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HomeMy WebLinkAbout0580DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -1 -44 BOX 7 Other Requirements I1certlfythat the system(s) as listed.seziVinq 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 regul ons,.in accordance with the led plan, and the permit issued 1iy the Putnam County Department O�f1 HHeealth. Oats Certified by P.E. Address License No. Any person occupying premises served by the above systems) 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 won as a pub''^- sanitary' sewor becomes available and fns a proval o the private water supply shall become null and volt, when a public water supply,'becomes available. . Such approvals are subject' to mods( tllov Change when, in the judgment of the Mch!sslo Health; such ev tion,. mod ca n or change Is necessary. Date . J By. c _ Title w r ° Pmm cawy DEPARamaTP OF HEALTH DIVISION OF ENVIRONMMM REALTH SERVICES gAIIII l ///I Owner or Purchaser of Building Section Block Lot 'Building Constructed by/� S�'Y►� -Q-r2 SA=X N�li� I,ocation - Street Municipality s-Tu�i Building Type rruw- Lzl/( �C dye Subdivision Name Subdivision Lot # . /2— GUARAN= 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. P,o The undersigned further agrees to accept as copciusive th e ti f the Director of the Division of Environmental Health ' ' of a tram C ty Department of Health as to whether or not the fail a of a to opera was caused by the willful or negligent act of the occu nt of th bu' ding uti 'zing the system. Dated this day of 193 Signat e Title kMJ -4 Gen Contr, ctor ( er) - Signature lCorporation Name (if Corp.) Corporation Name (if Corp.) r4zL Z a Address e r T 2 ter. rev. 9/85 mk l ADO /I. � TTT/�TT CA . :, * W �4 WLLL l,Ur1rLz1.LUV iCGrUAl DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only /2— 2 WELL LOCATION STREET AOURESS: O/ljlsKff&,;r— WN V1 I TAX GRID NUMBER: Cornwall Hill NY (Lot #17 WELL OWN. ER NAME. ADDRESS: Westchester Modular Homes,Inc., Route 22, Patterson,NY ❑ PBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary (3 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND.IHEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. %NO. PEOPLE SERVED _/ EST. OF DAILY USAGE gal. REASON FOR DRILLING ® NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH X65 ft. STATIC WATER LEVEL 30 ft. I DATE MEASURED 5/13/93 DRILLING EQUIPMENT (3 ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION . 1O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. 13 OPEN HOLE IN BEDROCK O OTHER CASING TOTAL LENGTH 92 tL MATERIALS: El STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 91 ft JOINTS: ❑ WELDED ® THREADED ❑ OTHER DETAILS DIAMETER 6 in. SEAL: ® CEMENT GROUT ❑ BENTONITE ❑ OTHER WEIGHT PER FOOT 19 lb./ft- I DRIVE SHOE ® YES 0 NO LINER: O YES ONO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? •FIRST O YES ❑ NO HOURS SECOND GRAVEL PACK O YES ❑ NO GRAVEL SIZE. DIAMETER PACK in. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST It detailed pumping t METHOD: O PUMPED tests were done is in- AD COMPRESSED AIR , formation attached? O BAILED ❑ OTHER 1 ❑ YES ONO If more detailed formation descriptions or sieve analyses LOG WELL LUG 11Y are available, please attach. DEPTH FROM SURFACE water Bear- ing we Dia- In FORMATION DESCRIPTION COOS_ ft. ft. WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD gpm. Sortace 30 ri li g in overburden clay it ro k at 301 16 6 100 0 2 Drilling in rock set casing, rout d. g 165 Dril ing in rock granite. WATER ❑ CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? OYES 0 N STORAGE TANK: TYPE Well Xtrol 302_ CAPACITY 86 GAL. WELL DRILLER NAME p . F . Beal & Sons, DATE ADDRESS 4 Putnam Ave. slGintTURE Brewster,NY 10509 PUMP WFORMATION TYPE sub • CAPACITY 7 g MAKER Gould DEPTH 1201 MODEL 05412 VOLTAGE230 HP� _ BREWSTER LABORATORIES Box 224 - BREWSTER, N.Y. (914) 855 -1930 SAMPLE NO. 8581 TEST WELL SOURCE: Westchester Modulars Lot 112 Cornwall .Ebtktes Patterson, N.Y. COLLECTED: 5/18/93 BY: P.F. Beal & Sons BACTERIOLOGICAL EXAMINATION Coliform Count, MF Method This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 5/22/93 0 per 100 ml. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Carnnissioner of Health - FIELD ACTIVITY REPORT - ADDRESS :-el C'e;'�.. --,2 r aL .No. G MAILING ADDRESS 411' /- P.O. Box Post Office Zip Code PERSON IN CHARGE OR INTERVIEWED Name and Title DATE TYPE FACILITY TIME / TIME LEFT Sheet of INSPECTION Orig..Routine Orig. Ccimplain Orig. Request Compliance Complaint Comp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other Explain FINDINGS: I -e'v --- � / /'—c --f" .07 '— — �_ INSPECTOR: �/� G "�� --f� TELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 T7Tr.F. To: Putnam County.Health Dept. 4 Geneva Road Brewster, N.Y. 10509 Attention: Bill Hedges Gentlemen: We enclose ( 4 ) copies of: EX B/W Prints 0 Reproducibles ❑ Specifications 0 Memorandum Description: "Construction Permit" "Design Data Sheet" SS -12 "Proposed SSDS" Job No.: 93006 Project: Proposed SSDS Section Two Cornwall Ri Patterson. N.Y. ❑ Reports ❑ Tracings O Copy of Letter O Above reflect revised SSDS location per your field review. Lot #12• Revision /Date No. •5 -4 -93 5 -4 -93 revised 5 -4 -93• Sent Via: Y7 Our Messenger O Blueprinter 0 First Class Mail O Special Delivery O Your Messenger G Hand Delivery O Copy to: J. Hatcher Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per. CP Harry W. Nichols, Jr., P.E. / LAURENT ENGINEERING ASSOCIATES, P.C. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 914.278.6108 CONSULTING SITE ENGINEERS Date: 5 -5 -93 To: Putnam County.Health Dept. 4 Geneva Road Brewster, N.Y. 10509 Attention: Bill Hedges Gentlemen: We enclose ( 4 ) copies of: EX B/W Prints 0 Reproducibles ❑ Specifications 0 Memorandum Description: "Construction Permit" "Design Data Sheet" SS -12 "Proposed SSDS" Job No.: 93006 Project: Proposed SSDS Section Two Cornwall Ri Patterson. N.Y. ❑ Reports ❑ Tracings O Copy of Letter O Above reflect revised SSDS location per your field review. Lot #12• Revision /Date No. •5 -4 -93 5 -4 -93 revised 5 -4 -93• Sent Via: Y7 Our Messenger O Blueprinter 0 First Class Mail O Special Delivery O Your Messenger G Hand Delivery O Copy to: J. Hatcher Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per. CP Harry W. Nichols, Jr., P.E. / 4A� ®OII. �' ��.f1�t TTTT AI�T TTTATT * ` r * 6V �jO4 WLLL UUrir1jz11Un AnrvAl DEPARTMENT OF HEALTH Division Of Environmental Health Services Y`" PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only :2 WELL LOCATION STREET AD WN /VI 1 Y TAX GRIO NUMBER: Cornwall xi11��� Patterson, NY (Lot #1 WELL OWNER NAME: ADDRESS: Westchester Modular Homes,lnc., Route 22, Patterson,NY ❑ PSIVATE 0 PUBLIC USE OF WELL 1 - primary 2 - secondary 13 RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal. REASON FOR DRILLING El NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL DEPTH DATA ' WELL DEPTH 165 ft. STATIC WATER LEVEL 30 ft. DATE MEASURED 5/13/93 DRILLING EQUIPMENT [3 ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. 13 OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 92 ft MATERIALS: ICI STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 91 ft. JOINTS: ❑ WELDED ® THREADED ❑ OTHER DIAMETER 6 in. SEAL: ® CEMENT GROUT ❑ BENTONITE ❑OTHER WEIGHT PER FOOT 19 Ib. /ft. DRIVE SHOE: ® YES ❑ NO LINER: ❑YES ®NO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? DETAILS FIRST ❑ YES ❑ NO HOURS SECOND GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE. DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST If detailed um in P P 9 METHOD: ❑ PUMPED i tests were done is in- B COMPRESSED AIR , formation attached? ❑ BAILED ❑ OTHER ; ❑ YES ❑ NO 1P1ELL LOG It more detailed formation descriptions or sieve analyses are available. please attach. DEPTH FROM SURFACE water Bear- Ing Well Oia- In FORMATION DESCRIPTION CODE. ft. it. WELL DEPTH ft. DURATION hr. min. DRAWOOWN ft. YIELD gpm. Surface 30 ri li g in overburden clay ou e s it rock at 30t 16 6 100 0 2 DrLIL-ng in rock set casing, rout d. 9 165 D ril.' ing in rock granite. WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? O YES ❑ NO STORAGE TANK: TYPE Well Xtrol 302. CAPACITY 86 GAL. PUMP INFORMATION TYPE sub. CAPACITY 7 9 MAKER Gould DEPTH 120' MODEL 7EHO 5 x+12 VOLTAGE MQ HP _ WELL DRILLER NAME P.F. Beal & Sons, DATE ADDRESS 4 Putnam Ave. SIGfATURE q Brewster NY 10 5 0 9 r ir- c':.. -- f�atal,.Ria1� %// \��f1�1�.1.a• tot 61 FE Semeo 011 -:Yahl®o pcN .uoo D — � o oa > w�eo +m r copboia 14 r5 Snpao uW op S� to eioi d T Ta�;.�� Adllrnae Waled S"*: 'Pile Saw i►ton Addveaa eel t�t.e St1 , BEE" 6y OIYa� 1RagNeama�tg •: 1 repreaant;thet 1 am whOliy and completely responsible for the design and location of, the proposed system(s), 1), that the_ separate*' se di sil stem above described will be P"', jtructed a$ shojMn on tM ephroved amendment there to and in accordance with the standards, rules a .fegY ns O Mm County DepartreMt'lol! Flsalth, and that•on completion thereof a. "Certificate of 'Conshuction compliance" satisfactory ' to: the Commissioner of •H"Ithwill be submitted to the`Depe tmerlt and, a. written guarantee will 'be furnished the owner, his arccessors, heirs of asgni;by thoaiuikIW. that 184r buildw will Dim in good operating oondilwn inY -Part, of, said ,Soer!ge disposes system durirp tl»:pwiod of two (21 YNMt Immediately following the dite Of, the tau - anee of tole approval of t1w Certitidte .of 'Construction CompllenAn riginal system or any re pairs t o; 2) that .the drilled well.deserieed 860 re wIM M leered ee Yigwn on tlas eppioveo plan and'thot sald.weli wih'bn accerdanas with'the stands ru aq rpu a� oii ns of the Putnam county Departmiat Af Date / 3, gnea P.E. �! R.A. — Address—_ License No APPROVED FOR CONSTRUCTION- This approval expires two years from tho data -issued unless construction of the building has been undertaken and is revocable for dues or'may be' amended or: modirie0 wren considered nmcesmry by the Commission®► of Health. `Any change o► alteration of'constructlon requires' a new permit... Appro4id'.for disposal of. domestic sanitary io"e,- and /ot private water supply 'only. Rev. Title Dees��� �'�- -- 10/88 IA�OIf. �' �A1T TTTTIArm d� 6V �i 4 L UUr1rLjziiUly nrUt<i WLL A- DEPARTMENT. OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET AO WNIYI Y TAiGRIO NUMSEi Cornwall Hill �� Patterson, NY (Lot 0174 WELL OWNER NAME: ADDRESS: Westchester Modular Homes,1�2Ic. , Route 22, Patterson,NY p PRIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary (3 RESIDENTIAL ❑ PUBLIC SUPPLY­ ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ` ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT gpm:INO. PEOPLE SERVED ,/ EST. OF DAILY USAGE gal. REASON FOR DRILLING ® NEW SUPPLY L F;ROVIDE ADDITIONAL SUPPLY ❑ TEST / OBSERVATION ❑ REPLACE EXISTING SUPPLY ❑.dEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 165 ft. STATIC WATER LEVEL 30 ft. DATE MEASURED 5/13/93 DRILLING EQUIPMENT f4 ROTARY ® COMPRESSED AIR" PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSIO "H ❑ OTHER (specify): 'WELL TYPE ❑ SCREENED ❑ OPEN END CASING..'. 13 OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH g2 ft- MATERIALS: 19 STEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 91 ft. JOINTS: ❑ WELDED - ® THREADED ❑ OTHER DIAMETER __L''_6 in. SEAL: ® CEMENT GROUT ❑ BENTONITE ❑OTHER WEIGHT PER FOOT 19 Ib. /ft_ DRIVE SHOE: ® YES ❑ NO LINER: OYES ®NO SCREEN DETAILS DIAMETER (in) SLOT SIZE LENGTH (it) DEPTH TO SCREEN (ft) DEVELOPED? •FIRST O YES ONO HOURS SECOND GRAVEL PACK O YES ❑ NO GRAVEL SIZE DIAMETER OF PACK in. TOP DEPTH tt BOTTOM DEPTH It.' WELL YIELD TEST If detailed pumping METHOD: O PUMPED tests were done is n- I .fl COMPRESSED AIR , formation attached? O BAILED ❑ OTHER - ❑ YES ❑ NO It more detailed formation descriptions or sieve analyses WELL OG� are available, please attach. DEWater Bear- Well Oia- Ineter FORMAT ION DESCRIPTION CODE, fing WELL DEPTH It. DURATION hr. min. DRAWOOWN ft. YIELD 9Cm. 1and Surface 30 ri li g in overburden clay ou e s it ro k at 30' 165, 6 100 30 2 Drkiling in rock set casing, rout d. 92 165 it ing in rock granite. WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ❑ NO ANALYSIS ATTACHED? ❑ YES O NO STORAGE TANK: TYPE Well Xtrol 302, CAPACITY 86 GAL. PUMP WFORMATION TYPE sub. CAPACITY _7 9___ MAKER Gould DEPTH 1201 MODEL 7EHO5412 VOLTAGE HP -..per WELL DRILLER NAME P.F. Beal & Sons, DATE Q ADDRESS 4 Putnam Ave. slGrntTURE Brewster,NY 10509 lURN" COMM DBIARMMfl' OF ®SALTS 7 , Dlahit 'd Ihrteesl W Haohh.�eeeleea: lcil WAK 1661 ? 191tyYeee to Faoelda _Featialt / Z oti CBtlII+iCA18 OF fJO A :: Fit : lit FOR S MAD„ DIlOSAL STST®N o Sraba.w.0 ► r r .ba Lot. �/ TM M"_' —= •°': _ O ,dApYe�trir, M+I 12n &R.4� Reo°"d ='O Date of PMVIG o Date Subdivision UlJidved Fee Enclosed Amn„nt t'%d ' WT �✓ il/ IA A ei 12M6 M, ATiJ: pfil Setfloo Depth.' waloob Design Piow G P . D ,90 RC® Nedlesdals ti sequb" Rhea #M b eomptated s.p�ra s...ii.�..si.a. a eclat d CraBoss 41 ,a • -a To:bo erNet+ttsi.by --- �� Address Wabae Sop*. FefbMe S.W* Adhisi S�pb Demsd by eer_�L Fafl..ta ... 0911W ; I represent, that 1 am ,wholly °aria complete)y responsible for• the dasiii and location of. the proposed system(s): 1) that live separate sew di Sol stem show despibeA wilQpe eoilst►ueted as drown on tM approvb armrWment the►e'to and in accorAana -with tf e;standards, rules a, . rpu ns o ream County Qep it "" 4 Health, an0 that on compNtioq thereof a 'Cettifkfats of Construction Compliance'' fatisfaCtory to the Comnlisslonei.of He lthwill be sybmittad;to tlis; 0epertnant an0 a- written auaranteo will pp furnishAtl'the,'owffW, his` wccenon, Mhs,a assigns by.tM buildei, thattNO builder will plaef in getld oPefatN/ eon01tion any, `Part of', said "age dispoael system during -the Period of two (2) yens bnmidietely'folbwing thedate Of the IM- afte 41C tM rapparal, of the certificab of Construdion:,,Compliance of the or I systern'er,eny.repesrs t wr ..2) that the drilled well described aiioeo county Deb da � o R„ apOrewtl plan antl that nib -well will be lnstellc� i ccordahc ' with .oho arWarro ru regulations, 04 the , Putnam Doti Sgnee P.E. R.A. Address License APPROVED FOR, CONSTRUCTION This approval expMes two years, from the date issued . unless construction of the building has been undertaken and is ►evocable fa cause or may W amended of modified: when,consldend necei i ry b the Commissioner of Health. Any change or alteration of co ruction requires new permit.. _;k-m -a for aifpOsel of dome�stie,-u�e)t try'>, piivat ter supply. only Rev. 10/88 fay. Tits %i11 i`1Fii"l - % -LAJ1V 11 Ur n r e L,111 DIVISION OF, AFALTS,SERVItES DESIGN DATA S'dFBT- SUBSUFACE SEWPZEE DISPOSAL SYSTEM FILE NO. Owner U P.ddress S r2F_UO E ,v ON KE�EZS Located at (Street) SG LA r- NSF T D(� I Sec. Block Lot (indicate nearest cross street) t=icirality p TT I�f 05n4 Watershed c4co TDI� SOIL PERCOLATICN TEST akM RDQUIRED TO BE SUFxMl= WITH APPLICATICNS Date of Pre - Soaking ! Date of Percolation Test 2 BOLE NLZgER Cl= ZDE PERCXILATIC N PERC O=C N Run Elapse Depth to Water Fran Water Level No, Time Ground Surface In Inches Soil Rate Start Stop Min_ Start Stop Drop In Min /In Drop 1 - D' �-� -1 2 0:3 C3 'a -7 - 4 3 2 10'41 3 4 5 1 .• Inches Inches ' 3o /* Inches 2 �l� / �5 2 3 4 5 NOTES: l.' Tests to be repeated at same depth until approocimately equal soil rates are' obtained at each percolation; test hole. All data to' be sukmitUd for review. 2. Depth reas,=enents to be made fran top of hole. rev. 9/85 DEPTH G.L. 1' 2' 3` 4' 5' 6` 7' 8` -7 9' . 10' 11` 12' 13" 14' TEST PIT DATA REQUIRED TO BE SUBMITIED.WIM APPLICATION DESCRIPTION OF SOILS ENCOUNYEERED IN TEST HOLES HOLE NO. HOLE NO_ HOLE -NO. INDICkTE LEVEL AT WHICH GROUNM= IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED 1 DEEP HOLE OBSERVATIONS MADE BY: P> . Li I-- Dl S DATE: • !" - 2m 3 DESIR4 Soil Rate Used II I 24in /1" Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capacity 2 50 gals.- Type ._ 4, . Absorption Area Provided By L.F. x 24" width trench Other NaSignature.. me G . �1�� N T �N�. �SSO rP • ['_ ' Address -72 SEAL s-�-f 's ON . N `i 125 0 ysF� No. 56124 - AROpr:§ I% &I THIS SPACE FOR USE BY'AFALTH DEPAPMffM ONLY: Soil Rate Approved sq.ft /gal. Checked by Date i DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL /-1_2 PCHD PERMIT # WELL LOCATION Street Address QTqVillage City Tax Grid Number �. WELL OWNER Name Mailing Add ess OPrivate O Public USE OF WELL T - primary 2- secondary IQ RESIDENTIAL O BUSINESS O INDUSTRIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, Q AMOUNT OF USE YIELD SOUGHT r gpm /# O REPLACE EXISTING SUPPLY tINEW SUPPLY NEW DWELLINGY PEOPLE SERVED r /EST. OF DAILY USAGE 6g gp al O TEST/ OBSERVATION Q ADDITIONAL SUPPLY 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING � I D WELL TYPE DRILLED 13DRIVEN DDUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES _l,/ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot Nd. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: 9J IA TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: >� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON SEPARATE SHEET ( ate) (s nature 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 thirt3, (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 drilling operations be contained on this property and in su a manner as not to degrade or otherwise contam' ce or groundwater. Date of Issue: 19 / Date of Ex ration 19� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller P�T'I'NAM C ®UNTSP I3E�ARTA�ENT ®�' Y�EA]L°I'%% APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: 0i II-wr N . peKO+AV1= 5 r2t?•\/oic AVE 2. Name of Project: 3.._. Location dyV /C: 4. Project Engineer: Jj`�r Itd 5. Address: License Number: Phone: o�S 6 .. T of P o ect : 1 e Private /Residential Food - Service •. • •Commercial , Apartments Institutional Mobile Home Park Office Building, .- Realty 8ubd.i- vis4on Other (specify) 7. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental. Impact Statement (DEIS) required? ............. D 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name of Lead Agency 11. Is this project in an area under the control of-local planning, zoning, or other officials, ordinances? ......... ............................... ►�In 12. If so, have plans. been .:submitted .to .such ...author-i.Lies?_.....� 13. Has preliminary approval been granted by such authorities ?_ Date Granted: 14. Type of Sewage Disposal_ System Discharge... a o a Surface Water _Ground Waters 15. If surface water discharge, what is the stream class designation ?........ N /A_ 16. Waters index number (surface) ........... ............................... 4_ 17. Is project located near a public water supply system? .................. Aa 9- 18. If yes, name of water supply K) 16, Distance to water supply r 19. Is project site near a public sewage collection or disposal system ?..... 9110 20. Name of sewage system Distance to sewage system �. 21. Date observed: 23. Name of Health Inspector: j�1�— t1 DZi }.►sI� 24. Project design flow (gallons per day) ...... ............................... 6"no 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. 26. Has SPDES Application been submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... U 28. Wetland ID Number .......... 29.-Is Wetland Permit required ? - Has application been made to Town or Local DEC Office? .................... 30. Does project require a DEC Stream Disturbance Permit? ................... N Pl 31. Is or was project site used for agricultural activity involving application of pesticides _ to orchards or other crops, solid or hazardous waste disposal;````-`. landfilling, sludge application or industrial activity? ........ YES or NO 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 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? o (� 35. Are any sewage disposal areas in excess of 15% slope? ........................ 36. Tax Map ID Number ........................................................... 37. Approved Plans are to be returned to: Applicant U 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 provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. J / n SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS:A�vN P -z- `3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date / -a - - cl3 Re: Property of Located atQ�j'L�,'r��j (T) Section Block l Lot 4!- Subdivision of �UJ/�jh� ci21 ©EFiG Subdv:" Lot # ��i ` Filed Map -7A Date 5.. Gentlemen: This letter is to authorize W, 045+10Ls� _ a duly licensed professional engineer b or registered architect (Indicate) to apply for a Construction Permit for a 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 Co Count P.E., Address Very truly yours, Signed. 4 Ge� Owner of Property 6 �5 .hyg!. Address Town Telephone Telephone LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 RANDOLPH W. LAURENT, PE. (914) 278.6108 - (FAX) 278.2658 HARRY W.NICHOLS, JR., PE. ffl CONSULTING SITE ENGINEERS January 26, 1993 Mr. William Hedges Putnam County Health Department Route 312, Geneva Road Brewster, NY 10509 Re: Individual SSDS Lot #12 Cornwall Ridge Somerset Drive Patterson,-N.Y: Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -12 "Proposed SSDS ", dated 1- 25 -93. 2. "Application For Approval of Plans For A Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 1- 25 -93. 4. "Application to Construct a Water Well ", dated 1- 25 -93. 5. "Design Data Sheet ". 6. "Letter of Authorization ", dated 1- 25 -93. 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 8. Money order in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely, LAURENT ENGINEERING ASSOCIATES, P.C. J Harry W. chols, Jr., P.E. HWN:bd 93006 cc: Mr. P. Donohue w /enc. Mr. G. Hatcher w /enc. PUINAM •OiY11- 1 E• 7 N ra OF HEALTH DIVISION OF ENVIRCMM%L HEALTH SERVICES DESIGN DATA SH1=- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. JO-I? -1'3 Owner IF— Address AJ5 F 4F ye)%iLLESaj'If Located at (street) �7p� Div. Sec. Block �_ Lot 44 ( iridicate heares cross street) municipaiity N)`- , watershed Date of Pre - Soaking %fir Date of Percolation Test HOLE NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min /In Drop Inches Inches inches V 2 �. P4- 41 3 4 5 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated'at same depth until approximately equal soil rates are •obtained at each percolation test hole. All data to'be submitted for review. 2. Depth measuremnts to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERM IN TEST HOLES DEPTH HOLE NO. HOLE NO_ ; HOLE NO. G.L. 2' 4' 5' 6' 7' 8' 91 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENC OUNTERFA INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNT= DEEP HOLE OBSERVATIONS MADE BY: �/j ..i(.(D %9 DATE:. DESIGN Soil Rate Used _ Min/1" Drop: S.D. Usable Area Provided No. of Bedrooms 'Septic Tank Capacity j'L p gals. Type eo G . Absorption Area Provided By L.F. x 24" width trench Other Name �( �T i2li iN . 1 – - Signature i Address �t�r -"� L- SEAL g j 01 F No. 56124' .y�� . - A90FESSIO THIS SPACE FOR USE BY'HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /ga.l. Checked by Date 1 r J -AA/. lA/ 111 f \O Q V C t O !t: I A� A ore Tian q 5 Slo 10 A ore Tian