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To ie' aiimbu eil by ' Aaa.mes
wdnr 2thy� F�
ea _FAseb S1111* Now by
Other 2at(�ira�ahtle
1 Ia"owl that 1 am wholly and compmety responsible for the design and location of the proposed system(gt 1) that the separate sawaae dl sYStem
abOVe dNRibed will be contt►uded as Shown on the approved anandment there to and In accordance with the standards, rules a regu M O
Oowtty Department Of Health, and that on eanplatiowthareof a "Certificate of Construction COrnpllanee" satisfactory to the Commissioner of NeRhwiM
be Vibloltted to the Oapertelent. am a - wrilterr rJormatee will be furnished the owner, his Mreosssas. he &$ or "$"a by the bunder, that sae bander win
poaee
in flood .OWN"* COMMON any Fitt Of sale towage dhposal sy.am durkq the period of two (2) yeas knrrledletoly following thedate Of the JIM.
1110a Of the *WOW Of ter CWtNtoate 0 Construction Cenlplierla Of the original system or any repaan th.fetoh 21 that the drilled well dose►tbed auger
ws N IOOated a shesrw M /M apprOrled path and that said well will be Installed M accordiijitom the nda les and fee—u a Ors f the putnem
Cewky De Mm" of tWtth. /�
APPROVED FOR CONBTRUCT10N:Th1p/lIVpow1
rf.rOrMle for tonne or may be enml*a or modhfled
feOYlle a new Jverm* Aimm oved fir dkwmM of
P.E. ".A.
4 r ICerUa Noa y 9��
construction of the building Ras ben undertaken and is
ter of Health. Any Change or ahtpatlon of cOMtllKtbn
10 vPM poky. a n/
TMb
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914). 225 -0310
_ �. v -.... . �! _�_.: s,.. �. t..�:.� _. ... •J' b.. _:,. -:'Nit • •... �. w:• - �. .. -v .. a•
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # JZ
WELL LOCATION
Street Address Town /Villa ty Tax Grid Number
r2 e
WELL OWNER
N e
r r 9"'y
Mailin Add
`° A� IV -V! h
2-- 17�°i' rivate
a Ala • ❑ Public
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL
® BUSINESS
® INDUSTRIAL
❑ PUBLIC SUP Y
❑ FARM
C]INSTITUTIONAL
❑ AIR /COND /HEAT PUMP ® ABANDONED
❑ TEST /OBSERVATION ❑ OTHER (specify,
O STAND -BY
AMOUNT OF USE
YIELD SOUGHT �� gpm /# PEOPLE SERVED t /EST. OF DAILY USAGE d0 al
❑ REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION M ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
®DUG []GRAVEL ®OTHER
IS WELL SITE SUBJECT-TO FLOODING? YES ice' NO
IF CELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. °—
MATER WELL CONTRACTOR: Name IV. Address :,/_�;&!!0''�
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAHE OF PUBLIC WATER SUPPLY: "'' TOWN /VIL /CITY
-"_'--_DISTANCE p
`� °DISTANCE -10- :PROPEit^tY FROM NEAREST WATER MAIN : ; � ° � W -_� . • �- -- .. . . • . � - .... - .... , . ° .
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(gate (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 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 oth •se contaminate surface or groundwater.
Date of Issue: / 19�y
Date of Expiration Vii) 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
RE IEW SHEET for CONSTRU N PERMIT
NAME OF O R S STREET LOCATION
BY f DATE Z_ TAX MAP,
DOCUMENTS.
Y. N
PERMIT APPLICATION
PC -1
WELLPERMTf; PWS LETTER.
® ENGINEERS AUTHORIZATION_
DESIGN DATA SHEET(DDS)
-DEEP HOLE LOG
CONSISTENT PERC RESULTS (3)_
PERC HOLE DEPTH
CORPORATE RESOLUTION
PLANS THREE SETS
EHOUSE PLANS - TWO SETS
VARIANCE REQUEST
GENERAL
LEGAL SUBDIVISION
SUBDIVISION APPROVAL CHECRJD
PERC RATE
M FILL REQUIRED
= CURTAIN DRAIN REQUIRED =]STANDPIPES
M EX- APPROVAL SSDS ADJ. LOTS_
M WETLAND (TOWN/DEC PERMIT It & D)
= DATA ON DDS PLANS & PERMIT SAME
-
ED PRE- 1969 - NEIGHBOR NOTIFIFICATION
= LETTER BI/ZBA
m 100 YR. FLOOD ELEVATION
-- UIRED -DETAIT:S'flN °-Pi.AN -S
SEWAGE SYSTEM PLAN - (NORTH ARROW)
SSDS HYDRAULIC PROFILE Q] GRAVITY FLOW
D/ J BOX=] TRENCH/GALLEY I= P- PIT DETAILS
® SEPTIC TANK - SIZE, DETAIL
WELL DETAIL, SERVICE LINE IF OVER
CONSTRUCTION NOTES (GRINDER RATE)
DESIGN DATA: PERC AND DEEP :RESULTS
TWO -FOOT CONTOURS EXISTING & PROPOSED
DRIVEWAY & SLOPES CUT
FOOTING /GUTTER/CURTAIN DIUJNS
COMMENTS:
=.DISCHARGE (OK)
C�J PERC & DEEP HOLES LOCATED
U, l REPRESENTATIVE OF PRIMARY AND EXPANSION
Cl�] EXP. AREA, SHOWN; GRAVITY FLOW, SUFF.SIZE
®CIF PUMPED PIT & D BOX SHOWN & DETAILED
= HOUSE - NO. OF BEDROOMS
= WELLS & SSDS'S WAN 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
k / YBARRIER FT HORIZONTAL: SLOPE 3:1 TO GRADE
LL SPECS
EPTH GAUGES
LL PROFILE & DIMENSIONS
= VOLUME
TRENCH
�LF TRENCH PROVIDED
1�160 FT MAX
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
SEPARATION DISTANCES SPECIFIED ON PLAN
FIELDS
EN'105 TO P.L., DRIVEWAY, LARGE TREES, TOP "OF FILL
201 TO FOUNDATION WALLS
M/ 100 TO WELL, 200' IN D.L.O.D., 150' PITS
100 TO STREAM WATERCOURSE LAKE (INC.EXPAN)
50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
10' TO WATERLINE (PITS -20')
P0' INTERMITTENT DRAINAGE COURSE
200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS
SEPTIC TANKS
=10' FROM FOUNDATION; 50' TO WELL
WELLS
=15' WELL TO P.L._
YC: -1
,1E'UVrM.& M
COUNTY DE1PaA,1:1TMEWrr C:)V M1EALTH
APPLICATION. FOR APPROVAL OF. PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant : 3 1154 �,710, T� a� -V'47
d�i4/�i ✓ /�J4' '
2. Name of Project: J— �L2% l? V to 3. Location T /V /C:
>' O�ll� �- Aer�o Cre'
4. Project Engineer. �1� t 5. Address: S
License Number. Phone�6
6. Type gf Pro.iect:
Y Private /Resi.dential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject to State Environmental Quality Review (SEQR)? A/v
Type Status (Check One) Type I.. Exempt
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? .........A1G
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? .....�,/.�........
13. Has preliminary approval been granted by such authorities? Date Granted:
14. Type of Sewage Disposal System Discharge...... Surface Water round Waters
15. If .surface water discharge, what is the stream class designation ?........
16. Waters index number (surface) ..... ......................... a...........
17. Is project located near a public water supply system? ....... I........... Al a
18. If yes, name of water supply Distance to water supply
19.
Is project site near a public sewage collection or disposal system ?.....
Distance to sewage system
W
!0. Name of sewage system
1. Date observed:
23. Name of Health Inspector:
!4. Project design flow.(gallons per day) ...... a.qg ..........................
.25. Is State Pollutant Discharge Elimination System ( SPDES) Permit requi.r-ed ?..x,16
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? .................................. ...............................
28. Wetland ID Number ................. :........ ...............................
29. Is Wetland Permit_.requ.ired? ..................................................
Has application been made to Town or Local DEC Office? ..................
30. Does.project require a 'DEC Stream Disturbance Permit? %UG
31. Is or was project site used for agricultural activity involving application
of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge. application or industrial activity? ........ YES or NO
32. Is project 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 a
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ...........
34. Are community water, sewer facilities planned to be developed within 15 years? ?
35. -Are any sewage disposal areas in excess..of 15 %, slope? �E
36. Tax Map ID Number. .................... .........................
37. Approved'Plans are to be returned to: ................ Applicant Lf-longineer
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 Class A Misdemeanor pursuant to Section 210.45 of
the Penal Law. -
SIGNATURES & OFFICIAL 'TITLES:, �
MAILING ADDRESS: I/�����'r' /7rA �i /' /•
PUTNAM COUNTY DEPARTMENT OF HEALTH
._ ...., _..._. _ _. _._ .. _. .. . .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.-
Date h�
Re: Property of �r SZ -e_
Located ate- -`may �•�� ,
(TYr 1�)Ielol5®ction 71t 4 Block ,/ Lot
Subdivision of
Subdv.. Lot Filed Map 4 Date
Pent 1 omen'..
This letter is to authorise �%�• �/ /� ���
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 @11'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,.
.. Very truly yours ,
.
Signe6�COi a a
Owner of Property
i. �1.- vvk 'A
Address & i
Town
Telephone
4
• REGISTERED MAIL
RETURN RECEIPT REQUESTED
Building Inspector
Date
Re: Construction Permit for single family
residence /
Applicant 'z-
Street e
Torn - -__ --
TMO �_! W.—
- - - --
Dear / 7 I"• �N/� /� - --
This Firm (1 ,am) submitting an application to construct a sewage disposal system
serving a single family residence on the above captioned property, to the Putnam
County Department of Health. In order to process this application the Health
Department requires that the following information be obtained from your office:
1., Prior to your Issuance of a building permit
A) Is Zoning Board approval. required for any variances?
Yes-- - - - - -- No --- - - - - --
B) Is.any portion of the parcel located within a regulated wetland or its
control area, and if so is a wetland permit required?
Yea-- - - - - -- NO --- - - - - --
C) Is any other local permit or approval necessary?
• _Yes- - --- -- No
If the answer to any of the questions above is yes, please contact the Health
Department in writing or by phone,.278 -6130 within 15 days of the date of this
correspondence. If the answer is no, you need not respond to this
correspondence.
Name --------------- - --
Health Department Inspector
JK /jp
wetland bh
Very truly yours,
v
Engineer, Architect, Owner
Pumm •• jm . DEPARnma OF
DIVISION OF •' •' ' E V L BEALTH SERvicEs
DESIGN Lek- SHEET= SMSUFACE SEWAGE DISPOSAL SYSTFNi' F ice.._..._.__
Owner Address
Located at (Street) ✓0r j.,k7 �i �� �° Sec. ;?J yBlock j Lot
(indicate earest cross street)
municipality '�� �� � t Watershed
SOIL PMRMUTION TEST DATA RBWIR D TO BE SUBNII= WITH APPLICATIONS
Date of Pre- Soaking - �' /-1 % Date of Percolation Test
HOLE
NUMBER CL CU 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
�7
l
4
ell
4
5
V
3
4
5
NOTES: 1. Tests to ba 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.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOUS Eb]COUN FRED IN TEST HOLES
DEPTH ....:_..;HOLE NO..
G.L.
1'
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
HOLE NO._ -
r!/
w HOLE NO.
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY:
�y,� // � 1� DATE:
j DESIGN
Soil Rate Used Min /1" Drops S.D. Usable Area Provided
No. of Bedroans Septic Tank Capacity �G'CCJ gals.
Absorption Area Provided By L.F. x 24" width trench
i
Other
� f
Nam �y�/ �� Signature
Address S
THIS SPACE FOR U,92 BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved . sq.ft /gal. Checked by Date
A.
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Putnam County Department of Health }
"Division of Environmental Health Services
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'Approved as noted for
x
_ .. conformance with
r applicable: Rules. and F.egu
a latons of. the
kx _ Coun Hle341tthD�yeJpartment E
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Signature :.8a Y
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