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County OapKtmint;.gf IlMttty and that on eomONtion thaaot a Catitieats' of yCon~truction:; aetory to tM CominitfbMr,:of MNKhwill
tM'atOmltted:" to tM'Dapa►tiri�nt ao0 a' writtM,ituaraM «, will`Oi furnisMd tM owner his s Oy the OuiIAN that said.OUlkW will
IsUtf aw pe0eopatatNig eabltlon any dart of saw snv+4e tlisposil ristam °tlu►Irp tM pa iatH folbstiing tMdice of the lfau-
apq e1 tM ipp►oval of tM CMtilieat�`o! ConArudiorr Complianp of tln,orgirNlsYstem r o tM£ hap d►tlld wNl aasaribad abort:
M►iN'Oa lOeatW H`tttaiMri 01< tIM'app►oveA;pMn anq tNt tiid wNi will,ti instalNO.` acco Putnam
Coiintyx of, N0411
SNnatl P E _�j IiA.
AdWea tacans• No
AOPitQVED`FOR CONSTRUCTION T apP►oval,expires4wo years `from the, date issuW ua s 4 i Ouildhig has teen undertaken and is
rwocabla foreuuae.a: may or,nl'antletl o► modHiad wMn eonsidarsd nsrestary; Dy tAe. COmnHs, rw,,.�� kfJ, 'Any change or ait ration'of construction
,. _
ttlOUNSS a� Mw`pamit.. 'ApproWO. for:'dis"Sei. "of "domestic unitary aewage,,,and /or privaM water supply only.
Rev..
10/8$ eta By TiRI.
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N
PUTNAM C"JINTY HEALTH .. DEPARDIENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Camnissioner of Health FIELD ACTIVITY REPORT -
ADDRESS
I . Street
24 No.
MAILING ADDRESS
P.O. 13CX Post Office Zip Code
W -ND-1 m • �i�� - - -- ---
PERSON IN CHARGE'
OR INTERVIEWED
Name and Title
DATE L21 Vedei) TYPE FACILITY
TIME ARRIVED . Lp 'i ;,;D TIME LEFT �[ f - 00
FINDINGS:
Sheet of
Orig. Routine
Orig. Canplain
Orig. Request
Canpl iance
Caftplaint Comp
Final
Group Illness,
Construction,
Reinspection
Field,'Sampling Only
Field Conference
Other
Explain ,
INSPECTOR:
Signature and Title
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
TELEPHONE:
PUTNAM COUNTY DEPARTMENT OF HEALTH-
Date
Re: Property of 07;4,07
Located at-
(T),Pet,4,ala Section 73 6�Bl o c k .2- Lot
Subdivision of
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to authorize :ZO
a duly licensed professional.engineer I T- 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
vxj t - _ SApejVe -p JJ3O '
-1- ' il ' - -- - -k -. . -' r
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersigned:
P . E YRA ZI 7-1—
XOdress'
Very truly yours,
Signed* t
er of Property
Address
Town
Telephone
Telephone
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(9.14) 278 -6130
TQiY . TC! f�!9 CT ZT7nrn ;?�.. Taj%ci!Tt '[� ;4•TT T T._
PCHD PERMIT #
WELL LOCATION
tre t AddrgAs
Town Village C ty
Tax Grid Number
WELL OWNER
Mv me G
M ACdidf r�=eCs� s� �i
"i/'
rivate
%'• [� Public
USE OF WELL
1 - primary
2 - secondary
„RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
t] INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT_ej'_ gpm /# PEOPLE SERVED_ /EST.
OF DAILY USAGE ®'VSal
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY O TEST /OBSERVATION
NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL
L1 ADDITIONAL SUPPLY
DETAILED
REASON FOR
DRILLING
WELL TYPE
OTDRILLED
[]DRIVEN
DDUG
GRAVEL
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES :� NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: --'
Lot No.
WATER WELL CONTRACTOR: Name
Address: i�.��d //
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ✓ NO
NAME OF PUBLIC WATER SUPPLY: — TOWN /VIL /CITY
.DISTANCE, TO-PROPERTY: FROM NEAREST WATER MAIN:.i��..... .
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE
ON SEPARATE SHEET
(d te) (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
thirt3, (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: 19
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
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET. fog.- CONSTRUCTION PERMIT
NAME OF OWNER - - - -- - ' - -- STREET LOCATION
BY
DOCUMENTS.
C7
Y
= PERMIT APPLICATION
m.PC -1
= WELL PERMIT;=1 PWS LETTER
m ENGINEERS AUTHORIZATION
= DESIGN DATA SHEET(DDS)
= DEEP HOLE LOG
= CONSISTENT PERC RESULTS (3)
= PERC HOLE DEPTH
= CORPORATE RESOLUTION
= PLANS THREE SETS
m HOUSE PLANS - TWO SETS
= VARIANCE REQUEST
GENERAL
m LEGAL SUBDIVISION
m SUBDIVISION APPROVAL CHECKED
m PERC RATE
FILL REQUIRED
CURTAIN DRAIN REQUIRED =STANDPIPES
EX- APPROVAL SSDS ADJ. LOTS
WETLAND (TOWN/DEC PERMIT R & D)
DATA ON DDS PLANS & PERMIT SAME
PRE- 1969 - NEIGHBOR NOTIFIFICATION
LETTER BI/ZBA SEPARATION DISTANCES SPECIFIED ON PLAN
100 YR. FLOOD ELEVATION FIELDS
tF[1C p.R 1� _ E t;_ HLS. f;;u'.I?� A'u.C_. _ `ii -� - - -
_ i'u [ i7 r. L.; LRI v E W6'fiY; %t1tcGE i R- iES, ilr i7`r' riLL
SEWAGE SYSTEM PLAN (NORTH ARROW) = 20' TO FOUNDATION WALLS
SSDS HYDRAULIC PROFILE = GRAVITY FLOW = 100 TO WELL, 200' IN D.L.O.D., 150' PITS
D/ J BOX = TRENCH/GALLEY = P- PIT DETAILS = 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN)
I7 SEPTIC TANK - SIZE, DETAIL m 50' TO CATCH BASIN, 35'.STORMDRAIN, PIPED WATER
TI WELL DETAIL, SERVICE LINE IF OVER . = 10' TO WATERLINE (PITS -20')
D CONSTRUCTION NOTES (GRINDER RATE) m 50' INTERMITTENT DRAINAGE COURSE
1:1 DESIGN DATA: PERC AND DEEP RESULTS = 200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS
T-1 TWO -FOOT CONTOURS EXISTING & PROPOSED SEPTIC TANKS
D DRIVEWAY & SLOPES CUT =10' FROM FOUNDATION; 50' TO WELL
L] FOOTING /GUTTER/CURTAIN DRAINS WELLS
=15' WELL TO P.L.
OMMENTS:
TAX MAP #
® DISCHARGE (OK)
= PERC & DEEP HOLES LOCATED
m REPRESENTATIVE OF PRIMARY AND EXPANSION
= EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
= IF PUMPED PIT & D BOX SHOWN & DETAILED
= HOUSE - NO. OF BEDROOMS
= WELLS & SSDS'S _W/IN 200 FT. OF PROPOSED SYSTEM
= PROPERTY METES & BOUNDS
= HOUSE SETBACK NECESSARY (TIGHT LOT)
® HOUSE SEWER - 1 /4"/FT. 4 "0; TYPE PIPE
= NO BENDS; MAX. BENDS 45 W /CLEANOUT
FILL SYSTEMS
=CLAYBARRIER
m10 FT HORIZONTAL: SLOPE 3 :1 TO GRADE
= FILL SPECS
=DEPTH GAUGES
= FILL PROFILE & DIMENSIONS
m VOLUME
TRENCH
=LF TRENCH PROVIDED
=60 FT.MAX
= PARALLEL TO CONTOURS
=100% EXPANSION PROVIDED
PLnIMM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN, DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
�'.`- "r`GR.sri r.�f1'S�..S : - uc.. �✓+:- R`� /. ?.v .u.,v c �s .or�s'.r ^+ <..�. .:rp.Y"`,rtiq.arrni—rd' W-as.�:s~s'.ti'a.u* �. .. �is+i•�pr v� `._. �. °sw.i...>:e+�+�ASY
Owner /�/1 ! /�) 0n :9;1 Address 3 G�za>i %i % ✓e %��
Located at (Street) C��°i J�io'i' 'tee Sec. 7-3. S Block 2- Lot
. (indicate nearest cross street)
Municipality ✓Q� �' � Watershed .
SOIL, PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of pre - Soaking // / 0 Date of Percolation Test %!% iyj
HOLE
NUMBER CLOCK TIME PERCOLATION PERCOLATION
Run Elapse Depth to Water Fran Water Level
No, Time Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop Drop In Min /In Drop
Inches Inches Inches
3 0 -3 /o
Je
2//
3 30 3v
/�
4
5
215 3
'.. •.n. .. .- �..ws�- �..wn+ -���.. yr._,.e.,�T. :.,� `� /_y.. �: j4' -c . �. w..- ..- _- .`.. °.T- .,....°...�- ..'�.. .w m. -a+ -- _...T -..y_� ..a•wr r�"•P...�Y7 rCe�'�4 r..•�-- C..�+*..+4o'rr..r-M
4
5
NOTES: 1. Tests to be repeated
are obtained at each
for review.
2. Depth measurements tc
rev. 9/85
at same depth until approximately equal Soil rates
percolation test hole. All data to'be Submitted
be made fran top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
-7
G.L.
to
29
lee ow
31
LAY
el
Sam
49
59
61
71
81
91
10,
ill
121
13'
4
INDICATE LEVEL,AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL To WHICH WATER IBM RISES AFTER BEING ENCOUNTERED - --
DEEP HOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used /0 Min/1" Drop: S.D. Usable Area Provided
No. of Bedrooms Septic Tank Capacity gals. Type '04'WO-5,
Absorption Area Provided By _ 3 3-3
Other
L.F. x 24" width trench
'0�,// Kll�z CC/
Name Signature
Address v r )v 4,_9 s of
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY-.
Soil Rate Approved sq.ft/gal. Checked by-� t-flg Date