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BOX 34
04540
WELL COMPLETION REPORT
3171
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services
COUNTY OFFICE BUILDING - CARMEL NEW YORK
3
This report is to be completed by well driller and submitted to County Health Department together with laboratory report of
analysis of water sample' indicating water is of satisfactory bacterial quality before certificate of construction compl.iance..is issued.
REPORTf MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION i
OWNER.
R,Timothy Dwyer,.Inc,
ADD Box 74, Patterson, NY 12563
LOCATION
OF WELL
Street) (Town) (Lot Number)
Barger Street Putnam Valley, New York
PROPOSED
USE OF'
WELL
BUSINESS
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ TEST WELL
11 SUPP Y El INDUSTRIAL El CONDITIONING ❑ ((SSpeciify)
DRILLING
EQU PMENT
COMPRESSED CABLE
if )
El ROTARY '{ AIR PERCUSSION ❑ PERCUSSION El (Specify)
CASING
DETAILS
LENGTH (feet)
3 2
DIAMETER (inches)
6
WEIGHT PER FOOT
.17
❑x THREADED ❑ WELDED
�1 E SHOE
L11) YES ❑ NO
X
G E
YES lJ NO
YIELD
TEST
x HOURS G.P.M.
❑ BAILED ❑ PUMPED COMPRESSED AIR 4 5
YIELD ?G.P.M.)
5
WATER
LEVEL
MEASURE FROM LAND SURFACE—STATIC (Specify feet)
25
DURING YIELD TEST (feet)
400
Depth of Completed Well '
in feet below Land surface: 400
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
SLOT SIZE
DIAMETER (Inches)
IF GRAVEL
PACKED:
Diameter of well including
gravel pack (Inches):
GRAVEL SIZE (Inches)
FROM (feet)
TO (feet)
DEPTH FROM LAND SURFACE
FORMATION DESCRIPTION
Sketch exact location of well with distances, to at least
two permanent landmarks.
FEET to FEET
0
18
Sand, Gravel & Boulders
® �L� PT _ HEALTH DE_' ,
� :OFFICE
C1 Z, N. Y�
jU �j i
18
22
Fractured Ledge
22
32
Hard Granite
32
400 -
Hard. Grey & BlackGranite
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
.
DATE WELL COMPLETED
5/5/81
DATE OF REPORT
5/8/81
WELL L E (5 re) e
0
Robert M. Mill, President -MILL DRILLING, INC.
22 0 C, -
AS
ns
PL P
)000 -GALLON SEPTIC TANK
?- �" LF X 2-4_A BS. TRENCH
T
3 3
33 0z j 331-
33'
7--
V
P� A
3 T
PUTITAM Co. HEALTH DEPT,
COUNTY OFFICE BUIlDr G'
IN
CAIML, N. Y. :10512
JUN
goals
Ya
Putnam County Department of Healt*j,
Division of Environmental Health Servicas
vt
Approved as notod for conformanos 00 withl.;
IT I
applicable Regulations of ths;
' P
C -
County H -Ith p t
'ff 71-
Hate
CS i
-4-J
l--j- 'N
t 11 it
sl
I.
tQ
AS CONSTRUCTED
SEPARATE SEWAGE DISPOSAL 4STEM
r
5F
'TOWN OF PIA
y-, a COUNN: NEW. YORK
DATE -,Kj 7) SCALE A.5 14 I. = MO -r Z.
jc?-.3:ikf1 SULLIVAN - $11- L
CONSULTING ENGINEER(
NEW YORK
Owner or Purchaser of Building
Building Constructed By
Location - eet
Building Type
P Aa,ig d//
Minicipality '
�
9
Section - Ward '�
c.
Block
Lot-
GUARANTY OF SEPARATE SEWAGE SYSTEM
I represent that I am wholly and completely responsible for the location,
urorkmanship; material', conatrizcti ®n and d rainage of the'sewajd disposal. :'sysem
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 Westchester County Department of Health,
and hereby guaranty 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 period of two (2) years immediately following the date of com-
pletion of 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 negli-
gent act of the occupant of the building utilizing the system.
The undersigned further agrees to accept as conclusive the determination
of the Assistant Commissioner of Health for Environmental Quality of the
Division of Environmental Quality of the Westchester County Department of
Health as to whether or not the failure of the system to operate was caused by
willful or negligent act of the occupant of the building utilizing the system.
Signature
Title
If corporation, give name and address
Dated this �_ day of f' t , t9q,
at
A)-,-I
Place & State PUTNAM CO. HEALTH DEP' T
CAHbtM, N. Y. 1051.2
Fozm S.3. 50 JUN 1 t 1981
a
BREWSTER LABORATORIES
Box 124. - BREWSTER, N. Y.
WATER ANALYSIS REPORT
SAMPLE N04644
SOURCE: Tim Dwyer well
Barger St.'
Putnam Valley, NY
COLLECTED:May 5, 1981
BYMill Drilling, Inc.
BACTERIOLOGICAL .EXAM NATION
Coliform Count, MF Method _ - 0- per 100 m1.
Thir rtrrrlt
inditater the
rourtt of
the famplt war
of fatisfacury ronitary
Ivality whin
the'. rample
war tollecttd.
May 9,.1981
Bickwit P. E.
Director
C. ()LINTY C'FPICE BU.IL.�j.b,
CARMEL
JUG c ��
_ PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y. 10512
CONSTRUCTION PERMIT •FOR SEWAGE DISPOSAL SYSTEM rm i% C
--• - F, _ °-' ___ - - _ !� L Town or Village -
LbcatudT'at�'— _ a S. _ ax ".niii'F.':- �•f?3�
Subdivision. t G Wr\ W T �✓ 7 Tax Map Lot N 7 Subd. k (/_�
Owner T; M Address P 13 X, `�n �T
Building Type
f ✓� t'rh� Lot Area
Number of Bedrooms 3- Design Flow C7 0
Separate Sewerage System to consist of ._. I Gal. Septic Tank
To be constructed by Vt
Water Supply: __ Public Supply From
Private Supply to be drilled by
Address
Other Requirements
Total Habitable Space C? Square Feet
and 2S Q ft. 2' tr ench / ( ) ( X )leaching pits
Address
I represent that I 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 cpnetructed as shown on the approved attachments hereto and in accordance with they 1,tand4rdb ;rules and regulations
of the Putnam County Department Of Health, and that on completion thereof a "Certificate of Construction Compld'aino�il satiaFactory;' the Commission-
er of Health will be submitted to the Department, and a written guarantee will be furnished the owner, his auixcesa0i "s :aherQ'oY,aiisigna by the build-
er, that said builder will place iq good operating condition any part of said sewage disposal system duringAhe pe iod'of tiro;;("): yeais immediately
following the date of the issuance of the approval of the Certificate of Construction Compliance of the or gins •wsystem•or any xepairs'theretol 2)
that the drilled well described above will be located as shown on the approved plan and that said well will be installed dns accordance with the stan-
dards, rules regulations of the,Putnam County Department Of Health.
j�o qq .�
J S 1 y� P.E " R.A.
Date Signed
Address 7 �+ e�� G�� �3 i #,e l_ieense No ^
APPROVED FOR CONSTRUCTION: This approval expires one year from the date issued unless con't4cticin of the "buildirig vhas beeriundertaken and is
revocable for cause or may be amended or modified when considered necessary by the Com stoner of Health, Any change, o►'altaraution of construction
requires a neW permit. Approved for disposal of domestic ni y sewage, and /or p►' a water su �1K -or►
Date- ^� By G/ Title..,
m
r PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
r �. ao - ��- „�,'�6 .,,. _ ?G s � :- c•;c.r, .... .a r. L.n^s- +_Fr'•4r +. . .- r• r:i -.
V
Re: Property o
Located at
Section t�f' — Block l Lot
Gentlemen:
This letter is to authorize G' V.
a duly licensed professional engineer or registered, architect
(Indicate)
to apply for a Construction Permit.for a separate sewage.syste.m ; „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
LV1111C1[LiU1/ w-Li.n 1615 maaLer aiui to. supervise. the cons trueciun.of said
system or systems in conformity with the.provisions of Article 145 or
147.,._,E�ueaton -_,aw, ,the .Public Health Law, and the Putnam County Sani-
tary Code.
P.E., R.A:,
29Tz
Telephone
Very{ truly yooks,
Signed
Owner of Property
To
Address
9( C -�-
Telephone
Y
06
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.,COUNTY OFFICE BUILDING, CARMEL, N . Y. 10512 r
U
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner V1 441 � 0 Address %� ., 3px 44
Located at (Street 13Ge ee, Sec. �F° Bloc k�^Lot Z
�indic e nearest cross street)
Municipality Tln G P'I L�rf / /NWatershed
SOIL PERCOLATION TEST DATA REQUIItED TO BE SUBMITTED WITH APPLICATIONS
oe
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
a,
3
/l��- /lob ;�!
..4.
5.
4'- 2-0
3h z_3 „1,L f 7
m
5
1
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. A11 data to be submitted
for review.
2) Depth measurements to be made from top of hole.
DEPTH
747
611
TEST PIT DATA REQUIRED TO•BE-SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE 'NO. HOLE NO. HOLE NO.
'100-1
121
V
.18 I
2411
3 0 it
3611.
4211
48
5411 .
6011
66
72
78
84
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WfUCH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY Vapi Date
DESIGN
Soil Rate Used�_DdrVi"brop: -S.D. Usable Area Provided ,1-6 c, v
Capacity Type
No. of. Bedrooms Septic Tank Ca Gals-.'
Absorption Area Provided By_2�rV_L-F.x24f1 .wkdtzh,4,rench.
Address -2_,C7 7 '7—,
`j .j e-
V-"
THIS SPACE FOR USE BY HEALTH DEPARTPENT
Soil Rate Approved Sq. Ft/Cal.
6EAL
!t
Checked by Date
I
130r19.r.- -. 54-,•-ccf
1
U Cj per_
)I /C//i
ly
P L A NI -� _
li
SOIL PERCOLATION HA -II' _ 1.0p) SEPTIi ; 7ANY
DEEP TES I II((IIII — - -'— (,AI LU t t
! -. t
ESTABLISFI ELEVATION OF HOUSE TO PROVIDE DRAINAGE L. :
SLOW EST ( XTURE
TO SEP "I IC TANK AND FIELDS ......... AREA RESERVED FOkSEWAGE DISPOSAL
SYSTEM TO REMAIN UNDISTURBEO.ALL CONSTRUCTION TO CONFORM TO STATE
AND LOCAL STANDARDS AND REGULATIONS ......... '•
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A.
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Futnam County Department of Health
Di.v _vlon of Env:i.ronm, :)naal fi�^1th Services
r,,_t or wico ipith
�1:: ga_a'si` ''s of'the
Z'3
tmo
e 4tIef ,`r$ate1:
J
8-3/Y /, ', /r 7
PROPOSED•
SEPARATE SEWAGE DISPOSAL `��. SYSTEM
13o rgr.^ 5 r cent
'mot TOWN OFt'• pU
1r1 L! Fry^ COUNTY;_ NEW YORK
DATE I Ll
SQ,ALE _-S .j%tt, q JOB NCJ:
FfVSOLLIVAN — i� . G
flE P
y vd2_Zcw INNG w G l 5 w V ENGINEERS
h
v lb
+i
.I
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3�
'7+� - -�
•- r, i
\ r Q
t / t' :/ � n � ! V C t � i
� aG� f T7
41 i �jevice
1
U Cj per_
)I /C//i
ly
P L A NI -� _
li
SOIL PERCOLATION HA -II' _ 1.0p) SEPTIi ; 7ANY
DEEP TES I II((IIII — - -'— (,AI LU t t
! -. t
ESTABLISFI ELEVATION OF HOUSE TO PROVIDE DRAINAGE L. :
SLOW EST ( XTURE
TO SEP "I IC TANK AND FIELDS ......... AREA RESERVED FOkSEWAGE DISPOSAL
SYSTEM TO REMAIN UNDISTURBEO.ALL CONSTRUCTION TO CONFORM TO STATE
AND LOCAL STANDARDS AND REGULATIONS ......... '•
a
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Futnam County Department of Health
Di.v _vlon of Env:i.ronm, :)naal fi�^1th Services
r,,_t or wico ipith
�1:: ga_a'si` ''s of'the
Z'3
tmo
e 4tIef ,`r$ate1:
J
8-3/Y /, ', /r 7
PROPOSED•
SEPARATE SEWAGE DISPOSAL `��. SYSTEM
13o rgr.^ 5 r cent
'mot TOWN OFt'• pU
1r1 L! Fry^ COUNTY;_ NEW YORK
DATE I Ll
SQ,ALE _-S .j%tt, q JOB NCJ:
FfVSOLLIVAN — i� . G
flE P
y vd2_Zcw INNG w G l 5 w V ENGINEERS
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� �' .,1 { �' ..� 3 ..• `�.. -, C • ; it .gyp N'
PUTNAM COUNTY; DEPARTMENT OF HEA
r ' Division of,Environmenral • Heaith, Services Carmel N- „1
-CONSTRUCTION PERMIT ,FQR SEWAGE DISPOSAL SYSTEM
�V=dItlof1 subdivision � °L
ownerI'���%Z� ��/ ��� Address —L
S F/L'
s }�
Building type L1 Lot Areab0� .�aj _-
r
Number of Bedrooms ����� n Total `Habitable Space' %d f Square Feet
-. Separate Sewerage: System ,to - consist of - - 1•d Gal Septic Tank °pa , ; (meal feet ?X - ,width trench
To be constructed by Address'
F -
w'Water Supply. Public Supply, From
_
_ Private Supply`to be drilled by
Address
I 'Other Requirements -
I a
I represent that I:am "wholly , and - completely responsible for the design and location of- the proposed systerri(s) 1) that the separate sewage disposal - system
above. described will be constructed as shown on the approved amendment thereto and, in accordance with the standards 'rules and ?;regulations of.-the u,nam
m. _... .
County Department ofl`Health; and that, on coinplefion.thereof a 'Cert�f�cate -,o - Construct�ori, Compliance satisfactory to the,Comrtii - sinner of .Healthwill
be submitted to the De_-a written; guarantee will be- furnished,.the owner his successors, heirsor'assigns ; by the;bwlder;;that said Builder will
in good operating condition•any part of said sewage disposal system durrng,,;the period of'two (2) •years immediately. following;fhedate'_'f the isSu
ante of. the' approva'I of the .'Certificate :::of'Construction.Compliance c; the' original syste,rn or -any repairs the eto 2) that the drilled well described above
will be located as shown on the a e9
p.proved, plan C that said well wilPbe installed' m accordance. -with the standards rules ;and <r ul-t of the Putnam
county Department of Health
Oate ^ _ / ig"
2 -AID D+ra p 3
Address -� _ ? — t License No c+- -
APPROV-ED-FOR CONSTRUCTfON_ Tfiis approval expires_ yeai from fhe date.''ssued'- unless construction of the�bwlding °has been = undertaken and is• .:
revocable for cause or,, may tie•- amended or modified when'.considered = necessary,.by °the` Commissioner ,'of Health' Any change o_r' alterat;ion of construction _ ` -
requires a new permit Approved for dls -si Ai of `domestic..sanitary ,se w a and /or private water supply only n
+ ''Date - - BY - Title
v
Pa y e pqrtmpqV of Health
... ,Putnam Count D
ipi
''V on of Environmental Sanitation
AFFIDAVIT' CQRPGRA-TE-*WN-ER, APPLICATION—,
FOR PERMIT APPLICATION SUBMITTED TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: CQmm1poip
Per of Health n the m",ter of application for
DIVA) %�°v rpprepont
that- 1 am an officer or. employee of the corporation and am outhprlzed
to act for � ;t z ,,- x t,/ C
��ajo7
(name" -epr n3.
P PZ To
haying. of fPcep at 2,
rh9pe Oftwo are
-M
/a4 A)(j
Prepi4pt
m1p and AUd"Fe"pi" T
pip
a TO
Tr.1
'Roo
,Prqr
'Name Fr7 Wdxress)
and a b
that T am and will be individually respoppi le for gTfy pr all got@
of the pprpqrqtion With respect to thp approval requested 9,1nd all @ub-
epqunt acts relating thereto.
Horn to befogs me this day signed
ce T
AA-7A A
UAVARD H. DkWER,
NOTA Y PUBUC
STATE OF YORK
, o,,- irnfssion expires Mach 30, 1, DWI"
orporAte
PUTNAM COUNTY DEPARTMINT OF HEALTH
IO.AT AL.;..HEALTk1-.c'8Zj4
Date /v ;
Re: Property of ira-7 e:+A r-'O.AJ - %�.2r�•
Located at,�/�(�
Section w Block Lot °2 7
-7-1-41Z LW x,06
Gentlemen:
This letter is to authorize JoH.�•' Sc.�n,Ja��,+�
a duly licensed professional engineer or registered architect
(Indicate)-
to apply for a Construction'Permit for a separate sewerage system; to
serve the above noted property in accordance with the standards, rules
or regulations as promulgated 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
- � sy to n -- ox�� -s ta;�ri� -- z eonforir�3 ty ti:�i - t iA =piTov i Suns
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly ours,
Signed
Owner of Property
132 1- ?4,uNUzJ - 4 VC
Countersigne . Address
P.E.,
Telephone
(Seal)
Address
f/ V
-Q-- f3
Telephone
v
;f F'IEI'.,D CJTECh LIST
Date: ?
Insp. by:
r
INITIAL SITE INSPECTIOT;
Yes.
No
Comments
,Property lines or corners found . . . . .
✓
Can estimate house location . . .
/
Will driveway need cut
Must trees be removed -n.ote these
Is deep hole representative of entire SDS area.
Additional deep holes needed. . . . . . .
Sufficient SDS area available considering
driveway, cut,house location,separation . .
distances etc.
✓
DEEP HOLE DATA
Water elevation: o •
L ` �'"'
Rock elevation: D
Soils descr_L,_)tion: SAAJY LVAP" w,'ra A ec1e-
Aq 4.
Daate:
FIl1 L SITE I1\1SPECTION. Insp. by :
House located where shoi,m on approved plan
SDS located vihere.approved .
- - - -
- Ijength of -trench measured
Width. of trench average
Slope of the line and trench acceptable
,
Room allowed for expansion trenches .. .
-- —
Over. fi, _ fromp s�aam�, iNiatercourse
50
Natural soil not stripped or SDS. area
tuulecessarily graded . _. .
10 Ft.. maintained from prop.line and
20 ft. from house . . . ... .
SepLaration of trench froii5 'house'; jaell
etc. follows p]_an.. .. . ..
Number of bedrooms checks . . . . . , ..
Stones, brush, stw:.1ps, rubble, etc,. greater
than 15 ft. from nearest trench
15 Ft . of peripheral soil horizontally from
trench
Junction boles properly set
Could surface run off from driveway, roads,
. ground surface, etc. channel near SDS
area. . . . . .
Does lot. drainage appear 0. K. in area of SDS
FINAL GRADING OF SITE ACCEPTABLE
r
PUTNAM COUNTY DEPARTMENT T OIL' HIKALTH
DIVISION. OF ENVIRONM 'AT, IM- ALTH SERVICES
R. ~ .. x
CdUN`1 `OPP CR 5,1UTMID16f "'CX
DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM. FILE NO.
Owner; ; TEM3'?'iZ C-11,'. T. Address
Located at ( Street —See. Block Lot ;2 %
n ica to nearest cross street) s v. ,'y,qp :+ APei J1, , 4tZ")"
Municipality 0`} j N3N__t Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME
PERCOLATION
PERCOIATION-
Run M apse
Depth,
to Vdter
Water Level
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Mina
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
1 zz ` 00 / /;`Qr 6-
"21
4
m
5
3%/,�'�/= //•"y3U�/ 3
5
Notes: 1) Tests to be repeated at same depth'u.ntil a proximately equal soil
rates are obtained at each percolation test hole. Ay1 data to be submitted
for review.
2) Depth measurements to be made from top of hole.
1
REVIEW CIIf,CK SHE . TET
Meets Std.
Yes ; No
- < 1' "r 0 .T.J11r' .11Z
House plans O.K.
Design data sheet
Peres presoaked9
30 pert test. depth
Const. results for 3 runs
D. Hole log 0. K. _
Remarks'
Corporate Affidavit for other^ than individual ✓ i
Authorization for engineer v j
setter from Water Supply if. applicable t
If variance requested -such noted on plans &_apps.
DTAILS _
�if change is proposed,)
Existing contours shown show new contours) L/
Slopes for driveway cuts.,-etc. shown v
bZater service line location
Footing drain, etc. location
Top slope, bottom slope of fill .
Percolation tests and deep test pit location. ;
SeDtic.tank size and conformance to std. f
3 B. R. house minimum
House setback shown .�
Distribution box ftg. below frost- !
All-water within 50 ft. of PL shown V ;
Plan and profile SDS
All other. wells and SDS..cl user .200!
shown, reference made i
Property boundaries (metes and bounds - clearly shown
SEPARATION DISTANCES SPECIFIED ON PLAN
10' to P. L.
20" to Foundation walls _
?0' to Nearest well
100' to stream, march, Zak
15' to Curtain drain
10' to water line (pi7ts -2
15' to storm drain
101'to large trees
10' from foundation to se
5' to pipe from leader d
, etc. (incl.expansion)
c tanx . . .
n & . fo —of znT
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