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631- 589 -8100
23.10 -1 -14
Rev. 86 PUTNAM CO UNTYDEPA RTME' NT
OF HEALTH
Division of EuvironmentaIA ealth Services, Carmel, ,N.Y. 10512
'Engineer Must Provide
1® P.C:H.D. Permit. #. �7 1
r5or)
CIE CA OF CONSTRUCTION COMPLIANCE FOR *SEWAGE DISPOSAL SYSTEM 4�6
IAcsted at
Owner/applicant /Name
Maftg Address
Y4
Separate Sewerage System b P
t by Address
Consisting-of 160(i Gallon Septic Tank and
Town or
= Map i , a
. BI 0 .2
T
Subdivision Name Subdv. Lot #
Date Permit ban
Water Supply: Public Supply From Address
'Qf"n
or:- VI Private Supply Drilled by Address P E-
BuUdingType Has Erosion Control Been Completed?
Number of Bedrooms Has Garbage, Grinder Been Installed?
Other Requirements
I certify hat (s) as listed serving the above premises were constructed essentially as shown on the plans of the completed work copies
tihfy the n a
of which are atta ed), and i' accordance with the standard rules and. regulation Wnce wi the file and the permit issued.by the
Putnam County De?artme t•Of Health.
Date*--,, Certified by L P..E, r R.A.
Address License No.
Any person occupying promises served .by the above Systeim(sj 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 sawaragis system shall become null and void as man as a pubt% unitary sewer becomes
available and the ip4roival of the 'pilvatewater supply shall become null:and vold-when a public water supply becomes available. Such approvals are
subject to modification or change,when, In the judgment of the commissioner of Heal th _Vch r tlon. modification or change Is necessary.
Date By. T t to
0
a
Wt:LL I,VJltLLllllly nr,rvni
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
STREET ADDRESS: TAX GRID NUMBER:
McManus Rd. Patterson, NY
WELL LOCATION
WELL OWNER
NAME: ADDRESS:
R &R Develo ment c o Richard Rapp,Drewville Rd. ,Brewster,
0 PRIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
KI RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP 0_ ABANDONED
O BUSINESS O FARM 0 TEST /OBSERVATION 0 OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
MCNEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 175 ft.
STATIC WATER LEVEL 30 ft.
DATE MEASURED 10/11/8(
DRILLING
EQUIPMENT
1EI ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT O CABLE PERCUSSION O OTHER (specify):
WELL TYPE
❑ SCREENED O OPEN END CASING. ® OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH 21 _ ft
MATERIALS: ® STEEL 0 PLASTIC. 0 OTHER
LENGTH .BELOW GRADE 20 tL
JOINTS: 0 WELDED ® THREADED 0 OTHER
DIAMETER ---L —in.
SEAL: O CEMENT GROUT ❑ BENTONITE. 0OTHER
WEIGHT PER FOOT 9 Ib. /ft.
DRIVE SHOE ® YES ❑ NO
LINER: O YES ®NO
DIAMETER (in)
SL07 SIZE
LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
SCREEN
DETAILS
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
❑ NO
GRAVEL
SIZE .
DIAMETER
OF PACK in.
TOP
DEPTH -ft.
BOTTOM
DEPTH ft.
WELL YIELD TEST It detailed pumping
f
METHOD: JPUMPED a tests were done is in-
O COMPRESSED AIR , formation attached?
O BAILED ❑ OTHER i ❑ YES O NO
WELL LOG if more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE
water
8ear-
In9
Well
Dia'
meter
FORMATION DESCRIPTION
CODE,
ft.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
ORAWOOWN
ft.
YIELD
9Pm.
Surface
2
Drilling
in overburden clay & bl
rs
Hit
rock at 2 feet
175
6
155
20
2
21
Drilling
in rock,set casing,grou
ed.
21 ,
175
Dr'
ling in rock granite.
WATEII ❑ CLEAR TEMP.
QUALITY 0 CLOUDY HARDNESS
O COLORED ANALYZED? ❑ YES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE Well Xtrol WX 250
CAPACITY 44 GAL. 13.6
PUMP INFORMATION
TYPE Submersible CAPACITY 7 g•
MAKER Gould DEPTH 150,
MODE L7F:H0 1 2 VOLTAGE 2._iOHP_1�2_
WELL DRILLER NAME P.F. Beal & Sons DAJ" /26/86
ADDRESS PO . Box B SIGfffMRE
Brewster,NY 10509
q
Owner or PurChaser of Building
Building Constructed by
Location - Street
Municipality
Building Type
Block
Lot
Subdivision Name
Subdv. Lot #
GUARANTEE OF SEPARATE SEWAGE 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 success-
ors, 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 initial use of 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 occu-
pant of the building utilizing the system.
The undersigned further agrees to accept as conclusive the determin-
ation of the Director of the Division of Environmental Health Services
of the Putnam County Department of Health as to whether or not the fail-
ure of the system to operate was caused by the willful or negligent act
of the occupant of the building utilizing the system.
Dated this day of T)=-QVLr_— 1996 Signat
Title
THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE
CERTIFICATE OF COMPLETION WILL BE ISSUED.
GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM.
Division of Environmental Health Services, Putnam County Department of Health
BREWSTER LABORATORIES
Box 224 - BREWSTER, N.Y.
(914) 225 -2072
WATER ANALYSIS REPORT -
SAMPLE NO. 6397
SOURCE: R & R Development. Corp._
McManus Road
Patterson, NY
COLLECTED: November 24, 1986
BY: P.F.Beal & Sons, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
hose Bibb - well
This result indicates the source of the sample was
0 per 100 ml.
of satisfactory sanitary quality when the sample was collected.
November 25, 1986 ( mac.
Roy Bickwit P.E.
Director
above describetl will be constructed as'shown on the.approved amendment there to and .in accordance, with the standards, rtiles an regulations o e Putnam
County Department . of Health,, anC that on comp etion thereof a 'Certdicate.r'of. Construction Compliance 'satisfactory to the Commissioner of Healthwill
be submitted to the Department, and a. written guarantee will be',furnished: the owner, h!s Successori, heirs or, assigns by the builder, that builder will
place in good'operating condition any part of; said sewage disposal system, Curing Me period of. two , (2) .years immediately following fhedate of-the issu•
ance' of the . a , .
pproval';of the. Certificate of Construction, Compliance '014,
f.the originai.system'or any. repairs thereto; 2) that the drilled well described above
will be located'as shown on the approved plan and that said well will be installeG in accordance vyith the, standards, .rules and }egu aeons f t Putnam
4Courity Department of Health
Date . Signed
Z
oZ
�,l1��V.
License No `V 466
Address
APPROVED FOR'CONSTRUCTION, This approval expires o
r,fro the .da a i,.
:.
unless construction of the building has been undertaken and is
- TevOCable for cause Or' may be amended or mod:fi4vhen.,con'
":no" sary t
miss' ne► 'of :Ili,
Ith. Any 'change or alteratidn. of construction
reQuues a ew permit. A proved for. disposal of dom it
�
1.
dy. age, r pn
to ter aupp
An_ly. `
(�
r Date ' BY
Title
,
M1
y PUTNAM COUN
y '_CONSTRUCTION PERMIT FOR SEWAGE - ''DISPOSAL'
.Located at -
'Subd'ivision
�Dwner /Addre9a
r. �;Bu"Id�n9'TYpe .. _� , ld7�ilJ/TirYLOtyArea� °'
Nu '15 f Bedrooms �kDesign Blow c /r /D nn (•
Separate Sewerage System to consist of w
,To be constructed
ywat.O supply:. Public `Supply _From
Private Supply,to be doiled by
s
- ' Address .�bZt%' T,
Other Requirements
jt
x +s-
1 represent that I am' wholly and completely responsible forthede�
above described wUl be constructed as shown on the approved amen
County „Department of? Health, ;;and that on co'mplet"on thereof a
be subm"tted to., :Department,' and :a ',wr"tten guarantee w"11 I
,'<place in'good :operaLng :condition any part '0' f seed e-. is
`'once of .the approval of'Ahe Certificate of Construction compl"
will be located a ;shown on the approved plan and Shat said well wil
County Department of /H-ealth
t` Address �•
s APPROVED FO.R CONSTRUCTION Thls approval expves one y
' '.revocable for cause or may- tie a`mended'or` modified when co "d ider
req n
uvesr'a ew er mn Ap roved for disposal of-domest' i
n
Oate By
:.Re :9-11i ",
K
r
Y DEPARTMENT OF .HEALTH Pexv i =- n
al Health Services +"Carmel N:. Y 1,0512 E„
If STEM £ ZN
Town or Viklag e
'Lot H - Renewal Q Revision sQ 'l
..
�1 Date`Of Previous Approval ,'j
F3. 11 Section Only ❑ I
D - P C H D Notification Required
Address
c
I
n and I,ocaUon of 'the proposed system(s),, 1) that the separate sewage disposal. :system
ment there io and ',in accor danmwith the standards, =rulei a—n regu a_ ons;o e : Putnam,
Certificate of Construction Compliance satistactory to the Commissioner "of,Healthwill
furn shed the owner 'his'successors heirs -or assigns,by the buUder,:.thit said builder will
sal system during the period of,two (2j years �mmediately iollowing,thedate of the assu-
z
}ce he ong"nal systemYor any`repaus; thereto 2)ahat f rilled'well. described above
_ y ,
ie installed in accord5nce -with th andar rules r' la s i of -the Putnam
4! {
P.E _ •R A. .-
.Lice 3e No. .
s
it from the date issued unless constructio: of the` tiuildIng "has been undertaken and` is
1. necessary by the Co ner';of Hea h Any :change :o-r tion of construction
f-y sewage a /or`y'�
Title
a
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 Address�i2tbS?72r
�f S/� ��jj
Located at ( Street e 1/11V0 0 Sec . Block Lot p,
n lca e nearest cross streeET
Municipality, g2j j /t Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number
CLOCK TIME_
PERCOLATION
PERCOLATION
Start -Stop
Ease
Time
Min.
Depth to Water
From Ground Surface
Start Stop
Inches Inches
Water ve1
in Inches
Drop in
Inches
Soil Rate
Min. /in drop
2
2,1
3
7-
,3
21
Z_
1
0
/o
/0
1,9
z L,
`3
3_1
Z
-? '-
�? - -�/
�/
19
ZZ
J9
Z y
3
y
4
0'.
/ Z
/ Z
1,9
z L-
.3
1
.
2
3
4
5
Notes: 1) Tests to be repeated at same
rates are obtained at each percolation
for review.
2) Depth measurements to be made
depth until approximately equal soil
test hole. A11 data to be submitted
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. HOLE NO.
G. L. T
6"
12"
18" ,r
24"
30„
136" Ir
`F2„ �1
48" 1/
54" V
6o„
66" ►�
72" t� '
84"
INDICATE LEVEL AT WHICH GROUND WATER ' IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUN FRED
TESTS MADE BY T Date Y1 Z_-�
DESIGN
Soil Rate Used 8 °/d Min/l "Drop: S.D. Usable Area Provided S?�vrJ
No. of Bedrooms J Septic Tank Capacity /a,) 0 Gals. Type
Absorption Area Prov ded By 3Z�_L.F.x2411 3b"— width trenc
Address
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Cal.
Checked by
Date
i.,
PUTNAM ^COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY SUBSURFACE SEWAGE DISPOSAL SYSTEMS
FIELD INSPECTION REPORT
r'Y12ffIefI �d
(Namb of 00hdfl (Street Location)
INITIAL SITE INSPECTION YES NO
Wetlands on/or proximate to property ..............
Property lines or corners found ...................
Can estimate house location .......................
Willdriveway 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 Descrintii
0 ft.
3 ft.
6 ft.
9 ft.
12 ft.
D. H. 2 Lot
Depth to G.W.
Depth to rock
Soil Description
0-ft.
3 ft.
6 ft.
9 ft.
12 ft.
DATE:
INSP. BY:
u. n. - ueep nuue
G.W.- Groundwater
D.H. 3 Lot
Depth to G.W.
Depth to rock
boil Descr
0
ft.
333
3
ft.
6
ft.
9
ft.
12
ft.
DATE:
FINAL SITE INSPECTION INSP.BY: )
YES
NO
CATS
House SSDS located per approved plan.. ..........
Length of trench measured 313-3
Width of trench average Ali.
Slope of tile line and trench acceptable.........
Roan allowed for expansion trenches ..............
Over 100 ft. from watercourse ....................
Natural soil not stripped or SDS area
unnecessarly graded........... ... ..........
10 ft. maintained from property line and
20 ft. fran house.... ........... ........
Distance well to SSDS (ft.) .......... 1.D )) ........
Number of bedroams 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�fran driveway, roads,
ground surface, etc., channel near SDS area....
Does lot drainage appear OK in area of SDS.......
FINAL GRADNG OF SITE ACCEPTABLE......
'
r'
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.• t�0U5� � vit�.t; wcATt0�l5 Q`
?W.GaKVIF1,1Y 5Y P. MUWTT
MATED 11.10. 8(0
""'IN
LOT *,2-
0,g35 iICK:5
441V
�Oq
1000 C,AtJ MllSOA+:�(
60 f-M TANK
35'
c
A .
QU tt>?30
io 6t. ,i MOrJtCY '5009T•1c TANk
L.F. 0 4A° 'T1QWC44
1fJ5TAU.6D '• .
1000 &AL, MASotoeY 5 P-nc. TANK
535 1,.F is ?A" T1213NGN
THIS IS T'O C.ERT1rY '1'Ii.1T THE Sr\r'AC1: DISPOSAL S1:STEAI WAS
CONTRUCI'ED AS INDICATED ON THIS PLAN AND THAT THE,
{ SYSTEh1 WAS INSPECTED BY ME BEFORE IT WAS COVEREI� Ot'1 ?R
Tt3E SYSTEM WAS' CONSTRUCTED IN ACCORDANCE. \'ITII ALL
TCHE RULES AND' CONSTRUCTED
OF THE PIITNAM COUNTY
. �'�Gi]NE1VrF Or }'tFh'Ll'H�
1
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t
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ruuL^w L;uunty Department of healti.
,lvision of Environmental Health Serv106e
ipproved as noted for conformance with
applicable Rules and Regulations of the
Putnam,County al Department.
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