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PUTNAM COUNTY DEPAR'TAkNT: OF ;HEALTH; . ENGINEER MUST. `
Division w
of Enronmentel Hailth, *Wctis, Carnlel, N ' Y 1051? PROVIDE' .:
PERMIT #.P59 -85
OF CONSTRUCTION COMP.,LIANCE FOR -:SEW AG E.DISPOSAL= ''SYSTEM T 'Patterson' [5:0,; 2286].
t, Town or Vill
y~9
t ocater! at .Deacon' Srri th Hi,hl Rd.' Tax' Map 42 ', 'look 2 .,
i
Ow ` •Denn 's & Dorothy .Diefenbagh ormerly R: J...Frackman _ ;- Tax Nap iota 3.3 suba' zpt s ".C"
separate sewerage, system built by North'•Country Construbtton Co_ Address Horsepound Rd Carmel, -NY . '105121
Consisting of 1000 • . Gal 'Septic Tank and 3T5' x24° w. x 18" Deep laterals
•
orner.revuirements .R- 0- B'Fill Section" .4400.sg.; ft. (38 cu. Yds.,)
Water supply: Public.SupPly From
Ix Private 'Su PPly .Drilled By Boyd Artesian' Wel l Co. Inc,. .
Address . Rte. 52, Carmel, NY 10512
euuding Tyae Frame= Modular. No. of 'Bedrooms Three. Date Permit Issued 5%19/87
Has. Erosion Control, Been Completed? .As required Has garbage grinder been installed? No
I certify -that the system(s).as`listed ;eervinq; the above premises,.were, constructed essentially as shown on the,'. plans of the completed work ( copies
of which are atthched), and.iri accordance with the standards, ivlas. and >ragulations,.in adcordancewith the.filed plan, and the permit iesued'by the
Putnam County Department Of'Healih.
oats. 16 July •1987_
Address rtu7-ra i r.!O�.. �armc;r. r
Any person occupying premises served' by the above system•(') shall promptlya
conditions resulting from such.usagii. Approval of •the separate sewerage sy
available and the "approval of the' private water supply shall become null `and
subject 'to modification* •or` change. when, in the judgment'of the CommiWc
Date J� J� 3 / / - � gy
P.E. X R.A.
License No. 29906
mey,be necessary to secure the correction of any unsanitary
null and vold"as soon as a public sanitary sewer becomes
c.water supply becomes availablc Such - approvals are
h revocation, r6od)fication or change Is necessary.
Title
_
WELL l:Ul"lYL1111VLV rtr•rUni Office Use Only
DEPARTMENT OF HEALTH !�
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
WELL LOCATION
STREET ADDRESS: WN /YI / 1 Y TAX GRID NUMBER:
b�gCr�jv 6SM I i i4 %MILL /,...17: �.� r" J, �J T7Eij tJ
WELL OWNER
NAME: ADDRESS: 'fifr�U�i✓
D _1111 1.S �J /� ��i���1c /-� / /s-- r,4x��e,eb A" i ,0,9 �
PRIVATE
❑ PUBLIC
USE OF WELL
X RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP O ABANDONED
1 - primary
2 - secondary
O BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
VNEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION
DRILLING
❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
' WELL DEPTH
STATIC WATER LEVEL — ft.
DATE MEASURED e"
DRILLING
❑ ROTARY. O' COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END. CASING. ❑ OPEN HOLE IN BEDROCK ❑ OTHER
TOTAL LENGTH fit
MATERIALS: 9 STEEL O PLASTIC O OTHER,
CASING
LENGTH.BELOW GRADE -;7 ft.
JOINTS: ❑ WELDED OrtHREADED ❑ OTHER
DIAMETER in.
SEAL: IrCEMENT GROUT ❑ BENTONITE ❑OTHER
DETAILS
WEIGHT PER FOOT Ib. /ft.
DRIVE SHOE 9YES ONO I LINER: ❑ YES 9NO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
OYES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft-
BOTTOM
DEPTH It.
WELL YIELD TEST I If detailed pumping
METHOD: O PUMPED 1 tests were done is in-
'COMPRESSED AIR , formation attached?
O HAILED O OTHER, i 0 YES O NO
tf more detailed formation descriptions or sieve analyses
ELL LOG are available, please attach.
[!DEPT H FROM
URFACE
Watwell
Bear-
ing
Dia-
meter
FORMATION DESCRIPTION
voce
it.
tt.
WELL DEPTH
ft.
DURATION
hr, min,
ORAWOOWN
ft,
YIELD
gpm.
Surface
/0
JI)e -j /�4jW Pi4A/
0
1
re) r
f 3
SF'tlrr�
WATER ❑ CLEAR
TEMP.
QUALITY O CLOUDY
HARDNESS
O COLORED ANALYZED? O YES ONO '
ANALYSIS ATTACHED? O YES 0 NO
STORAGE TANK: TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE
MAKER.
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME &)V!) /� % G- S �
ADDRESS � � SIGi1k URE
"Yorktown Medical Laboratory, Inc.
321 Kear Street
Yorktown Heights, N. Y. 10598
(914) 245 -3203
Director: Albert H. Padovani M. T. (ASCP)
-�en b A c h, e� ►s
Q 0, eZIY� 3 0 6 C_
LAB i CA.004720
Collection Station Used:
Carmel Peekskill _
Mt. Kisc _ New City _
Date Taken : / .l kf' ilM
Date Received:
Date Reported:
Collected By: b.
Referred By:
Sample Sourc e : PA C*Q r tuCxk(4 -
�'�
LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF WATER
GENERAL BACTERIA
Standard Plate Count per 1.0 ml
(Agar plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (MFT)
lc Total Coliform per 100 ml_
Fecal Coliform per 100 ml
Fecal Streptococcus per 100 ml,
MOST PROBABLE NUMBER TECHNIQUE (MPN)
V
_ Total
Coliform:
MPN
Index
per
100
ml
Fecal
Coliform:
MPN
Index
per
100
ml
OTHER ANALYSES
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NOT APPLICABLE)
OF A SATISFACTORY SANITARY QUALITY ACCORDING NEW YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED.; AT THE TIME OF COLLECTION.
f
j LEGEND
RDS Recommend Disinfect -
Albert. H. Padovani, M.T. *(ASCP);,Director ing Water Source
ELAP #10323
TNTC = Too Numerous To Count
CONF = Confluent
< = Less Than.
> = Greater Than
I II.
IV.
V.
VI.
APPENDIX C _
/. FINAL SI INSPECTION Date �y
Ins tea b
;;CATION I �- �v GWNER �. r �C
# C66��
/ - 'D1 # OR SUBDIVISION LOT a
-
YES NO
CCM_^4II�fCS
Sn"T+VAGE DISPOSAL ARFA
a_ SDS area located as per approved plans
b. Fill section - Date of placement
2:1 barrier _ LGTH WIDTH AVG . DPI`H
I P
_
c. Natural soil not strinned
`
d. Stone, brush, etc., greater than 15' fran SDS area.
e_ 100 ft. fran water cour e /wetlands.
SEW-AGE DISPOSAL SYSTEM
a. Septic tank siz - 1,000 1,250
b. .Septic tank in tailed 1 vel
I
c. 10' minimum fran ' tion
I
I
d. No 90° bends, clear-out within 10 ft. of 45° be-nd
e. DISTRIBUTION BOX
1. All outlets at same elevation - water tested
2. Protected below frost
---I
I;
3. Minimum 2 ft. or- Lainal soil between box and tr�_=nches
f. JUNCTION BOX --proc-arly set XLNI
Pot
g. TR Eb=
1. Length re^.uire i Ic Lencth ins tall
2. Distance to wat=rC0 se n-_ sared _ ft.
—�'(
3. Installed accord-ing to plan
TP I
4. Distance center to center
I
5. Slope of trench acceptable 1/16 - 1/32 " /foot.
I I
I
6. 10 feet fran rcL-6--ty line - 20 feet - foundations
I
7. Denth of tranccz < 30 inches fran surface
I
8. Roan allowed for excansion, 50%
I
CL
9. Size of gravell 3/4 - 1 " diameter
10. Death of grave? in trench 12" minimum
11. Pipe ends canned
h. PUMP OR DOSE SYSTEM
1. Size of tmm 'cza*nber
✓ �, R4r�
2. Overflew tank
—'
I_ J h c, c CA
3. Alarm, visual /audio
1 S
4. Pump easily accessible manhole to grade
JS j C.Y,5J2d
5. First box baffled
---I
6. Cycle witnessed by Health Department
estimated flew per cycle
HOUSE
a. House located per anproved plans.
b. Number cf bedroans
I
I
WELL j
a. Well located as per approved plans
I
b. Distance fran SDS area measured ft.
c. Casing 18" above grade.
d. Surface drainage around well acceptable.
OVERP.LL WORKMASHIP
a. Boxes properly grouted
I
b. All pipes partially backfilled
c. All ipes flush with inside of box
d. Backfill material contains stones < 4" in diameter
e. Curtain drain installed according to plan
--�"
f. Curtain drain outrall protected & dir.to exist.watercours
./`
g. Footing drai-zs d-iscnarce away from SDS area
h. Surface water protection adequate
i. 'Erosion controi provided on slopes reater than 15 %.
t
NS , CTION PERMIT�FOR SEWAGE DISPOSAL SYSTEM � tom` �� �'��$
' Deacon Smith Woods snbd rota 0"'
idlvlilon Name >�. t .
` +Dennis &Dorothy Diefenbach
nor /Applicant Name
} x a19 iTaxter Road }
Wog Addreeo � i
sr :
1,uA3, n - Y piA i, i
�,pe,�v Modulart, tot `a 3 5 14
6 C
mbri'r of Bedrooms Three z Design Flow G P D
t x 4
S,_
1
iaiate Sewerage System'to coneilit of 1' Gallon Septic Tank end
qR To bo conatrucfed by t' r
e s a
ater'SSapPU 2 Pa68c ,Supply From '
ort X Private- SOPP1YrDrWed
hei Rixidiementa R '0 B f i 11 s e c t s On { 4400-
�s ql �` f 4
iPPROVEO F
evocable 4 or .
squires s Y
aa!
11.:=
s
fiLY..
.'t
,s X.
a a
.a
t
"' Englueer' -to Provide'Permit
x;
��on CERT�ICATE OF COMPLIANCE`
r t
3Y�
P "atterson
Town or ti,, age '' r
�`�� � ��_�' •Revielon ;p S' 0 228,6 ,r •�
w
�ggn f.
Zip 53
103 i
yi
v � Yds a
)nly nDept6 yolame
otiBcatlon le Regalred When FIII le completed
;Y18 "� deep, "w a ti
y t
e (s) 1) that the separata` sewage dosposal'system
the standaitls rulesan regu a ions o•;'� 0 ,. a nam
rice satisfactory to tha Commissioner of Heelthwill
heirs or assigns by the builder; that said builder`.will s
(2) years Irtimedrately following the -date ofthe�ifsu �
birs thereto; 2)` thst;the drilled wall "Cescrid'eC above a ••
ttaindards rule reg
s and,ua_ ohs of ,the Putnam j
p M 4 \ ,
R.A.
License Na
uction of, ;he budding has, been undertaken and is
wtHalth iAny change or alterstlon ot%;eonstructton
ri
�/ �17�Jj
r ,
Title �,i i�
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
OMEN WIPAMO�1_
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
Deacon Smith Hill Road T. Patterson 72 -2 -3.3
WELL OWNER
Name
Dorothy & Dennis
Mailing Address CIPrivate
Diefenbach 19 Taxter Road, Irvington, NY 105330 Public
USE OF WELL
1 - primary
2 - secondary
® RESIDENTIAL
® BUSINESS
O INDUSTRIAL
OPUBLIC SUPPLY OAIR /COND /HEAT PUMP OABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
OINSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT
five gpm /# PEOPLE SERVED six /EST. OF DAILY USAGE 400 gal
REASON FOR
DRILLING
NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY. 0DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
Residential
WELL TYPE
OX DRILLED
ODRIVEN
ODUG OGRAVEL ®OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Deacon Smith Woods Lot No. "C"
WATER WELL CONTRACTOR: Name ?
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
Address:
YES X NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: Over one mile
LOCATION SKETCH & SOURCES OF- dONTAO- NATION PROVIDED (see Dwg. #1, Job #S.0.2286 by
O ON REAR OF THIS APR�LICATION XO O SE ARAT SV4T John H. Prentiss, P.E.)
15 May 1987'.
(date) ," (signature)
Cj L,,
PERMIT
TOCONSTRUCT 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 s.hall:
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 y the Putnam County
Health D artment.
Date of Issue: 19 P-_-L er I ing f icia
Date of Expiration: 19
Permit is Non- Transferr le
Mite
H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF
f, P FIELD INSPECTION REPORT
"to-t k - 4
AlltllalU
(Name 'f Owner) (Street Location)
INITIAL SITE INSPECTION YES NO
Wetlands on /or proximate to property..............
Property lines or corners found ...................
Can estimate house location .......................
Will driveway need cut ..............................
Must trees be•removed - note these ................
Deep holes representative of entire SDS area......
Additional deep holes needed ................ ......
Sufficient SDS area available considering driveway
cut, house location, separation distances,etc...
Adjacent wells/ septics ............................
D.H. 1 Lot-
Depth to G .-W.
Depth to rock
Soil Descripti
0 ft.
3 ft.
6 ft.
9 ..ft.
12 ft.
D.H. 2 Lot
Depth to G. W.
Depth to rock
Soil De
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
..
DATE:
FINAL SITE INSPECTION INSP.BY: I YES NO
House SSDS located per approved plan .............
Length of trench measured
Width of trench average
Slope of tile line and trench acceptable..........
Roam allowed for expansion trenches ..............
Over 100 ft. from watercourse .....................
Natural soil not stripped or SDS area
unnecessarlygraded ........... ..... ..........
10 ft. maintained fran property line and
20 ft. from house . .. ............................
Distance well to SSDS (ft.) ......................
Number of bedrooms checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. from nearest trench ................
15 ft. of peripheral soil horizontally
from trench ..... ...............................
Boxes properly set ...............................
Could surface runoff from driveway, roads, -
ground surface,.etc., channel near SDS area....
Does lot drainage appear OKjn area of SDS::.......
FINAL GRADNG OF SITE ACCEPTABLE .................
HEALTH SERVICES
i
DATE: 6- �
.� i
INSP. BY;
D.H. - Deep Hole
G.W. -- Groundwater
D.H. 3 - Lot. -
Depth to G. W.
Depth to rock
Soil Descriot
0 ft.
3 ft.
6 f t.
9 ft.
12 ft.
APPENDIX B
PUTNAM COUNTY DEPAR2,,MU OF HEALTH - DIVISION OF ENVIRaMNTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
(Name of Owne
REVIEW SHEET,- CONSTRUCTION PERMIT
DATE
wi BY: .
(Street Location)
DOCUMENTS
Pen-nit Application
Corporate Resolution
Plans - Three sets
Engineers Authorization
Design Data Sheet (DDS)
Deep Hole Log
s/s
Consistent Perc Results (3)
Perc Hole Depth
SUBDIVISION
Perc
Fill
cd
House Plans - Two sets
Well permit; PWS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked _
Ex- approval SSDS Mj. Lots Checked
Wetland (Tcwn/DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Sewage System Plan - (north arraa)
Sewage System Hydraulic Profile - Gravity Flow
Fill Profile & Dimensions - Volume
D or J Box;Trench /Gallery; Pump pit details
Septic Tank - Size, Detail
Well Detail, Service Line if over
Construction Notes
Design Data: perc and deep results .
Two-Foot Contours Existing.& Proposed
Driveway & Slopes Cut
Footing /Gutter,Curtain Drains (discharge OK)
Perc & Deep Holes Located
Representative of primary and expansion
Expansion Area;shown;gravity flow,suff. size
If Pumped Pit & D Box Shown '& Detailed
House - No. of Bedrooms
Wells & SSDS's Win 200 ft. of Proposed System
Property rtes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4" /ft. 4 "0; Type pipe .
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Trees,Top of fi'
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Take (inc. expa
15' to Drains - Curtain, Leader, Footing
35'to catch basin, sto=mdrain,piped watercour.
10'. to Water Line (pits -20') -
50' inteumittent drainage course
Septic Tanks .
10' from Foundation; 50' to well
15' Well to PL
A .� �i�j1T�J���
9
represent a . am, wholly and completely responsible for -the.
above deicribed.'will be, constructed as.shown on the approved ar
County. Department .of.., Health,,;and that.oncompletion',therec
be submitted ;to the Departmenf; and'a'wntteri guarantee iw
place. in good ..opeiating cotrdit ion: 'any part of ;said sewage'
once of the .. approvat;of, the °Certificate; of Construction Con
will be located as shown on the approved,plan anddhat slid well
County'.Departnient of ,Health.:
Date '
�.- A ,1
Atltlress 1�
a.
APPROVED F,OR _Co `'
fVSTRUCTION . This approval expdes`on
revocable for cause'or-may be'amerided or modified when -consi
requires a new x germit.! A' r ved .tor':disposal of, domestic.,.3
Date
ignaird location-of the
dment theeao and m;a
Car tifiant tr
o , of Cons
-t
,)e� °.furnished the owner,
io6a1: ce% o system, during . the
anf the.ong�nal'sy
i%ai instalietl 'in,
in, accordi
4d
that the
C`om0yanc0 sat{sfactory to the Commissioner of.Healthwill
iccessors ;Heirs or assigns by`the liul{der, that said builder will
dof two (2) years Immediately following the Gate of the;issu-
)r'any repai'r's thereto; 2) that ,'the drHlad' well described above
vh tFiel' Bards, rules and regu aeons: of. tho Putnam
CP.E. Q R.A.
►�� l� -�� _License
es construction otthe buili ing nos been'_underteken and is
signer orf, Hea h.y ' • Any change or alteration of construction
f , ._� '
Title
% _7
p
W-7 ENGINEER .T0PROVIDE PERMIT, #
PUTNAM-'COUNTY-,-:DEP,kit�MtNT�:'O- V HEA_L"T-.1H,
iON
_,CER)L�ATLOI COM
�P
4
Ser
Diviiiioi?..Of Eniironinentpl Health io�� Qiriive1,.-_'.' F_ERM IT
CONSTRUCTION: PERMIT: fOR .SEWAQE'bl' AL
Tow -Village--7�
Deacon,_ n,, Shii th, •Hi 11 Road 72 Bi 'Cic 2
Locai. -,at 'Tax Map 0 1,6t 13
bedcori Smith Woods
Subdivision staw. •L*t 0 R..iwel b "Revision
owner /Address 1
, Robert' J. Vra6kinani 12 E. 86" .St. NY, NY 10928of previ.us . i 7—
;•Buifdih,i:t,ype Frame Lot, .Area' -3,514, acres Fill section.&niy
Numb6' 600 P.C., H. D.-.!Siotification Required
,r.of Bedrooms Design Flow.G/P;D IT,- Cz
System .to to consist of 1000 -a 1. -septic Tank and
Separate Sewerage G 375':: x .'24 wide laterals'
To be constructed by: Address
Water Supply: Public, Supply:, Froni
X Private Supply be drilled. by
Address
Q33 f
other Requirements -R-Om-R F-ij j 6* t _i 4449 cu ids i
I represent %that am wholly and completely, respctnsabie*, or the , es!gq Ang,.lockion of the proposed_- system(s);.l) that the separate' sewage Aisposal system
above described will bicoinitriict6d h'- amendment thirii� t; and - rules I regulations of, .1the Putnam
-,,as shown „, inaccordance with the standards, rt and .
- . il� "'. ; . � 1. �. �', C-1-1
u- bepair ment o - ;Health, land that 'opcompletion ., en o 'Construttio
county t it' "i" 6omP`Ha*e sa t i sfa'c't'*or"y �t o the, ommiisioner of Healthwill
s6ri, or aisigni. by, the biii-lder. that said`tiu'� i*lder will
be submitted to the--Deoartrent�, and -a' writte`,g'94r"* t lbe`,fuihished. the owner, s, succes
' d - ' i” d - ' ' any ' ! 11 'n ;�q, ee:�yyj will
place. in joc, operating coq� ition pa�,t of said• iewage tdis"(_iyst" "ik tw-'p,( years'lmrnediately fd1l wing thedate ofthe issu-
ance per iod of 0
itiof _'Coqst . !upt - ipj sanc . e.,o the,6 'I system; ato; 2 . )t that I t the d . rilled *6 . 11 'described above
thce of the approval ,of the Certificate 6rnpi f r I
ginasy., eT� or any ippairs then
'Will ; — -_
we s- 1'.!iiiicordiiin `with`, the�4tandards, rules and reguFM?ns of the*,- Putnam
11 be located as shown on the approv said, _ Wi!lbdJnstalled:in,, cii
., County *Department - of Health
er
bate
November 9,5-
�8 ve , .
igned P.E. R.A.
2920
r-
APPROVED FOR C6.
revocable for cause or
requires a new. p6rmi
Date
Rev. .6/85
�:Address CL AL,
;TRUCTION h abordVal exdires7ii
1'..qi,,TodJfi ed w , h en.c , 4
disposal of do me st
rfriimthe dita -isiuid ur*
necessary,` "' "I
�by 'the Co M
I z:_ - I - . - . I _71 _
License No.
leis conitructiori of the building has. been undertaken and is
qn%df, ,.LHealth.
Any change or•alteiation of construction !�t r on y
Title
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING,-CARMEL,.N. Y. 10512,
DESIGN DATA'SHEET= SEPARATE SEWAGE DISPOSAL•SYSTEM FILE•NO:
Owner �o,6eri ./. /�Yarc,E..,ar, Address e' ce ;5••+. `�.
- - - aft Sow /F4 /veal's 5460f. ort "C'•
.Located at (Street K11 Sec 719 72 Block 2:, .Lot' 3
6dicate nearest cross s ree
Municipality, /�cy2r s oN Watershed (5;-,,, h
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
21131 .12o( _30 I I I
4(24-o 1319 39 �4 17 3
.. 2
FU's,'4AM COU ",TV
DEPT.. Ql✓ HEALTH
Notes: 1) Td'�ts to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. App data to be submitted
for review.
2) Depth measurements to be made from top of hole.
Hole
Number
CLOCK TIME
PERCOLATION
PERCOLATION..,
No.
Start-Stop
Elapse
Time
Min.
Depth-to Water
From Ground Surface
Start: Stop
Indies Inches
Water Level
in Inches Soil Rate-
Drop, in Min. /,in drop
Inches
j 1 110f
1113
19
2
iz
3
21113
11+7
3 1147
1223
36
4 1 113
12.0
36
v4
3-7
3 I I- iir,
Z 11110
1 1
�1
L4
17
3
21131 .12o( _30 I I I
4(24-o 1319 39 �4 17 3
.. 2
FU's,'4AM COU ",TV
DEPT.. Ql✓ HEALTH
Notes: 1) Td'�ts to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. App data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. m HOLE NO. HOLE N07
G.L.
0
6n Or dHicS
121 5l�M� Co
18" -
24" L+ brow Lao sd w e
30" w Traces Cia
36"
Gm ve
42"
48"
5411 LQ a ✓10 e't
60 cJ ...
66"
72.11
78"+'
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED No h
INDICATE LEVEL TO WHICH WATER LEVEL RISES..AFTER BEING ENCOUNTERED IVoh�
TESTS MADE BY Date
. DESIGN
Soil Rate Used I Min/l "Drop: S.D. Usable Area Provided J' ao g2
No. of Bedrooms hcre* Septic Tank Capacity 1100 Gals. Type _H so
Absorption Area Prod By �-L.F.x24" p—_--_-3_6' width trench.--
Other
Q -0 -6 Ail S ,, 6" a 2- J g No.
Name igna ure
J04N H. `° S, P. E. 5 NT ti
Address R09 FAIR -878-6170 SEA
mkit W512 .,
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: 2 0�
Soil Rate Approved Sq. Ft /Gal. Checked by 292
ES
/ • /Q'aYii.:i)W..^M•r aTlwwy"•SY•' rw.ini4%.rr +.7+i..� tr ww ..wti+ MrW - vr/.+r..a/�rr —� - jj � "r
yJINAM COt3NTY DEPAi "OF SEALTH DIVLSION Oil Zvi, BZALTB SERVICES -
INDIVIDUAL TER • SUPPLY & - SUBSURFACE SEVGE DISPOSAL SYSTEMS
REVIEW SHEEP F- ' CONSTRUCTION -PERMIT
DATE REVIEWED:'
r �, y .%��/l o� l c° c -c�.r� ��rzil f` ��•%� �'� BY:�� -- -- ✓�
(Name of / Owner) (Street Location)
YES ( N0 DOCCMWM 2�1
-ermit Application G'
orporate Resolution
lans - Three-sets
ngineers Authorization'
esign.Dita Sheet (DDS)
Deep Hole Log
Consistent Perc Results (3)
30" Perc Hole
Other
Ouse Plans - Two sets
f M - Letter
ariance Request
DQUIRED DETAILS ON PLANS
ewage System .Plan
ewage System Hydraulic Profile - Gravity Flcti:
'ill Profile & Dimensions - volume
) or J Box;Trench /Gallery; Pump pit details
septic Tank - Size, Detail
Tell Detail, Service Line if over
:onstruction Notes
)esign Data
:parr -Foot Contours Existing & Proposed
)riveway & Slopes Cut
?ooting /Gutter Curtain Drains
?erc & Deep Holes Located
Representative of Sewage & Expansion Area
tension Area'; shown; gravity flow,suff. size
If ' Rmtped Pit & D Box Shown & Detailed
louse - No. of Bedroans
Bells & SSDS's w /in 200 ft. of Property Io�ted
?roperty Metes & Bounds
.louse Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 "0; Type pipe
No Bends; Max. Bends 45° w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, Large Tres
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. exxn) .
15' to Drains- O=tain,Storm, Leader, Footing
25' to Catch Basin
10' to Water Line (pits -20')
Septic Tanks
10' fran Foundation
50'.to Well
15' Well to PL
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj, Lots Checked
Wetland (Town/DEC Permit R'& D)
Data On DDS Plans & Permit Same
"j PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512.
DESIGN DA TA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
nis��ie�rtibac�
Owner Address Deaco S••tti,' /�
Located at ( Street Sec 7n 72 Block I. Lot
�lndicater nearest cross
street)
Municipality �. soil Watershed Cew-(y„
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
31117 12 23 34 1 1 '
4 1113 ! Z j9 3.4 )14
17 3
5
Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
Hole
Number. CLOCK TIME
PERCOLATION
PERCOLATION,:.
Elapse
Depth to Water
Water Nvel
No.
Time
From Ground Surface
in Inches Soil Rate:,,;
Start -Stop
Min.
Start Stop
Drop in Min. /in drop '
Inches Inches
' Inches
2 ' 113 1 t+77
__ 14
31117 12 23 34 1 1 '
4 1113 ! Z j9 3.4 )14
17 3
5
Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA'REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ,ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO., HOLE NO.... Z .
G. L.
6" or a►,ics .
12" 5a.Jd to
2411- L-t: brow Le
30" w Tralces < <a
3611 move r s«�4cr
42 e
60 ".. .
6611.
721
is
78
84"
Sam e
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED. NO ne
INDICATE LEVEL TO WHICH. WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY , (E(. F T.) 1 o/is /tS I' -vcs. (N.F T Date 16 4818,;-
DESIGN
Soil ; Rate Used I r_ It Mirk/1 "Drop: S.D. Usable Area Provided S'dod�l
.No. of Bedrooms Tltrev, Septic Tank Capacity (000 Gals. Type
Absorption Area Prov de
By L. F. x24" �r width trench.—
Other
Q -0 4 631 ' h 34" y ? (442- ) N -E
ame igna ure
JOHN H. U- 117"s, P.E.
Address RO9 FAIR „ 1 -878 -6170 SEA -K Wig
.:THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: z c
6 3`
Soil Rate Approved Sq. Ft /Cal . Checked by 9��� 'NO' 2920 �`
ap
i-
T-
.0
fill
�I hoLlii PIPE .
"'' IA,
'7r' I
{ � � 3 �✓Gp 2001
vJG U.I
I�000 x..L
�- - ric -rim x
,�,
14 , OrK
Op �
L
LA�6�AL Col -off'
G a.c 375
`
•
-(o-rA L
?v
2 •o,� • (=ILL S �t \
¢38 tea! � T� r• ° `
X,
8s,
`Ube
W
82-6
7 i
�°
T
i-
T-
.0
fill
�I hoLlii PIPE .
"'' IA,
'7r' I
{ � � 3 �✓Gp 2001
vJG U.I
I�000 x..L
�- - ric -rim x
,�,
14 , OrK
I � 311
�D
Q
Nj
U
IK
. rage
dispo. —iI sysiem was constructed as"
NOTES: indic.rted in this plan and that the
system wrrs inspected by me before it
cok-r-ed over. -The system was
cnstrurtod in accordance with al
tat rulc!% and regulations of -
r:n• I'.•:.II.II. the. N.Y.ti .l
..oOFESStOJMgI ..
0
i
r
J I LT"
OWNER:—
LOCATION Street:��- �.�L�/- �f��1�'�/ -
Town:_figr /' J`%County:�G /��_ State: /�• —�
Su8Div S 1 C 111Th,�j/QDD��-C�
Map:�TAX_ 1
Block. %' _ _ _ _ LOT Ns
Builder:/_ __LA, — — — — — . — --
Dawn: o,u,r Dote: _AG 87 scale: ,i_6O/ Job 9- 228
r
Dw 9.
JOHN H, PR ENTISS PE.
CONSULTING ENGINEER
RD r', F`tr�� t:� CARMEL NY 10512 —(9141 878 -6170. 2.
t
I
i
DIMENSIONS
A -
Ad-
B
C
-- — - i- -T
T4 -/ -BI -
C
�►
=_ 48 = 8
A -
D
.-Lt2 0B -
D
=_ - PZ� -1oT e
A-
A
G
H
=�z= 6_
QL / �T /8 -
T
G
1't
a
- C?
/
Qt
JQ
�-
N
_
0
i
r
J I LT"
OWNER:—
LOCATION Street:��- �.�L�/- �f��1�'�/ -
Town:_figr /' J`%County:�G /��_ State: /�• —�
Su8Div S 1 C 111Th,�j/QDD��-C�
Map:�TAX_ 1
Block. %' _ _ _ _ LOT Ns
Builder:/_ __LA, — — — — — . — --
Dawn: o,u,r Dote: _AG 87 scale: ,i_6O/ Job 9- 228
r
Dw 9.
JOHN H, PR ENTISS PE.
CONSULTING ENGINEER
RD r', F`tr�� t:� CARMEL NY 10512 —(9141 878 -6170. 2.
t
I
i