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03575
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PUTNAM COUNTY HEALTH DEPARTMENT o O
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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YES &0- Internal Use Only PERMIT 0 LAJI
❑ pair Permit issued in last 5 years 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 � TOWN v�,v�q %l TAN # %, —1 N OWNER'S NAME ao ✓6v; ffln6d PHONE #
MAILING ADDRESS � A" ee o0*1v JAJ /oy�•��• y al gr
APPLICANT
Name & Relationship (i.e., owner, tenan
DATE ��G / 5 FACILITY TYPE PCHD COMPLAINT # ,54-/0
PROPOSED INSTALLER Agen"I jaC, �L�` -- c PHONE #. f
ADDRESS 2Z &9rtyed56, &aet� (�Jzn2 REGISTRATION /LICENSE #
Proposal (include a separate sketch locating the house, property lines, all adjacent tells 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. �^
'`Z � ✓om / / 6 hc,, �-r /eJYt a ✓� Y -r � /J :9 Ag ny
Z
I, as owner,agree to the condition stated on this form
SIGNATURE TITLEgf2&�vjvj ✓ DATE
(owner)
i; =tlae spt ?c-�n. Steller ;G'�re4Y0G�mr�ly�ujth..thc. rvii4SJC?s:cf -+ his - °!!?' -!t 0 t� 0SL'pt?P$ygli'r!"i.f °paf. _.._..._.._
SIGNATURE TITLE DATE -0
Qinstaller)
Proposal aooroved with the following conditions:
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 consider a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will functio
5. No completed work is to be
Signature & Title
until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
tZl Dni���
to -7(1
n' 4v-
Date
is in compliance with applicable codes
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Yes
Date
No ❑
Rev. 2/07
4:
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
REQUEST FOR FIELD TESTING
All information must be, u�lly completed prior to any scheduling. Date: Z7`"vc% Z�;,?O r3
Engineer or Firm: L" Phone
Person to Contact: _ 'ry
❑ New Construction
Reason: KDeeps
Road /Street:
Repair Program
❑ Peres ❑ Pump Test
Town: Tir�Rrri �!'
Subdivision:
Owner: �ioy.�,c%c/i A .Pa Z 2.e S f
❑ Addition Program
Tax Map #: �'S' 6 —1 —/ 4
Lot #:
Project not within NYC Watershed.
NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TES NG
..- .,vim..•...,.. ..,t• - ^�f-. �__. ._�...e..s.. ..-. ..., a .. .. —.. a... .._.. -. —, .... ... =r.r -•�- _ -..... 4q+.._r ... .,C...�.a. ow ...r... �. ...-� �.. ... .0 -..:y ..... a.., ...... ..... _,... �.+wr..r•.�.�
YES NO
❑ Proposed SSTS within the drainage basin of West Branch, Croton Falls, or Boyds Corner
reservoirs.
❑ El Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
❑ 59, Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
❑ a Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required.
❑ W- Proposed SSTS for a Commercial Project
It is the responsibility of the design professional to provide the above Information prior to soil testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the response.
if you answered yes to any of the questions, NYCDEP must witness the soil tests. This Department will
coordinate a mutually suitable time for field testing with the Design Professions and NYCDEP.
If a project has been determined to be Delegated based on the above response and then subsequent
Information indicates NYCDEP Is required to witness the soil tests, it will be the sole responsibility of the
design professional to schedule re- witnessing of the soil testing with NYCDEP.
FOR COUNTY USE ONLY
DATE: TIME:
COMMENTS:
I
Req.for field test:kly 4/16/2009
473 116
® o PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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APPLICATION TO CONSTRUCT A WATER WELL ll►t ® d� H
please print or type P,C�h—DH ?@ li I,?;# 3% _ W
Well Location
Street Address: Town/Village: Tax Map #
Map AA?• & Block / Lot(s)
Well Owner:
Name:
Address: 1
Phone #:$c, .
Use of Well:
is Residential _Public Supply Air /cond /heat pump _Irrigation
'l- Primary
Business Farm Testimonitoring —Other(specify)
2- Secondary
Industrial Institutional Standby
Amount of Use
Yield Sought gpm # People Served Est. of Daily usage
gal.
Replace Existing Supply Test/Observation Additional Supply
Reason for Drilling
New Supply (new - dwelling) ' Deepen Existing Well
Detailed Reason
/
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ....................................................... ............................... Yes
Nom
Is well located in a realty subdivision? ........................................... ............................... Yes —No
Name of subdivision Lot No,
Water Well Contractor: 454V ,i�r/G. Address: /464
146/)
Is Public Water Supply available on site. ......................... ............................... Yes _
No
Name of Public Water Supply: Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/pla .
.Date:. �/ i�' - - ::. Applicant Signature., :!� %� % �iG
r... e:. _ t_& store
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam Countv Health Department.
take appropriate action to assure that any and all water and 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.
APPROVED FOR CONSTRUCTION: This approval expired years from the date issued unless construction of the
well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified
when considered necessary by the Commissioner of Health. Any revision or alteration of the approved plan requires a
new permit. Well to be constructed by a water well driller certified by Putnam County.
Date of Issue d Permit Ispl Official: �
Date of Expiration 3 Title: , ,, { (, L •�„ �,-_
Permit is Non - Transfe
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Rev. 3106
_ c�a
PUTNA0I COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TIiEATNi ffiN I' SYST €M
owner:
Address: n � —� -- .--LAC
Located at (street): TM 4 Section. Block _ Lot
Municipality: Watershed:
SOIL PERCOLATION TEST DATA
Witnessed by:
Date of Pre - soaking: Date of Percolation Test:
Hole No..
Run No.
Time
Start —
Stop
Elapse
Time
(thin.)
Depth to
water from ground
surface
(inches)
Start - Stop
Water
level drop
in inches
Percolation
Rate
min /inch
1
Z
3
1
2
3
4
z.
1
2
3
4
�.
5
1
2
3
4
5
Notes:
1. Tests to be repeared at same depth, until approximately equal percolation rates are
obtained at each percolation test. hole. (i.e., < l min for 1 =30 min/inch, <2 thin for 31 -60 mini inch).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form DD-971. p� tor''_
TEST PIT DATA ,
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
_ -
DEPTH HOLE #rM HOLE # _ HOLE # HOLE # }HOLE #
G. L. ..t'
0.5' l .
2.0' LID&
2.5'
3.0'
3.5' Loa M
4.0'
4.5'
5.0'
5.5-- LoC- r^
6.0'
7.0'
7.5'
8.5
9.0' „
10.0'
Indicate level at which groundwater is encountered 0A e
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: Date
Design Professional Name:
Address: �—
S ipa= -ee:
Design Professional = Seal