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PUTNAM COUNTY: DEPARTMENT WHEALTH
Re V . 3186 Division of Environmental Health Se_rvlces_, Carmel, N.Y.10512
Engineer Must Provide
P C:H D Permit N
tCEATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM,
own o
Located st S + Ta:� BI k_ —lot
Owner /app8cant Nam PS Former -ly Sabdl - onw -, �` .. "gbdv. Lot p
MaWng Address /`OI lie, Zip ' Date Permit bianea
AN
Separate, Sewerage Sys( built by �+,f Address
Consisting of Gallon Septic Tank and
Water,Sapply: Pabllc A
Supply From ddress ,p 1
ors Private- Supply Drilled, by , G r
Address "
Building Type i4C'� �� Has Eroslon Control Been Completed?
Number of Bedrooms . Has Garbage Grinder Been Installed?
Other Requirements
I certify that.the syetem(s) -as listed nerving the alwve'premisae were cone oted essentially pe shown on;th plans of the completed work ( copies 11,
of which are attached), and in- accordance with the etandaids, rules and rag 1 tiona,,in ao `zdance ith the led an, and the permit issued by the
Putnam County Depar�tjment Of Health
Oats
�i% -�✓ �� Certified by P.E. X R.A.
Address v T7 J License No.:, J�p
Any person occupying promises served by the above, system(,) shall, promptly. take such action as may be necessary to secure the correction of any unsanitary
conditions resulting from -_such usaye 'ADProvalr of the separate seweraos system_. shall become null and void a$ soon as. a pubs;= sanitary ewer becomes
svallaDIs and the .approval of the :private water. supply shall become +null and void when a public water supply becomes availsbW Such approvals are
sublset t�o jmoditlntt/on or/ch"agngreywh- in the Judgment of the Commisiionit_of Health, su revocation, modification or chanp is necessary.
Date / r+!� 6 �`/ / / . �. .Title
0
M
COUNT 4 DEVARTTIU-Tr OF J3•AVA11
OF r:VV1RCQM T W', RrAT,7fi SEnVXCW
2-3,
Owneii)r 15a, la",er;' r:_rS_8U4i1 Section
Constructed by
i4,tsaltion - Street
1_5
BdlldinW_Type
- ) 7
Lot
nuWivision Lot.
MAP101-22 OF SU11SURFAC9 DISPOSA 8YSM4
I represent that I am wholly and ccmPletely resp;onsil:,Ie for the lcczt oh,
ularlm=ship, n• Ltexial, construction and drainage of the. sewage. dispQsal system
serving t;A-a &6ove aes=tboa proporty, zqnd that it; has -been o:)nsLractea. as sho"M. on
tha approved plan or aiNzovecl 'Uleno'A'ant there•o, and in acuordance'. with tho
stanclards, rules and regulations of the' Putnam Coupty..Dqpzx�nt.. of Health j.' and
.,hereby guarantee to the Q"aMer'r his succlazzorsf h6lirs'.0r* assignn, to place in n 9Qod
operating condition any part of raid- -by me wbic'11. falis� to,
Opamto for a Pariod or- two year's Lallea-Late—ly J-.o cm,-big, the date or approval cj.C- - Uie
"Certificate of ConstrucLion. Ccxnp.1_j'.;-_iijce" r . or . an, .1 or, any
ny
repairs Mdc' by me to stAU j system, exc. VL wht�rn the failurej tx) operdb;� properly is
eau Sett by the W-11.3-IfUl UL IIH-14j1itient ac t. of duct (Y_cupant.vf Uie building utilizing
the sy.qbmn.
'he undersignc� further agrees to accept as LvrtUwiV(-- the letenUmtion of
the Directoe of the Divj.5ior1 of 11fi:,al-th $eJvlues of the Putnam COLUILY.
Department of Ticalth as Lu w1lictlici: or.- niuL U)e failuric- of tj1?_- 6ystcmm W vperaLe was
caused by the W111ful or. m 11ye-ILt act of tht: vt;c;uptint.. of the bui2cling utilizing
the system.
tta this
day of 3.9
X..
rev. 9/as
T*
Nawe (if Corp.)
7
CZ,*-Mit! COIL-P.)
- ---9 -11 7 ' id'. . 229 0117 F'02
FIOM F'rF:= DDEl-TDH.L HOMES
CAMO LABORATORIES, INC.
367 VIOLET AVENUE
POUGHKEEPSIE, NEW YORK 17601 1��Z
-001-1 #10310 Tat. (914) 473.9200
Cert,: PH -0593 Fax (914) 473.1962
13ACTERIOLOGICAL EXAMINATION OF WATER
' ck�
Ian
e No. moo? �5% Data Coil'd 7 7- �- Time o T(me Sut;mitted _,� � Mt 64mple SPC �w-
-to, '- ` " CAN110 L.og No. —. Pacility rype Bacteria Count
M1. Samplo Memt rane &e3
a Requested r - - - faetrigerated7- - -- -. L
-- C1O1if`orm Count
I by: �. 1�tlkl rmt. Agency Coil'd for "� t4bf4 �ur.r-.� Ckt+ a �Q831`Gount
Time q Tlme
Itication of Source: L I.. .10tu p Read f
ding Point:. 4 �4,r.
�.� Date a�
Sample Reported by:'
ty Chlorinated when Sampled: Yea d No Free Comb. _01-1
pH
ULTS OF EXAMINATION OF WATER:
1100 ml. MEM8MANE F=ILTER METHOD /100 mi. MEMBRANE FILTER METHOD /100 ml.
{t.
Coil form Group ___ __ _ Total Coliform; of Present Fecal Coliform __
Total CaUteirm: Present ( )
=ecal Coliform STANDARD PLATE COUNT
FOOAI C611form Indicated:
) ( Bacteria per mi.
Yes No
Them results Indicate eampl was was not) of satisfactory, Sanitary quality.
Reported:
)rted 8y: it Notified:.
1MENTS:
Amount Paid:
Amount Due: �---
Check Number: .�.�
R p
4.,T�v
V. A. CRAUER WELL DRILLING
DRILLING CONTRACTORS
RD #2 8OX �8'5 RED HOOK. NEW YORK 12071
19 (914) 976.4996 876-4900
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FROM : PRESDDEHTDAL HOMES 229-0117 PHOf--IE NO. : 22-3 0117
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D.A.
CRAUER WELL DRILLING
DRILLING CONTRACTORS
RD #2
BOX 385 RED HOOK, NEW YORK 12571
(914) 976-49968-7G 4900
Elapsed
Drawdown
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Time
GPM
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Remarks
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cat
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County
be sibi
of co�struetioi►' Complianq' tatisfattoryr to',thO Comeelialoner4 ,w will
the awn r his sucbsswr; IMVS or assiiins by',thO buildw that, Yid btiUdei will
duiiny 'the period; o4 tvio,(2) VOWS immediately folbwitq thddsto of the tau-
t
o►.Ony.rOpaNS thanto; 2) that thil drilted will daicraw above
Iacwrdan h t endaM; �uNs end rapu , o s -ot 'the' Putnem
dab iffued upless construction ot. the buikliny .has been undertaken and is
``by the'Cominissioner ,of .MM1th. Any chanip Or alteration of 'construction
"QIId or p wale/ su .AiY ..
5
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
WELL LOCATION
��^^ Street Add el.
JG'^t GN �T r i v -G
"L* Tax Grid Number.
=11� .. �J
WELL OWNER
Name P
.
Mailing Address
' ��
❑Private
❑Public
&SE OF WELL
primary
2 - secondary
® RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
® INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND-BY
D ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT S_ gpm /# PEOPLE SERVED J /EST.-OF DAILY USAGE al
❑ REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY
SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
09NEW
°-'
WELL TYPE
rknJ DRILLED
®DRIVEN
[]DUG ®GRAVEL.
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES A NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO �SITE: YES _)!�__NO
NAME OF PUBLIC WATER SUPPLY: J1r! /f7 TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: o ye r . / ryNt k
LOCATION SKETCH & SOURCES OF CONTAMINATION PRO
®ON SEPARATE SHEET ;L ��_o
(da e) sig ature)
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
thirt,- (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 n t to degrade or otherwi3�, contamAi -e surface or groundwater.
Date of Issue: _2 19��''`'-
Date of Expiration 1 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET for CONSTRUMON PERMIT
4E OF OWNER
DATE �6 8� �` TAX MAP #
DOCUMENTS. / �r
�P ISCHARGE (OK)
�P�IT APPLICATION
1 ��-PERI -DEEP HOLES LOCATED
LL PERMIT; PWS LETTER ��.,� il ESENTATIVE OF PRIMARY AND EXPANSION
,m . ; SH OWN; GRAVITY FLOW, SUFF.SIZE
rSI(aN NFERS AUTHORIZATION PU PIT & D BOX SHOWN &DETAILED
DATA SHEET(DDS) 17U96USF --NO. Of BIDROOMS
DEEP "HOLE LOG SSDS'S WAIN 200 FT. OF PROPOSED SYSTEM
CONSISTENT PERC RESULTS (3) PERTY METES & BOUNDS
OC HOLE DEPTH BCD SOUSE- SETBACK NECESSARY (TIGHT LOT)
RPORATE RESOLUTION `CL��HOUSE-SEWER - 1 /4 "/FT. 4"0; TYPE PIPE
PI� NS THREE SETS �
,I .. O SU E PLANS -TWO SETS NO BENDS; MAX. BENDS 45 W /CLEANOUT
VARIANCE REQUEST a, FILL SYSTEMS
GENERAL CIA ARRIER
t' m 10 FT ORIZONTAL: SLOPE 3:1 TO GRADE
f LFAL SUBDIVISION m SPECS
SUBDIVISION APPROVALCHECKED m gp GAUGES
� PfR _RATE
REQUIRED ILL PROFILl _DIMENSIONS
m VOLUME
PX_REQUIRED PPROVAL MAIN DRAIN ES TRENCH
SSDS ADJ. LOTS �' '. CH PROVIDED
T.AND (TOWN/DEC PERMIT R & D) 6BATA ON DDS PLANS &PERMIT SAME L TO CONTOURS
1969 - NEIGHBOR NOTIFIFICATION PROVIDED
�3
SEPARATION DISTANCES SPECIFIED ON PLAN
�L�EET•I`ERBI/ZBA
1"100 YR. FLOOD ELEVATION
FIELD
UIREH DETAILS ON PLANS
,�x"10%' �"� L., DRIVEWAY, LARGE TREES, TOP OF FILL
&SDSE SYSTEM PLAN - (NORTH
fJ 20' T -FOUNDATION WALLS
Toy
HYDRAULIC PROFILE GRAVITY FLOW
_'cD LL, 200' IN D.L.O.D., 150' PITS
4j-D OX m TRENCH/GALLEY M P_ PIT DETAILS
CS C TANK -SIZE, DETATT.
;��j 100,f6-S-T-RE AM WATERCOURSE LAKE (INC.EXPAN)
,L 5W-TO C C -H BASIN, 35' STORMDRAIN, PIPED WATER
��LL DETAIL, SERVICE LINE IF OVER
��JpLT�TER LINE (PITS -20')
STRUCTION NOTES (GRINDER RATE)
D DATA: PERC AND DEEP RESULTS
m 0'- UMRMITTENT DRAINAGE COURSE
O -F CONTOURS EXISTING & PROPOSED
,W 200 FT. RESERVOIR, ETC.ED 150 FT. GALLEY SYSTEMS
SEPTIC TANKS
D WAY &SLOPES CUT
CLl 10' FROM FOUNDATION; 50' TO WELL
OOTING /GUTTER/CURTAIN DRAINS
VARGLS-
-MMENTS:
j _1_1' WELL TO P.L.
]PU'TNAM COUNTX DEPARTMENT ®F HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
ti. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ......... ...............................
12. If so, have plans been..submitted to such .. author .sties ?.......................
13. Has preliminary approval been granted by such authorities ? Date Granted: - -
14. Type of Sewage Disposal, System Discharge...... Surface Water t- Ground Waters
15. If surface water discharge, what is the stream class designation ?........
6. Waters index number (surface) ........... ............................... 1014
:7. Is project located near a'public water supply system? .................. AU Q
8. If yes, name of water supply N /'r Distance to water supply
9. Is project site near a public sewage collection or disposal system ?..... _ A
-0. Name of sewage system /�S�l1r • Distance to sewage system
1. Date observed: te 23. Name of Health Inspector: /ti, /u, A'A"5 1
4. Project design flow (gallons per day) ...... ............................... Lz()0
1
pr�� tad. At"e-Ir
1.
Name and Address of Applicant: r
-72LC l: ►�
2.
✓n
Name of Project: 01?6rf J Location /C:
L,), `73
4.
Project Engineer: , , 5. Address:
License Number: Phone: Z-- 1?/ -�6, av
6.
Type of Pro ect: ;: ; •. ;; t: : _ .
private /Residential Food..Service ....Commercial ,
Apartments Institutional Mobile Home Park
Office Building : Realty Subdivision Other (specify)
7.
Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt LIZ
Type II. Unlisted
8.
Is a Draft Environmental Impact Statement (DEIS) required? .............
-/V/)-
9.
Has DEIS been completed and found acceptable by Lead Agency? ...........
10.
Name of Lead Agency
ti. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ......... ...............................
12. If so, have plans been..submitted to such .. author .sties ?.......................
13. Has preliminary approval been granted by such authorities ? Date Granted: - -
14. Type of Sewage Disposal, System Discharge...... Surface Water t- Ground Waters
15. If surface water discharge, what is the stream class designation ?........
6. Waters index number (surface) ........... ............................... 1014
:7. Is project located near a'public water supply system? .................. AU Q
8. If yes, name of water supply N /'r Distance to water supply
9. Is project site near a public sewage collection or disposal system ?..... _ A
-0. Name of sewage system /�S�l1r • Distance to sewage system
1. Date observed: te 23. Name of Health Inspector: /ti, /u, A'A"5 1
4. Project design flow (gallons per day) ...... ............................... Lz()0
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.._ UU
26. Has SPDES Application been submitted to local DEC Office? ............... —
27. Is any portion of this project located within a designated Town or State �J
wetland? .................................. ...............................
28. Wetland ID Number ........................ ...............................
29. -Is Wetland Permit., required? I .............. ............................... /�O
Has application been made to Town. or Local DEC Office? ..................
I
30. Does project require a DEC Stream Disturbance Permit? rJ
31. Is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste disposal','-'""'
isposal;`
landfilling,*sludge application or industrial activity? ........ YES or NO /V
32. Is project located within 11000-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 C
DESCRIBE:
33. Is there a local master plan or file with the Town or 'Village? ...........
34. Are community water, sewer facilities planned to be developed within 15 years?
35. Are any sewage disposal areas in excess of 15% slope? ........................ N Q
36. Tax Map ID Number ......... ............................... . .......... 2-�," — 3 7
37. Approved Plans are to 'be returned to: ................ Applicant 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 be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury,- that information proyided on this
form is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A Xisdemeanor pursuant to Section 210.45 of
the Pena 1 t
SIGNATURES & OFFICIAL TITLE'S
TAILING ADDRESS: % g r- e,.r,2::S /�- 2'
Zb :t ►fd 6 ! SiRV Z661
*rr • ,..._ t
ti 1 nd
o {.
PUINAM COUNTY DEPARTMENr OF HEALTH Lb-T '
DIVISION OF ENVIROMOMM HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTal FILE NO.
Owner 10,/,. Address Z1 V 01-�'� AVf- F YOEO' f'Al2K iJ Y.
IoM 5�-r �t�lv�
Located at (Street) e V�9NS r52 "o Sec. _� Block 1 Lot
(indicate nearest cross street)
Municipaiity N .Y' Watershed
Date of Pre-Soaking % R� Date of Percolation Test
HOLE
NLZMM C1= TINM P RCOL=CN
PERCOLATION
Run Elapse Depth to Water Fran
Water Level
No. Time Ground Surface
In Inches Soil Rate
Start-Stop Mina Start Stop
Drop In Min /In Drop
Inches Inches
Inches
4
5
1 ..
2
3
4
5
1 �_� -ID.ov ID 22 Zr 3a �
2 Io ;off, In i5 I D ZZ 25 3�
3 10 ;16, I P:Y�
4
3°g W �.f
i aew'z X
NOTES: 1. Tests=tobe repeated
'at same depth until apprcximately equal soil rates
are obtained at each percolation test hole.. All data to'be submitted
for review..:.
2. Depth measurements to be made fran top of hole.
rev. 9/$5
2 :25 I
22
3u
4
5
1 ..
2
3
4
5
1 �_� -ID.ov ID 22 Zr 3a �
2 Io ;off, In i5 I D ZZ 25 3�
3 10 ;16, I P:Y�
4
3°g W �.f
i aew'z X
NOTES: 1. Tests=tobe repeated
'at same depth until apprcximately equal soil rates
are obtained at each percolation test hole.. All data to'be submitted
for review..:.
2. Depth measurements to be made fran top of hole.
rev. 9/$5
TEST PIT DATA RFJQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS EDK)OUNTERED IN TEST HOLES
G.L.
t�
2'
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL, TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: oty; n DATE: (p
DESIGN.
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided dOD 5
No. of Bedroans �j Septic Tank Capacity p gals. Type fend•
Absorption Area Provided By �2DD L.F. x 24" width trench
Other
Name 1boL_ �A1a��NT Signature
s
Address ��iAItZ1I�!P p1 �1 SEAL
�ROA x.045781
J 4 1 LI. ZLAI oNP
THIS SPACE FOR USE BY HEALTH DEPARMM ONLY:
Soil Rate Approved l + err 'f P*d checked by Date
[uuJaM wunry oeparrmenr or i-iealth
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT. APPLICATION SUBMTTTED- TO
PUTNAM COUNTY HEALTH DEPARTMENT
TO: Commissioner of Health - In the matter of application for
�'._. ^ ; — -- — — — —' •— — -- —. -- 7
— represent
- --- - - - --- - -- o P .
that .I am anofficer or employee f the corporation and am authorized:
to ac t for .--�- j —�
— — — — �-
(name,of�.cornporat�ion)
having offices at _7 `1�� >�- _
— --- - - - - -- - - - /'�
Whose officers -are
President a ��� _i�• -0CC� L `
ame ana address -`
)
Vice- Presieient�jt — r
_ ..-..
• - . me and — Addr_ ess)
Secretary. — `C
—
Na— me and Address — �'' �•
Treasurer'
_ ^,
(Name and
Address)
and that I= am-and
will be individually
responsible fon any-or
all
of. the- corporation
sequeit `relating
With respect to the
approval requested ftd•all.sub-
'
acts
- thereto.
Sworr� to before me
this y D
Signed
�
Of _`lc. i»ei
—day
19 %a
—
Title
Notary FUbl '
wutnctsS
my commissa emn AUG. In
Corporate Seal
I
�t#
AD -BUILT
1-10.5'
3
-10. 5'
81.5' .
5
X5.5'
�
108.5'
130.0'
8
1 1.2.5'
13:2.0'
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I G.S'
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t'iYtnam County .Department of .116tLrth
ion bt EnairQ medal eaith.Snrv'c�.
.rOv'ed as notoa for cori'er Glice with
L9Alioab3a iul *a a: r;,�oulationB of the
'utr�am *�Coi * hg 11th D61Partment .