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BOX 27
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03429
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION.OF ENVIRONMENTAL HEALTH SERVICES
R D
d 63-1)
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Y" NO Internal Use Only
Q ❑ Repair Permit issued in last 5 years
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland
SITE LOCATION qS & cvl v, kQ4W TOWN
OWNER'S NAME Ej'),eeti ; a}
MAILING ADDRESS 4
PERMR #
❑ Not in Watershed
❑ Delegated
❑ Joint Review
Ile TM# %S. N'�"I�•��
PHtNE # 91%S -5,W- 3114
APPLICANT 4 h to oa gielit (Cv�l�- f�R��O ✓,
Name i, Relationship (.e., owner, tenant, contractor)
DATE 7 I FACILITY TYPE &)e,41;AJ_� P HD COMPLAINT #
PROPOSED INSTALLER UJS IN)AAACrnvi� S?"t6 PHONE# 8G'-
ADDRESS 6;%sn REGISTRATION /LICENSE #
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
.nature and extent of the repair.
I, as owner,agree to the
SIGNATURE
(owner)
I, the septic it
SIGNATUi
(installer)
on this form
TITLE DATE 7 ��
ions of this permit for the septic system repair
TITLE DATE /
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Proposal Approved ❑ Proposal Denied ❑
Inspector's Signature & Title Date Expiration Date
Re air proposal is in com liance with applicable codes Yes ❑ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
PUTNAM COUNTY HEATH DEPARTMENT �
VJ
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL. FOR SEWAGE TREATMENT SYSTEM REPAIR
YES N Internal Use Only PERMIT # ` t1-SY
❑ Repair Permit issued in last 5 years FIT Not In Watershed
❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION v �, TOWN TM #
OWNER'S NAME A el '-ri Z_ PHONE #, _ S 5' 319b
MAILING ADDRESS 1- ncoly% P d A,4m m Ua 4 t /V ! Jo57
APPLICANT ls' s � o o5 �Ah , 5ee yi& ..S C`I bc�_ g E J f r /91
Name & Relationship (i.e owner, tenant, contractor)
DATE FACILITY TYPE kP__S41lf(.VL1 PCHD COMPLAINT #
PROPOSED INSTALLER' PHONE #fzp q�
ADDRESS Cr2t 4 t✓ REGISTRATION /LICENSE #
:S C)-7q
Proeosal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
I, as owner,agree to
SIGNATURE
(owner)
I, the septic it
SIGNATUR
(Installer) '
this form .
DATE S
ions of this permit for the septic system repair
A 1
TITLE Oc) �n� � DATE 1
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pro osal Approved Proposal Denied ❑
If, 1e� /1" 410
I pector's Signature & Title Datd Expiration Date
Repair or000sal is in compliance with applicable codes Yes No D
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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ab� � -,, Dlel� e[I�eLeatmaulal HaaW 8an'le�e. 4a�e1I�i.Y. D4137t tDa Pese+Oda � e �
SIMCMMICATROFCCROUAM
7 PW= "11'=WAft 111111on" UM= Femm. 0
L4 td ri
BankP•� .�
[� -� 91i.
Ot+a /A�rt
ialltri ii7i f)►q,2i�Ti�1,�.,L —.__ �. I'L ec ✓
—, ••� Daiae a= Prevlaao AjF��- �cj c_., / '7 i �g3 � '(
11.■rrD Aiwa ►�FL� i�_:3t' J67 Town z1p -J S'l
p, a Subdivision Annrov d Fee Enclosed ❑ e,,,-,,,,*
IM A.
Fm Sol 11111
Daalyt Flow G P D JJ,, PCHD N H �q� When la IS ease kd t
� SlM� is issad ) d Gasoo Slob Tub md-144
Ty be, eaoaaatei,ry—
Wag"' SII!!b Fimo• Addreea -- y
an
I repremu-that 1 am wholly and completely nsponslble for the design and location of the proposed system(gs 1) that these rate saw di!a��YI s�yyatom
County will b• constructed d shown on the approved amendment there to and in accordance With the standards. rules a regu ns o7- i�i"Rinarin
Oounty DopartnNnt OI' ►1aeNh, and that on completion, thereof a'*Certifieate of Conatruetton Compileneo" atlsfactory to the Commissioner of McPutna ll
a submitted to the Department, and a written guarantee will a furnished the owner, his fuCOMW16 Miry or assigns by the builder, that aid builder will
film in good operating oandttlon any Dart at aid eawago disposal system during the period of two 2
or of the apP►Owal Of the Certificate of Construction Compliance of the O.IginaI system or any rooks years . Z) ele lately following th dad�de� ado
wW M kliated as 111M on the approved plan and that aid well will ha installed M acoorean with r std
AMY of ►Iaalth 4 ules reguM oWss-of the PutMm
Date 4, g. ��
Sa,nee
Address
APPROVED POR CONSTRUCTION :Thh approval
revocatile.for cause or may be an:er:ded or modied when considered sn recesary by
t the Commissioner ofruMOSlth of he cAeng eMOrhaaltberceatbnOtroor�structlons
reouUea a Permit. Approved for disposal of domestic sanitary sew and /a phrase water supply H only.
Due.
PUTNAM COUNTY DEPARTMENT OF HEALTH
V. 3116 Division of Environmental HeaIW Servlcelr, Caimel, N.Y. 10512
Engineer Must Provide
1 I - -- P.C.H.D. Permit li -
.�... �. •` v..�ar..rs+.a. . ,+ .....o-.. .. �.:; -a��- _..+.... _ ^� -- +.w .P. .- ....— ...•... -I-: ..... ....... j ... ....:p- ..may..•. -..ter ..o-- rs.. -.
�
7 � '^ .��• � p ..•:„ �. � �• FOR SEWAGE- `DISPOSAL SYSTEM} _., � ,� ~ y • / •
CE CATE OF CONSTRUCTION COMPIdANCE Town or V -�
Located Tar; Map_ 1 BI Lot. L
Owner/ Ilcent Name �� 2 l /mac /1 a Formerly Subdivision Nam ubdv. Lot N
9 r Zip ADS � Date Permit issued
1VIaiWng Address
r �� �oa..o r� t) �[k'� C
Separate Sewerage System built by Address
Consisting of - Gallon Septic Tank and
Water Supply: Public Supply From / Address
or:� Prlvate Supply Drilled by� . ?dJ " ° c Address�'T7 ----
Building Type -sj�n Has Erosion Control Been Completed?
Number of Bedrooms Has Garb a Grinder Been Installed?
Other Requirements / r
I certify that the system(s) as listed serving the above p emises were constructed essentially as on t plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and regula in ccordan th the f le plan, and the permit issued by the
Putnam County eat Of Has h. i /�j n
5) Certified (b P.E. Z R.A.
Oats _ /
Address
License nea No.
Any person occupying premises served by the above system(:) shall promptly take such action as may be necesar to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become hull and void as soon as a pub(: Unitary sewer becomes
available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are
subject to modification or change when, in the judgment of the CommissionW Of Health, -h revocation, modification or change Is necessary.
Date `�� ��`'- O �P L�—�r✓ eye /
i
PLPH'R)AlY! COYRY DEPAWrMM OF KM TB
Division of Env04ommlental Health Swvkm. C=m d. Fl.y.19512 augineer to Pnvide Poemtlt d
om Cfl RTIFICATL: OF COMPLIANCE
CONSTRUCnON PERM FOR SEWAGE DISPOSAL. STSTM PesmOQ d �
Nam tebd. let +y -., z,..
Tan Map Ltlsr$ i
Danes /AppDtcamt Name M01=70 �{� ��� t G � Llenewal____ ❑ � �n
Date of Pteviona Approval �C> 9'� ' ` "�
It Addre®o —% �i+t1 �L�l7 To". m 2�lp 0�24�
Banding Type 1=> I Let Area - ` `0 �� AIC-
Nttmbes of Ltedtoem® Fm !F�CHD don Only Depth_Vobun®
Deatgu Flow G P D �%� Nod&m&n Is Renulred Wben Fill le completed
B Ya �PGallon Septic T.* rand �� �-- A t
Separate Sew "e system 4o conelta4 of
To be oaimbucted by_ ^ \ t �� s
Water Supply: Pu blle Supply From Addreas
or: kPPrivate Supply Drilled by � ' .� /`Add,=
Other Blequireaaents
I represent that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules—and regu a ,ons o e u nam
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance', satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written 'guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will
Place in good operating condition any part of said sewage disposal system during the period of two (2) years im diately following thedate of the Issu-
ance of the approval of the Certificate of Construction Compliance of the original system or any repairs theret 2 that the drilled well described above
will be located as shown on the approved plan and that said well will be installed . a Ord ce wi the sts rds rul a
County Department of Health. egu aZiions of the Putnam
Date , ' p �l Signed t�
P.E. _ R.A.�Ir.
Address___ License No ,;
APPROVED FOR CONSTRUCTION; This approval expires two years from the date issued unless constructs n *of the building has been undertaken and Is
revocable for Sjuse or may be amended or modified when considered Vicessary by the Commissioner of Health. Any change or alteration of construction
requires a permi Approved for disposal of domestic�sanita�ry'' sewage, and private water supply only.
Date / BY 'e, �-'"cD
PLTI N AM C ®11M'fY DEPARTMENT OF HEALTH
(� Division of Environmental Health Services, Carmel, N. Y. 10512
ENGINEER TO PROVIDE PERMIT #
ON CERTIFICATE OF COMPLIANCE,
PERMIT PV -5 -85
CONS UCTION PERMIT FOR SEWAGE DISPOSAL -SYSTEM
Town or Q age
Located at Lincoln Rd ° Tax Map 73 Block 1 Lot 17.2
Subd. Lot t Renewal _ Revision _JA May 1j 1986
Subdivision
Owner /Address Stanley & Stella Brown _ 434 Cove.' Rd o y Date Of Previous eval A-nri 1 R 1 AR5
lAT I�dl[L V a 1.i c
Building Type `S o F o D o Lot Area ° llJ Fill Section On y
Number of Bedrooms Design Flow G /P /D 600 P.C. H. D. Notification Required Yes
Separate Sewerage System to consist of 11000 Gal. Septic Tank and 37 5 L. F o x 210 trench
210 -B Peekskill Hollow Rdo
To be constructed by
J °Jo Construction Address
.Putnam Valley, N.Y.
Water Supply:
Other Requirements
Public Supply From
X Private Supply to be drilled by
Address
Perimeter seal
is
&.Sons Inc.
vepa, , Brewster, N.Y.
curtain drain & 3' fill section.
I
1 represent that 1 am wholly and completely responsible for the design and,location of the proposed system(s); 1) that the separate sewage dsal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules n a regulations 'T ispoe Putnam
County Department of Health, and that on completion thereof a "Certificate - of Construction Compliance" satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will
place in good operating condition any part of said sewage disposal system. during the period of two (2) years immediately following thedate of the issu-
ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be Install In ccordance with the sta rds, rules and regulations of the Putnam
County Department of Health.
Date May 1, 1986 S P. E. X
Address Perk's Blvd., Cold S- rijacr. N.Y. 10516 License No. 49nng
APPROVED FOR CONSTRUCTION: This approval expires one y r from date is d unless construction of the building has been undertaken and is
revocable for cau of ma be amended or modified when considers n ce by th missio er f Hoe h. Any change or alteration of construction
requires a new p r- ' A ved for disposal of domestic sani r e, and
/o ri e r ply only.
Date By A/ Title
r v PUTNAM. COUNTY DEPARTMENT OF HEALTH_ ic 1 Permit i P ..
Division of Environmental Health Services, Carmel N: Y 10512
} Putnam VAlley
.:, &ONSTRUCTION PERMIT FQR SEWAGE DISPOSAL SYSTEM rage
Linco'n Rd., Put5lam Vai'le;-
""�•��° _�... -�.:, .. - -� •.Bl�c`k ". .. ....r,:•g ..Lot b 17 • �._.. .. -..�;
Located at Tax Map
Subdivision
'owner /Add ;e:
. Stan'ley &. 'Stella Brown
Lot N Renewal _ ❑ Revision _ ❑
Date Of Previous Approval
S F . D... 1.05 ac Fill Section Onl ❑
Bu;Idm9+T�YDe ' Lot Area -- y
4
Number of Bedrooms Design.Fio . . H. D. PC N D Notification Required
l, /Plop
L
Separate Sewerage System to consist of Gal. Septic Tank and 500 L F X 2'-0 trench r'
To be constructed by Address
Water Supply: Public Supply 'From
} _X Private Supply to be drilled by Norman ANderson, Putnam VAlley, N.Y.
Address
Perimeter seal i.ndicated on plans. Placement of 3' of fill.
Other Requirements
I represent that I arty wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage dispose, A.W. stem
above described, will be constructed as shown on the approved amendment there to and�:in accordance with the standards, rules an regu a ons o e am
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner.of Healthwill r
be submitted to the. Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns. by the builder, that `said builder will 4i4
place in good operating condition any part of said sewage disposal system during the period, of two (2) years immediately following the date of the issu-
ance of the approval of-the Certificate of Construction Compliance of the original system or'.any repairs thereto; 2) that the drilled well described above
.will. be located as skwvn on'the approved plan and that said well will be install accordance with the standards, rules and regu a ons of the Putnam a+
-County Department of, Health.
Date Nicer 7:� 7 �3R5 Si - w
' P.E. X R.A. +
Pork's Blvd., Cold S ring, N.Y. 10516 49002-"
Address p g License N0.
APPROVED. FOR CONSTRUCTION: This approval 'expires one,year from the date' issued unless c s ction of the building has been undertaken and is
revocable for cause. or may be amended or modified when considered nec ry th ommissio of Health. Any change oration of construction ^r
requires a ne r per A o or disposal of domesti nits age, . ntljo p vale - - --
.. =�
Title.?
Date BY 9j
r� Rev. 9 -81
d
`
I
PMAMcouNTr DEPARTNM oFaEALTB
. o Division of Environmental Hesllth Servkfae. Carmel. N.Y. 10514 Engineer to Provide Petmit
on CERTIFICATE OF COMPLIANCE
-.•" ('T.CE3dII?!':Tdfi �.sx ':nn ..ee.,.i�:r vvu�wi�i ": - Permit _M
Located akt �I /I1_"oW
Subdt,Wm Name
Owner/,
.. .,, •.' ¢eg ..�-. �.•- 1 L% � fU1 ->.P" \,•• "- ^«a.ae.�.iw+iww.�w .... I�-�'7
F
Town or Village
Tax
.Lot I I
] 1..,;?
t Date of Previous Approval �( � I � to j S
Wiling Address '17isdei'1�4Ki I>:/� Town M4 t n.
Building Type kr�tti'p Lot Area dt?
Number of Bedrooms Design Flow G P D PCHD Noti9cation Is Required When Fill completed
`3 Cep C�
96paraft Sewerage System to consist of p� on Soptic Took crud__ �',J i - � _ Lk Ll
To be constructed by v 7�) Address ~R
Water supply: Public supply From Address !!
or: Private Supply Drilled by
Other Requirements: �v1 N1 �h? 1r_..[ �L V -- M � ���
�+ - 3-
1 represent that I am wholly and completely responsible for the design and location of the proposed system s); 1) that the se
( parato sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regu a rons o 0 Fulnern 7
County Department of Health, and that on completion thereof a °Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
,be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will
.%ace in good operating condition,any part of said sewage disposal system during the period of two (2) years immediately following thedsts of the Issu-
;e of the approval of the Certificate of Construction Compliance of the original syste or any repairs f veto- 2) that the drilled well described above I
\be located as shown on the approved plan and that said well will be install anc with th d rds, les and regu a ons of the Putnam
ntY Osprrt nt�of H lth.�7
Signed f P.E. R.A.
i
Address —Z22 License No
a
VED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of/ a building has been undertaken and Is
s for cause or may be amended or modified when considered necessary py the Commissioner of Health• /Any change or alteration of construction
; now permit Approved for disposal of domestic sanitary sewage, and /or priv two vwater supply only. /��� '7":7
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FINAL SITE INSP°CTION
• InsFe_•ted by r
•;CATION % �`" •`I C G �� a /� Civ2lE S (- . -
-� '-7 3. /
a !1 r �-_- el <-- mm 4 nn cr=nT-u -m TrW. Tuff #
• . ..i'. �."' .p..T .F.. ^was- r:e.Ja,r:w .. - [f -" --'rc �.. _s .... .. .. .r. -. _ ..+�.
S=face'drainace arcund
:.J.N:f- .:raYkiv•wr -.n -. „ - �ii�...,!n
IVIJ L Ljr•
Sr y�_..- DISPOSAL AREA
a. Sus area lccated as per armroved plans
b. Y U section - Date of placQnent
2:1 barrier. . LGM . WIM "a AVG.DPTH
-?
✓ � , a.
c.
Natural soil not stri rcd
AL pipes flush with in
d.
d'.
Stone, brush, etc_, greater than 15' from SDS area_
C , -tain drain installed
f.
e.
100 ft_ from water course /wetlands. '
Frotinq drains cu.— scnarai
h.
Si3 TMEF DIS'r'OSAL SYS=
a. Sentic tank size - -14W 1,250
L
oszcn concroi nrnui r?i
b.
Septic .tank installed level
c.
10' minimum fran fcundation
d.
Nc 90° bends, cleancut within 10 ft. of 450 bend
Ai
e.
DISTRIBUTION EOX
1. All' cutlets at same elexraticn - water, testers
I
2 _ Protected be? cw frost
{ a /7
3. Minimum 2 f t. criginal soil be taeen box and trenches
E.
JUC=ION EOX = rcce_-1v set
I I
Z
1. Lencth rear - I,encth 1n5ta11 ea
--
2. Distance to wat=ccurse measur ft.
3 . Ins a 11 f_:-- acccr=cr to plan I'
4. Dis Dance center to center
5. Slcrz of trench accemta ble 1/16 - "1/32 "/foot. (
I
6. 10 feet f_an prcre—rty line - 20 feet - four_daticns i
I
7. Depth of t_e_ncn < 30 jzic'hes fran surface 1
1
8. Rcan alleged for e cansicn, 50% 1
I
9. Size of Gravel 3/4 - 1 #" diameter I
'
l0. Deptn of =vell in trench 12" mi nimtnn
L. Pine ends Grpe.^_
Z.
PMED OR, DOSE SYSTRAIS _ _.....I
'Size' of ` i� c�amce�� e . -..... �.. �: �-__...- ..._...........................
...
- �.. -...
.. • ...�..... �.
2- Ch7t= -fI cw t_7nk l
3. Al;; =, visual /audio
4. Puma easilv accessible manhole to cr
5. First bQx Yaffle---;
6. Cycle witnessed by Health DeDartnent
estimated flcw per cycle
IV. MUSE
a. Fcuse located per apnrcved plans.
b. Isk-mcer of bedroans
V. WML
a. We?1 located as per approved plans
b. Distance fran SDS area measured
C. C asinq 18" above a'rade.
d.
S=face'drainace arcund
VI _ OVaq;vr . 6yORkCyi ASHIP
a.
Yes properly arcuted
b.
A -I pines pc -, ally bac
c.
AL pipes flush with in
d.
Badkfi11 material conta.
e.
C , -tain drain installed
f.
Certain drain cut all
g.
Frotinq drains cu.— scnarai
h.
Surface water prot°✓tiei
L
oszcn concroi nrnui r?i
e.
Lde
ft. '
de of box
s stones < 4" in diameter
ccordin_q to plan
tected & dir.to ecist.waterc
awav from SDS area
adeauate
cn slopes are_=ter than 15 %.
i
PLTrNAM COUNTY DEPARrMENr OF HEALTH - DIVISION OF ENVIRONMENZAL HEALTH SERVICES
INDIVIDUAL NAM SUPPLY SUBSURFACE SEDGE DISPOSAL SYSTEMS
.n:,.- - �Tf- e.;.�"•, ;,.:v.. .;.:, " . %uSti _.� ~ .. _� � >. .�r/'y'� "iiVa7r�A..A1VtV •BVGC'l�[1 .,. c;.�^,,. �.. .. p:R�.•��ir,�. %,u% ._.s �/ i.. v';.+.��f "�vp-•is,,,• ;i':i•-y',
0�-4 -� e�►1,z,/ Jclwt
aQ.T J (y. a J.arury DATE:
INSP. BY:
(Name of Owner) (Street Location)
INITIAL SITE INSPECTION US NO I CM4am
Wetlands on/or proximate to property ..............
Property lines or corners found ............... >...
Can estimate house location ° ..................0.000
Will driveway need cut ............................
Mast trees be removed - note these................
Deep holes representative of entire SDS area......
Additional deep holes needed ......................
Sufficient SDS area available considering driveway
cut, house location, separation distances etc...
Adjacent wells /septics ....................0010....
"1110 -, _7' JIL)f
D.H. 1 Lot Lot
�to G.W. a' Depth to G.W. Ca! _
Depth to rock Depth to rock
Soil DescriDtii
0 ft.
1 � , , ue k
3 ft. �)�m �ZOL r
6 ft. wad
Soil Descriptior
0 ft,
3 ft.
6 ft.
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 Lot
Depth to G.W.
Depth to rock
Sou Descrl
0 ft.
3 ft.
6 ft.
9 ft. 9 ft. 9 ft.
12 ft. 12 ft.
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
CIXMMENrS
House SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable.........
Roam allowed for expansion trenches ..............
Over 100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded ............................
10 ft. maintained from property line and
20 ft. from house ..............................
Distance well to SSDS (ft.) ......................
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ................
15 ft. of-peripheral soil horizontally
from trench ..... ...............................
Boxes properly set .............. 0................
Could surface runoff from driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
FINAL GRADNG OF SITE ACCEPTABLE ..................
1 /
DEPARTMENT OF HEALTH
Division of Environmental Health Services
WO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
m .pJi -... tstly!!: -. � -' . -. - .r 4✓•":• -i. .w- . .. - - _ •- •. ,.- ;.- .I�.- .. -.I :. a•... • .. �... - ..•r'+...��'.•. J.t i, tn..
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
}1 Street Address
Town/Village/City Tax
GridN']umber
WELL OWNER
Name Mailing Address
Ck p
0- Private
O Public
E OF WELL
1 primary
2= secondary
EkdSIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
[]OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED /EST. OF DAILY USAGE4SO ' gal
REASON FOR
DRILLING
M31EW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
❑ TEST OBSERVATION
DETAILED
REASON FOR -
DRILLING
-�
WELL ' TYPE
[31IRILLED
DRIVEN
DUG
GRAVEL ❑ OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L/ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:1-czc���4�
Lot No.
WATER'WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM'NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
AR OF THIS APPLICATION SEP T
(date) natuKg)
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 1� �,7
:
Date of Expiration: 19 ermlt ssuin f i
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 rlranrrc ry rnr- Gicl 1 nri 1 1 cr
POST OFFICE ADDRESS
RFD Z PUTNAM VALLEY. N. Y.
10879
914 838.3333
TOWN OF PUTNAM VALLEY
NEW YORK
Paul J. Kastuk , Highway Stip 1 t .
f
April 4, 1985
County Health Department
County Building
Carmel, New York 10512
ATT: Mr. Robert Tort(ani,
Dear Sir,
The Putnam Valley Highway Department agrees to re- direct the
flow of water from culvert pipe under Lincoln Road, which flows on to
.parcel of land, Tax Map No, 73- 1- 1.7,2, that Mr, Stan Brown plans to
purchase.
This will be accomplished with the installation of a.catch basin.
ft " of Y - tMt P peYtg�, .� v....
P- Fe�ove-r -to • €i y "foo, "right of-
-r--to ad;�en. ,, ro -.- -
This will be done before Mr. Brown commences site 'improvement work,
Sincerely,
PAUL J . STUK -/
Highway Superintendent
DAVID D. BRUEN
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Mr. Lawrence Belluscio
Perks Boulevard
Cold Spring, NY 10516
Dear Mr. Belluscio:
April 23, 1986
r.
JOHN SIMMONS, M.D.
Deputy Commissioner
Re: Brown SDS Construction Permit Renewal
PCHD Permit PV.5 -85
Lincoln Road, PV, TM 73 -1 -17.2
Review of plans and other application materials relative to
above referenced property received 11 April 1986 has been completed
by this Department. Based on site inspection on 17 April 198
a.review of the construction plans dated 7 March 1985 and'pursuent
'to Article III of the Putnam County Sanitary Code and Part 75 of
,the New York Official Compilation of Codes, Rules and.Regulations:
You are hereby advised that the proposed method of providing
sewage disposal and water supply are considered inadequate for the,
following reasons:
r 'l..r� -" T g}�: oiirid_�wa;ter.:was =f4'vx}d• .to exist -withirr- :2Z-- f- eet..o:f,- g-rade,.. _ _ -
2. Less than 50 feet between sewage disposal system and "catch - --
basin or pipe outlet has been provided.
3. Less than 100 feet to a year round stream or 50 feet to a
seasonal stream has been provided.
4. Location of wetlands on property and separation to sewage
disposal system has not been indicated.
As such approval of proposal cannot be•granted. If you have any
questions, please call me at 225 -3838 or 225 -3833.
Very truly yours,
James S. Hodgens
Assistant Public Health Engineer
JSH:amm
cc: / File
Stantley and Stella Brown,434 Cove Road, PV 10579
JSH
TWO COUNTY CENTER - CARMEL, N.Y. .10512 (914) 225-3641
D
f
r
RPo�2. PUTNAM VALLEY. N. V.
_ 1057@
914 526.3393 = i`
TOWN OF PUTNAM .VALLEY
NEW YORK
Paul J. Kastitk, iiighway SAIp't.
April 4, 1985
County Health Department
County Building
Carmel, New York 10512
ATT: Mr. Robert Tortoni,
Dear Sir,
The Putnam Valley Highway Department agrees to re- direct the
flow.of water from culvert pipe under Lincoln Road, which flows on to
parcel ' of - .land, Tax Map No. 73 -1 -17.2, that Mr. Stan Brown,plans to
purchase.
This will be.accomplished with the installation of a catch basin
_., t acrddtrona� p 2Fe:: aver. :to ; f;%.f.t.y, fp4t. righ_t;c =rywa;_adjacent to property • -
This will be done before Mr. Brown commences site improvement work.
Sincerely,
J
AUL J. STUK
Highway Superintendent
PUTNAM COUNTY DEPART OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
FIF�I,D, INSPECTION;,REPORT.,.
DATE: ~17
G1 �sa�lrt'�,vtit� _ �1 INSP. BY:
(Name of Owner) (Street Location)
INITIAL SITE INSPECTION YES NO COMMENTS
Wetlands on /or' proximate to property ..............
Property lines or corners found.. ........ o ....... o Can estimate house location .......................
Will driveway need cut ............................. /U
Must trees be 'removed - note these ................ +�
Deep holes representative'of entire SDS area......
Additional deep holes needed......... .... ....
Sufficient SDS area available considering driveway Z
cut, house location, separation distances,etc:.. ? 2 � CB?
Adjacent wells /septics... ..
D.H. 1
Depth; G:W.
Depth to
3 ft.
6 ft.
9 ft.
D.H. 2 Lot
Depth to G.W.
Depth to rock
Soil DescriDtia
0 ft.
3 ft.
6 ft.
9 ft.
`. i 2
D.H. - Deep Hole
G.W.- Groundwater
D.H. 3 Lot
Depth to G. W.
Depth to rock
Soil Des cri tion
0 ft. I
3 ft.
6 ft.
9 ft.
DATE:
FINAL SITE INSPECTION INSP.BY:
YES
NO
COMMENTS
House;SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope,of tile line and trench acceptable.........
Room allowed for expansion trenches..............
Over 100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded........... ... ..........
10 ft. maintained from property line and
20 ft. fran house ......................... .....
Distance well to SSDS (ft.) ......................
Number of bedrooms checks ........................
Stones, brush, stumps,.rubble, etc., greater
than 15 ft.;fran nearest trench.. ..........
L5 ft'. of peripheral soil horizontally
from trench ..... ...............................
Boxes properly set...... ... .....................
2ould surface runoff fran driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
EINALiGRADNG OF SITE ACCEPTABLE.......... ....
MM
.�Q
u�
; ,:. �., :�•4•, ". - f PUTNAM'..COUNTY 'DEPAR'IkPP-*'61? r-HEALZ11.
DIVISION OF ENVIRO'11M MAL HEALTH SERVICES
me
Owner or Purchaser of Building
Building Constructed by
Location - Street
L
Municipality
Building
Section Block Lot
Subdivisio4 Name
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
.,:_.o- .,,,.o on. any, pArt,. of . said system constructed ,.by me ;which : fails toy..
__...� _. _. ... _ _ _.
operate -for a periocT of t 3o years immec3ia ely follaiaing fhe"�a£e 6 --& proval- 'of -tlie
"Certificate of Construction Compliance" for the sewage disposal system, 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 Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system t to was
caused by the willful or negligent act of the occupant of the ' lzaing utilizing
the system.
A n ,
Dated this day of inn4 19 Signature
Title
General Contractor (Owner) - S gnature
Corporation Name.(if Corp.)
LA- httan a UIR 1A //104
d�diress
zev. 9/85
mk
Corporation Name (if Corp.)
Address
/4 C� ®O /I. T-T TTT1Al'fT
WELL UUr1rLL11UA rrrUni
y :,* DEPARTMENT OF HEALTH- .
��• , ", = 'u�'w•i7ivisori1.Of �Environinental `He�al`th ~Services -
FIB Y� PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
��� '
WELL LOCATION
STREET ADURESS: WN/ l TAX GRID NUMBER:
Lincoln Rd. Putnam Valley,NY
WELL OWNER'
NAME: ADDRESS:
Edward Stevens, 9 Brook Lane, Rye.Brook,NY 10573
p pgIVATE
O PUBLIC
USE OF WELL
1- primary
2 -.secondary
II@ RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
❑ BUSINESS O.FARM O TEST /OBSERVATION O OTHER (specify)
p INDUSTRIAL O INSTITUTIONAL ❑ .STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH zo 5 ft.
STATIC WATER LEVEL 10 ft
DATE MEASURED 8/25/$9
DRILLING
EQUIPMENT
C@ ROTARY XX COMPRESSED AIR PERCUSSd p DUG
❑ WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH _ 31 _.— ft.
MATERIALS: fI STEEL ❑ PLASTIC ❑ OTHER
LENGTH BELOW GRADE 30 ft.
JOINTS: O WELDED aTHREADED ❑ OTHER
DIAMETER __ S --,--in.
SEAL` J] CEMENT GROUT O BENTONITE O OTHER
WEIGHT
PER FOOT — 19 '1b. /ft.
I DRIVE SHOE OYES ONO
I LINER: DYES ZI NO
SCREEN
DE TAILS
`
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
_
o YES o NO.
HOURS,.
SECOND
GRAVEL PACK
❑YES
❑ NO
GRAVEL
SIZE:
.DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
OEM It.
WELL YIELD TEST If detailed in um
P P 9
METHOD: ❑ PUMPED i tests were done is in-
(COMPRESSED AIR , formation attached?
O BAILED ❑OTHER ; ❑YES ❑ NO
WELL LOG ` 11 more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
Bear-
ing
Well
Oia-
meter
In
FORMATION DESCRIPTION
G70E
ft.
tt.
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It,
YIELD
g(;m.
Surface
10
lDrilline,
in overburden clay &
bl .
it rock at 10'
205
6
185
7'—z
0
31
Drilling in rock,set casing,g
ou
granite,
WATER O CLEAR TEMP.
DUALITY ❑CLOUDY HARDNESS
❑ COLORED 'ANALYZED? .O YES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK : TYPE E
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME P. F. Beal & Sons , Inc unT�/ 0/90
ADDRESS PO BOX B IGTJ1tTURE
Brewster,NY 1059
3/89
Irs .
ed.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
'WO COUNTY CENTER - CARMEL? N.Y. 10512 (914) 225 -3641
r � -.a an;. .'.. . "`,'M _..... .: .:. .. 1.`-1 .��- s -t�. -o :r �r Srwi .�f 7r•'.. .I`_i ... -.� n., _
APPLICATION TO-CONSTRUCT A WATER WELL ,p�/•5
PCHD PERMIT #
WELL LOCATION
Street Addres
,Two Village City Tax
Grid Number
Name
Mailing Address
GWrivate
WELL OWNER
M kJ L-• ,-
7 L-0"0 o
13 Public
USE OF WELL
OIRESIDENTIAL
O PUBLIC SUPPLY C AIR /COND /HEAT PUMP
® ABANDONED
1- primary
13 BUSINESS
O FARM O TEST /OBSERVATION
O OTHER. (specify:
2 - secondary
® INDUSTRIAL
0 INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
5 gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE -4�gal
REASON FOR
UNEW SUPPLY
O PROVIDE ADDITIONAL SUPPLY
® TEST /OBSERVATION
DRILLING
O REPLACE'.EXISTI G SUPPLY ® DEEPEN EXISTING WELL
DETAILED
lio
v
�.REASON'AFOR
DRILL•I•NG .
-WELL TYPE
DRILLED f
[DRIVEN Li GRAVEL
® OTHER
I' i WELL SITE • SUBJECT "TO' FLOODING,?., YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name 77, Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES L,--'NO I
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 T SHE
C) f FT?
(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 s.hall:
1.
2.
3.
Date of
Date of
Permi t
2/87
Pump the well until the water is clear.
Disinfect the well in accordance with the requirements of the Putnam
County Health Department attached to this permit.
Submit a Well Completion Report on a form provided by the Putnam County
Health Department.
Issue:�`�" 19
ermit Issuing f icia
Expiration: 19
is Non - Transferrable White copy: H.D. File
Yellow copy: Bui.ldin Ins'pect�or
Pink Copy:
g
Owner
Well Driller
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\ a plicati n for:
represent that I am an o ficer or employee of the corporation and am authorized
to act for�l�f ='sl�J
(Name of Corporation)
having offices at �� cc� %� �t i•
Whose officers are:
President: 'MbP
(game and Address)
Vice,— President:
(Name and Address) l
eere.tirya._
Treasurer:
(Name and'Address
RLIGrim
<<
(Name and Address)
and that I am and will be individually responsible for any and all acts of the
Corp o ration with respect to the.approval requested and all subsequent acts relating
theret).
Sworn to before me this /6 day Signed:
of L. rn 6s �� 19-' Title:
Nota= Public;
y J
;KEVIN L WRIGHT .
Notary Puft State of New York
Qualified in Putnam County '
Commission Expires
\� 8/84
5
4 .1\
1
Corvorate.Seai
� e
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.t�'L :t {: J.�.n.Il��.w ... .4uti Ya r x �` R.. l� � •i � x .. - - r
Date ^
?7 c
Re: Property of bL�dIi7 \Az
Located at
(T) Section Block t..`, Lot I.
Subdivision of
Subdva Lot # Filed Map ## Date
Gentlemen:
This letter is to authorize V V/ e C'14 e=-L.' r\-t-y
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 systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersi-g
PeEa, ReAe, # z
Address
Telephone
Very truly yours,
MO
1 'NJ\
Signed
Owner o
n
Address
Telephone
perty
d
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- COUNTY'OFFICE''BUILDING,- - CARMEL, N. "Y:
DESIGN TA HEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner 4 ... a �... �row.n Address 5�3Y c.o✓e. .. 7v +�4�•y, 1Ja. sy7 . y. .
Located at (street ) ,L/ j .Aeot H Sec. ..73 Block Jr 1 _Lot '! I. 'L .
Indicate nearest cross
" street)
Municipality ! w H w ry 1 ti &M (_ 4 �y+atershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
. .0 7
y
I f 3
Number
CLOCK TIME
PERCOLATION
PERCOLATION
/a%
Elapse
Depth to Water
Water ve
No.
Time
From Ground
Surface in Inches
Soil Rate
30
Start -Stop Min.
Start
Stop Drop in
Min. /in drop
Inches
Inches Inches
1
11:333 11; 5'L I S. S-
/ qyz.
30
ce
i4 2 .-7 s-
eto'.
3
/2 :13V =[z:jl 2Szs-
!Y
4
12 :Yo / :o7 y' ;Z 7.75-
/ y
/7 3,
t. zy —•
1
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 from top of hole.
. .0 7
y
I f 3
9,33
`A xy 1
1/: b I
/7.'7S .
/a%
,SyY 3
Sa/
3
12; /(PV 12'.g&r-
30
[ 'L
I ?/,g 2.e75'"
i
1:43
30
1IA—
i4 2 .-7 s-
eto'.
1
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 from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS 11,MOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
611
1211
1811
2411
3011
3611
4211
4811
5411
6011
6611
1211
7811
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED st
- 9- -WATER
INDICATE- -LEVBL-:--T0--11 .-IBV-EL--,--.,RISESt-A-FT-ER-,BEING--ENCOUNTERED�
-NaTe-
STS
DESIGN
Soil. Rate Used Min/l"Drop: S.D.. Usable Area Provided- <LAC
No. of Bedrooms Septic Tank Capacity 11�6 Gals. Type
Absorption Area Provl—ded By 0 L.F.x241'
-,i�,, ench.
Name Egmill w3g�l-b bignature
Address & It rr- S Pe-ek 45 i SEAL
gf,-2(d 6
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft/Gal. Checked by
4 114�1 -
A.
r.0 4,
Alf%
�o
J.
0)
Date
i
PUTNAM COUNTY DEPARTMENT OF HEALTH_
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
r'T.... ... r. w.. :f. + _ - .....Y... r.� _ . f ,.VCr : .:T'.' n,. • .-T •.f,, .. .rTR.. _..r. r..... .s�.. .' ..
COUNTY OFFICE BUILDING,'.CARMEL, N. Y. 10512'
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
_.,.Owner ���,�c> �;�•,�� �-� iA� ��cs:y Address
Located .at (Street ,-Ilq6a_;v Block 1 Lot 1.-7,2-
61cate-nearestcross street)
Municipality -mac 1)nfJ[..r Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
z- (
31
'L 3/4-
Number CLOCK
TIME -'�
PERCOLATION
PERCOLATION
Run
Elapse
-Depth
to Water 'Water
Level
No.
Time
From Ground'Surface
in Inches Soil
Rate
Start -Stop
Min.
Start
Stop
Drop in-- Min. /in
drop
Inches
Inches
Inches
2 0 0
3
C�
I
9 -71
Z' �
to's
314
7 3td
z 4....0 J
C
�
0.
19
z- (
31
'L 3/4-
ZI' /D
i.5
`I—
1 5
Notes: 1) Tests to be repeated at same depth until apppproximatelyy 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
_DESCRIPTION 'OF SOILS ,ENCOUNTERED IN TEST HOLES _
._. a .'... Re. 1e. •1 .._..- . - C2 .I rna a •.. iP. s ♦`..l .._ .. I. ..•�.i- . _.
DEPTH' HOLE NO.- HOLE NO• "Z_ HOLE.. NO.
G.L. c •, car -� r L
6"
1811 < <
2 n
30,1 k' Ir
3611
4211 ' of
4811
5411 1 r 1 1
6011 i r
1r •1, _
6611,
7811
i1
8411 r
Ci�,, t� r
. INDICATE LEVEL AT WHICH GROUND WATER IS .ENCOUNTERED __ Cd
dT�IuATF,e L:TO:.tii�f ICH..WATER ._ T -RISES AF' EP, BE? T�� ENCOUNTERED
_ - - TESTS MADE BY :X_- r w.
, DESIGN-
Soil
Rate Used II-49 Min/1 "Drop: S.D. Usable Area Provided
f ,
No. of Bedrooms Septic Tank Capacity co Gals•
Absorption Area Prov ded By F•x24" width hetrenc •
Address - ZCl SEAL - o'
i"r a c4✓l
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY • �o o • 048AGO
Soil Rate Approved Sq• A /Cal. Checked by Ess«