
requires a permit. Approved - foa,ditposal of domistie sanitary
Rev.
10/88 Date
m
ice se No
i,the tlats issued unless construction of the building .Ms been undertaken and is
,sary.,by the Commissioner of Health. Any change or alteration of construction
., and only. .
Tit
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
A_Y'PLICATION � TO � CONSTRUCT ' A WATER` WELL
PCHD PERMIT # 1 ��
WELL LOCATION
Sweet Address
/y7
own illage City
6
Tax Grid Number
3 -
WELL OWNER
ame
Marling Address
ADPrivate
O Public
USE OF WELL
0) - primary
2- secondary
19 RESIDENTIAL
D BUSINESS
D INDUSTRIAL
D PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify,
0 INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT S gpm /#
0 REPLACE EXISTING SUPPLY
® NEW SUPPLY NEW DWELLING
PEOPLE SERVED /EST.
O TEST /OBSERVATION
® DEEPEN EXISTING WELL
OF DAILY USAGE�'dy star
L1 ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
< G
WELL TYPE
DRILLED
DDRIVEN
®DUG OGRAVEL ® OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: L'
Lot No.
WATER WELL CONTRACTOR: Name T,[34> Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __NO
NAME OF PUBLIC WATER SUPPLY: A TOWN /VIL /CITY
DISTANCE TO PROPERTY% FROM : NEAREST -: WATER: MAIN:_
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
®ON SEPARATE SHEET
(date) s ature
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.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue : -z' 19 g�
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
_PUT'NAM. COUNM DEPARTMENT OF HEALTH -
DIVISION OF ENVIRONMIIML HEALTH SERVICES
bESIGN' DATA :SHEET- SUBSUFAC-E-SEWAGE DISPOSAL ,SYSTEM .- ,r, X10,
Owner /:'/VAT Z ,4:/�= A17 . Address /S
Located at (Street) lf� Sec. 3y . Block _ Lot /
(indicate nearest cross street)
Municipality 7`TiC',`rCit/ Watershed.
SOIL PERCOLATION TEST DATA•REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of
Pre - Soaking
Date of Percolation Test
L07- /
HOLE
NUMBER
. CLOCK TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water From
Water-Level
No.
Time
Ground - Surface
In Inches
Soil Rate
Start -Stop Mina
-Start Stop
Drop In
_. Min /In Drop
- Inches Inches
Inches
/ -
/O /S. ZZ L5e o
3„
4
r
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 sukmitted
for review. '
2. Depth measurements to be made frcm top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. Z HOLE NO.*
G.L.
T 2' S� /��Sr: Mil s%�I� �eraw
5
6' Srn�,s
8'
9'
10'
11' .
12'
14'
INDICATE LEVEL. AT .IfdICH;.GROUNDWATER IS - ENCOUNTER-W.
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:', /i4��.re7� G'�! /<1'srci� ?i DATE:
DESIGN
Soil Rate Used -/U Min /1" Drop: S.D. Usable Area Provided
No, of Bedrooms Septic Tank Capacity gals: Type �o�c
Absorption Area Provided By l_ L.F. x 24" width' trench
Other
_ .. ► i �� C ►v c W, yo
Name Af/ .cNT'�NGiiY�Er�/G �ssi- frF_r, Vic.. Signature N� l
Address SEAL
y C,
No. 56124
THIS SPACE FOR USE BY HEALTH DEPARTMENT -ONLY: Rp�`ti;�t``./
Soil'Rate Approved sq. ft %gal. Checked by Date
y. APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL.SYST'EH
Name: and Address of Applicant: &!!VE :4 ,EwT
/%giro rtTi y Lj�
2. Name of Project: ' 160 3. _•_Locationo/V /C:
4. Project Engineer: A,4'e 1x1 e&;,�x��s 5, Address: Nillbrooke Office Cent
Brewster, NY 10-509
License Number:. V7-; Phone: (914) 278 76105
.6. T'Y� of Pro ect:
Private /Residential Food.Service ....Corenercial ,
Apartments. Institutional Hobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject•to IState Environmental - Quality Review (SEQR) ?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted. _ c
8. Is a Draft Environmental Impact Statement (DEIS) required? ............:..
9., Has DEIS been completed and found acceptable by Lead Agency?
. 10. Name of Lead Agency
1.1 -:.Is this project in an area under-'the control of •localplannifig., zoning,
orother officials, ordinances? ..........................
12. If so, have plans been .submitted to such : author. s ties ........... :..........
13.-Has preliminary approval beep 'granted by such authorities? Date Granted: N /.�
s .
14'. Type of Sewage Disposal: System Discharge...... -Surface Water'_ k_Ground Waters
15. If surface Hater discharge, what is the strean class designation ?........
:6 Waters index number (surface) —�-
'�. Is project located near a public water supply system? ..................
°. If yes, name or water supply Distance to water supply /.cd
9: Is project site near a public sewage collection or disposal system ?.....
0: Name of sewage system /II/ Distance* to sewage system
1. Date observed:_.
23. Name of Health Inspector:
Project design flow (gallons per day) .....................
2.
25. Is State Pollutant Discharge Elimination System (SPOES) 'Permit required? o
.,,...� :. -: .�. 4n ... �. �"..�. ....r -: n.:.� • -ai /v^ ^v :_....+,ur �.:. .. .-. r•... ..ev._. ns. v. �:.r. --,. .. .r ..r. ?•-- '�•. -m. .� ....:G+a.� � .� ..cs. ...:....c.. ......•i. <. .. Y- .'. ...a.' .. .n..r�. .0 a� -.:. -..... ....- .a._.r
26. Has SPDES Application been submitted to local DEC Office? ...............
27. is any portion of this project located within a designated Town or State
wetland? ................................... ..........................•.... C5
28. Wetland ID Number ..... .................. ............................... _A/ ff
29. -Is Wetland Permit;• required? .............. ............................... . A16
Has application been made to Town or Local DEC Office ?. ................... —A.14
30. Does project require a .DEC Stream Disturbance Pe uit? A/o
31. Is or was project site used for agricultural activity involving application
OT" pesticide$ to orchards•or other crops., solid or hazardous waste disposal, .
landfilling, sludge application or industrial activity? ......... YES or NO 11%v
32. is project located-Kithin 1;000,feet of existence of abandoned landfill,
hazardous waste .site, salt stockpile, landfill, sludge disposal site or
any other potential known-source of contamination? ............ .YES or NO _ A/6
DESCRIBE:
33. Is there a. local master plan or fiie•with the Town or Village?
34. Are cow, :munity water, sewer facilities planned to be developed within 15 years? O
Alo
35. Are any sewage disposal areas in excess or: 1.5� . 1gPe.'_.`_. - _-
_. •. _ .
36. Tax =Hap ID N umber ......... ................. ............................... 231,-3 —I
37. Approved Plans are' to be: returned to: .................. ' Applicant k• Engineer
if the application'is signed by a person other than tFie applicant shown in Item.1, the.
sW ication must be-accompanied by•a Letter of Authorization: Failure to comply with this
provision may be grounds for the rejection °of any submission.
I hereby affirm; under penalty of perjury..- that information provided on this
form is true to the best -of cry kno►rTe�fse and be 1 ief. Fa Tse sta'tezents ',made
herein are pun ishab Ie as a Class A Hisdea,eanor pursuant to Section 210..45 of
the. Pena 1 Law. 1 q
3IGNATURES & OFFICIAL TITLES:
MillbroUe Office.Centre
!AILING ADDRESS: Brewster, NY 10509
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES-,
Date
Re : Property of /5/NAI,- /AEA,7
Located at
(T) 4 .c Sa 4/ Section Block Lot /
Subdivision of A6 /0- Z,¢s,pgA%T
Subdv. Lot / Filed Map # Date
Gentlemen:
This letter is to authorize - /,��RY L--/ Al 14,11614 s a;,-
.
a duly licensed-professional engineer V or registered architect.
(Indicate
to apply for a Construction Permit for a separate sewage-system, to
serve the above noted property in accordance with the standards, rules
or regulations As promulagated by the Commissioner of. the Putnam County
Department of Health,.and to sign all necessary papers on my'behalf iu
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law,
tary Code.
Counters
is Health Law, and the Putnam County San!-
R.A. , #l7
Address
kZIV
Telephone
Very truly yours,
Signed 'j
Owner of Property
yp
Address
Town
91r - 9i/ - ?Z /x
Telephone
LAURENT ENGINEERING
ASSOCIATES, P.C.
-...:, .. .,.., MILLBROOKE'OFFICECENTRE - ...
Route 22 8 Milltown Road
Brewster, New York 10509
RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FA)O 278 -2658
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
November 20, 1995
Mr. William Hedges
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS
Tamany Hall Road
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing SS -1 "Proposed SSDS ", dated 11- 15 -95.
2. "Application For Approval of Plans For A Wastewater Disposal System ".
3. "Construction Permit for Sewage Disposal System ", dated 11- 16 -95.
4. "Application to Construct ,a Water Well ", dated 11- 16 -95.
-... : S. "Design, Data_ Sheet".
6. "Letter of Authorization ", dated 11- 15 -95.
7. Two (2) copies of Residence Floor Plan(s).
8. Money order in the amount of $300.00, review fee.
We would appreciate your review, approval and issuance of the Construction Permit at your
earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nichols, Jr., P.E.
HWN:bd
95083
cc: Mrs. A. Laurent w /enc.