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BOX 5
00193
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00193
ALLEN BEALS, M.D.,-J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
MARYELLEN ODELL
County Fxecutive ,
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 - 1390. �s
Fax # (845) 278 -7921
APARTMENTS — CONDITIONS FOR APPROVALIRENEWAL
Approval is effective for a three year period. Failure to renew the pe fihm. -the three year
period will terminate the availability to renew said permit or apply for a new permit. '"� �—..,•
Please submit the following:
1. Certified check or money order for $100.00.
2. Coliform bacteria water sample results from the apartment drinking water supply.
4. Septic tank pumping receipt plus a letter from the pumper that the tank is in
satisfactory condition. '
5. Certification from Building Department that the dwelling is in Compliance with
Town Code.
Approval by this department is for the water supply and subsurface sewage treatment system
only. The applicant must apply for and receive approval from the individual town to occupy the
accessory apartment and must comply with all applicable rules and regulations set forth by the
town.
Failure to supply adequate quantity and quality of drinking water or a failure of the subsurface
sewage treatment system may result in the immediate revocation of the approval by this
department.
The permit is void upon change of ownership or change of owners address and cannot be
renewed by the new owner of record.
AccessoryApartments
P
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E.
Director of Environmental Health
Date:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
MARYELLEN ODELL
County Executive
ACCESSORY APARTMENT RENEWAL APPLICATION
STREET) A Qv- % ckt , �!. zg TOWN #,ej— a-n TAX MAP #
NAME �S PHONE_ftfO?' ,3 / E L PCHD.#
MAILING ADDRESS da ,m . e
MAILING ADDRESS OF APARTMENT Sam- �e—
NUMBER OF BEDROOMS IN MAIN HOUSE ,3
NUMBER OF BEDROOMS IN APARTMENT 1
Please submit this form and the requirements on page two to the Putnam County Health
Department at 1 Geneva. Road, Brewster, New York 10509, Phone (845) 278 -6130.
Approval is effective for a three year period. The applicant must reapply before the end of
each period to renew the legal status of the apartment. Failure to do so will void said
permit and, therefore can not be renewed. A change of owners address or change of
ownership for any residence holding a permit will also void said permit and cannot be
renewed by the new owner of record.
F A 21AW1111!FIN 0
�.
Approved Date From: To:
By Title
OFFICE US COMMENTS
AccessoryApplication
r\
s 4i,
.c
P 04
TOWN OF PATTERSON :: DATE./p
`BUILDING
DEPARTMENT INSPECTION REPORT }
Owner:
Contractor.
Building Permit #, Date-Issued.
Job Site:
i
INITIALS
INSPECTIONS
FOOTINGS FORMED /REBARS
`BASEMENT FLOOR SLAB
FOUNDATION BLOCK/POURED
FOOTING DRAINS
ROUGH FRAMING
ROUGH PLUMBING & HEATING
FIRE BLOCKING (if required)
INSULATION
SHEETROCK - SCREW INSPECTION
FORM COMMERCIAL ONLY
FINAL
OTHER (specify) �,
r!
COMMENTS'-
,
_,'',
}
o
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i
r\
CERTIPMATIE OF OCCUPIANICY AND COMPUA-INCE
of OHIO,
;jaffrrsV-nl 'rh
W rIER - 19, .
20,03
-mar: ISSUED—Oc—t-a-b "- 27
•
THIS IS TO CERTIFY-THAT MaAgoAet P",salacqua
ON THE PROPERTY,10P Same.
LOCATED ON 12 Mick-hou,&e Road
HAS BEEN SUBSTANTIALLY CONSTRUCTED TO THE REQUIREMENTS OF
THE BUILDING CODE ZONING ORDINANCE AND LOCAL
t LAWS OF THE TOWN
OF PATTERSON, NEW YORK AND MAY BE OCCUPIED AND USED AS
Acce4.6o&y Apattment one ged4oam, 2-CaA, GaAaae, AeaA- entAy
Building Perm, it -Date'd 4-25-03
.............. p er mit No... Applica'tio'n No ........3..4..5.8 ..
........
SECTION ........ BLOCK ......... 3-.
.............. LOT .... ....... :
FEE $ MOO
is
015
34.13-'
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights,.N.Y. 10598
(914) 245 -2800
Albert H. Padovani, Director
** TEST REPORT **
LAB #: 9.200398 CLIENT #: 9818 NON STAT PROC PAGE: 1 of 1
PASSALACQUA, MARGARET
12 BRICKHOUSE RD
PATTERSON, NY 12563
DATE /TIME TAKEN: 06/21/12 09:00
DATE /TIME,REC'D: 06/21/12 10:00
REPORT DATE: 06/25/12
PHONE: (845)- 878 -3188
SAMPLING SITE: ACCESSORY APT KITCHEN TAP SAMPLE TYPE..: POTABLE
12 BRICKHOUSE RD, PATTERSON, NY PRESERVATIVES: NONE
COLD BY: MARGARET PASSALACQUA TEMPERATURE..: <20 >4.00
NOT'ES...: COLIFORM METH: MF
i
START DATE /TIME END DATE /TIME FLAG PROCEDURE
RESULT
06/21/12 0330 06/22/12 0330 MF T. COLIFOR ABSENT /100 ML
NORMAL - RANGE METHOD
ABSENT SM 18 -20 9222B
COMMENTS:
MFTC ota Coliform = This result indicates that the water
(was) (was not) of 'a satisfactory sanitary quality according to
ew York State and EPA federal drinking water standard for
this parameter. This comment applies to the Total Coliform test
only.
SUBMITTED
THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC,
AND RELATE n TO T E PLES RECEIVED BY THE LAB
BY: JZ'(V
Albert H. dovani, M.T.(AS P)
Director
ELAP# 10323
PUTNAM COUNTY D PART M.IENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT #
Located at Town or Village
Owner/Applicant Name k �A'V. ✓A�- Tax Map Block Lot
Formerly
Subdivision Name
Subd. Lot# •
Mailing Address —zip",
Date Construction Permit Issued by PCHD
`Address .,I
Separate Sewerage S >'. A
geSystembuiltby
Consisting of u Gallon Septic Tank
and 1 U u (-J e Im-',
Other Requirefftents:
Water Supply; Public Supply From —Address.
rr
\4 S.0
or:— Private Supply Drilled by Addfess
-TI L, completed? Building Type Has erosion control been co leted? YL
Number of Bedrooms Has garbage grinder been installed?
F
I certify, that thee-system (s), a0i*d, serving .,premises we . constructed onstructed essentially. as shown on the as- ng the above re
built plans (copies of which are attached), in accordance'with the issued PCHD Construction Permit and "approved
plans and the standards, rules and regul ions�o Hepartment of Health.
Date: P.E. RA
(Design Profil.ss"
Address (e: L'V 7al)
(_,N v License # L
Any person occupyig"premises served by the above system(s) shall,pronipd 'tiil& such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage.- Approval of the separate sewage
treatment system shall become null and ;void as.' soon as a public sanitarysew& becomes available and the approval
of the private water supply shall become null 10i& 81'd when a public water supply becomes available. Such
approvals are, subject to modification'..or change when, in the judgment of the Public Health Director, such
revocation, modificagion oz
change is necessary.
B
Title: Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC-97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT #
Located at 1 Z
Subdivision name
'13 P -%cAe- "t)vs,�
Date Subdivision Approved
y1f 31 Town or-V�e 07l)
Subd. Lot # Tax Map 13 Block Z- Lot rl
Renewal Revision .
Owner /Applicant Name KUaH Date of Previous Approval
Mailing Address r Z I �t�c r2- I�vvsrC� (2y . 'FAniaz-&. w Q"r Zip 12563
Amount of Fee Enclosed
KBuilding Type ?-�S i be;kM,&L Lot Area 1,19m-No. of Bedrooms
N�
_ Design Flow GPD
CY, . rio
Fill Section Only. Depth Volume
PCHD NOTIFICATION IS REQUIRED-"WHEN FILL IS COMPLETED
Separate Sewerage System to consist of -7 5a gallon septic tank and 10 0 l."�F,
Other Requirements: C.t-�%j uA-s 0 �� 5o' r� Arc S
To be constructed by I Tv nrr- j>Eqrjz*" urn Address
Water Sup IV: Public Supply From
Address
A efts
or:. Private Supply 94led y- Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto
Signed: E. V R.A. Date o
Address L� UL-0 TZr, G J� Ttn't_ 1,?,`�, 10 S6 License # 6114+ p
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new permit. Approve ar a of domestic sanitary sewage only.
gy. Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Own r; Orange copy - Design P ofe
F
:o
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
RE: Property of
Located at
LETTER OF AUTHORIZATION
K4 Afv-r
t Z 13 % C4--- WO-0 s cF—
T / N. 'J. Xrru- Tax Map # 13 Block Z- Lot -7
Subdivision of
Subdivision Lot #
Gentlemen:
This letter is to authorize , -F-.4'4 iu-E:�u S i'wc_ Qn�,_
a duly licensed Professional Engineer _�_ or Registered Architect to apply
for the required wastewater treatment and /or water supply permit(s) to serve the above
noted property in accordance with the standards, rules or regulations as promulgated
by the Public Health Director of the Putnam County Health Department, and to sign all
necessary papers on my behalf in connection with this matter and to supervise the
construction of said wastewater treatment and /or water supply systems in conformity
with the provisions,6� - ` a ;145 and /or 147 of the Education Law, the Public Health
Law, and the P��Goi_nt� anitary Code.
` Very truly yours,
� t
Countersigned: Signed: Gtr./
P.E., R.A., # :: =� (Owner of P perry)
Mailing Address: L4 01-0 lZr G
T2— Tzfz-� -, rF--- �
�� r �•_.j "�', i "fir f'
State: Zip:
Telephone:
�I.'7 111
Mailing Address: �c) 60- )
?-C -e rs 0 k_-� , Q y 12 s2,1 3
State: l 2 Zip: k L51
Telephone: a
n PUTNAM COUNTY DEPARTMENT OF, HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner Address 1Z. jW
Located at (Street) tJ , `f.S , V 3 l l Tax Map 13 Block Z- Lot
(indicate nearest cross street)
Municipality Drainage Basin 'E��5 T-
SOIL PERCOLATION TEST DATA
Date of Pre - soaking 3 Date of Percolation Test
percolation test hole. (i.e. < 1 min for 1 -30 min/inch, _< 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
De th to Water
Water
From Ground
Level
Percolation
Hole No.
Run No.
Time
Start - Stop
Ela se Time .
(piVlin.)
Surface (Inches)
Start Stop
Drop In
„ Incises
Rate
Nun/Inch
l
a 11i - Z'3(,
2(
2
2;316 - 3: 08
3c)
3
331
7.9
ZI.'�i
5
Z
l
oG - 7,14'
Z6
Z 1 Z 7
b
3.
2
A) `fv -. 3'Qr
2S
ZJI� z8`�Z
3,�
3
3.00 3:3o
z _ Zl` /z
4
335 - 3'sl'
2/
ZZ - Z6
�
3,S
5
-�
-: C!% ��
IN
l
'AE
'INN
2w
gee
N, SJ
m.up
5
NOTES: I . TP.StC to hP rPnPAt&A nt came HPnth
1
anti) nnnrnvimnrPly amini na�rr%krinn ratPC nrP nhtninPA Ar Pgrh
percolation test hole. (i.e. < 1 min for 1 -30 min/inch, _< 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
1L`D1 rll Lt11t�
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L.
0.5'
1.0'
1.5'
2.0'
2.5'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
7.0'
7.5'
8.0'
8.5'
9.0'
9.5'
10.0'
Indicate level at which groundwater is encountered
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: �� 1A, L-- Cyc/or
Address: 4 O`F'� G �,4 ►►- �,�.uS
-
0,Y o S09
Signature:
a
14.164 (9195) —Text 12
PROJECT I.D. NUMBER 617.20 SEQ.R
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS. Only
PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT � /SPONSOR .
IMZ``i PAST r&1-4GQVA
2. PROJECT NAME
FA S 5 t, L A C.aL4- "►YJ z�r.
3. PROJECT LOCATION:.
P/'Y�1u pv'i'3. -,-'A
Municipality 0 County
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provloe map)
ij Tr– C e�&Ttor" & F 1-3 r7m cwf dkvuS fE- fWla1.2 A 0 0
WY,
5. IS PROPOSED ACTION:
0 New Expansion ❑ Modlflcatlon/alteratlon
6. DESCRIBE PROJECT BRIEFLY:
PI21 NCj 01416244,U �� l Je4zeATI
s V9 514ZIC-A C(--r S r f7w-z- 1i +S PL-SA
�-
7. AMOUNT OF LAND AFFECT' ED: /
Initially 0j acres Ultimately y' OS acres
S. WROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
es ❑ No If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
02�4sldentlal 0 Industrial 0 Commercial 0 Agriculture 0 Park/Forest/Open space ❑ Otner
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
59443 ONO If yes, list agency(s) and perrnlUapprovals
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL?
Yes O No . If yes, list agency name and pormlt/approval .
TACI 5-n "35 Q Lv F�cLt u 5 c o o'
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE. MODIFICATION?
pixes 0 No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
A PD p IlcanUs onsor name: Date: _._t.1.._`f v�3
Slgnaturs:
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
PART 11— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF.
❑ Yes ❑ No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? It No. a negative declaration
may be superseded by another Involved agency.
❑ Yes ❑ No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Arcwers may be handwritten, if legible)
C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
CJ. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly.
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not Identified in C1-057 Explain briefly.
C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly.
0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑ Yes ❑ No
E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
❑ Yes ❑ No If Yes, explain briefly
'ART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect Identified above, determine whether it is substantial, large, important or otherwise significant.
Each effect should be assessed in connection with Its (a) setting (i.e. Orban or rural); (b) probability of occurring; (c) duration; (d)
irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. If
question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action
on the environmental characteristics of the CEA.
❑ Check this box If you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration.
❑ Check this box if you have determined, based on the information and analysis above and any supporting
documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Print or Type Name of Responsible Officer in Lead Agency
Signature of Responsible Officer in Lead Agency
Name of Lead Agency
ate
Title of Responsible 0 flicer
ignature of reparer (11 dif Brent from responsi e o icer)
,a
..1,
C,6\
R, X804 0,,
85't
PROPOSED
0
/ 0 �0)
4i rye/
iQ pUT.
s4o 311
56't
O
EXI5TING EXISTING
i Ql. _" 533 °30'00 "W
WELL EXI5TINO 0 H.
`_! + ELEGTRIG r
SERVIG ll4TW ! ? j J
it
1 10'
EXISTING
PROPOSED w CvlSrllaCj Via. Y �,�c� n�l.A /
ADDITIOt
irY..�
•ti � 3 00 „,C � ?aC2�
EXI5TINCG
GRAVEL —
DRIVEWAY
R= 130.00,
\
O�
j
�f
35't
1 r E G v
1•
z•— '+r-"�+ —^+
r „k....'�
N
t 3�`ryi, a z4' ,y � z { "'"�^ � t>t�fu 2� ,.{,r 4� 4s" .t �o- q -. ✓' .� rye�.�`„1 �' ht rt r`,
,�.'� t> w'�. L, 4r:.... �.d 1,_5, .�3�.Up �� ri .4.,..':.. ,� �''i t• �'�?°`y.znY, �� tr S,s,. ,� `4
MAR
�
\
*, `t { f w a OFHEA LT:H z x
+� t i [ PUTNAM CO,UNY IPARTMENT_ x _
1 y
z D)vuion zof Environmental Health aServices, Cacme% N Y 4105123.
t st sr',.,:k t t�tr � r S i't, v �i dpi t y .?�v t a , X � 7a t.,.r �+'s ter.._ r �. a.,? 3,� K� q ?. ,�+.• .ham h M1,t _ >kt '. � s v . .
CERTIFICATE`OF, CONSTRUCTION COMPLIANCE FOR SEWAGE D SPOSA:'M, STEM Patterson V
OF FV 111898
C`rOSS )Road
'4 t.00ated 8tf -" t �. � . tt ,�Y � s 10
Sec
.. z �, ri +t:N w J E. >,r� .�.. � ;` a♦ Ta to r i a�-` n
�;;McGI asson `;Builders , Inc �` Job
01156 '
Y < T-� ' 0%in }er' ���n ` `, Add ►e5501`�enei °daA�e �:.'tCarrriel ,
NY
separate Sewerage System butltzby $ 3
1000 240 +k l 36 inch wid hrt[enah
Consisting of Gal Septic.Tank Lineal FeetA X
None PiA t f r t$ t In _ �` 1 c r t: tt Y a• z i c .�� ,r 1 i",
r Other ,requirements ,
r I....' l .kti A♦ s )} t 1 t
kti r t•:✓` -�. 2.'` 4r •Y
*Water Supply Public Supply From
i
X Private Supply Drilled BY Boyd ArtesianWe11 Co. Inc ; C
i
I. R D 5�,' Rte �52y; Carmel , NY i
r 'Address
:Bu�ld�n9`.TYPe ,Frame t , „ of ►oo Three z'�. {. 3/28/Z3>> .
t
No Bed ms Date Permit Issued
Has ;Eroslo' Control Been Completed? YeS
ar- A"%
y ,
'
r. a'•certif.'.that the''s `stems '$saisted serviri "the above premises were constructed essentially as shown on the plans of the ;completed work;(copies,of which are..,,
attached); and ,m, accordance with the standards, rules and = :regulations plans filed, and the permit issued Putnam County` Department of 'Health.?'
zti ;Date _9 October 1973 Certified by • P E X R A
K ^6 6, Box 353 Ca erl ANY 1,0512 n +x`F1tkr++ k s 292Q� �t
Lkense NO \ m
_ Any;;person occupying premises served by the above systems) shall, promptly take such action as may be neces ary to ;secure the'correction of any unsanitary'
.. iA �.t. -v k.:. >„� - W iti -,i ^A� i+. t!' n 4 S d
..;conditions resulting from, such, Usage.,''"' `of the separatensewerage ;system,shalltbecometnult andxvoi ? o a>public >sanitary:sewer becomes,`
3 , r - mss. 1
",available and the;, approval of the private waterrsupply stiali become null `a when a'' Lbl�c ply becom available :;Such:'approvais,,are,,
subJect to modrficstton or change when, : in the Judgment of mmission ealth ryreVo on' mo lion or than a is necessary n
// �- %O I► � t 4 t i .r �' .i '^ is l `4 � t,
� .Date / •� L i � r`� B.y, r r � a � t'�k�" des' ,.f s orw �'!t� re's, TitlOi a
....._..a.s...�� ...,..i_..,_ �.._� _.........___. ��..r.�_.i;._..._..,.._..?,..__ _..a.. _...._. �._. w.. �.._.._._...._._..�..�... _.v._+_ `.�_.,.a,�..�....,. �'_u..... ..............�•;= .5.- ::a...:
J3
r
�J
d
BREWSTER LABORATORIES \
Box 224 - BRMSTER, N.Y.
WATER ANALYSIS REPORT
SAMPLE NO. 29%2
souRm PlcGlasson Builders, Inc.
Cross Road
Patterson, N.Y.
COLLECTED:
-BY: McGlasson Builders, Inc.
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 samplt
was collected.
June 16, 1973
t
Ro ickwit P. E.
Director
l• ",'ELL GO!'Vi U TION REPORT" / PUTNANI COUNTY DEPARTNIENT•OF I'iFAi.•F1 -1
3/71 n 1 Division of Environrcnontal Health Services.
COUNTY OFFICE BUILDING CAFtPViFL, F Gy 'd YORI<
This retort iS'to be CDnipleted by well driller and submitted to County Health Department together with Iabo'ratory report of
analysis of water sample indicating water is of Satisfactory bacterial quality. before certificate of construction compliance is issued.
REPORT MUST BE SLIBMI'FTED WITIiIN 30 DAYS OF WELL C01"A'LETION
s_ - --
oavlaER -•
.,'NAME;
McGlasson Builders
ADDRESS -
Carmel X-.Y.
LOCAYION
OF WELL
--
(No. & Street) (Town) (Lot Numborj ' .
Rt. 311 and Buick Rouse ad. Patterson N.Y.
PROPOSEp
USE OF
WELL
($cor.
DOMESTIC BUSINESS i
ESTABLISHMENT FARM (_) TEST WELL
PUBLIC AIR OTHER
CI SUPPLY INDUSTRIAL El CONDITIONING .(Specify) . f
i DRILLING
EQUIPMENT
( COMPRESSED CABLE OTHER
L]- ROTARY AIR PERCUSSION � PERCUSSION �. (Specify)
CASING
DETAILS
LENGTH (legit) UTAf4IIE,R(ineh. -s) WEIGHT PEP. FOOT DRIVE SHOE(
22 / I 26 THREADED ❑WELDED ®YES I_JNO
- - -J—
WAS CASING.QR`Q J) F 7
YES FI NO
YIELD
TEST
HOURS G ;P.m'
LJ BAILED PUMPED ® COMPRESSED AIR 20
YIELD (G.P.M.
� 2O
WATER
LEVEL
—
MEASURE FROM LAND SUP. FACE- 'STATIC(Specily feet!
10
—�`�
DURING YIELD TEST (feet)
total . drav4down
Depth of Completed Well 125 f
in feet below land surface:
SCREEN
MAKE
LENGTH OPEN TO AQUIFER (feet)
DETAILS
`
SLOT SIZE
DIAMF.TEP. (inches)
r
IF GRAVEL
PACKED:
Diameter of well including_
gravel pack (inches):
GRAVEL SIZE '(inches) FROM (feet) TO (toot)
DEPTH FROM LAND SURFACE
-
FORMATION DESCRIPTION
Sketch el'act location of well with distances, to at least
er
permanent land arks.
FEET to FEET
: .0
I 5 -
sand
Boyd Artesian W,II Co., In
5
125
-
limestone .
i
r
If yield was tested at different depths during drilling, list below
FEET
GALLONS PER MINUTE
w
DATE WELL COMPLEILD
6/1/73
p T . O �ct,c wr
�/Fl1 ?f3
_
wr_:L.I_ r rl t_crt (• i,���((�t�n�) � 5,- Roote 52
A-1
/%aYUr Calmel, N. Y. 1051?
_®
x E ,
p v15$ 4 y + 7a 4 DlVISIOh �Of aEhVllORm @/►tiBI H @alCi
ti CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
Cross Road
} Located at
C -
� a`Sutidiv�sion � '• ''�«.� o�,s�,. `, y4 .�a� � c `k � :� ` � � +r.s
Owner
McG{lasson Builders, Inca f�
Builtlsng TYPe''' Frame +x4 r' 3 + ` +u ' L�otk Area t '
s t
;Number of eetlrooms```Three
Sepaeate'Sewerage.System to consist of IOOO Gal rSeG
To be " "constructed
by': Owner
r i3 t
- )Mater 'Supply, Public?Supply From s
t
Prroate'Supply" to be drilled tby
Address
NoneOther Requirements 3
* '
1 represent that l am wholly and completely, responsible fo�'the design, and loci
above descrsbed''W's II be constructed as shown on the approved amendr e4R4ner
County "Department oft Heaith,''and that on completioh thereof a .Certificate
be submitted +t'o the Department, and a;.writtgwguarantee will be furnisfie
"Place m � s
good operating condition any -part ;of said sewage disposal ysten
once, of, the approval of the :Certificate„ of Construction :,dbmpi7ance of tti}
will be located as shown on the approved plan and that said well wUl be mst lei
+ "County ?Department of Health'
rV14/73F
i
:'Date
{ l Address _
APPROVED FbR)i ONiTRUCTION Tfits approval expires ne ye" from,tF
revocable for cause or may be {amended or modifietl when con tl necessarj
:requires a new permit pprove'd for dispo_sWoof domestic saniteryrsewaye
M
2 F
t a * 1
s
n
Patterso����
t > 4
vSyy x 4CY'fownr;Or i lldge' c •� y..'-
B lock, } = 4
SQ�1 X56-
Job "
enei~da `Avenue. ".
rme Y 51 ;2 L s
z
} 1300 on 1" 1
le Space y Sglare''Feet•.
nriea� feet' x 36 °inch .' ,width trench
w
tem(s) lj''that the45eparate ,�sewagedisposaP,ayste`m
irthe standards;�rules;an regu a_ ons.o ' . e - u narn
ince A ij actory to -the Commissioner of Healthwill
heirs or assigns by the bwlder that said builder will•
(2) years immediately tollow,ing .the'date of.'the'issu
hereto -2) that tile, drilled well. described, above -
st � ards, rules 'and reguia i� on�f the Putnam:,
a f License No 27206.
ruction ofthe building hasbeen undertaken and. +is '
F�Health Any change' or alteration :of.constructiori
only ,
aV O
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
A a
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner Re- : zq�Pr T�dress �oss
Located at.(Street // Sec. Block Lot
�Indica e nearest-cross. s ree
Municipality .Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO.BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK
TIME
PERCOLATION
PERCOLATION
Run
Elapse
p
o : a er
waUer ve
No.
Time
From Ground Surface
in Inches Soil Rate
Start -Stop
Min.
Start
Stop
Drop in Min. /in drop
Inches
Inches
Inches,
4
Notes:' 1) Te'ts .,to be repeated-,-At same
rates are obta' ;i hed at each ;,percolation
for review.
2) Depth measurements to be made
depth until apppproximatelyy equal soil
test hole. All data to be submitted
from top of hole.
I o
DEPTH
G.L.
6"
e
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO.- HOLE N0.
T
12"
aragyhec g
"-
18"
2411
3011
/
3611
42 "
/Il1�l� hl®
48"
S 4h e� aC
5411
Roehr
60"
66"
7211
78"
84" No I" /
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED fie,
,INDICATE LEVEL TO WHICH WATER VVEL RISES AFTER BEI G fDate. COUN
TESTS MADE BY Pee • (N. F.'
A%.K 44h. *-/+.s
y1J4J 1 V l7
Soil Rate Used //-/rMirvl "Drop: S.D. Usable Area Provided _ Jgdo
No. of Bedrooms e— Septic Tank Capacity. /00 ��
.0 Gals. Type ,�' �sokyry
Absorption Area Provided By���L.F.x2411 5b" width trench.—
Other Apple
name John H. Prentiss, P.E. bignatur
Of SIONq�
Address R.D.-6, Box 353 P e.
Camel, N.Y. 10512 N Re�� %ss���
,F
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY
Soil Rate Approved Sq. Ft /Gal. Ch Date
NO.
Of T'N StAtEa
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MA
M
SI,
AW;
..........
i:.
r
e
NYS
�ou-r
l5$ 39 W
56't
EXISTING
533 °30'00 "W
EXISTING
25q.6O'
85't ;:
PROPOSED
WELL
EXISTING O.H.
ELEGT'RIG
SERVICE
JUNCTION BOX
150 GAL G.O. 1
2
SEPTIC TANK
G.O. 2
,f
i
FN
°ry
PROPOSED
ADDITION
EXISTING
DyyELLING
\O
e 00
EXISTING
GRAVEL
35't
j
DRIVEWAY
EXISTING
�o
RL X80 as,
-� o 0
L _36.gO
R =1901pO
°p•Op, `y I
/4
/C9
01/1
A5 -BUILT MEA5UREMENT5 (IN FEET )
jTN Q M I M:E 1-1 FUE
INEER5 - ARCHITECTS
4 OLD ROUTE 6, BREWSTER, NEW YORK 1050q
(845) 27q -678q FAX (845) 27q -676q
O PUTNAM EN6INEMN6 PLLG 2005
FUR5UANT TO NEW YORK STATE
ARTICLE 145, 5ECTION 7209 5U
15 A VIOLATION OF TH15 LAW FOF
UNL.E55 HE 15 ACTING UNDER THI
A LICEN5ED PPOFE551ONAL ENGI
AN ITEM IN ANY WAY. IF AN ITEM
SEAL OF AN ENGINEER 15 ALTEREI
ENGINEER SHALL AFFIX TO THE ITI
THE NOTATION - ALTERED BY- POLI
51GNATURE AND THE DATE OF 5U
AND A 5PECIFIC DE5CRIPTION OF
ALTERATION
TANK
JBOX
00. 1
CO. 2
1
2
A
22
33.5
B
35
10
2q.5
31
23
121
G
13.5
44.5
23
125
jTN Q M I M:E 1-1 FUE
INEER5 - ARCHITECTS
4 OLD ROUTE 6, BREWSTER, NEW YORK 1050q
(845) 27q -678q FAX (845) 27q -676q
O PUTNAM EN6INEMN6 PLLG 2005
FUR5UANT TO NEW YORK STATE
ARTICLE 145, 5ECTION 7209 5U
15 A VIOLATION OF TH15 LAW FOF
UNL.E55 HE 15 ACTING UNDER THI
A LICEN5ED PPOFE551ONAL ENGI
AN ITEM IN ANY WAY. IF AN ITEM
SEAL OF AN ENGINEER 15 ALTEREI
ENGINEER SHALL AFFIX TO THE ITI
THE NOTATION - ALTERED BY- POLI
51GNATURE AND THE DATE OF 5U
AND A 5PECIFIC DE5CRIPTION OF
ALTERATION