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BOX 4
00092
-- -.
R 3/86 PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N.Y. 10512
.� Engineer Must Provide ,. a�
\ r > P.C.H.b. Permit N 1
` CATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM Pa I d'
Town or Villaire
Located at ° t-• r/ Tau Man L 3: Block Lot
�8 Ct ci nn.
Owner /applicant Name Formerly Subdivision NemeN�/ Sabdv. Lot k -
MaWng Address r ZIP Date Permit leaned
`Separate Sewerage System built by L'G C P' ci ' `'B SE R Address
Consisting of a–�� -s Gallon Septic Tank and F
Water Supply: Public Supply From
' Address
by ®
or. 4.e—' Private Supply Drilled Address
er ,e j e,
Building Type kt.f LO , .11=S
Has Erosion Control Been Completed?- // Ile
Number of Bedrooms Has Garbage Grinder Been Installed? /t/d
Other Requirements
I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work ( copies
of which are attached), and in accordance with the standards, rules and re; °ions, in acco dance with the led lan//1� and the permit issued by the
Putnam Countynn Department Of Health.
Date i !
Caltified
P.E. eR,A. q
Address
A wt ^+%crGCea�= L��ifense No. _ s
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from such usage. Approval of the separate sewerage system shall become null and void as soon as a pub(:: sanitary ewer becomes
available and the approval of the private water supply shall become null a water supply becomes available. Such approvals are
sub)ect to modificat on or' change when, in the Judgment of the Com r cation, modification or change Is necessary.
Date A By Title
PUI'NN4 COUN.PY DF_PP.RT4EN7r OF HEAME
DIVISION OF ENVIROLMaUP.L HEALTH SERVICES
Owner or Purchaser of Building
Building ns.tructedy�by f
Location - Street
m: icipality'
)CT �l dew, I
Building Type
_ 13 , / IS,7
Section Block Lot
/Jo ✓1c (r�,� �woc/L C --, �, ,vhf
Subdivision Name
2
Subdivision Lot
GUARA..NEE OF SUBSURFP.CE SS GE DISPOSAL SYSTal
I represent that Y 'am wholly and completely responsible for the location,
wvrki-oanship, material, construction and drainage of the sewage disposal system
serving the above described property, and that it has -been constructed as sham on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Deparbrent of Health, and
,hereby guarantee to the o;,mer, •his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
op=erate for a period of two years immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made by rrP to such systen, 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 Environ.�rental Health Services of the Putnam County
Deoartment of Health as to w=hether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of building utilizing
the system. _
Dated this 57 day of G 19�
General retractor (Owner) - Signature
Corporation Name (if Corp.)
.fGS Aldr_,L"
YC1r_0_C1LJL% lAr /0 /6,5"6
rev. 9/85
mk
Signature
Title
Corporation Nan)-_ (if rp. )
P es
AC, to/ / 6
BREWSTER LABORATORIES
Box 224 - BREWSTER, N.Y.
(914) 855 -1930
- WATER ANALYSIS REPORT -
SAMPLE NOB 615 TEST WELL
SOURCE: Custom Built Construction lot#2
Cushman Rd._
Patterson, N.Y.
COLLECTED:1 -16 — 9 5
BY:' . F . Beal & Sons
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method 0 per 100 ml. .
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
1 -17 -95
OACT
P N -Rf
a WZWL t,.vrirL rj11ULN A -Mrunt
* * DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
•- /G .— ��
WELL LOCATION
STREET ADDRESS: TOWN/vil"(77CIly TAX GRID NUMBER:
Lot #2, Cushman Road, Patterson, New York Z 3— —,/ Z
WELL OWNER
NAME: ADORE SS: 3 Babbit Road
Custom Built Construction Bedford Hills, NY
O PRIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL O PUBLIC SUPPLY O AIR /COND.IHEAT PUMP O ABANDONED
❑ BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
[K]NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 185 ft.
STATIC WATER LEVEL 30. ft.
DATE MEASURED 9/14/94
DRILLING
EQUIPMENT
® ROTARY 10 COMPRESSED AIR PERCUSSION ❑ 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 87 fL
MATERIALS: O STEEL O PLASTIC O OTHER
LENGTH BELOW GRADE 86 ft.
JOINTS: O WELDED G THREADED O OTHER
DIAMETER 6 in.
SEAL: ® CEMENT GROUT 0 BENTONITE E3 OTHER
WEIGHT
PER FOOT 19 lb ./ft.
I DRIVE SHOE ® YES ❑ NO
I LINER: O YES ®NO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH
(it)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
OYES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST It detailed pumping
t p p 9
METHOD: ❑ PUMPED t tests were done is in-
0 COMPRESSED AIR ;formation attached?
O BAILED ❑ OTHER ; ❑ YES ❑ NO
WELL LOG
It more detailed formation descriptions or sieve analyses
are available, please attach.
DSURFACEl`t
Barr
in9
oa�I
deter
FORMATION DESCRIPTION
p0E
it
ft
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
s�;,;Ce
30
Dr
ll '
ng in overburden clay & boul
ersj
30
His
r
ck at 30'
185
6
120
8%
30
87
Dr
llAnq
in rock, set casing, grouted
87
185,Dr,liAnq
in rock granite
WATER ❑ CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES ONO
STORAGE TANK: TYPE Well Xtrol WX #251
CAPACITY GAS. 62
WELLDAtLLERNAME p.F. Beal & Sons, Inc DATE 1 0 95
ADDRESS 4 Putnam Avenue SIGNATURE
Brewster, NY 10509
PUMP INFORMATION
TYPE submersible CAPACITY lOgpm
MAKER Goulds DEPTH 140'
MODEL 1OGS07412 VOLTAGE230 HP 3/4
3/ ov
B��zYy L. Beal
APPENDrX,C FINAL SITE INSPECTION
STREET LOCATION
PERMIT # _ TM # OR SUBDIVISION LOT #
I. SEINAGE DISPOSAL AREA
a. SDS'area located as per approved
' b . Fill section —date of p l acwwt
C.
Natural soil not sr-
d.
Stone.brush.etc..gr
e.
100 ft. from water
11 SEWAGE D 1 SPOSAL SYSTIEIM
a.
Septic tank size -
b.
Septic tank install
c.
10' minimum from foi
d.
DISTRIBUTION BOX
1. All outlets at s:
2. Protected below 1
3. Minimum 2 ft. or-
e. .JUNC:T I ON BOX - proper I y set
f. TRENCHES x
1. Length required - U
2. Distance to watercourse measured
3. Installed according to plan
4. Slope of trench acceptable 1/16 - 1/
5. 10 feet from property line - 20 feet
6. Depth of trench < 30 inches from sur
7. Roam allowed for expansion. 100%
8. Size of gravel 3/4 - 13" diameter cl
9. Depth of gravel in trench 12" minim
10. Pipe ends capped
g. PUMP OR DOSE SYSTEMS
1. Size of pump chamber
2. Overflow tank
3. Alarm. visual /audio
4. Pump easily accessible manhole to gr
5. First box baffled
6. Cycle witnessed by Health Department
estimated flow per cycle
II. HOUSE
a. House located pe
b. Number of bedroc
V. WELL
a. Well located as
b. Distance from SD
c. Casing 18" above
d. Surface drainage
OVERALL WORKMANSHIP
a. Boxes properly q'
b. All pipes Partia
c. All pipes flush
d. Backfill materia
e. Curtain drain in.
f. Curtain drain ou
g. Footing drains d
h. Surface water pre
i. Erosion control _j
i
M
I
DATE: `
Inspected by : ' �R
YES I NO I COMMENTS
. f
PU,TKAM COUfq*T DjMA T1 Mff OF HEALTH
b1� DMdeas d l Sai+ lees. Clu" N.Y ]oslz e.
.�
IM17 .7ZON PSM FOR SKWAOE DEPOSAL SYST6l1I .
�eae-to pt,6a Rrsdt
KATE OF CO
r '
T. Map Ma faf �C2, 2
Yeoewd_ ❑ Qer4ien ❑
Date of Prevision, *Mmvd ` 1 �(
Mai s AA" _�, 11 you,010 M r% Tow, M &LOFA 6, T-1�1 zip
Date Subdivision Annroved Fee Enclosed .Amnlint
9,M1M4 TRW Lot Ares I D L Pill Scene, O,b Deah valets
N�ae et Gk Daft. Flow G P D - =— PCHD Notldcadm Is Repdred Wise, FM. b oafmpl And
S" liW Sass mp Syett� to Comm ait�GaBes Bantle Task <
To he cMzb eged.b7 T 1.� Address
water Sete: Pli■e SMP* Fesa Addfen
in (Z --Prly M SaPPb DAM by
OIMr
1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that .the separate swr di sal stem
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a reou qns o nam
County Department of Mae and that on cornplefion theeof a '•Gertifkits `of- Construction Compliance" satisfactory to the Commissioner of Health will
be auismitted to - the Department, and a written guarantee will be furnished the owner, his sucesnws, heirs or assigns by the builder, that mid builder will
91we in good .opeating condition any part of said is disposal system during the period of two (2) yews Immediately following the date of the Islas-
so" of the approval of the' Certifkate o1 Conitruction,'l:ompiiancis of the Iorginal system or any repairs hereto; 2) that the drilled well described above
WIN be located at shown on;the approved plan and that laid well will be.in in accords,nee w the stn• rd ru and regulations of the Putnam
"nty Department of Health.
Hate Signed " D P.E. v . R.A.
M4 Address P s No �� "d
APPROVED FOR CONSTRUCTION. This approv, expires two;yMerf from the d issued u less construction of the building .has been undertaken and is
en
revocable for cause. or may be amded.Or modified when considered necessary by, the Commissioner of Health.. Any charge or alteration of construction
►e0uires a new permit. _& Wowed for disposal of domestic sanita�r Vii. private Water pply 0
Rev. /fL/ Title
/�-'—
10/88 ODate BSi
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # P 10-71
WELL LOCATION
Street Address
To illage Cit
Tax Grid Number
._
WELL OWNER
Name I mailing Address
pal U , p D p t
®'Private
05 O Public
b SE OF WELL
C.1' primary
2 - secondary
RESIDENTIAL
O BUSINESS
E) INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
0 FARM O TEST /OBSERVATION O OTHER (specify
UINSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVEDq' -�5 /EST.
EI REPLACE ' EXISTING SUPPLY O TEST /OBSERVATION
NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL
OF DAILY USAGE _gal
GI: ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
'1
WELL TYPE
ODRILLED
DRIVEN
DDUG
GRAVEL.
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES t✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Ldt No. I
WATER WELL CONTRACTOR: Name `rj.�' Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: t;k TOWN /VIL /CITY
,DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: N�h
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
iiF ,,,,4,.
—�
(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 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 de rade or otherwise contamin surface or groundwater.
Date of Issue• 19 �•--
Date of Expi "tion 19� Permit Issuing Off ic'
Permit is Non-Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
FY.7T'r7.A.L� CO'CJ�7'r"X" i7�p.A.R.TM>ENT
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: D ►�l L_f=-V ii i G7
A 0 FAA,- rJ
2. Name of Project: 1�PD�? ��b5 3.._; Location T/V /C:
4. Project Engineer:` 11,!.,e;jl 1i1 -�OJ�� f�_____. 5. Address:OD
License Number: Phone;
6.
Type of Project: - n:- - ' �., - :' - ^` : '� •
Private /Residential.. .> -Food _Service Commercial'
Apartments Institutional Mobile Home Park'
Office-Building : %.Realty, Subdivision Other (specify)
7.. Is this project subject' to State.Envi.ronmental Quality Review (SEQR)?
Type Status (Check One) Type I.-- Exempt ✓
Type Si. Unlisted. _.. .
.8. Is a Draft' Environmental Impact. Statement (DEIS) required? ................ tJU
- 9: Was DEIS: been completed and found acceptable by_Lead Agency. ?......... n)
ha
10. Name of Lead Agency
11. Is this project in. an area under the control of-local planning, zoning, :.
or other officials, ordinances? K)
12. If so, have plans been _submi.tted to such . author .sties ') ..................... n1 /_
13. Has preliminary approval•been granted'by such authorities ? J� A_ Date Granted:
14. Type of Sewage Disposal: System Discharge...... Surface Water y Ground Waters
15. If surface water discharge, what is the strean class designation ?......... O/A
:6. Waters index number (surface)
:7. Is project located near a public water supply system? .................. . n1�!
8: If yes,, name of water supply _ 1S./A Distance- to`Iwater supply ,
.4: Is project site near a public'. sewage collection or disposal system ?..... U.0
0.. Name of sewage system !J /t Distance to sewage system
Date' observed: 23. Name of Health Inspector:.
2.
25.. Is State-Pollutant Discharge Elimination- System (SPOES) Permit required ?.. 6Jv
26. Has SPDES Application been submitted to local DEC Office? .. .... /A
27. Is any portion of.this project located within a designated Town or State
.wetland? .. .......... . .........:.....................
28. Wetland ID. Number ...................... ......... .......:'............ Q/4
29..'Is.Wetland Permit• required ? ................... ...... ....... ........
Has'applicat,ion been made to Town or LocaI;DEC Office? ................. 0IA1
30. Does project require a DEC Stream. Disturbance Permit? Q0 .
31. Is or was project site used for agricultural activity involving application .
of pesticide$ to orchards or other crops, solid or hazardous waste disposal'
landfilling,•sludge application or industrial activity? .......:.YES'or NO x.10
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 k1Q
DESCRIBE:
33. Is the.re�a local master plan or file with the Town or Pillage. ...... .. `�
34. -Are :,community water, sewer facilities planned to be developed, within 15 years ? --* VNKN)VWQ
35. Are any-sewage disposal areas in excess of'15% slope? ....... �D
36. Tax Hap ID Number .. ............................... ..:...... ..........
37. Approved Plans are to be. returned to: Applicant Y_ Engineer
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 grounds for the rejection of. any submission.
0
S' ,
t -L I(,; . %T!. - 1 I I I
2 I; ja - 1;
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4 I IZ
s
1
2
.3
4
S
. 30-
.V-
DIVS .. :i OF AFALTS SEjM...:
s,
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM
FILE: NO. _.
C wnex Address.._ . /u
� /�L l�) t7-A
Located at. (Street) GI ?HMAhA KaAc) Sec. Block
(indicate nearest cross street)
I- tmicipality j2 AY��K �D f� _
Watershed GzOTD t�l
Son PEROQLA'I.'IC7N TEST DATA PBOUMED TO BE SUBMITTED WITH APPLICATICNS --
Dat.r- of Pre- Soaking 1L.115- 90 skate of Percolation Test 11- -0
Nu.mm C LCCK TIME PERCOLATIC N
PERdC=CN
pan Elapse Depth to Water Fran
Water Level
Tine Ground Surface
In Inches
Start-Stop Min. Start Stop
Drop In : Min/in Drop
Inches Inches
Inches
�l t » :p 0 ;11 3 7A
3 II :D - I I ' 33
S' ,
t -L I(,; . %T!. - 1 I I I
2 I; ja - 1;
�Z 3
4 I IZ
s
1
2
.3
4
S
. 30-
NO1�5: -1.: Tests to be repeated* at same depth until- apprcaimatel.y -eTaal -soil' rates
are: obtained at.each- percolation test hole::- All data, to* be submitted
for.'review. - - -
2. Depth 'neasurements to be made from top of hole.
s,
NO1�5: -1.: Tests to be repeated* at same depth until- apprcaimatel.y -eTaal -soil' rates
are: obtained at.each- percolation test hole::- All data, to* be submitted
for.'review. - - -
2. Depth 'neasurements to be made from top of hole.
TEST PIT DAT". EIQiTIRED TO BE SUBMIZfiED WITH 1 CATION ;
DESCPIP'1-,JN OF SOILS ENCOUNTERED'IN TEST'mOLES
DEPTH HOLE NO. ..: HOLE, NO.... 2.... HOLE _ No
G. L.
Ta!So I L- 70PG I�
l`
2' SAND`i LG?aNt S4NDY LG3hM
3'
S`
LOAM GLA'(�Y I-OA A
61
7,
9`
10' -
11r - -
12` '. =
131, - -
14' _
INDIC:i1TE LEVEL AT WRICH GROONI7rOTER. IS EDXWNMUD
INDIME LEVEL TO WHICH MTER LEVEL RISES AFTER BEING ENOOUNm2ED
DEEP BOLE OBSERVATIONS MADE BY: DATE:
DESIGN
Soil Rate Used /G - 2 o Min/1" Drop:- S.D. Usable Area Provided
No. of Bedrccros Septic Tank Capacity 12 Q gals.- Type
Absorption Area Provided By L.F. x 24" width trench
Other
Na.�e %1( /�J -kQ(�� (_ _ Signature Nrcyo
Address D SEAL
THIS' SPACE.' FOR USE BY HEALTH DEPA MAF1gr OILY: \,;" ..... _
Soil Rate Approved sq:,ft /gal Checked by. Vie+
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH-SERVICES
Date.
Re: Property of
Located at
(T) �j��'j- j�jJ Section 1:97. Block Lot
Subdivis.ion of k�DU�Lpjo� MIJI
°Subdv.- Lot # Filed Map # Date
Gentlemen:
This letter is to authorize
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 accor.dance'with the :standards, ru_tes
or regulations as promulagated by the Commissioner of.:the Putnam County.
Department of Health, and.-to sign all:nec;essary papers on my behalf in
connection with this matter and to supervise the cons - truction 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 Cod
Counters
P.E., R.
Very truly yours,
Signed
Own of Pr perty
Address
A -ddr e s 1-
Telephone
Town
(114) 62g -. j?'jD .
Telephone
O
0 "noun CEO
O_
A5— BU /L T
O1HENS 1ON k,,,.. HART j11'N FT.)
N°
A
B
/
3320
13.30
2
46.50
24.20
3
46.30
29-80
4
51 90
3.5 ZO
5
55 90
4t 00
6
59. /0
4680
7
51.60
70.00
6
44.00
59-50
9
41.00
6250
/0
35.00
58.60
l i
29.610
54.60
/2
10600
79-00
13
106.00
78.60
14
10900
82.00
l5
WOO
8500
l6
/ll. 60
86.60
WELL
2�° OdOle
.. goo
flutima ccr.mcl-ljr
Avision of 11,3a1th