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Rev. 318 'H PUTNAMCOUI
p� Divislonof Egli rWnme
Y DEPARTMENT OErHEALTH y� ' O ;� 1 O
:IHealth Services, Carmel, N.Y 612
Engineer Mast Provide
P C:H D Permit
0
q `
FOR SEWAGE DISPOSAL SYSTEM, , P sr i O h .
//��
Vggco 7 ! Town or V_ W j
Located at. JMtL �s�i' �' f!�d, Ter= "MaP Block_ Hof /
d ,* it: lrl��CkMQa�„erl "—' Subdivision Name 4 ~' Sabdv. Lot q
Owner /applicant Name �� Y _ •
MaWng
ZIP : O B' . • Date Permit Isaned a
Separate Sewerage System built by Address 2: �'• /r
�-
w ,
Consisting of [Sb n Gallon Septic Tank and rL9 �°��• ic;f tr�e� `L:R-�lrn�c
Water Supply:' Public Supply From ddress
or: Private 'Sapply DrWed bAi'l' S P4 : W 41 as ,
_ e o �. k4' ke :4::A ft,w pW Y 144 Z,
Building Type. "e d fe F g err Has Erosion Control Been Completed? yo"
Number of Bedrooms ite Has:Gar age Grinder'Been Installed? �
Other Requirements i`iD „�•
I certify that.the sysiam(s)'is listed serving the above premises were constructed esseritialiy'ae -shown, on the plans of the completed work ( copies
of which are attached), and in accordance with the standard's, rules and regulations, in accordance with filed plan, and the permit issued by the
Putnam County Department Of Health.
Date "rt fledb+y .,.- ' ` �t P.E'%k A R.�r.
Address t�f >{@ . N I �/��T r Llcena No. yfcri
Any - person occupying premises served by the above system(s) shall promptly take such action as may be: necesury.to,secure the correction of any unsanitary
conditions resulting from such usage.' ;Approval of•the separate'seweraye s iin'.ifiali become null and void,ais soon as a pub, :sanitary sawer•becomes
available and- the'approval of the ,private water. supply shall'become Bull and_ void'.when a' public water supply becomes available. Such approvals are
subject to modification or change when' in the judgment of the,.Com"issioner of. Nbalth, such revoati�o�n, >modiflutlon or change Is necessary,
” ��►�
Date T It Is
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- �-WELL-.COMPLETION REP -ORx
;
DEPARTMENT OF HEALTH
Division Of Environmental Health Sewices -
r; r,
PUTNAM EOUNTY DEPARTMENT OF HEALTH
WELL LOCATION
STREET ADDRESS: (OWN /VILLAGEICIIY TAX GRID NUMS—•''.. >
�( 10d.
. a c)y► c
WELL OWNER
NA E' (01'wk L'tilsba AODR SS:
/t 6.Q/L� ✓IAGbc%bt v> �. T `¢ 1v1� Kra l vKS�J �t 1 �-
O •PRIVATE,
Q .PUBLIC
USE OF WELL
® RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /CONO. /HE T PUMP ❑ A ANOONED
1 - primary
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑..OTHER,(specify)
2 - secondary
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY El
AMOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
tB. NEW SUPPLY = ❑ PROVIDE ADDITIONAL SUPPLY O TEST %OBSERVATION
DRILLING
❑ flEPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
D�
WELL DEPTH c3 ft.
STATIC WATER LEVEL _:,.,. ft.
DATE MEASURED "22
DRILLING
❑ ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG
EQUIPMENT
O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. M OPEN HOLE IN BEDROCK O OTHER
TOTAL LENGTH ft.
MATERIALS: 19 STEEL O PLASTIC O OTHER
CASING
LENGTH .BELOW GRADE ft.
JOINTS: ❑ WELDED ® THREADED O OTHER
DETAILS
DIAMETER in.
SEAL: ® CEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT -L 1b./ft.
DRIVE SHOE ® YES ONO
I LINER: O YES ®.NO ` t
SCREEN
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
DETAILS
SECOND
HOURS
GRAVEL PACK
O YES
GRAVEL
DIAMETER
TOP
BOTTOM
O NO
SIZE:
OF PACK - In-
DEPTH ft.
DEPTH It.
WELL YIELD TEST I( detailed pumping
WELL LOG It more detailed formation descriptions or sieve analyses
are available, please attach.
METHOD: O PUMPED i tests were done is in-
10 COMPRESSED AIR , formation attached?
DEPTH FROM
SURFACE
Water
Bear-
Well
Dia-
O BAILED O OTHER ; ❑YES ❑ NO
ing
meter
FORMATION DESCRIPTION
tt)t1E
tt.
(t
WELL DEPTH
DURATION
DRAWOOWN
YIELD
Surface
S 'D aU6 &4C
ft.
hr, min. '
,It.
J OS
S
/l.(rCR --A"
X
WATEN O CLEAR TEMP,
QUALITY Q CLOUDY HARDNESS
O COLORED ANALYZED? OYES . ONO
_....._.__._.....
ANALYSIS ATTACHED? O YES O NO
STORAGE . TANK: —TYPE
CAPACITY GAL.
PUMP INFORMATION
TYPE CAPACITY
WELL DRILLER nNA'ME �3 y � /9 � f;a 4 olu 6D, _w DATEg�, g,
/.��
MAKER 0. EPTH
ADDRESS X' - S E !
MODEL • VOLTAGE HPWL
l/� %
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Yorktown Medical "Laboratory, Inc
321 Kear Street .
Yorktown Heights, N. Y. 10598
(914r245-3203
Director: Albert H. Pado van i M. r. (ASCP)
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LAB /`" YiC.02�971
Collection Station Used:
Carmel Peekskill
Mt. -Kisc _ o _ Nev City —
Date Taken:
Date Received:
Date Reported: 2 - 9-
Collected. By: M4 yOffoo/ AI(as'I
Referred By: 1O'lf
Sample Source: 7}110 ;
LABORATORY REPORT ON BACTERIOLOGICAL QUALITY OF-WATER
GENERAL BACTERIA
_ ✓Standard Plate Count per 1.0 ml
(Agar plate @ 35 °C)
MEMBRANE FILTRATION TECHNIQUE (.MFT)_
L/ Total Coliform Der 100 ml
Fecal Coliform ner 100 ml
_ Fecal Streptococcus per 100-ml
YOST PROBABLE NUMBER TECHNIQUE (MPN)_
_ Total Coliform:
Fecal Coliform
OTHER ANALYSES
MPN
Index
ner
100
ml
MPN
Index
per
100
ml
.
THESE RESULTS INDICATE THAT THE WATER SAMPLE (WAS) (WAS NOT) (NOT APPLICABLE)
OF A SATISFACTORY SANITARY QUALITY ACCORDING 0 TV NEW YORK STATE DRINKING
WATER STANDARDS, FOR THE PARAMETERS TESTED, A TIME OF COLLECTION.
w
a
Albert H. Padovani, M.T. ASCP), Director
LEGEND
RDS = Recommend'Disinfect-
ing Water Source
< • .less than
TXTC & Too Numerous Too
Count
tb� exl G�/1'
t ENGINEER TO PROVIDE PERMIT
PUTNAM COUNTY: EPARTMENT OF HEALTH
��1`a.y QN CERTIFICATE F OMPLI N
Dfvisfon 9 ,, Environmental Health" Services Carmel N Y 10512 PERM I T
OONSTRUCTION.PE.RMITJOR, S WAGE:`DISPOSAL SYSTEM T. _Patterson
Town illage
e'a` Deacon "Smith:H11"1.Road. T'3 3.1
Locatd t Ta'x ",'Map Block lot
Subd Lot it ". _
subdivision ..Deacon Smith Woods Renewal Q Revision
Ow ner /Address Rober,t�_.. J Fracktrian •.12. E... 86' St:; , NY_; N Y;. 100.28
Date; Of, Previous Approval ' f
Building Type MOdlllar Lot Area Z 124 aCY'es. Fill' Section Only (]
L ,
�.Nurn of Bedrooms ' T ee Design Flow G /P /D; - "600 P C.' -H D. _Notification Required t
Separate sewerage System to 'consist of 1000,= Gat "Se`ptic Tank ,and'' 4249 X; Z4't wide, laterals
r
To be constructed ,by ., 9 Address
Water Supply: °' PubiiC Supply _From
X, ;Pnvate SuPPIy. to be drilled by -
Address
; •Non.. ,
other Requirements e :.
l represent that 1 am wholly and comptetely`resporisible for the design and location of.: the proposed system(s);, 1) that the 'separate sewage disposal system
above descnbed will be constructed as show "n on"the`approved amendment therwo anti_ in accordance`with , the,standards, rules sn re a tons,o e u nam .
County 'Department of Health,`antl "that on_ completion thereof a, "Certificate of Construction Compliance" satisfactory to the Commissioner "O Heatthwill
.be submitted to'the Department, and '' -.a written_ guarantee ;will be;furmshed the .owner his successors, heirs or assigns "by' the builder. that said builder will ,
place in ;good oDerat,ng ",condition any" part of said sewage disposal system,:- during ;the period o1;tWO (2) years immediately followuig ;tliedate. of the issu-
a
ante of "the approval of the :Certificate .oL Construction Compliance of the original "system "or. any repairs 16 dto; 2) that "the - drilled well, described, above r
Will be located as shown on the approved plan and, that said well will oe;installed.dn accordance.With the'standards, rules and regu a ons of the Putnam
C untyt Department "of 'Health
Date Novertber 1 198.5 signed e:. i+'c�s.e'H P e: x R.A. 1
Address NY:10512 License No 29206,':,,
APPROVED FOR. CONSTRUCTION This approval'expires"one year from the date:;idsue 'unless'consfructiort of the building has been undertaken, and is
"
revocable -.for cause or may, be amended oc. °mod�fied:when c s�dered.necessar,y,by the, m issionor. -of: Health. Any change or alteration of construction,
requires. a new permit '"Approved. for disposal of dourest "_- dar sowag and /oa` rry e- pdy only "'
Data �" gy :. Title
Rev: 6/85. i
0
PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL MM SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
3 / FIELD INSPECTION REPORT
1 f6ic �/ o�I ll �1 ZC DATE:
INSP. BY:
(Name of Caner) (Street Location)
INITIAL SITE INSPECTION YES NO COMMENTS
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 driv ay
cut, house location, separation distances;'etc ..
Adjacent wells/ septics .........................
D.H. 1 Lot
Depth to G. W.
Depth to rock
Soil Descriotii
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.
D.H. - Deep Hole
G.W. - Groundwater
D.H. 3 Lot
Depth to G. W.
Depth to rock
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
Soil Descr
DATE:
FINAL SITE INSPECTION INSP.BY: 10
YES
NO
CAS
House SSDS located per approved plan ............
Length of trench measured 2- l
Width of trench average
Slope of tile line and trench acceptable.........
P "�,f j/��
Roan allowed for expansion trenches ..............
Over 100 ft. fran watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded.......... .... ........
X
10 ft. maintained fran property line and
20 ft-fran house ..............................
-
Distance well to SSDS (ft.)..... ..............
Number of bedroans checks ........................
Stones, brush, stumps, rubble, etc., greater
than 15 ft. fran nearest trench ................
15 ft. of peripheral soil horizontally
fran trench ..... ...............................
/Pat' /' ��✓�vvs' �� f
Boxes properly set .. ...... .....................
Could surface runoff fran driveway, roads, nnom,
ground surface, etc., channel near SDS area..i�
/X/5/
rd
Does lot drainage appear OK in area of SDS.......
FINAL GRAM OF SITE ACCEPTABLE.. ...
/
I
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 - 606 J. FYackwnh. Address D2 am S I iej•
C&
Located at. ( Street 6dicate-nearest (2{,e , / ( Secj7 2 Block I'. Lot 3. 1.
cross s ree
Muni cipalitY P44ieesvi Watershed. Cho-( -ow
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION. PERCOLATION.
apse Depth to Water a er ve .
No. Time From Ground.Surface in Inches Soil Rate,
Start -Stop Min. Start Stop Drop in Min. /in drop'"
Inches Inches Inches
DEPT, OF HEALTH
Notes: 1) Tuts 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
DtPTH HOLE NO. HOLE NO, HOLE NO.'
G.L.
6n
12"
18"
Xt
30
36"
421
48"
60"
66"
7211
78'1
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED
TESTS MADE BY (t4.(-.T) (o /1,6/8 r- (6sc s (N. �.1" Date to t4 Ig 15 `
DESIGN
Soil Rate Used ( (6'10 Min/1 "Drop: S.D. Usable Area Provided x`000 :0 It
No. of Bedrooms Tb ree Septic Tank Capacity, (0 do Gals. Type Mi somr _
Absorption Area Provided By 4L9 L.F.x24" ✓� width trench.
Other Qo" P
Name Signature F Jet`
JOHN H. PRENTISS, P.E. IV
R09 FAIR ST 914 - 878 -6170
Address CARMFL9 NEW YORK 186 '
THIS SPACE FOR USE BY .HEALTH DEPARTMENT ONLY: y
0
Soil Rate Approved Sq. Ft /Gal. Checked by �� No. 292��0
THE S1 N1
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- $Pdcoved as noted for conformance with
CBS l.tcable I{gles and Regulations of the
p� ;Putnam County IIealth Department.
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"AS BUILT" DATA. ..
ucture located from survey by surveyor noted below
II located by: Surveyors survey -_ _ — Il®-•�� _ —_ -- _ _ _
Well drillers report —
Engineers mesuremants -o_
tk, boxes, pit&,galleries & laterals located by:Contractor:
Eng mesr:
Health rapt:
Id nspection by: Health dent ® do I e:� �
Engineer date :_ `1 = f�L—��o
Thr_c t> !.o c.,rtrfV Ihat ;.h'_ %evayc
dispnsai s'sten ::as constructC<I as
NOTES: indicared or this plan and •. irac the
system 'was rnspecte,' !Jl' :lf: 'iF (n!'ry it
was cov.-rt,d „-er. The s•: c .:n ':as
constructed in a c c ord.'u: Le t'r r!l
standard rcics and rc rn la_ivc; nt
the i'.':. it.D. f. t!:. `:.Y.S.D.I ?.
D I ME N S I ON_ S
SANI IAKY 5YJ ItM UtJthiV laJ;oulL:n.: ;
__
LOCATION Street: -P GQ ' ! 'HI—rH r PO D. ''
Town:_?, 1j —�?oN County:oj�rl a__�L
SUBDIVISION:P—�Zzl_hj
Block _ _ _ _ LOT Nt 51 — —
Builder
_f
Surveyor:Gb.��aSOG - --
f
Drown: Date: y Scale
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J O H N H. iP "R F N T I.S S
CONSUVTINA 'F+#rc'ruecn
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LOCATION Street: -P GQ ' ! 'HI—rH r PO D. ''
Town:_?, 1j —�?oN County:oj�rl a__�L
SUBDIVISION:P—�Zzl_hj
Block _ _ _ _ LOT Nt 51 — —
Builder
_f
Surveyor:Gb.��aSOG - --
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Drown: Date: y Scale
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J O H N H. iP "R F N T I.S S
CONSUVTINA 'F+#rc'ruecn
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