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BOX 22
Is 0 or
'I No
17-2 . �.{ If ` I. I � a i
I
02621
` � I• •• � �1• • 'fit 1� •1 : �►• Y.
DESIGN DATA SHEET- SUBSUFACE SFWAGE DISPOSAL 'SYST+E�Nli�_C�` FILE -NO:
Owner Addressl
Located at (Street) ���� �u Sec. C'J o� , Block J Lot �• S
(indicate earest.cross street)
Municipality Ci Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking
Date of Percolation Test
HOLE
NUMBER CI,OC;R TIME
PERCOLATION
PERCOLATION
Run Elapse
Depth to Water From
Water Level
No. Time
Ground Surface
In Inches Soil Rate
Start -Stop Min.
Start Stop
Drop In Mi.n /In.Drop
Inches Inches
Inches
H
3
4
5
2
2
3
4
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 fran top of hole..
e /oCz
G.L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
u'
12'
13'
TEST PIT DAM REQUIRED TO BE SUBM=MD WITH APPLICATION
DESCRIPTION OF SOILS ENXXXDnEPM IN TEST HOLES
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
� j,•}
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:
DATE:
DESIGN
Soil Rate Used Min/1 ",Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity � gals. TypecotiC , r
A k
Absorption Area. Provided By `TyU L.F. 1 x 24" width
Other /. '� (407 ) (5% I 4v, ►
Name �, �I'� I I� �d�j��� Signature J, .•_
Address P�`�� 2Z ..... SEAL
067446
90FESSI0NP
THIS SPACE MR USE BY HEALTH DEPARMENT.ONLY:
Soil Rate Approved sq.ft /gal, Checked by Date
PC –:
P UT NAM C O UN TY D E PART M E N T O F H EA L TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: �THLee- —590u �
2. Name of Project: (C'�i� L' ✓T %Di^� 3. Location T /V /C: -�
4. Project Engineer: (,;J`�NL�,J,i�G 5. Address: Zell
License Number: Phone:
6. Type of Project:
Private /Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7.
Is this project subject to State Environmental Quality Review (SEAR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted
8.
Is a Draft Environmental Impact Statement (DEIS) required? ..............
I
9.
Has DEIS been completed and found acceptable by Lead Agency? ...........
_� —
10.
Name of Lead Agency • `
11.
Is this project in an area under the control of local planning, zoning,
or other officials, ordinances? ......... ............................... _
12.
If so, have plans been submitted to such authorities? ..................
r
3.
Has preliminary approval been granted by such authorities? Date Granted:��
4.
Type of Sewage Disposal System Discharge...... Surface Water Ground Waters
5.
If surface water discharge, what is the stream class designation ?........
6.
Waters index number (surface) ........... ...............................
7.
Is project located near a public water supply system? ..................
'N
� Tler
8.
If yes, name of water supply Distance to water
supplylfi I M(LV,
9.
Is project site near a public sewage collection or disposal system ?.....
_
0.
Name of . sewage system Distance to sewage
system tAltf:;�
1.
Frt,t�C 2 g
Date observed: �J 23. Name of Health Inspector: (�
4.
Project design flow (gallons per day) ....... .............................
:5>C>
2.
� J
_ -_25. Is State Pollutant Discharge Elimination System (SPDES).Permit required ?.. >
26. Has SPDES Application been submitted to local DEC Office? ............... !v ^
27. Is any portion of this project located within a designated, Town or State
wetland ?............ .....................
28. Wetland ID Number .......................................................... NIA
29. Is Wetland Permit required? .........
Has- ap'plfiq%tion been made to Town;or Local DEC Office? .............
30. Does'1'project require a DEC Stream Disturbance Permit? ..........:........ �
31.; ls:- :;or` was, project site used for agricultural activity involving application
pe'sticides to orchards or other crops, solid or hazardous waste disposal,
"-landfil:l_ing, sludge application or industrial activity? ........ YES or NO I�
32. Is piroj:e;ct located within 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
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? .....�1"P 211$
34. Are community water, sewer facilities planned to'be developed � with in 15 years ?? �Q
: - 35. Are any sewage disposal areas 'in excess of 15% sl'ooe? �.�! ... � .� `°
36. Tax Map.ID Number*. ........ ..........................._rJ� : 2-7,S
37. Approved Plans are to be returned to:. ................ Applicant. Engineer
If the application is.signed by a person other than the applicant shown in Item 1, the
application 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 my knowledge and belief. False statements made
herein are punishable as a C1as,S A Hddpmeanor pursdant to Section 2f0.43 of
the Pena 1 Law.
SIGNATURES'& OFFICIAL TITLES:S�,[ �C• T�LL�-
MAILING ADDRESS: �`G
Public Health Director
�.: LORE- TTA,,;- IGLINARI..R.N.,.n,IY1_.S
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 &tAt4l$ 2W0448
Charles Brunke
110 Wiccopee Rd.
Putnam Valley NY 10579 Re: Accessory Apartment- Brunke
Three Year Approval - l to Wiccopee Rd.
Town: Putnam Valley Tax # 52 -3 -7.5
Dear Mr. Brunke:
I have received and reviewed the plans for the proposed accessory apartment at the above -
mentioned residence. The proposal for the apartment has been approved as per plans bearing the
approval stamp form this Department dated June 4, 2001 The apartment is approved for three
years with the following conditions: -
1. The total number of bedrooms in the apartment must remain at One without prior
approval by this department.
2. The total number of bedrooms in the main house must remain at hree without prior
approval by this department.
3. The area of the existing sewage disposal system, and its expansion area, must"be
maintained.
4. All plumbing fixtures must be updated with water saving devices, i.e., new low
flush toilets, restrictors 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 Putnam Valle,
If you have any questions, please contact me at your convenience.
Very truly yours
William Hedges
WH :kg Senior Public Health Sanitarian
cc: BI
a
a.
BRUCE, L.FOLEY. * �
- F�Ik i�ictt�i "'15tiecw .._._.� r.L�R TiA °�rldl:tiYARi RW, XSN.
Y 0 Au Mate Pubftc ifeadth Dimetar
- Director qJ Fettent Sesvtare
DEPARTMEW OF HEALTH
I Qeam Road
Brewster, New York 1OS09
£nvltenmtatal HtsltQ W3) VAX 043j273 -MI
���QY saw {ets (8a3) Zzs -BSSS tvrC 0ai) 278.667$ Fu(945)278.6003
$arty Eatervent9oa (8a� z78 • GOIa lreaePoot CSt3} 2786082 F�c (B3lj 218.6tii8
Date 0
Renewal 0 0
Yes No
SjMET ;j 16 w i ec C PC'e 9 TOWN PtAiIIIA VW1 bvasis # 2^ / — 1
NAIELk,rles RP-n ke PHONE ��S �_ PCHD
MAILING ADDRESS .I I& w• cc o y c c V `, I I c —,l
MAWG ADDRESS OF APARr;.A T
NUMBER OF BEDROOMS IN MAIN HOUSE
NUM BER OF BEDROOMS IN APARMIN .
Please submit this form and the tequiremems on page two to the Putnam County Health Dept-, 4
Geneva Rd., Brewster, NY 10549, Phone 278 -6130.
Approval b effective for a three year period. Abe Irpplit: t must teapplp at the of each
period to renew the legal status of the apadmea
8tgsu to of Appiieaat
Approved ' to o/ to G �1
n We
F7�
Cvmmeats /) 7
(
J�
a„ s
l BRUCE R. FOLEY
F
{ Public Health Director
..DEPARTMENT1
1 Geneva
Brewster, New
LORETTA MOLINARI R.N., M.S.N.
04 Associate Public Health Director
. Dinwtar.:...gf J'atient- Services` --
OF HEALTH
Road
York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
Putnam County Dept. of Health
4 Geneva Road
Brewster, NY 10509
Gentlemen:
Re:
Residence
Tax Map --3
Town ALL f_
According to records maintained by the Town, the above noted dwelling
IS
IS NOT -
--
in compliance with Town code and the total number of bedrooms on record is
This information has been obtained from:
CERTIFICATE OF OCCUPANCY:
ASSESSORS RECORD:
OTHER S I Tk- 10E-4- T10 1 a 01
T
Building Inspector
BFhouseguidelines
M�...E. VIRQNMENj'AL.5 VfCES.::_. _ .. ,.�...:._._,.. . -..1 _.
21 Kear tree
Yorktown Heights, N.Y. 10598
(914) 245 -2800
Albert H. Padovani, Director
LAB #: 32.103391 CLIENT #: 13387 NON STAT PROC PAGE 1
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N --------- N N N N N N N N N N ------ N N-- N- N N N N N N N N
BRUNF:E, CHARLES DATE /TIME TAKEN: 05/21/01 08:45A
110 WICCOPEE RD. DATE /TIME REC'D: 05/21/01 02:30P
PUTNAM VALLEY, NY 10579 REPORT DATE: 05/24/01
PHONE: (845)-526-3915
SAMPLING SITE: 110 WICCOPEE RD. SAMPLE TYPE..: POTABLE
PUTNAM VALLEY, NY, 10579 PRESERVATIVES: NONE
COL'D BY: CHARLES BRUNKE TEMPERATURE..: < 4C
NOTES...: KIT TAP COLIFORM METH: MF
--------------------------------------- N ----------- N N N N NNNN NNN N N N N N N N N N N N
DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
05/21/01 MF T. COLIFORM ABSENT /100 ML ABSENT 1008
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WATE' t;D(WAS NOT) OF A
SATISFACTORY SANITARY QUALITY ACCORDI HE NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS
TESTED, AT THE TIME OF COLLECTION.
SUBMITTED BY: /
Albert H. Padovani, M CP)
Director
FLAP# 10323'
914-737-3700 FAX=CALL FOR
CORTLAOT SERVICES I INC.
MQNTIPSE-, NY 10548
11
BILL ADDRESS
CHARLES BRUMM
pia OPM
PUTNAW"It.1M, .16579
0
sjOttc
*TKS: 1 DIG:11 TYPE:Precast
P-p
GALLONS: 100:0
CONDITION :
LOCATION: (R) rear corner of house
COATS C
A3
CT:
CODE DESOIPt±
.... ON
gop SEPTIC
EiVu SE-ptic
N
"No
SUB-TOTAL:
TOTAL DUE THIS INVOICE:
QTY
0-
TOTAL AMOUNT DUE: rZ 03
AMOUNT PAID:.
CBECK# or CASE:
RECEIVED BY:
ZMr AS
OF05/23/2001
0.00
�.q bAYS
0.00.
0 DAYS
0.00
-thys
0.00
T-�3'I*A; DUE
0.00
N
"No
SUB-TOTAL:
TOTAL DUE THIS INVOICE:
QTY
0-
TOTAL AMOUNT DUE: rZ 03
AMOUNT PAID:.
CBECK# or CASE:
RECEIVED BY:
WELL COMPLETION K1!'.FUkC1' Office Use Only
:TIEN,
DFP�
Division Of Environmental Health Services
OF HEALTH
rUTNA114 COUNTY DEPARTMENT
—STREET AOURESS: TDwNjVILLAZ11CIIY TAX GRID NUMBER:
Pei
WELL LOCATION
[1c) W ic C-C 0 cl_e,� M -3 —75'
WELL OWNER
NAME: ADDRESS: @IVATE
T LA." '7 V-.,A 0 PUBLIC
USE OF WELL
11_,R�SIDENTIAL 0 PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ASANOONE
I - primary
0 BUSINESS 0 FARM 0 TEST/OBSERVATION 0 OTHER (specify)
2 - secondary
0 INDUSTRIAL 0 INSTITUTIONAL ❑ STAND-BY . 0
AMOUNT OF USE
YIELD SOUGHT 9pm-1N0 PEOPLE SERVED EST. OF DAILY USAGE — gal.
REASON FOR
❑REPLACE EXISTING SUPPLY ❑TEST/OBSERVATION ❑ADDITIONAL SUPPLY
DRILLING
rDXtW SUPPLY (NEW DWELLING) ODEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 5—ck) ft.
STATIC WATER LEVEL —ft. I DATE MEASURED
DRILLING
()NOTARY 0 COMPRESSED AIR PERCUSSION 0 DUG
EQUIPMENT
❑ WELL MINT ❑ CABLE PERCUSSION 0 OTHER (specify):
WELL TYPE
❑ SCREENED OPEN END CASING 0 OPEN HOLE IN BEDROCK 0 OTHER
TOTAL LENGTH ft.
MATERIALS: C3 -STEEL 0 PLASTIC 0 OTHER
CASING
LENGTH BELOW GRADE ft.
JOINTS: 0 WELDED &THRE ADED 0 OTHER
DIAMETER lo in.
.
SEAL: MENT GROUT ❑ BENTONITE 0 OTHER
DETAILS
WEIGHT PER FOOT 1b./ft.
, DRIVE SHOE_ 0 YES U-NO-1 LINER: D YES LIQBO
DIAMETER (in)
SLOT SIZE
LENGTH (11)
DEPTH TO SCREEN, ✓ (It)
DEVELOPED?
FIRST
0 YES ONO
SECOND
HOURS
GRAVEL PACK
0 YES
GRAVEL
DIAMETER
TOP
BOTTOM
❑ NO
SIZE:
OF PACK — in.
DEPTH tL
DEPTH K.
WELL YIE19 TEST 1. It detailed pumping
it more detailed formation descriptions or sieve analyses
�
:WELL LOG are available, please attach.
METHOD: OILIMPED
O'COMPRES9D AIR
I tests were done is an-
formation attached?
DEPTH FROM
suRFACF
Wafer
Be ar-
Well
Dia-
CODE
0 BAILED 0 OTHER
❑ YES ❑ NO
ing
meter
In
FORMATION DESCRIPTION
tt .
It.
WELL DEPrili
DURATION
DRAVIOOWN
YIELD
s"urtiice
c; ✓,e 6 4 v aiqep?
It.
hr. min.
It.
9PM_
Sc- 11 ls,4
n
FWATER C] IEAA
TEMP.
QUALITY 0 IOUDY HARDNESS
0
C35)LORED ANALYZED? -OYES ONO
ANALIISAT'TACHED? 0 YES 0 NO
STORAGE TANK: TYPE 30),
CAPACITY GAL.
PUMP 1J4F(YMATI0hI
i
TYFE_�S--J,-^-1—S!4/f' CAPACITY
WELL DRILLER NAME DATE
MAKER r t-4 J,
d -�,s OEM 40
ADDRESS C4 SIGUXTUPE
M OOEL
—3- HP T
VOLTAGE''
v
p C) C
/0"
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
_ " ' ..... S.t^. 'P!vr A_J:;� . ...
• APPLICATION TO CONSTRUCT P,` WATER �WELL Fl. YP CHD PERMIT #
WELL LOCATION
Street Address Town VVil age ity
Tax Grid Num�r
WELL OWNER
Name Mailing Address
MIu. F_P_ 3 5e4 (5
Private
OPublic
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
0 BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify,
0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY 0
AMOUNT OF USE
YIELD SOUGHT (N gpm/ # PEOPLE SERVEDF k-YVVEST .
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION
XNEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
OF DAILY USAGE T- al
M ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
ODRIVEN
DDUG GRAVEL. C3 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X_NO
IF WELL IS LOCATED nIN�A R TY SUBDIVISION, NAME OF SUBDIVISION:
%
1ni I Y�'J��1 S Lot No.
WATER WELL CONTRACTOR: Name P b Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO
NAME OF PUBLIC WATER SUPPLY: �ZA TOWN /VIL /CITY
---••- -DISTANCE•- TO -PROPERTY- -FROM-NEABZES-T WATER MAIN: • .i rgg ._ M� L
LOCATION SKETC & SOURCES OF CONTAMINATION PROVI
ON SEPARATE SHEET
(date)
signatu
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
thirt;* (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
any and all water or waste products from such well
property and in such manner as not to degrade o
Date of Issue: 9 13 19 13
Date of Expiration /Z 19
shall take appropriate action to assure that
drilling operations be contained on this
r otherwi e co�nta /minate surface or groundwater.
� 4
Permit Issuing Official
Permit is Non - Transfer able White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
m
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
July 27, 1993
Ken Hurley
Cashin Associates
Route 22
Brewster, NY 10509
Re: Proposed SSDS: Brunke
Wiccopee Road
(T) Putnam Valley
Dear Mr. Hurley:
Public Health Director
Review of plans and other supporting documents submitted at this time relative to
the above - captioned project has been completed. Comments are offered as follows:
1. Note wetland limits on plan
2. Remove or cross out as built legend
3. -Two sets of house plans have not been submitted.
Upon Receipt of a submission, revised to reflect the above comments, this
application will be considered further.
Very` t my your;
Robert Morris
Assistant Public Health Engineer
RM/jp
.
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET
for CONSTRUCTION PERMIT
NAME OF OWNER Ck %✓� " ^ >;S�TREET;I C)1TION L.0 r �' i/
BY DATE
TAX MAP
DOCUMENTS.
Y
DISCHARGE (OK)
PERMIT' APPLICATION
ERC & DEEP HOLES LOCATED
C -1
REPRESENTATIVE OF PRIMARY AND EXPANSION
WELL PERMIT; PWS LETTER
EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
ENGINEERS AUTHORIZATION
IF PUMPED PIT & D BOX SHOWN & DETAILED
- DESIGN DATA SHEET(DDS)
HOUSE - NO. OF BEDROOMS
-.'DEEP HOLE LOG
WELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM
J; CONSISTENT PERC RESULTS (3)
PERC HOLE DEPTH
E12PROPERTY METES &BOUNDS
CORPORATE RESOLUTION
u. OUSE SETBACK NECESSARY (TIGHT LOT)
PLANS THREE SETS
OUSE SEWER - U4 "/FT. 4"0; TYPE PIPE
NO BENDS; MAX. BENDS 45 W /CLEANOUT
�] HOUSE PLANS - TWO SETS
' FILL SYSTEMS
VARIANCE REQUEST
YBARRIER
GENERAL
MI FT HORIZONTAL: SLOPE 3:1 TO GRADE
LEGAL SUBDIVISION
m LL SPECS
SUBDIVISION APPROVAL CHECKED
DEPTH GAUGES
PERC RATE
FILL PROFILE & DIMENSIONS
FILL REQUIRED
m VOLUME
URTAIN DRAIN REQ
mSTAIVDPIl'ES
TRENCH
EX- APPROVAL SSDS ADJ. LOTS
EIF TRENCH PROVED
WETLAND (TOWN/DEC PERMIT R & D)
60 FT MAX
DATA ON DDS PL .NS & PERMIT SAME
PARALLEL TO CONTOURS
PRE -1969 -NEIGHBOR NOTIFIFICATION
LETTERBI/ZBA
00% EXPANSION PROVIDED
SEPARATION DISTANCES SPECIFIED ON PLAN
® 100 YR MOOD ELEVATION - -�. _ : : ;. -- -:
REQUIRED DETAILS ON PLANS "'
�FIEL-D-S
" t �r -r10 "TO F-:•L.,'.DRnrEWAY LARGE TREES, TOP OF FILL
SEWAGE SYSTEM PLAN - (NORTH ARROW)
- w� - .
ZO' TO FOUNDATION WALLS - _
SSDS HYDRAULIC PROFILE m GRAVITY FLOW
D/J BOX m TRENCH/GALLEY m P- PIT DETAILS
100 TO WELL, 200' IN D.L.O.D.; 150' PITS
100 TO STREA_Nf WATERCOURSE LAKE (INC.EXPAN)
SEPTIC TANK - SIZE, DETAIL
C 7 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
WELL DETAIL, SERVICE LINE IF OVER
m IV TO WATER LINE (PITS -20)
CONSTRUCTION NOTES (GRINDER RATE)
W DESIGN
ER51Y INTERMITTENT DRAINAGE COURSE
D
DATA: PERC AND DEEP RESULTS
E F1', RESERVOIR, ETCI 150 FT. GALLEY SYSTEMS
9
EP O -FOO XI
T CONTOURS EXISTING & PROPOSED
L SEPTIC TANKS
RIVEWAY & SLOPES CUT
CD10' FROM FOUNDATION; 50' TO SWELL
FOOTING /GUTTER/CURTAIN DRAINS
WELLS
M15' WELL TO P.L.
COMMENTS:
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date g , 199--5
'Re : Property of Cf 4ARC.e�s �K�T�•i
Lo c a t e d a'%.-:. Ull I cr.OF
(T) P(tj�J/((,#ySection Block Lot��
Subdivision of W��,b•T�S
Subdv. Lot # Filed Map Date
Gentlemen:
This letter is to authorize �[It�TS,t ? C
a duly licensed professional engineer 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 in
connection . with this matter-and-to ,supervise the construction of said
system or vsystems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
OF NEW r0 Very truly yours,
HAEQ
Signed
Owner of Property
Countersigne
P.E. , R.A. , # .:,:.�`�•
o Y Address
Address Town
Telephone
Telephone
4r Gx :�xl ��ti SfYa9� NORTH
ANALYSIS DATA SHEET
C✓'
TYPE: PW
LOCATION: 110 Wiccopee Rd., Putnam Valley, NY
I REPORT TO: Charles Brunke
ADDRESS: 110 Wiccopee Rd.
CITY, STATE, ZIP:Putnam Valley; NY 10579
DATE COLLECTED: 06 -20 -94
TIME COLLECTED. 7:15 AM
i
COLLECTED BY: C. Brunke
REPORT DATE: 06 -23 -94
j LAB # : 94 -4139
SAMPLE SOURCE : . W6l l ...tank'
DATE
ANALYSIS RESULT UN =TS METHOD A31ALYZED
Total Coliform Absent
COLILERT 06 -20 -94
THIS SAMPLE AS RECEIVED AT THIS LABORATORY NIET
THE REQU ENT OF NEW YORK STATE DRINKiNGWAITE it STANDARDS.
Av
Laboratory Director
NEW YORK STATE ELAP CERTIFICATTON NUMBER: 11215
618 C icck Tower Commons, Rte 22, Brewster, NY 10509/917 - -7600 i Fa-c 914 -29i -0556
is
PUTNAM COUNTY DEPARTMENT OF HEAVIE
��.. DIVISION .OF.: ENUIRO11ZEFI'AL
Owner or Purchaser of Building
Ck4" rI e5 w or vyn
Building Constructed by
H & +�/i "CC& ire RI)
Location - Street
Municipality
Rvnc h
Building Type
3 7. 5
Section Block Lot
/° U - 2 -��
1Vi ile per 'C5 -te'i
Subdivision Name
L 17
Subdivision Lot #
GUARANTEE 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. pera.od .of .two- years immediately following the date of approval of the
°" °Certif �ate'bf Coiistr�ict on "Compliance" for`the'sewage tii pdsal sysfeii; o "r
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 Environinental 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 77,0 4 day of 1414V 19 74- Signature
Title
e
Genera n actor (Owner) - Sigma ure
Corporation Name (if Corp.)
Address
rev. 9/85
mk
�-
k. �, f►nn a
Corporation Na1me (if Corp.)
Address
/n, orti-il 1-111 Z11 C1120_._-):& 1.TVT T t%r%UDT VIrTrNA1 D1C`nf%Dfr
V1 wa
DEPARTMENT OF HEALTH
V a i;m - --'C
PUTNAM COUNTY DEPARTMENT OF HEALTH
'71A-UTAOURESS.
Office Use Only
A, 74
,%v
WELL LOCATION
WNIVILILAUICIlY TAX GRID NUMBER:
A a
/jr) W;(_Lcpct, Zj - A-Alrom 11co Poe L,
WELL OWNER
NAME: ADDRESS:
E-V,�_U_r [,.t S V 72 0
R 'f L.-_ r, k _ — t AAa. 1/4/d
0-fBIVATE
0 PUBLIC
USE OF WELL
1- primary
2 - secondary
OPqfSIDENTIAL 0 PUBLIC SUPPLY 0 AIR/COND./HEAT PUMP 0 ABANDONED(
❑ BUSINESS 0 FARM ❑ TEST/OBSERVATION 0 OTHER (specify)
0 INDUSTRIAL ❑ INSTITUTIONAL 0 STAND-BY ❑
AMOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE _ gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST/OBSERVATION ❑ADDITIONAL SUPPLY
GPWW SUPPLY (NEW .DWELLING) DDEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH '5-00 ft. I
STATIC WATER LEVEL _ft.
DATE MEASURED /1-A-A-3
DRILLING
EQUIPMENT
DI;OTARY 0 COMPRESSED AIR PERCUSSION 0 DUG
0 WELL POINT .0 CABLE PERCUSSION 0 OTHER (specify):
WELL TYPE
0 SCREENED Q-0PEN END CASING 0 OPEN HOLE IN BEDROCK 0 OTHER
CASING -
DETAILS
TOTAL LENGTH a I n tL
MATERIALS: C3,STEEL 0 PLASTIC 0 OTHER
LENGTH BELOW GRADE /9-SLft.
JOINTS: OWELDED M-THREADED OOTHER
DIAMETER -in.
SEAL: Qt6M_ENT GROUT 0 BENTONITE OOTHER
WEIGHT
PER FOOT 1b./ft.
I DRIVE SHOE. 0 YES 01Wd
LINER: riyEs allo
SCREEN
DTAI_LS
. DIAMETER (in)
SLOT SIZE
LENGTH (it)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
OYES ONO
-HOURS
�SECORD-
GRAVEL PACK
0 Ya
OS
0 N
GRAVEL
SIZE:
DIAMETER
OF PACK IrL JOEFTH
TOP
tL
BOTTOM
DEPTH — ft.
I
WELL YIELD TEST If detailed pumping
METHOD: 0 PUMPED t tests were done is in-
0 ,,COMFRESSED AIR :'formation attached?
0 SAILED 0 OTHER i 0 YES 0 NO
it more detailed formation descriptions or sieve analyses
VELL LOG are available, please attach.
DEPTH FROM
ACF
.SURF
Water
Star.
ing
-.In
Well
Di2-
meter
FORMATION DESCRIPTION
COCE
WELL OEM
ft.
DURATION
hr. min.
DRAWDOWN
YIELD
Land
Surface
1"!rl
Q4 v1drAe
Sc- A is
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? 0 YES ONO
STORAGE TANK: TYPE ry l 3 0 .1,
CAPACITY GAT,.
WELL DRILLER NAME DATEt
ADDRESS t44,,,"4*
Peo /9 OGMtTM
"
PUMP INFORMATION
TYPE S 1A, I' CAPACITY
MAKER DEPTH 40
-
MODEL VOLTAGE 1-10 HP 3/y
11
-2100
V1 wa
..r v i"nta W U1VTY DEPARTMENT OF HEALTH ..
Division of Environmental Health Services, Carmel, N.Y. 10512
4
b 1 \ erMastProvide V vP.C.H.D. Permit N in CERTIFI ' OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SY
Located at
., .. Owner /applicant NNaam� e
Mailing Address 1-�� L
trs�
Separvte Sewerage System built by
Rum
STEM
Tax Map Block
GG Lot
Subdivision Nam Sabdv. Lot 57
- �� Date Permit Issued 3 3
Consisting of
,-r-c7 a i 1 Gallon Septic Tank and
Water S- _apply° Public Supply From
ors �Pdvate Sup Address
��pply Drilled by Address
Balidhtg Type �?j f( AVI Elsa Erosion Control Been Completed? `�
Number of Bedrooms Has Garbage Grinder Been Installed?
Other Requirements qL9Pf5' 1' ((,V PIA-10 p---,
I certify that the system(s) as listed servin the
Of which are attached), and in accordance with the serve premises were constructed ess V.-rd.:c.sw Putnam Count De tandarda, rules and regulatio the plane of the completed work (copies
Y par ent Of ealth. filed lion Date P , and the permit issued by the
A Certified by P,E. q,A t�
Address A Any person occupying premises served Dy the above system(>a shll " "ar No. I
conditions resulting from such ufage. A promptly take such action as may be nocaslarY to secure the correction of any unsanitary
available and the a Approval of the separate sewerage system shall become hull and void as soon as a Publ': unitary sewer becomq
approval of the water supply shall become null and void when a Public water supply
subject to A+odifieation or change when, in the judgment of the COnamissi
-e�� 7 // becomes available. Such approvals are
Date
�L IliLI . tion, modification or change is necesairy,
e
- - Title
101s611lR i el[ll� fr C1011=R HDalll?ms Al Wffieela�s! . i M .
7MEMI ii.T . 101 b P"WHO lwm* 0
101m >!at �A= OWN" 5111=
r
M I 1 1 <21- -V 17 3
Rev..
t n /nn
all
ToEro �jI% or Tats /
Te y V L i M,
Menewd._O MevlaleR 0
Dale as ltrevMo
ray AA&M r Tewta
Date Subdivision ARproved 3 ��� S Fee Enclosed
1DEMOS T%w ( Lam' . Ind A a ✓ , Q t � M 0*
lima r Design Flow G P D 56x:> '
P® Notmea" 1111 sgpnvs sawano . r asn" t� Septic Ta "i 4nn
2 W IDS
v��_ r__A t_
ZIP IC7'5-11
Depth vehtoe
waiw sopptn )rlYe Sup* Fkglls Aade.s
on Soo, `r0�saa<.aa
407 Gy -1m5fo i' a999 5LO� M&Y-
1 r•preaant'.that 1 am whotly and conpletaly responsible for the design and location of the Proposed syWm(gs 1) that the "Wets fawaga difpofal system
above described will be constructed as drown on the approved amendment there to and In accordance with the standards. rules 60 rgu ns
Cewlty OeOertinent of NMR14 and that on completion thereof a °Certificate of Construction Compliance" setlsfentory to the Commlebner of Maalthwill
M fabnlR[e to the Department. amt a written guarantee will be furnished the over, s sucesaws. heirs or assigns by the tender. tWO dale builder will
place in geed .ep NW4 aon"W" shy part of Mist @swap disposal system duriaM t led s bmnedistMy f011Owkl6 thedate Of the MW
and of the apprevat of the Certificate of Construction Cempllence of the er sy any repairs t i 2) that the drllle well dewl0ad dove
will be located as poyn��t a aplle — i Pion and that old well will r ha n 'w h the stsma rule" and re ons f the Putnam h.
Data �
APPROVCO FOR CONSTRUCTION% This approaal anPir two s from the date issue unless construction of the building lees been undertaken and is
NvocebN /o► aearN M ale+► a amended or modified wen con nec"ary by the Isslomer of MnwRh. Any change Or alteration of construction
feaYNea a �MJw Perm /''Approve fer disposed of domest Y and /or • water supply only.
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