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pDTNAM.COD'NTY DEPARTMENT OF HEALTH
(Division
CCTION
Permk :N
PEIIM[T FORARWAGE DISPOSAL SYSTEM
w :
t
Vmage
Located at �1 ,,.
own or
,�j
Subdlvlsbn, Name / 1.0 Arr � � � � Satid. Lot N Taz Map
Block
(G / tp-� 0/y% J 4I Renewal_
Revleton t ❑
Owner /Applicant Name
' Date of Prevloge Approval
' : /mod .. %� �' Town .
Mailing Address
ylP
1J f"�'Y"c �ti � ". %�G�l'✓v /' .
_
%, O 2 `7 ` S.cd.
Only
BulldtoQ Type Lot Area'
Depfb Yolttme.
Number Bedrooms Design Ftow G P D X �� PCHD.NotMtxtion 1s Required When Fill is completed ..,
�3 �l /�
`v✓> c'�. rte.
Sepaeate,Sewerage Syttem•to oonslst of Galbn' Septic Tauk an
To be constructed b - Address • -
Water.SuppU'i ; . Ptak Supply. From `, :. A .'
on Private Supply= Drilled by' . —A "m
Other Requirements •_._.
I-It
c _` or
I represent- that I am wholly antl eomDletely responsible for the design antl• location of p.oDosetl
1) -that the separate sewage' disposal.'system
above described will be constructed as shown On the'approved amendment their t0 a' c ' °I
Counz " in t fti ono
IecITa:"�p0!-Iica_o
ndards, rules an regU 0 ons o e u ham
1 ifict6ry* to f Health will
be.: . I I I., — _ ". ; 6.
submitted' to :the Oepartment,,and .a': written gurantee will be',turnished t ow is ""
s or signs by the build6 ;lthat said bulldir will
r
Mace in good boasting condition any..•part of',said sewage disposal system rIn
o ( ears mmediately following. the date of the ism -' '
once of the aDOrovii of the certifiute of Construction: Compliance of tne. Este
Pill, 2) that, the drilled well described above
will be located7i'shown on the approved plan snd tAat sold well will be installed ac rda [
sta rd�s, ules and repu aT oil ns of the Pulnam, _
County De rtment of Health
Date S nail
Address o�y" O
_ License No
t > _
APPROVED FQR'CONSTRUCTI'ONrThis.s roval'ezpnes.two years `from the`tla a P, p�Ff�s�
�
n of the ,building hai,been undertaken and Is
construction
revoeable for: use or may be.•amended or odiffediwhen considered necessary.jr. the? isf
ealthx , Any change or.ilteration of
requires a permit. A Droved foi Isposal of domestic sanitary sewage,- and /or: ste wa er 'supply only.
Rev. Dats M
��rzT
tle r -!
i
m
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT
WELL LOCATION
Street Address �l
6 t e GY e-'e- / .11^07 ? CU
Town/Village/City Tax Grid Number
T l' l xr— .. r — �fLr
WELL OWNER
Name
Maili g
Address
9W-rrivate
❑ Public
USE OF WELL
1 - primary
2 - secondary
OIRESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM ❑ TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
O ABANDONED
❑ OTHER (specify
AMOUNT OF USE
YIELD SOUGHT
gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE -,.4000 gal
REASON FOR
DRILLING
EW SUPPLY
OREPLACE EXISTING SUPPLY
❑ PROVIDE ADDITIONAL SUPPLY
0DEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
(136RILLED
DRIVEN
ODUG
®GRAVEL
®OTHER
IS WELL SITE SUBJECT TO FLOODING?
YES d**' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: /__/
Lot No.
WATER WELL CONTRACTOR: Name
Address: j3/&
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES b" NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION
Z
ON REAR OF THIS APPLICATION
(date)
PROVIDED
PERMIT
ON EPAR�E T✓ /�
(signature)
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 thirty (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 Depa tment.
Date of Issue: 2— 19
Date of Expiration: 19 �� ermit Issuing ffic�a
Permit is Non - Transferrable white copy: H.D. File
Yellaw copy: Building Inspector
Pink Copy: Owner
287 Orange copy: Well Driller
At,
6
PUTNAM-C
DIVISION GE-'.,
y.0. M
I_ -i,
Re: Property of
A.
Located at
.(T) Ana - S, ec t'i
OW 1";
Subdivis ion of
'Nt
Subdv. Lot Filed '?4aP Date.
Gentlemen:
This letter is to .authorize VOPO
a duly licensed professional engineer or-registered architect
(I'n dicate)
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 'd.*
system or systems in conformity with the provisions of Article 145:or,
147, Education Law, the Public Health Law, and •he-Putnam County-.,Sqni
�iIZ
tary Code.
Very truly yoxir
NEW
Co ter
9
P.Eo Ro A* C
Address
ephone
Ida
Si. ` d'
.)gne-;
I
M,im
o_
APPEMIY B
PU'I'NPM CGUi v- DEP.AM= OF MUTH - DIVISICN OF ENVIF ME= HEALTH SERIV
IIIDr7IDML WATER SUPPLY & SUBSURFACE SZv-A DISFCSnL SYSTEMS
RFy'=W S "= - CONS7M=ION PF RMST
/ DATE RE=
( Name of rear) (St=mt Location) v �-
CC. API I YES I NO ( DCC'UM=
Permit Amplication
_ -- Corporate Resolution
Plans - Three sets s/s
Encineers A_uthorizaticn
Design Data Sheet (DC<) SUEDIVISICN
�-- Deep Hole Lcg
Corsistent. Perc Res;1l _s (3) Fill
Perc Hole Depth C.;
House Pans - T6 o se__
�� I •�{- ---... d'" -i� -� Fz�:ni t; P;�� 1= _ per
!" I Variance Reruest
I I C��Ar,
Lc---a1 SaEdi.vi sign
Seri sign Accrova_ C:ec:�a
��E:� -ac_ rcval SSOS Ad'. Lots C�i ec.k a
E- �et and (Tcw-n /DEC Ps-=-i= R & D)
/-1 Date Cn DCS Plans & Per it S«e
L-7 encZ provided I I I RE LTx DETL r c CN PT .] \S
r= «ui r I -- Sewage S s *.t P 1 an - (:_orth a=-0w)
G_60 ft. ma:,-. I , �; I S "wage Svstan HvdrauLic Profile - G- m-Wit: F? .
lel t contours ntours I Fill Pro ' & Dirrens_ im
cns - Vbi-a
-- I � D ole ;Trencz /Gallery; F� pi = de ails
� � I Septic T- mk - Size,
�j We?! Detail, Service Line if over
Ccnstracticn Notes (grinder rte)
<--I -- Design Data: cerc and de_p resu] =s
Two -Foot Contours Existing & Proposed
Drivewav & Slopes Cut
Footing Cstter,Cur=,in Drains (d-- charge CiC)
Perc & Deep Holes Lccatz
Fes, SYS I Representative of pri =- y aria eIc-- ansicn
clav'bch_r i er Expansion Area; shown; gravity flow, suff. size
10 ft If Pmced Pit. & D Box Shcw-n & Detailed
fill notes I House - No. of Bedroans L
new sue. �`i� Wells & SSDS's w /in 200 fof Proc:cs Sys":
de th sauces - Property Metes & Bounds
House Setback Necessary (Tight let)
_ House Serer - 1/4"/ft. 4'10; �T_,-pe pipe
0 yr. fl�2& elev. I No Bends; Max. Bends 45" w /cle=nout
SEPA_RATICN DISTANCES SPEC!F=D CN PT_�N
Fields
10' to P.L., Drive:wav, Loge Tr=°..s,Tco or _
20' to Foundation Walls
200 ft. reservoir, etc. 100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (inc. er
150 ft. tricall /- 15' to Drains - Curtain, Leader, Footing
35'tc etch hasin,stor =ain,oicea ur-t =''cal
10' to Water Line (pits -20')
50' inte_*mitte_ht arairace coarse
Sentic Tanks
10' fran Founcaticn; 50' to well
15' Well to PL 9
PUTI'NAM COUNTY DEPARTMENT OF HEALTH
• DIVISION OF HEALTH SERVICES
DFSIGN. DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner
le %c,
Address
Located at (Street) Ipaw. ed.- /�/"� Sec. Block 5 Lot ZO ;,i-
(indicaatte nearest cross street)
Municipality � // e j' -5U Watershed
Date of Pre-Soaking � Date of Percolation Test
HOLE
NUMBER CLOCK
TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water Frog
Water Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start -Stop
Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
30
.
-3
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated
are obtained.at each
for review.
2. Depth measurements tc
rev. 9/85
at'same depth until approximately equal soil rates
percolation test hole. All data to'be submitted
be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENOOUN'IERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. HOLE NO.
G.L. / G_: , Au %
1' �r
3'
4'
5'
6'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: DATE: `Zv
DESIGN
Soil Rate Used C1 Min/ � °J :D op: ;;;; S.D. Usable Area Provided'' f�
j 4 L 6
No. of Bedroars _ Septic Tank Capacity .. S gals. Type
i
Absorption Area Provided By y �L:F. x24" width trench
Other
Name
Address
G/ /
THIS SPACE FOR USE BY
Soil Rate Approved
Signa
2489 -
DEPARTMENr ONLY: ?RofE
sq.ft /gal. Checked by
Date
.R
\I
Y
qv
o, ,
ZVI A CP
9
peyc
A De
Al
le*
L r-
all
k-
411
Jr 7 110"7
I X., AIIIP
a
Division Of
)Utr.am of the
�— //,/# /,.,c -Ti.,l
Ties S -;, .-,' :'V Z �-� 1,77, 10^:' Iqt Provide for
ill""a -!.;.Ct ;on ol m3t a3la-on zequires
the approv�-'- of the �*atn,= CowiTy- Deparment of Health.
We,// to y, e- 1W
V,7.5 41-
/Joie.
X.s JSa v-P,'O ,Pe7
+-; •-- ::. �r'r_^-'+-- ;"'_---'—"._'_ •.*^�'-'s?�nc-r , '+-r ,—;ter i t.F r-�". '_� -"` .. r �.. T r
Rrr�1. 3:86 PUTNAM.COUNTY DEPARTIIZENT OF HEALTH M, t
r Division of Environmental 13edth Services, Carmel, NY 10512'"
Englneer'Mpst Provide r 7� �c�
P C.H D Permit i (((JJJ 7
CERTiFIC OF.CONSTRUCTION.C.OMPLL4INCE FOR- SEWAGE.DISPOSAL SYSTEM
Town or Village
Located it Tax Map_ BI Lot
Owner /applicant Name �Formerty $ribdivistone Subdv Lot N
M>1Wng Addr4as 33 d Zip f0 /l/ Date Permit leaned
Separate Sewerage System built by Address ' ' L
Conslsting of % •� S Gallon Septic Tank and
Water Supply: Public Supply From Address
or: Private Supply Drilled by do/�� Address ���° I✓S Y�si
Building Type �� /�. �.'! G� Has Erosion Control Been Completed?
Number of Bedrooms Hes Garbage Grinder Been InetalledY
O
Other Requirements '7
I certify that the system(e) ss :listed:ierving the. above'. premises` were conativcted,essentially as shown.on the.plans of the completed work ( copies
of which are attached); .and in accordance with the standards, raise and iequla 'ns, in d ord" , wit the fL d plan, and the permit issued by the
Putnam Count Department_ O Health !
Date /Certi ed by (jY6 P.E. y R.A.
Address O // ,0PV License No.
Any person occupyinp,premises; served by the ove system(!) shall promptly fi a such action may be`neeesury to secure the coriectlon 'of any.ununitary
conditions resulting from such mays' Approval _of the 'uparate,sewer'ege system shall become null and void as soon as a pubt(_ unitary sever becomes
avallable and the approval of the private water•'supply shall : become null :and void' when a' public =weter supply becomes available. Such approvals are
subject to modification or change when,�inn the judgment of the C�Omnas�sione�r,2 the -alt eh revowtlOn, modification Of change Is necessary.
Oats
PUrNAM COUN'T'Y DEPARTMENT OF HEALTH
DIVISION OF ENVIROVidEMAL HEALTH SERVICES
Owner or Purchaser of Building
Building Constructed by
r1�'✓Q �?� /�i1��7 G�O cZ
Loca /tiion - Street
& ASS O�
Municipality
Building Type
Section Block Lot
�/7X /G U// .4 e
Subdivision Name ��/
Subdivision Lot #
GUARANTEE 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.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the bui ing ut5fl izing
the system.
Dated this _1_ �� day o 19 O Signa
Q a Title
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Corporation -Name (if Corp.)
Address
i
BREWSTER LABORATORIES
Box 224 - BREWSTER, N.Y.
(914) 279 -4945
- WATER ANALYSIS REPORT -
SAMPLE NO. 7339 HOSE BIBB WELL
'SOURCE: Greenspan Builders Lot #8
Flintlock Ridge
Patterson, N.Y. 12563
COLLECTED: 5 - 6 - 8 9
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 -9 -89
Thomas Meyer
Director
p per 100 ml.
1. .. . .
< E..
y
WELL LOCATION
WLLL UUr1rLLiiU1V ArjrUAi
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
` p
�/ — 1>
_
STREET ADDRESS: wNlvll 1 I Y TAX GRIO NUMBER: 7
Flintlock Ridge Patterson, NY Lot #8
WELL OWNER
NAME. ADDRESS: '
Greenspan u' f anor Y 10 10
❑ PRIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
® 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
® NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY ❑ TEST /OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 340 ft. I
STATIC WATER LEVEL 30 ft.
DATE MEASURED 11/27/88
DRILLING
EQUIPMENT
® ROTARY ® COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING. EI OPEN HOLE IN BEDROCK ❑ OTHER
CASING
TOTAL LENGTH _51i— fL
MATERIALS: (2 STEEL ❑ PLASTIC b OTHER
LENGTH.BELOW GRADE 53 ft.
JOINTS: ❑ WELDED 13THREADED ❑ OTHER
DETAILS
DIAMETER in.
SEAL: ® CEMENT GROUT ❑ BENTONITE ❑ OTHER
WEIGHT
PER FOOT I Ib. /ft.
DRIVE SHOE ® YES ❑ NO
LINER: ❑ YES C NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE LENGTH
(ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
❑ YES ONO
HOURS*
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL DIAMETER
SIZE: OF PACK in.
TOP
DEPTH tL
6OTT6M
DEPTH It.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED � tests were done is in-
® COMPRESSED AIR formation attached?
❑ BAILED ❑ OTHER O YES O NO
�a�ELL LOG 1f more detailed formation descriptions or sieve analyses
b`J are available, please attach.
DEPTH FROM
SURFACE
Water
Bear-
I ^9
Well
Oia-
peter
FORMATION DESCRIPTION
CODE.
ft.
it
WELL DEPTH
ft.
DURATION
hr. min.
ORAWOOWN
it.
YIELD
9Fm.
land
Surface
37
D
it
ing in overburden clay & b1drs.
t 4ock
at 371
340
6
320
12
37
54
D
it
ing in rock,set casing,groute
.
40
Dr
114n
in rocksgranite.
WATER O CLEAR • TEMP.' .
QUALITY O CLOUDY HARDNESS
❑ COLORED ANALYZED? ❑ YES ONO
ANALYSIS ATTACHED? O YES ❑ NO
STORAGE TANK; TYPE Well Xtrol 250
CAPACITY 44' GAL.
WELL DRILLER NAME P.F. DATE
Beal 8c Sons,In 8
ADDRESS PO Box B sicN7MRE
Brewster,NY 10509 � ,
PUMP INFORMATION
TYPE submersible CAPACITY 7 g
MAKER rroui d DEPTW60
MOOEL7EHO5412 VOLTAGE�20_HP_2.__
'A
)iiNir DEPARTMENT OF HEALTH
d6 Sikrvlciii W&W N Y 10512 Jbm&Mr' to N6 vW PC
on CERTIFICATE OF
VONSTRUCTIO SAiT
,;I;IMAG4 OWv
'17
#
ion _NQ -4 1:lnRM
AppliciAt Nails
Date of Priviiiins Approval
main, g
71p-- WAS
J
FUa - Seetlo , Z
y Veptk-� �-, volume: ,
Rv. Number of Bedrooms :' De igb k*O b P
PCHD NoWkidlou W Re4u6iki When Fill le completed
I tsb 4, F �;Aq5s6ovr ISAJC rl
% , -and'
S41; Sewerage ixgte�, ot tf§ Tank
To bccoiishiWied,bi
y
AA"
Water apply. P Supply From IA Addiieie
, WAC
Date
ry
on k PrlvMv Supply DrMW I
t I am wholly and completely 11.1p0..ibli f?(,tho esign,ln I
3 will 'be constructed AS'shown on
: L. .'' ' ' the,a_v: O.. iv e d .; . amendment V
tmmnt 40slih aniAhit on completion t heri&i 6irtiii
t6 the* Oepartment, and a,�rijton guarantee will.be. f urnis
operating co Kition_ihy
pik.-bf said , ;,Sewage"dlspo . W : I 'Syl
iprovai of ' mo , cortificat -a of .Construction dompllinc'izs,bf
as shdwn on the appro`v'ed•pl�an and that said t�i al . I' will 61 Insta
moot of' Health.
'Add
`iPPROVE6 FOR CONSTRUCTIOP
I" OCII blo for "lisi 6ir,may 68"amen
new permit', A
RP1011
Mpl?!oval-j?•p,j,!ps two yeais.frc
M'Od ified-when coniiaOisj..nec
lodsal, of d&nlesflC.iiniii;yjN
. D2iti6hOf the
sere ,to apd_ in a
.aii,:bvconitro
fie,'
s); -1) that Of
.tion (compliance'.'
, I c I o n-pilince . .s, itis4iEioryto the Commissioner of. k4alth will
iisiuibo",s iiin
or assigns by th'a bu ildor, that- said builder will
f ia!�kly •f.ollowing 44aidatip of,the Issu-' -
?m or;iiny rspaiis' the► ;2) hat, th ! OrWid wolf'dejcribiitl above
and .regulatJ1011111 of 'trio Putnam
R-A.
L License No—
unless 'construction '.of'i , he building h I as I" been : un dertaken and, i's
imissio`ner�'*oi Health. "'A*n,y,.c*han'ge or aliorotion:oi construction
supply only.
Title
Renewal p Revision p
Owner %Appmcant Name'
Date of Prevtoas Approval
,.:.. - Address )c . 55C� Town •f5Ql�Ct. t,f:r l� A1401C ZI t o S l 0' .
Maplag:' O . �o P
8 .T)* �°51IZ 6496 GE Lot Area -; '3t� .flC k2�EiS FW Section Only
_
Y De th Volume
Number of "Bedrooms D eilgn Flow G P." D !�, ®p PCSD Notification is Repaired When FM Is "completed,
Separate SeweraYe Syatem'to ooaelat of LDOO" Gabon Septic Tank and _33 S To be oonetracted by �� �i/.FSF'!�-ff/�ED- Address
Watei SUPP!)`: Pdbllc S Address
bpply'From : . '
or:. Private SaPPIY Domed hY�O �� Address
Other Regalmmente , I"1 � = "D . B. r iLL. L SI _ GII • 4'`DS
_
I. represent that 1 am wholly and completely responsible for the tlesign' and location :of -the pioposed system(s)p' 1); that the separate sewage disposal system:
above described will be�constructod as shown on t►ieppprovei! amendment there to and'in.accordance'with the standards, rules an regulations o the. u narn
County Oepartment ..of; Health, . and that on conipletion thereof a. "Certificate 'of Construction Compliance" satisfactory to the Commissioner, of Health 'will,,
be submitted to : the Oepa►tment, and; a written guarantee.wUl be furnished the owner, his. successors, heirs or assigns by the builder that said, builder' will.
place in good "operating �ondition, any part o/ laid sewage- disposal system during'tlie period of two,(2) years immedistely following thedate:ot the issu-
once of .rife' approval of the .Certificate of; Construction Compliance of 'the original system_ of any repairs there ,•2) that the drilled. welt described above
will be located�as shown on the'approved plan and that sa�tl well mAli be installed n accordance with t andar rules and re- u a�iions of the : Putnarit
County D, rns�ntt f Heal�t�1�j
Oate 6 Y -t(�! Signed: P.E.i�._ R:A.—
APPROVED FOR,CONSTRUCTION TAis,approval•expves�t'oyeark
revocable for cause.or may rn
be`aenoetl or modified when co sideied
-requires a new permit. pp ' ad for disposal,of domed' nI
Rev.
1/87 Date 8y
CSA L- tjy License No 2-47'206
'issued :unfits construction, of the building" has been undertaken and is ,
he ComWWn, f Health. Any change or alteration of construction'
x� pr at pp only. 1� _
/ Title / %��/
Aj NAM COUNTY .DEPAFaMU CP HEALTH
' DIVISION CFENvjRcamMkL HEALTH SE MCES
DESIGN DATA SHEEI- SLWUFACE SBgAGE ' DISPOSAL SYSTEM' FIIZ NO.
Owner / RtJOI_ D��R6>✓J- tSF'AI�I Address C BOX 33o Y
Located a't (Street) Sec: t Block 'S Lot SdB
(indicate nearest cross street)'
Municipality
90M PFPOQLATICN 7 S'r DATA ,RDQU='
Date of Pre- Soaking z ..g . 138
•Watershed•
TO BE SUBMITTED WITH APPLICATICNS
Date of Percolation Test -z • z . ee
HOLE
NUIBER CI= TIME
PEROCILAZZCN
PERCDLAT . ..
Run Elapse
No. 'Time
Start-Stop Min..
Depth to Water From -
Ground Surface
.'Start -Stop '
Inches Inches
Water Level..
In Inches Soil Rate
Drop In HWIn Drop
Inches •
1 oo - �j : 29 'Pij
Z I
2 : 2�4
z I
Zy
3
3-D 5'l- io:►8 21
zt
Z9
3 °•�
4 Io: t8- /,o :4s 2-1
ZI
2q
3
5
70
3 10'o -i - t0'3 -1 30
2Z
r
4 Io • 3`7 ► o l 3o 1.2 ZS 3 !c7
5
2
NOTES: ' 1. Tests to be repeated' at same depth unbil •apprmimately aqua]. soil rates
are'obtained,at each percolation test hole. All data to* be,subnitt�d
for review.
2. Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO • BE SUE!
ED WIC APPLIC
a
DEPM. HOLE'-NO. I HOLE NO.; 2. HOLE NO
G. L.
31
4' ,.
5,
9• .
10'
12•'
13,
..INDICATE LEVEL AT WHICH GROUNDWATER IS ENOOUNTERE D r-JA
INDICATE LEVEL TO WHICH, WATER LEVEL RISES AF32R Bffi1G IIMUIERED
DEEP' HOLE OBSERVATIONS MADE BY:' DATE:
DESIGN
Soil Rate Used E3-/o Min/1" Drop: : S.D.• Usable Area -Provided tpop cA
No. of Bedrooms 3 Septic Tank Capacity foc a _ gals'. Type N�AaoN�Y
Absorption Area Provided By 3 a 5 L.F. x 24" width trench ;
Other I o �, i �-.�- s-1 Cu Yns� K,i -1ME
4 t'
Name Signatures
Address o u r 2 SEAT,
THIS SPACE FOR USE BY'•HEALTH -DEPARMFM ONLY:
' APPENDIX B
PUTNAM COUNTY DEPARMMU OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
(Name of Owner
REVIEW SHEET - CONSTRUCTION PERMIT
DATE R=-vv�D : %
BY:
(Street Location)
DOCUMENTS
Permit Application
Corporate Resolution
Plans - Three sets L-- ,Sls-,
Engineers Authorization
Design Data Sheet (DDS) SUBDIVISIODL
Deep Hole Log Perc
Consistent Perc Results (3) Fill
Perc Hole Depth cd �r
House Plans - Two sets
Well r'--;-permit; PwS letter
Variance Request
GENERAL
Legal Subdivision
Subdivision Approval Checked
Ex- approval SSDS Adj. Lots Checked
Wetland (Town /DEC Permit R & D)
Data On DDS Plans & Permit Same
REQUIRED DETAILS ON PLANS
Swage System Plan - (north arrow)
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 (grinder rate)
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;shoan;gravity flow,suff. size
If Pumped Pit & D Box Shown & Detailed
House - No. of Bedroans
Wells & SSDS's Win 200 ft. of Proposed Systems
Property Metes & Bounds
House Setback Necessary (Tight lot)
House Sewer - 1 /4 " /ft. 4 '0; Type pipe
No Bends; Max. Bends 450 w /cleanout
SEPARATION DISTANCES SPECIFIED ON PLAN
Fields
10' to P.L., Driveway, large Trees,Top of fil
20' to Foundation Walls
100' to Well; 200' in D.L.O.D, 150' pits
100' to Stream, Watercourse, Lake (ine. expan
15' to Drains - Curtain, Leader, Footing
35'to catch basin, stormdrain,pioed watercours
10' to Water. Line (pits -20')
50' intermittent drainage course_
Septic Tanks
10' from Foundation; 50' to well
15' Well to PL 9
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #?-1 _I 88
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
WELL OWNER
Name
Mailing Address
P.o. 8ox 330
4KPrivate
O Public
USE OF WELL
1 - primary
2- secondary
ja RESIDENTIAL
0 BUSINESS
13 INDUSTRIAL
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY
O ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT", ,J gpm /# PEOPLE SERVED p,&m /EST . OF DAILY USAGE soo gal
REASON FOR
DRILLING
JZNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
❑REPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL
❑ TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
Pt-
WELL TYPE
❑DRILLED
DRIVEN
EIDUG
13GRAVEL
a OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ,< NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
L,- rTi -i-- F�n.jA sS/iI -I- Lot No. g
WATER WELL CONTRACTOR:
Name
Address:
IS PUBLIC WATER SUPPLY
AVAILABLE
TO SITE:
YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED��
RON REAR OF THIS APPLICATION ON SE• T SHE
f
(date) s at
ti
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 thirty (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.
Date of Issue:""�.'� y
Date of Expiration: 19 Permit Issuing-Official
Permit is Non - Transferrable copy: H. D. File
'ldn i
2/87
Ye11aW Copy. Bui g InspectAr
Pink Copy: Owner
Orange copy: Well Driller
It
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL .
PCHD PERMIT #, /''/ 7
WELL LOCATION
Street Address Town
Tax Grid Number
WELL OWNER
Name Mailing Address
E P.o_ E?eK 15'10
IKPrivate
F3'U.LAR Ft:. MA J0P_ OPublic
USE OF WELL
1 - primary
2- secondary
RESIDENTIAL ❑ PUBLIC SUPPLY
0 BUSINESS O FARM
0 INDUSTRIAL O INSTITUTIONAL.
O AIR /COND /HEAT PUMP 0 ABANDONED
O TEST /OBSERVATION ❑ OTHER (specify
O STAND -BY O
AMOUNT OF OF USE
YIELD SOUGHT Mu1 5 gpm/ # PEOPLE
SERVED) , /EST . OF DAILY USAGE eE, ®o gal
REASON FOR
DRILLING
NEW SUPPLY OPROVIDE ADDITIONAL SUPPLY OTEST /OBSERVATION
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
dew �ssrp��.1- r�,a•�
WELL TYPE
216RILLED
DRIVEN
DDUG
GRAVEL ❑
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES '>< NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
L,-r -rt_e ' ' or b OLL-t- Lot No. g
WATER WELL CONTRACTOR:
Name-I;'
�� -Cj�?' r.t�n i�
Address:
IS PUBLIC WATER SUPPLY
AVAILABLE
TO SITE:
YES NO
NAME OF PUBLIC WATER SUPPLY: IA. TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED Q "nP�'�4
r-ION REAR OF THIS APPLICATION EP TE S
(date) 11 : signa . `e
PERMIT '�,� ° '60'
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 thirty (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 Repo t on a form provided y t P t a t
Health Departm t.
Date of Issue: 19
Date of Expiration: 1g mit ssuing OfficW
Permit is Non - Transferrable
2/87
White copy:
Yellow copy:
Pink Copy:
Orange copy:
H. D. File
Building Inspector
Owner
Well Driller
i
i
.. j
on��
_GLj
I
1 ,
a