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22.12 -1 -3.3
BOX 7
00533
SQ`�.G. AI __^ TTTATT
•`~ ry
W Y�
WI_,LL UVVIL LL' L 1.VLY RL',L kinL
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: TOWNMILLACKICHY TAX GRID NUMBER:
0.0, ��G o _ z j
`PRIVATE
WELL OWNER
NAME: ADDRESS:
❑ PUBLIC
USE OF WELL
1 - primary
2 - secondary
116RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND. /HEAT PUMP ❑ ABANDONED
O BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL 0 INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT S gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE ���
. gal.
REASON FOR
DRILLING
❑19 PLACE EXISTING SUPPLY ❑ [--]ADDITIONAL ADDITIONAL SUPPLY
�TEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH _ DS ft. I
STATIC WATER LEVEL ft.
1 DATE MEASURED 9a-
DRILLING
EQUIPMENT
❑ ROTARY eCOMPRESSED AIR PERCUSSION O DUG
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED ❑ OPEN END CASING OPEN HOLE IN BEDROCK 0 OTHER
CASING
DETAILS
TOTAL LENGTH ft.
oe
MATERIALS: VSTEEL O PLASTIC O OTHER
LENGTH BELOW GRADE ft.
JOINTS: ❑ WELDED THREADED 0 OTHER
DIAMETER in.
SEAL: ❑ CEMENT GROUT O BENTONITE YOTH R
WEIGHT
PER FOOT �� Ib. /ft.
DRIVE SHOE: YES O NO
I LINER:OYES 140
SCREED!
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
❑ YES ❑ NO
OURS
SECOND
GRAVEL PACK
OYES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TO
DEPTH ft.
Tram
EPTN tt.
WELL YIELD TEST If detailed pumping
M 00: O PUMPED tests were done is in-
COMPRESSED AIR , formation attached?
O BAILED 0 OTHER ❑ YES 0 NO
1PIELL LOG 1t more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
ing
Well
Oia-
Deter
FORMATION DESCRIPTION
ON
fi
ft
WELL DEPTH
It.
DURATION
hr_ ' min,
ORAWOOWN
ft,
YIELD
gpm.
Surface
l4
3aS
c�
/do.
o
r
WATER YCLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE 4A fro 02,5� Cif' /
CAPACITY GAL.
WELALR�lgf�E HYATT &SONS, INC, DATE )
ADDRESS l�TT MM Well Drilling SIWATURE
Rte. 311 R.R. 2 Box .4 "7d A .
PATTERSON, NEW YORK,-1,4563
PUMP IIN,,--LLFOR__i__ff,�ATION
TYPES CAPACITY /0 CA
MAKER ` DEPTH %
MODEL VOLTAGEQAJ_ HP
J/ V7 r
r.
B59 S' 07%-Y
r
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2 ST��Y
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THDS IS TO CERTIFY THAT THE MAGE DISPOSAL SYSTPmI X59
WAS CONSTRLIC^__J AC Tn1T' J *.T THIS PUM AND THAT
THE SYSM47I.S, »L 11 719033 IT WAS COYF.2%+ � 3EeG
13 ACCORDAVOR It
YgfYTE All 1 r" :i VD i??nRU3,.LiT100 OB THE FMAM j
I d3�1gY I Iu �G iR iB mws. ?
111G 7T -70;p
i
LOT # 9
AS SHOWN ON I
F?ESUBOIVISON M/ P OF 'I GOROON J. E SUSAN L. G-2EENr=" FILED MAPr- z" OS FILED
TOWN OF PATTERSON PUTNAM CO., N`I.. j
SCALE
PR ap:� /ze•� Foe
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THDS IS TO CERTIFY THAT THE MAGE DISPOSAL SYSTPmI X59
WAS CONSTRLIC^__J AC Tn1T' J *.T THIS PUM AND THAT
THE SYSM47I.S, »L 11 719033 IT WAS COYF.2%+ � 3EeG
13 ACCORDAVOR It
YgfYTE All 1 r" :i VD i??nRU3,.LiT100 OB THE FMAM j
I d3�1gY I Iu �G iR iB mws. ?
111G 7T -70;p
i
LOT # 9
AS SHOWN ON I
F?ESUBOIVISON M/ P OF 'I GOROON J. E SUSAN L. G-2EENr=" FILED MAPr- z" OS FILED
TOWN OF PATTERSON PUTNAM CO., N`I.. j
SCALE
PR ap:� /ze•� Foe
I
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PUTNAM COUNTY DEPARTMENT OF HEALTH
V DIvNIon 6it>�vEraemenhl:Healfh Seevloer;" Caemel, N.Y 1OS12 �,J- � �
k P.C.H D.`Peimk N l �
-
CATE OF CONSTRUCTION COMPLIANCE FOR* SEWAGE DISPOSAL SYSTEM _v'Q/ii
- _
To *n or w111W
Lot Taz:Map' . l.3 Bloch " _ �.
Ownedapocant Name � t1SS�Li�Foemetly Subdivialen :Nabte��
" e•
Mafts •• L�l;�f✓�.. zip'. �. Subdv. Lot 4t_
Fee Enclosed Amouri 12- 004AD. /? Date Perinit :Issued
XFili�dey
/Z--
Sep� rte Sewerajle; System bast by
�}
Conalliyt of h•vCT Gallon Septic Tank - and -�tjI .1. Xs� Cf➢ l •l�`�/GiP�I•�a(/ '�id
Water Supply: ftbHe Supply From Address
/oar: Private Supply DNllea by : _ *7 Address T / . % �. (%x
Lot. -Si2e��H88 EroSjALCnnYYnl RPPT fmm�l PtPr? Building Type
Number of Bedrooms Hsa Garbage Grbmder Been Lnetalledl.
other iss+galeemente -
I certify that the systee(e) as fiat " seriring the above premises were-constructed essentially as shown: on -the pl s of the completed work Y copies.
of .which .are. attached), aed'in accozdenca rith`the standards,'rules and reg io: cordanc- th fil lan, end the permit rasa by the
Wtnas Cou /nty D psi nntnof�nealfh.
Date /''��' /✓ ati /lad by P.E. R.A.
Address License No.
Any parson occupying promises served by the.above systSM(s) shall promptly take such action as be'neoaaa►y t , sewn the correction of any unssn t ry
conditions. resulting from such ussg . Approval, of the sepsraw sawwaee,system shall baoonte null and vow Is so'" as a pub('= unitary sawaf l scbfn_
avallabN and the approval of. the private,wafar wPPIY shall bicoma null,ina,vo_ when a Dub " wits► supply becomes wallable. Such approval; era
subject to'o m��oddiiifficationorr chhaannnggeeGGwhen, in the judgment of the CommisWonor of , eh revocation, inodNkation'o► chino* Ii ntoanry.
Date G / /. / y
3/89 f
a
-�.
e
'NORTH AMERICAN
LABORATORIES, INC.
ANALYSIS DATA SHEET
COUNTY: Putnam
LOCATION: Fussell residence
REPORT TO: John Fussell
ADDRESS: 73B Ludingtonville Rd.
CITY, STATE, ZIP: Patterson, NY 12563
DATE COLLECTED: 10 -14 -92 -,
TIME COLLECTED: 8:45 AM
COLLECTED BY: Client -_
REPORT DATE: 10 -16 -92 -� -'
SAMPLE: DW 8349
SAMPLE SOURCE: Bath tap
DATE
ANALYSIS RESULT UNITS METHOD ANALYZED
Total Coliform Absent COLILERT 10 -14 -92
1
THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET
THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS.
4&
boratory Director
NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218
618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914 - 278 -7600 / FAX 914- 278 -7754
PU'INAM COUN'T'Y DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
��To Ap v-
Own
er or Purchaser of Building
She
Building Constructed by
7?, 3 6 C09) '11/L � ��Ile r-1
Location - Street
14e's /-,V
Municipality
Ze-,5/,0,%/-
Building Type
13
Section Block Lot
6ae.o^ ee ele -
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
workmanship, material, construction and drainage of the sewage disposal system
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 Putnam County Department of Health, and
hereby guarantee 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 years immediately following the date of approval of the
"Certificate of Construction Compliance" for 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 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 Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of -he builddiing %utilizing
the system.
Dated this
of/ 19 i,-;V
Contractor (Owner) - Signature
Corporation Name (if Corp.)
ee 23 6 G,VPiIL- f7624 L'/
Address
rev. 9/85
mk
Signature
Title -
,� �Q
;k ?&Z
Name (if Corp.)
V
&,
fl)
.Cl
N
U
9
- - - - - - - -
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5DB N�F LOG.ON
// � •' � NO °%4=53 %Y \�,—= -� � - -- �9.�2
LEGEND / � - - - - -_ ------ -- - - -- - -- ��
7XI9 lit,
✓DNL7 /oN BeX / , / /� i ' N Ck`
• 4�D /A. PERT. PiP6 /� /'/ /� � /T�-�,-- �`- 1 _ —� / ��\� '�O,
e PERC. TEST / / 9 pg' /�►� =' � � ' /s Fi. Ec ! __ _ %— ` p 0 — � � �
V'�
9W / /ELL
PR OR
/ D
So /[ Z.v�oeargs /o.✓ j �/ ?° � / �.Q�i �.� / R�9a � _ 2' • ' �� � � �_ � � — ..
o -/' T� SoFL j /. 700 C�P� A ZS8
,r/
.!T
p;�FRC' /PASS
/sue
9 9,5' 9 / / `� / �9 /� • Putnam County silt of Health
Divis n of Env n 1 Health Servicss
l D
proved nosed for conformance with
le Rules and Regulations of the
Coun Health Departme t.
'6 Signature & Title Date
C,4CANF /LL�CRAOC S�P
riAY ftAw� /YOl SC
AREPA.�ED iO.r ,
• JDUN FUSSELL
S /Tt�ATd /NTifFE
> o.#VN Of AmrxzrQow
9Ei�ic f rr I SCALE: /' -So, of Mew r0R
y✓ ' S i KoN n DAr6 ! - / 1- !o s y��pM F. ?F��
%'DLEP XJB �� /Di P KB$0,C.OT/ON T.geNLNEt 2 F
Curr.�.N .W.N C/�/fwC/B6� �6!/: //- /O- 9� i • =_,.� P
r i
ey '• o
%/BK r. /"_ /C• .._ �.COie,a��siawns sC)�vc,.vei"r / 'rfp i+
=A ry /wc, N• Y. /A06/ O*eFESSIONay
? i°
_ I
� I
3
W
J
Lw
O
a
w
" o
W
u
QI
2
W
a
SOLID ROCK
MIN GROUT
:AL
fICKNESS
12
_T
CASING 20 FT. MIN..
LENGTH UNDER ANY
CONDITIONS.
USE CLAY PUDDLE CORE
BETWEEN CASING AND
--
DRILL HOLE.
,/7 f
CASING,
10' MIN.% IN ROCK
SANITARY SEAL
ON WELL CAP
- SCREEN VENT
T- WELDED SLEEVE
48° MIN.
IP TYPE COUPLING
ti..._ FROM PUMP
TO PUMP -
'LL CASING I
BUSHING OR
CAULKI NG
TYPICAL SECTION
OF
DRILLED W
_ A5PHALTIC /
. r II SEAL II"- _�
. INLET 1�1 �i• �� I
RING - I I O OUTLET 4 -0° 5• -0"
CONCRETE SEPTIC TANK 1�.1
L —f~J
SLABS POURED IN PLACE I I I -
�' ARE DESIGNED TO 1
SUPPORT A MIN. LOAD OF L - -
300 P-S.F "
PLAN
LOCATION STAKE ---1+ -
,i 12. MIN. ,
REMOVABLE MANHOLE, BARS, 6 OL 36° MAX. REMOVABLE MANHOLE, 20° MIN. OPENING
/�3 � -
20" MIN. OPENING 7 4" SOLID PIPE WITH TIGHT
CAST IRON PIPE, WITH
TIGHT JOINTS
I/4 1FT. MIN. SLOPE INLET
CAULXED JOINT
SANITARY TEE -
I
I
ASPHALTIC SEAL
n Z INVERT OF INLET
' I 3"ABOVE INVERT
(i
I a OF OUTLET.
LOLL
LEVEL
I I -
7
I-i��✓ BAFFLES MAY BE
I m
USED INS -EAD
1'
OF SANITARY TEES
u
I~
1 CEMENT PARGING
I W
2 p
� p
ON INSIDE
Y J
JOINTS, GRADED 1/8 ' /FT. MIN.
OUTLET -►
CAULKED JOINT
SANITARY TEE
6" MIN. WALL THICKNESS -
FOR POURED IN PLACE
CONCRETE
I
-
5 ECTf ON I cLEaN SAND
TYPICAL. 1200 GAL. CONCRETE. SEPTIC- TANK
SEPTIC DETAILS
prepared for
�^ / of NEW YO
.. ._./ o fTi✓ �l UJ -6-4 C_
q
prepared by ✓ I`
WILLIAM F. ZEILER
Professional Engineer S Land Surveyor �, y
Concord Road - Mahopac -New York 10541 '3 nl
(914),628-4764
FA PRO iES51G%P�
- CONSMUCTT_ON NOTES ---
SUnSURFAC'z SL fiGE S'fST_S S W =I, WXrE Su ?per -
aurCDrnG
S- c °YING SINGLE F ?1"TM:
E.:RTX BaCxsiLL i • ! .
t_ 10 fe*_ ct t`_ ors Sa�iS sc
-t
2. S::,_S to !:a =—c-ea by t`= csicn c`_.^ =M I .. _..
t • / /.,_.'7�A,.r ^ ( - ' ' _ ` 1 :c =2_ � t 2-+� CaLS DL_Cr tJ 1aC k �' - !T
18 MrN. h
.....
• .
3. to r-,3r Egrets a _`Z s;_1
sal t3 ;w ; r!
-r� �. .ti•-' -..- . �' •i - �1 I B� MIN.! a rdar= .i - t:_2, plan, any r= misicrus t_h�ato' c�M
T111?S a^
ra- =-:la`cns Oi the pe_^.,L-, lss.L C'Yt__7-_-:t2 aG_
{ P_RFORAT£'J PVC • °O - M jO CT - -£,YCf
LLLL���. LLL___ 48'MIN.
Sw. aO5NxE E 9 OR CRUSHED I f a/ffPE, a_CE I ' . 4. 1ri-ni Z �2_ yield Oi S C^= =5. r__ �-ed ' i_i ds la S t :cFb =^. $ , �� i.
ar ,
�
6'- ( so Nf f to to Pu== C=r1-_/ re;:a=�.= of .
�z Lz1 Ij 1 5. The sewer system design shown hereon does not provide for the installation
SECTION of a garbage grinder,:. such installation requires the approval of the Putnam
Z ION Pf�O ILf GRCUNO I County Dept. of Health.
war-_R. F �" Rocz \ales PucTi_�i Svr_ ^_ = P ^�^sa3.
tray be z' io - to for 60 to °0 days oLcTr plate:= c
ar-4 be bey t-= a_� =:. C�_t_i D_--n_n= os F_a t`1 for
DISPOSAL TRENCH DE AJL ( INSTALL ON CENTE =1 �ri�r_ta _s ue a. `_ saw- s�a : late Of p_���t ,ice ba�— -
-re'znr t Rc_"I CcT.ztti rzz-ert of 1�. =T!7
- 2. °tsi of lzee °� s">1 be Suitable for sewaq -_ -`sor-`cn, b✓ f=se of :'_-.es
_ or ct_ crsuitable nateri =, and spa l Y have an in -pLace rate
_ at leas-_ to that _, t = nazure.1 soil after the *ivied s-tah T ; —t cn
j - period. 'CF< er-c = /zrczi`-- pe_=crz a firal percnT =t=ca test i._
' t _ f II aft_ sc_>_b+ T i -- 't'_ca.
_ / 7 n r pn 3. _� =r cars f; 111 , clay ! ar*i�_ , s`al1 �» a cer=z �_ie , soy! With 1i' e or
_ . �I L ill C t .IJAO I U BOX I ro sawace z: art cn capacity.
- DF IAI j_'f ` ' /' ^ =1 I' 4. Depth o ,��es will be required is t o fill section, one at each corner,
gip' C / /!mil
1 j! ton of slope and one in the center of the fill pad.
• INS i -a•• —�- . _ _ y•Ien °_' :.
5. Fill suitable for sewage absorption should contain no more than 5% and
preferably no more than 2% fines by weight. Fines are clay and silt particles
_ • �,( that pass a 200 sieve and, no more than 10% by weight, of the fill material
should pass a 100 sieve.
T °o° Da SEPTIC DETAILS --
Re over ' r °o! a prepared for
° •°
'01 RE
prep- 6 red by ,r
Cu2;: //,I G2� /fi �rzLLI ?itF. ZEIIE? �� t ✓l
°= ofessioraL Z -veer S Land Su =veg0- 1 L:
Concord cad ':a ^ N:J
onac -e !o r:: _0541 : := .
�au:astc:,t
1623 -4 3��dr
PRECAST SIPHON CHAMBER. SC 4 X 4.130 OR 170 GAL. CAP.
;r
4' -0"
I I
t I
t I
t
4' -0
" " t
I t
L- -- -- - - - - -�
6" WALLS-
6"
A
6"
TOP VIEW SIDE VIEW
r-8 "DIA. INLET i-24" DIA. COVER
I�
SECTION A —A
SEE NOTE
SIPHON
GALLONS
DRAW
A
a
c
D
E
3"
130
13"
29"
19"
7Y."
15"
23"
4"
170
17"
33"
23"
11 %1,
18"
28"
I
I
I
I
I
I
I
O i/N ��SSGrL C,.
SPECIFICATIONS
• Concrete Minimum Strength — 5,000 P.S.I. @ 28 Days
• Steel Reinforcement — ASTM A- 615 -75, Grade 60, 1" Min. Cover
• Design Loading — Standard-Units: AASHO H10 -44
Optional Units: AASHO HS20 -44
• Construction Joint — Sealed with 1" Dia. Butyl Rubber or equivalent
• Siphon — Set to dim. "C" and encased in concrete by others
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A ,OPKCAWH'
F,
1777
4 .V
4_
V.4
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r
bvl�on Dye
77 -- T-,_ a. 9
i- 7 Tt: 77,
77
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rMilil cam
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tN 549, 11
6115
T.
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CE
:7
he r
-as
Y,!,�Pj"Osible, for ,ItSj d _ftn &nd'rkIt&tkk�,,'bfTI WKS fli..mwtoie
Awoo" ,Sy"!!
bi oupi6i*4"k
icorve vo
4i wyao,twe.,60
the twwwt
all 'Opi
. - "0 - 1, -'-PW PC kf�sy_ — it Cdowlbod
WilliAM sysWhi,oi�*ny-
I iwavore-val, 411ow i",M)"
tNt this
ITWIllibe-In m
X
, d6"
L',gAm,� -w
3�,
` APPROVED ley 1;0335 -is
unless Leon uct s'; kGn,'A
hit,
- 44-14—
WE
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL % �j
PCHD PERMIT #� /-��/
WELL LOCATION
Street Address
T Village City Tax Grid Number
WELL OWNER
a Mailing
d .LS ML- ' A6
Address
rivate
Public
U WELL
t prim
2 = secondary
.'RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O BUSINESS O FARM O TEST /OBSERVATION
O INDUSTRIAL C]INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT_ 70-gpm /11
PEOPLE SERVED � /EST. OF DAILY USAGE , al
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY
'- SIXPLY NEW DWELLING)
O TEST /OBSERVATION El ADDITIONAL SUPPLY
13 DEEPEN EXISTING' WELL
DETAILED
REASON FOR
DRILLING
lU 2- y
-- Ive &zrl,a
Qle
4
WELL TYPE
,DRILLED
DRIVEN
QDUG
GRAVEL
Q
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION. aro'Abd yox.11AI L
Lot No.
WATER WELL CONTRACTOR: Name Zyt L) LA16 A Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 9.�NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH §v SOURCES OF CONTAMINATION PROVIDED
Al Zf ry ON SEPARATE-SHEET �.
L 0
da e) (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
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
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 d.rill i4 operations be contained on this
property and in suc a manner as not to degrade or of rwi a contami ate surface or groundwater.
Date of Issue: 19 %
Date of Expiration 19 it Issuing Official
Permit is Non - Transfer able White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
d `
RAM
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Property of
Located at /J /3 1&U6-7-04)V /LL
(T) ��� G�JI.�!'p� Section Block 2— Lot
Subdivision of �'� iQ,� O u J c ` J&" „s4A)
Subdv. Lot ## Filed Map # 'Z- Q 17� Date
Gentlemen:
This letter is to authorize % /6,L /,-7W %.
a duly licensed professional engineer L- or registered architect
(Indicate)
to apply for a Construction Permit for 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 all 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 t
_ Signed
Countersigned :�
P.E. ,r', z
Address
Telephone
.Address
Town
X73 - 3
Telephone
DIVISION OF MrZaNM= REALTH.SMICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILES NO.
Owner t a G:. - Address '
I Alerlw J w-rc'"
C�
Located at (Street) ZVb1AJ 6?7 A) 1111, C ' ,7 Sec. / Block 2. Lot/,/
(indicate nearest cross street)
Municipality AA71-,6;-XSQd Watershed
-2
SOIL PERCOLATION
TEST DATA REQiT1FtED TO BE SMMITTED - W= APPLICATIONS
Date of
Pre - Soaking
Date of Percolation Test
`1/i dv
4
'
HOLE
NGSEE R
CLOC.'K . TII
PERCCILA CN
PERCOLATION
Run
Elapse
Depth to Water From
Water Level-
No.
Time
Ground Surface
In Inches
Soil Rate
Start -Stop Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches---
r
r
-2
_
3
4
'
1
_
2
3
_.
5
.. 1
2
l
3 ae
4
5
1. Tests to be repeated
are obtained.at each
for review.
2. Depth measurgnents to
rev. 9/85
at same depth until approximately ec l soil rates
percolation. test hole. All data to* be ` submitted
be made free top of hole.
OF
10'
;iii .A1 ,-74..1
14'.
SNDICAM LEVEL AT WHICH GROUNU,,MM IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER' BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: L G /%} i /' G /C CX DATE: 5136
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided
No. of Ber3roans Septic Tank Capacity /2-00 0 gals.. Type , C_? ,,ycxe7g- '•
Absorption Area Provided By L.F. x.24" -width trench
Other % .A aWZ 'd 1 b6- 01he7?NLJ Ae 9/AI -- --•e,
Name 14' 14 /fj�'9 / - 766-7 -- Signature
Address SEAL :4-
OR USE BY HEALTH DEPAR2ME C ONLY:
00FESS100p1.-
r
Soil Rate Approved sq.ft /gal. Checked by Date
p?p�Mzx 3
C,cul CZ_ Di�� �SICN OF vi -cOI4 T"^r, -` -r l'3 SL.: -,S
nZ) _T v �C?_ ;�= SUPPLY & SU: SUR AC✓ =A C O= SpC_S.=T S_ Z=S
) ull
c-f Cam: == )
CGS ^`
Pre-1963,
X4 d� Al IG.G/ C� � Sa. OeEwED:
L
Nei2i�3or notification
I
T•r trend orovided
=w`_'= B
60 f r,. I i
z
m
fill notes
new sec.
G'CeO`'1 Can'. =_s
100 vr. _1004 P, eJ. i I I
200 f �_. red°_= JO i _ rI etc.
House Plans - Two seL-S
jti2_l1
Varia''C° P- °St
S/S
S77-_7'-, 77 cZ CN
(�) l__
cd
L- a--al Subdivision
Suor-i "v i slon A.-DO-Oval l.:'': =Z:tic1
Ex-aoor val SIDS 'Ad� . LtitJ C. jec'Kad
i•T ?and Pe__,:i ` ? & D)
me
r_`.? On DDS Pl:s & - __,: i t Sal
sewace v1J.e11 -Dla:l - (nor .1 G= _CT.V)
F4_11 Profile l e & 17- -.-s_c =r
D or J 0.^X; _c'G'?�C= 11�_J; !> =-) pi=
S_Z)t- Zen'{ - S_Z °,
re_-_ it
wa_' 1 De_ i1, _, Vv Ce T.i_, i= over
Cr^st_uctuicn Notes (gri_ d_r rate)
resign Ea ta: _-ar.- and aeeo results
r�'/•i i �t Col: �oI'T"J .1�
S t i - C7 & Pr O_DcS -"
Drina ay & S_cc=s C'ut
�'ootlnC/G�lttcr,��rtai_7 Drains (C_Sz-- _: = C-1K)
P_rc & D=eo Oles Lcoc _ed
.0 =z) a— t_. e of pr_Ta= j and
it P---.--2d Pit & D Box S:1c;,n & D_ta1_ _d
House - ?.O. of Bedrocros
Wells & SSDS' `. wlin 200 ft. . O P-o x ==' iSfais
Pr:vDP_: V Metes & Bo-'InCs -
ro' -ass y _ck 'Necessary lot)
House S� a - 1r a01, rL
No Be _ds; may. B? ^5 45" w /Clean tit
S?an :-�-TICN DTS:ir\-C_—_ S SPECIFIED CN PI AN
Fields
10' tO P. L. , Dr; �av, Te T _1 1' .
20' to Fo',!n_; icn ;•; =lls
100' to Fell; 200' in D.L•.O.D, 1301 Its
100' to St_ = ..._m!, J' •a `ercc= se, ?a}:e
13' to
35'Lo CLCa C.asir1'S 0II,�1_�
10' to water Line (o_ is -20')
50' irtez --1r? t Sn— dra-' =e co'; ,-
S=oho Uun s
10' tray, Fc)cmdation; 50' to well
YFS kNO
DOCIDEE 'Irs
I I
P__rnit Prol i caticn
I
Corporate Pesolsticn
I
Plar.S - 1 :r=e Se t S
I v le I
-rcir =rs zat�ncri zat_cn
VI I
Design Data Sheet (DDS)
I vor
Lx
L It
_ erC ZcJ� __
P_rc col°_ Deo h
Nei2i�3or notification
I
T•r trend orovided
=w`_'= B
60 f r,. I i
z
m
fill notes
new sec.
G'CeO`'1 Can'. =_s
100 vr. _1004 P, eJ. i I I
200 f �_. red°_= JO i _ rI etc.
House Plans - Two seL-S
jti2_l1
Varia''C° P- °St
S/S
S77-_7'-, 77 cZ CN
(�) l__
cd
L- a--al Subdivision
Suor-i "v i slon A.-DO-Oval l.:'': =Z:tic1
Ex-aoor val SIDS 'Ad� . LtitJ C. jec'Kad
i•T ?and Pe__,:i ` ? & D)
me
r_`.? On DDS Pl:s & - __,: i t Sal
sewace v1J.e11 -Dla:l - (nor .1 G= _CT.V)
F4_11 Profile l e & 17- -.-s_c =r
D or J 0.^X; _c'G'?�C= 11�_J; !> =-) pi=
S_Z)t- Zen'{ - S_Z °,
re_-_ it
wa_' 1 De_ i1, _, Vv Ce T.i_, i= over
Cr^st_uctuicn Notes (gri_ d_r rate)
resign Ea ta: _-ar.- and aeeo results
r�'/•i i �t Col: �oI'T"J .1�
S t i - C7 & Pr O_DcS -"
Drina ay & S_cc=s C'ut
�'ootlnC/G�lttcr,��rtai_7 Drains (C_Sz-- _: = C-1K)
P_rc & D=eo Oles Lcoc _ed
.0 =z) a— t_. e of pr_Ta= j and
it P---.--2d Pit & D Box S:1c;,n & D_ta1_ _d
House - ?.O. of Bedrocros
Wells & SSDS' `. wlin 200 ft. . O P-o x ==' iSfais
Pr:vDP_: V Metes & Bo-'InCs -
ro' -ass y _ck 'Necessary lot)
House S� a - 1r a01, rL
No Be _ds; may. B? ^5 45" w /Clean tit
S?an :-�-TICN DTS:ir\-C_—_ S SPECIFIED CN PI AN
Fields
10' tO P. L. , Dr; �av, Te T _1 1' .
20' to Fo',!n_; icn ;•; =lls
100' to Fell; 200' in D.L•.O.D, 1301 Its
100' to St_ = ..._m!, J' •a `ercc= se, ?a}:e
13' to
35'Lo CLCa C.asir1'S 0II,�1_�
10' to water Line (o_ is -20')
50' irtez --1r? t Sn— dra-' =e co'; ,-
S=oho Uun s
10' tray, Fc)cmdation; 50' to well