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BOX 36
04744
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04744
PUTNAM COUNTY HEALTH DEPARTMENT Q
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
A1311
PROPOSAL.FOR SEWAGE TREATMENT.SYSTEM REPAIR
NO Internal Use Only a PERMIT # R
Li ,L,--1,K/ Repair Permit issued in last 5 years L%�- ' bt in Watershed
❑ epair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
11 Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION '/2 GIAGL dW TOWN 6Akk. W- ehrJL(4(TM# 91.26-1 —23
OWNER'S NAME 0 R(GL,(L PHONE # 9 / y Z3--7 q.775--
MAILING ADDRESS ,? 1 14 0 L L L, w f'/<t'� o Iv i
APPLICANT t9 W NC,n__
Na e & Relationship (i.e., owner, tenant, contractor)
DATE I t 3 FACILITY TYPE % S F PCHD COMPLAINT #
PROPOSED INSTALLER /` to( L-ys "r4t&,J0 PHONE#
ADDRESS Seto,- .�(wc'K P Ce(�t aZ 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
I, as owner,agree, to
SIGNATURE / := ' V
(owner)
?� .ttSe�i:_iast�iU?r, „;tJrep. to cumply,witl:'
/J
.conditions,of this Dermit for the septic s tem- repair•
SIGNATURE TITLE
(Installer)
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
DATE
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 backfill ntil authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pro os Apr v d 6I Pro sal'l nied ❑
It C d `a it 13 Q I 113 I
Inspector's Signature & Title Date Expiration Date
Repair proposal is in compliance with applicable codes Yes L9' No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
Putnam County Department of Health
r Division of Environmental Health Services .
I 1 SSTS Repair — Final Site Inspection
Date: t � I (S 3 Inspected : bL Installer: LaiLt t 0o O
p
Street Location: ��¢ i t ,e� Owner, 4.4 e,---
Repair Permit
1. Type of System: Conventional 0 Alternate 0 Comments:
2. Se tic Tank
Yes
No
-N/A
Comments
a. Septic tank size -1,000 ...1,250 ... other ...
/
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
t
I L�
d. Distribution Box
F- i. All outlets at same elevation (water tested) ...
ii. Protected below frost .............................
iii. Minimum 2 ft. Original soil between box &
trenches
/
!/
e. Junction Box — properly set ...........................
f. Trenches
J. stem completely ened for inspection
ii. Length required Length installed -
iii. Pipe slope checked ... ...............................
iv. Installed according to plan .......:.............
v. 10 ft. from property line — 20 ft — foundations .. .
vi. Size of gravel' /, -1 % " diameter clean .........
/
vii. Depth of gravel in trench 12" minimum .........
viii. Ends ca ed .... ...............................
. Pumg or Dosed Systems
3. Sewa e System Area
a. SSTS Area located as per approved plans
b. Fill section —
c. Distance from water course /wetlands
4. Overall Workmanship
a. Boxes, properly grouted and installed correctly ...........
b.. All pipes flush with inside of box .........................
c. Backfill material contains stones <4" diameter .........
d. Curtain drain & standpipes installed according to plan
V
e. Curtain drain outfall protected & dir to exist watercourse
V
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............................
Additional Comments:
"AL +aV, 6 D � We roon RFS! Rev - 011312
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-23
E>aSTING
ONE STORY
ONE BMROOM
RESIDENCE
LANDING VATH STEPS
TO GRADE
f (.9 �,c
z•_ 2l tt
SEPTIC TANK
W-eAPAQML— p
E>MNG PROPERTY
LINE
WELL U0MVLh*111JN rJ1rUA1
. . . . . . DEPARTMENT OF HEALTH
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
STREET ADDRESS: T6WN/VIEEXG11CII7" W'GRIO NUMBER:
/eb - P07-664M 11AA-1_F_
4 q
WELL LOCATION
WELL OWNER
-
NAME: ADDRESS'
S7A"MlT AZqms d RXeL
BIVAT E
PUB LIC
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP 0 ABANDONED
❑ BUSINESS 0 FARM 0 TEST/OBSERVATION ❑ OTHER (spec*ify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND-BY ❑
MOUNT OF USE
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE
REASON FOB
DRILLING
VEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY ❑ TEST/OBSERVATION'
-0 . REPLACE EXISTING SUPPLY D DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 05- - ft. ISTATIC
WATER LEVEL _*__Q ft'.
[DATE. MEASURED 10
DRILLING
EQUIPMENT
0 ROTARY 19 COMPRESSED AIR PERCUSSION 0 DUG
0 WELL POINT 0 CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. 0OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH' A A ft
TEEL 0 PLASTIC 0 OTHER
LENGTH .BELOW GRADE ft
-MATERIALS:
JOINTS: 0 WELDED I rHREADED O.OTHER
DIAMETER 40 in.
SEAL: XCEMENT GROUT, 0 BENTONITE 0 OTHER
WEIGHT PER FOOT lb./ft.
11K
DRI E.
I VESHOXYES ONO I LINER:OYESZNO
. X
SCREEN
DETAILS
'DE.
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
-'FtB5T'
.0-YES0NO_
HOURS*��*4*.;Ca-
'M;1-j'-----.-----
GRAVEL PACK
11 YES
0 NO
GRAVEL
SIZE:
DIAMETER
OF PACK, in. I
TOP
DEPTH — IL
BOTTOM
OEM ft.
WELL YIELD T I EST If detailed pumping
MEJHOO: 0 PUMPED 1 tests were done is in-
)KCOMPRESSED AIR r formation attached?
0 BAILED 0 OTHER 0 YES 0 NO
It more detailed formation descriptions or sieve a . nalyses
WELL LOG , are available, please attach.
DEPTH FROM
SURFACE 1Bear-
Water
ing
Well
Dia-
Meier
FORMATION DESCRIPTION
cone,
ft.
I fL
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpill.
Land Surlace
Al
4-10
IL -IN
( F &
P,
�7
t w 0- 7.9 Is
Igo
kq_d
8d&X-411
X60' 11I�
WATER 0 CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
0 COLORED ANALYZED? 0 YES ONO
ANALYSIS ATTACHED? 0 YES 0 NO
—jo
STORAGE TANK: TYPE
CAPACITY GAL.
dc�
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE — HP
WELL DRILL NAME A JDATO
E �ftaG, /E
XWI711
ADDRESS SIG? . IMRE
Q0yy_MJNq 101111/
_N'.' I
WLLL %.AVr1r.LD"V0 nr"
DEPARTMENT OF HEALTH
' -livis:1on of Envif&rimeftal�H'a
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
ISTREET AOURESS:
4? A 6-IV&-6
TAX GRID NUMBER,
4 IV--- f C-/ R Cj_ 9 RID - 11AA.L9-Y
WELL OWNER
NAME:
S-7-A A_9V_rTg/A/
ADDRESS:
ali AbAms L
BIVATE
PUBLIC
USE OF WELL
1- primary
2 - secondary
A RESIDENTIAL -0 PUBLIC SUPPLY 0 AIR/CONO./HEAT PUMP -0 ABANDONED
0 BUSINESS 0 FARM 0 TEST /OBSERVATION 0 OTHER (specify)
C1 INDUSTRIAL 0 INSTITUTIONAL 0 STAND-BY ❑
AMOUNT OF USE
REASON FOR
DRILLING
YIELD SOUGHT gpm./NO. PEOPLE SERVED EST. OF DAILY USAGE
kN EW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY 0 TEST/OBSERVATION
30 REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH
/00,5 -ft. 1
STATIC WATER LEVEL 7-�-0iftOATE.
MEASURED Z0'
DRILLING
EQUIPMENT
0 ROTARY
0 WELL POINT
� COMPRESSED AIR PERCUSSION. 0 DUG
0 CABLE PERCUSSION 0 OTHER (specify):
WELL TYPE
0 SCREENED
0 OPEN END CASING. 'OPEN HOLE IN BEDROCK 0 OTHER
CASING
DETAILS
TOTAL LENGTH
ft
MATERIALS: TEEL 0 PLASTIC 0 OTHER
LENGTH.BELOW
GRADE ft
JOINTS: 0 WELDED - "READED OMER
DIAMETER
SEAL: CEMENT GROUT 09ENTONITE OOTHER
WEIGHT PER FOOT
1b./ft.
DRIVE SHOE.XYES =NO
UN8:0YES
SC BEEN.
DIAMETER
(in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (it)
DEVELOPED?
_0:rES__ 13 No-
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE
DIAMETER
OF PACX In.
TOP
DEPTH —ft.
BOTTOM
OEM N.
WELL YIELD TEST
METHOD: 0 PUMPED
COMPRESSED AIR
0 8AIUD 13 OTHER
if detailed
i tests were
' formation
1
❑ YES
pumping
done is in-
attached?
0 NO
'WELL
.11 more detailed formation descriptions or sieve an2tySES
LOG are available, please attach.
DEPTH FROM
SURFACE Isear-
water
Well
Dia-
Meier
In
FORMATION DESCRIPTION
coal,
It. ling
WELL DEPTH
It.
DURATION
hr. min.
DRAWOOWN
It.
YIELD
gpm-
Land
S Jr"cL
Surface
Al
IL
[IL,and
aAAbiz*_.,
0
WATER 0 CLEAR
W A T E'
UALITY 0 CLOUDY.
Q U
QU A
0 COLORED
ANALYSIS ANALYSIS ATTACHED?
TEMP.
HARDNESS
ANALYZED? 0
0 YES
YES ONO
ONO
-;b_rK4,0M -Wn T-.!
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
PUMP
PE
TYPE
MAKER
Moo L
E
CAPACITY
DEPTH
VOLTAGE —
HP
DRILL the I DATE
WELLDRILL NAME 16C721CI Cllae,&a
ie
ADDRESS 11GIIIAM
.4 e
,
TOWN OF PUTNAM VALLEY
WELL DRILLERS LOG AND REPORT
�_ _:,•
C?UMPL.ETION E
Thi r port is to be completed by well.driller and submitted to,
Bld , Department, together with laboratory report of analysis of
water sample indicating water is of satisfactory bacterial quality.''':
Well Location A 6-A 14S [.�qN�' eIiPCZ L M99) 1I14L4L
W Tax Map Street a"c. Bl a Lot
Welt, owner _ LF l� /N u r
Name Mailing Address City or Town
Tel.' #�a� =asp!
x
Well. Driller Dbyd Artesian Well Co RDS Rte. 32 Carmel RY
Name Mailing Address I C tv or Town
TOTAL. DEPTH OF WELL; Feet
_ . -
Depth from Mve description o formatioms penetrated, such
Ground Surface ass Peat, silt, sand, gravel, clay, hardpan,
shale," sandstone, granite, etce Include size of
,v (diameter.) -and ..(,fine q. ..medium-, coarse:} ,
. `... • ... ._: . y °' _ � � . ,.•. ' �ola'� o� ..materi'a'l; 's�c'ructuie; ('Loose; _.packed, _ ° •'� � -~ °.- ...
cement, soft, hard). For examples O fte to
27 fte fine, packed, yellow sand; 27 fte to
saa f +-
Feet to Feet
Formation Descri tion
CASING DETAILS
YIELD TEST
WATER LEVEL_
SCREEN DETAILS,
Length Rte
Bailed
or
ped H rs a
Measure from
•.'
Statics Ft
land surface
. Make t
Diameters6 Inches V
ield s GPM
When Bailed
or Pum ed Ft
Slot
Len h Ft Size
Kinds 19
Diameter In
TOTAL. DEPTH OF WELL; Feet
_ . -
Depth from Mve description o formatioms penetrated, such
Ground Surface ass Peat, silt, sand, gravel, clay, hardpan,
shale," sandstone, granite, etce Include size of
,v (diameter.) -and ..(,fine q. ..medium-, coarse:} ,
. `... • ... ._: . y °' _ � � . ,.•. ' �ola'� o� ..materi'a'l; 's�c'ructuie; ('Loose; _.packed, _ ° •'� � -~ °.- ...
cement, soft, hard). For examples O fte to
27 fte fine, packed, yellow sand; 27 fte to
saa f +-
Feet to Feet
Formation Descri tion
4/o' Leo P I/
a q 5 7
s
- -r ov7' &)A TCN 60- 73 070-//—
-
r ' 6 ,eA A/M As7o -- 90 /.ir»
0 5-8 0
3057
/D -- 3- �O
Date Well Completed Date of Repo �
Well Driller
na
BZS 1 -77
7
PUTINAIM COUNTY DEPARTMENT OF HEALTH
DMSION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREAT'NENT SYST j
Owner:. Address:
Jt
Located at (street): TN11;* Section: Rio ck Lot i-�!
M unicipality: t4r\tx rA Watershed•
SOIL PERCOLATION TEST DATA
Witnessed by: AOL-
Date of Pre - soaking: Date of Percolation Test:
Hole No.
Ran No..
Time
Start —
Stop
Elapse
Time--
(min.)
Depth to
water from
round
9'
surface
(inches)
Start:- Stop
Water'.
level drop
in inches
Percolation
Rate
min'Anch
2
3
-.4
2
3
4
2
3
.. ...........
4
2
3
4
3
Notes:
I. Tests to be repeated it same depth until approximately equal percolation rates are
obtained at each percolation rest. hole. (i.e., < i min for 1 =30 min/inch, < 1 min for 31-60 min/ind; ).
All data to be submitted for review.
2. Depth measurements to be made from top of hole.
Form MAI. P1 1 of 2
VEST PIT DATA , '
DESCRIPTION OF SOILS ENCOU' N'TERED IN T'ES'T BOLES
��� �•-.Q .- d °_.:.._'z'.e= `: ;�.o- •- •'°'w. -••� �4 -Ta:. c-. �.:.., }��•a =:. "�a`..:o- .':::`..'..., T� .�.;. _..T•, Fr _,....,T'«�� .�4._r`4:ie.a. p... -�... �..v ��v.w`�:,�_-
'_ i • - ::F+."a � •-3� _ .• b . -fie+ .� `�'.?��= � .` ..e =�n�.. W ..y. � DEPTH HOLE HOLE # I HOLE # _ HOLE # HOLE It HO L E #
G.L.
0.5'
1.0'
2.0'
2.5',
3.0'a-
3.5'
4.0' S .
4.5'
5.0'
6.0' S
7.0'
7.5' .
6.0'
�9J .0'
7::5J
10.0'
Indicate level at which groundwater is encountered nt
Indicate level at which mottling is observed on
Indicate level to which water level rises after being encountered AIIA
Deep hole observations made by: Ab L Date I
Design Professional Name:
Address:
Sipature:
IDesiagm Professional = Seal