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PuiNAM boUtgry DEPARmimr OF HEALin
DIVISION OF E MaNM ZrAL HEALTH SERVICES
✓ er or Purchaser of Building Section Block Lot
r
BuIldinllg Constructed by
Location - Street
Municipality
L17T/
Subdivision Narre
1
Subdivision Lot ff
GUARANI.'EE OF S(JBSURFP.CE SOS GE 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 rre 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. r
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environiental 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 building utilizing
the system.
day of /�D�/ 19 9 Signature
Dated thi
Title
Gener 11 Contractor. (ZSwner) - Signature
J
(� SS
Corporation Nam (if Corp.) 6x_ 14
es
Addr — (o
rev. 9/85
mk
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ation Na�Tp_ Ji
PA,dress
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1S h'}SrS�SJS4 Ll ®� �8V �9 JS1i�l�JSV JS1l1S�8V �1 ��td LAIM®R JS OIREE3 q REM,.
A Division of Northeast Laboratories, Inc. CT Cert: PH -0404
N ABS DANBURY: 22 Ii�ERmosu AVENUE - DANBURY, CT 06810 and PH -0606
BERLIN: 129 HILL STREET - ]BERLIN, CT 06037 NY Cert: 11471
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
R W. HUTTEMANN
2 HOLLIS DRIVE
BROOKFIELD, CT 06804
DATE SAMPLE COLLECTED:
TIME COLLECTED:
COLLECTED BY:
DATE RECEIVED @ LAB:
DATE(S) TESTED:
TESTED BY:
REPORT DATE:
5/22/95
1:45 P.M.
R HUTTEMANN
5/22/95
5/22/95
LAB#PH0404
5/24/95
SAMPLE SITE: GREENSPAN ASSOC., VISTA DOLORES- LOT #1, PATTERSON, N.Y.
SAMPLING POINT: KITCHEN FAUCET
SOURCE: WELL -NEW
TREATMENT: NONE
TEST PERFORMED - - RESULT: RECOMMENDED 1AMIT
BACTERIAL:
Total Coliform (Bacteria)
CHEMISTRY:
ABSENT per 100 ml ABSENT
Chlorine Residual ND mg/L
ml = milliliter
mg/L = milligrams per Liter
ND = none detected
RESULTS BASED ON SAMPLES SUBMMED:5 /22/95
SAMPLE, AS TESTED ABOVE: M or IMNOT POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
wj4wv.�� a.
CT: DANBL/RYzYREA (203) 748 -7903 - FAX (203) 748 -0652 • CT: AEJVBRTlAI1U1HARTFDRD.A1tE4 (203) 828 -9787 - FAX (203) 829 -1050
DEPARTMENT OF HEALTH
um WELL UUF1rLETIULV tcr:rutu
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET AOURESS: wNl I TAX GRID NUMBER:
Dolores Vista Rd. Patterson
WELL OWNER
NAME: ADDRESS:]
Greenspan Assoc. P.O. Box 330 Briarcliff Manor,N.Y.
8VATE
IOPPUIBLIC
USE OF WELL
1 - primary
2 -secondary
IN RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND.IHEAT PUMP ❑ ABANDONED
❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify)
O INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY O
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED 4 / EST. OF DAILY USAGE 300 gal.
REASON FOR
DRILLING
[REPLACE EXISTING SUPPLY ®TEST /OBSERVATION ®ADDITIONAL SUPPLY
®NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 300 ft. I
STATIC WATER LEVEL 51 ft.
DATE MEASURED 5- 2- 9 5
DRILLING
EQUIPMENT
❑ ROTARY tl COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED O OPEN END CASING OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH __A2_— fL
MATERIALS: X] STEEL O PLASTIC ❑ OTHER
LENGTH BELOW GRADE _ 41 ft.
JOINTS: ® WELDED ' fI THREADED O OTHER
DIAMETER ti in.
SEAL: 6 CEMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT 19 Ib. /ft.
I DRIVE SHOE_�O YES ❑ NO I LINER: G YES ®NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (it)
DEVELOPED?
FIRST
❑YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH ft.
BOTTOM
DEPTH K.
WELL YIELD TEST ' If detailed pumping
METHOD: O PUMPED 1 tests were done is in-
6 COMPRESSED AIR , ' ormation attached?
❑ BAILED ❑ OTHER ; 0 YES O NO
WELL LOG If.more detailed formation descriptions or sieve analyses
are available. please attach.
DEPTH FROM
SURFACE.
water
Sear.
Ind
wen
0ia-
in
FORMATION DESCRIPTION
CIOE
ft.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRAWOOWN
ft.
YIELD
gpm.
Surface
30
NO
8
Hardpan
300
4.5
300
6
41
39
i
WATER CLEAR TEMP.
QUALITY n CLOUDY HARDNESS
❑ COLORED ANALYZED? IR YES ONO
ANALYSIS ATTACHED? 6 YES ONO
STORAGE TANK: TYPE Diaphram
CAPACITY 82 GA]�.20
PUMP INFORMATION
TYPE SubmersibleCAPACITY 5
MAKER G 01 1 d S DEPTH 2 4 0
MODEL VOLTAGE HP
WELL DRILLER NAME John Findorak a►L
ADDRESS 36 Coley Rd. SIGN
3/89 ` -v - -- W11L011, �'L. V
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L-OGA T ION5
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P L..A N
THI5 15 T0. GERTIFY THAT THE 5EVAGE 1)15f'05AL 5- (5Tf -rl \VA5
CONSTRUCTED AS INDICATED ON THI5 PLAN AND THAT THE --
5'(5TEM NVA5 IN5PEGTED. BY ME BEFORE IT \VA5 COVERED OVER. 1254 GALLON MASONRY SEPTIC TANK
THE 5Y5TEil iVA5- GON5TRUGTED IN AGGORDANGE 1VITH ALL 400 L.F. AT 24" TRENCH
THE . KULE5 AND REGULATIONS OF THE PUTNAM COUNTY DEPT.
Q OF HEALTH.. .
✓'..t., r f.i't -,z�.c " %`- ,z.4' f � Y ,3'q•- r r.. ,.. =' `' «f� f '.. � � �I ?ts -�B! ";� ., �� :�Y
�i
=20'
NOTE
HOU5E, WELL AND
DRIVEWAY INFO. TAKEN
FROM 5URVEY M
TAGONIG SURVE'(ING
DATED, 9/23/95
N5TAI -LED
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`oZ �p
:PCHD PERMIT. # -
WELL LOCATION
Street Address
o Village City Tax Grid`; Number
A,
WELL OWNER
Name
Mailing Address
10910
Private
O Public
USE OF WELL
- primary
2- secondary.
"SIDENTIAL
O BUSINESS
O INDUSTRIAL
D PUBLIC SUPPLY
O FARM
0 INSTITUTIONAL
Q AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT gpm/ # PEOPLE SERVED ® /EST. OF DAILY USAGE &' O al
❑ REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION 13 ADDITIONAL SUPPLY
S'1M S PLY (NEW DWE ING D D.EEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL •TYPE
MdILLED
DRIVEN
DUG GRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES _jeL-NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: v
Lot No.
WATER WELL CONTRACTOR: Name 7-js n. 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
F3ON SEPARATE SHEET
8 f 9
(date) (signature)
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
thirt -y (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.
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 such a manner as not to degrade or other iisse.contaminate surface or groundwater.
Date of Issue: 19
Date of Expiration 19 S Permit Issuing Official
Permit is Non - Transferrable
3/89
White copy: HD File Pink copy: Owner
Yellow copy: Bldg. Insp. Orange copy: Well Driller
9
APPENDIX 3 .
'UTNAM COUNTY DEPARTMENT OF HEALTH - DMSION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS
REVIEW SHEET for CONSTRUCTION PER JIT
E OF OWNER l �� t
DATE .Z•o- TAX MAP # ,� . / 2 °�� •r. 5/O
DOeOMENTS..
'ERNIIT APPLICATION a'.'
Ir 1
HELL PERMIT P
NGINEERS AUTHORIZATION
)ESIGN DATA SHEET(DDS)'`
)EEP HOLE LOG r
:ONSISTENT PERC RESULTS (3) t.I
'ERC HOLE DEPTH
;ORPORATE RESOLUTION
'LANS THREE SETS
#OUSE PLANS - Tw Q" MTS
1ARIANCE REQUEST
GENERAL
EGAL SUBDMSION
UBDIVISION
ERC RATE
(OK)
P HOLES LOCATED
kTIVE OF PRIMARY AND EXPANSION
AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
f1PED PIT & D BOX SHOWN & DETAILED
�1 E - NO. OF BEDROOMS
& SSDS'S WAN 200 FT. OF PROPOSED SYSTEM
R METES & BOUNDS
SE SETBACK NECESSARY (TIGHT LOT)
OUSE SEWER- 1/4 "/FT. 4 70; TYPE PIPE
NO B S; MAX. BENDS 45 W /CLEANOUT
FILL SYSTEMS .
:.SLOPE 3:1 TO GRADE
GAUGES
ILL REQUIRED ? v, ROFTLE & DDr ENSIONS
.URTAIN DRAIN REQUIRED: S VOLUME
:X- APPROVAL SSDS ADJ. LOTS . TRENCH.
VETLAND (TOWN)DEC PERMIT R & D) CH PROVIDED
60
)ATA ON DDS PLANS & PERMIT SAME a T.T.Fi.TO CONTOURS LOA
RE -1969 - NEIGHBOR NO CATION
E1TER BUZBA 100% EXPANSION PROVIDED
SEPARATION DISTANCES SPECIFIED ON PLAN
00 YR. FLOOD ELEVATION'' FIE
BRED DETAILS ON PLANS P.L., DRIVEWAY, LARGE TREES, TOP OF FILL
EWAGE SYSTEM PLAN - (NO 0' FOUNDATION WALLS
SDS HYDRAUL OFILE GRAVITY FLOW 0 TO WELL, 200'. IN D.L.O.D., 150' PITS
V J BOX NCH/GALLEY m P- ETAILS O STREAM WATERCOURSE LAKE (INC.EXPAN)
EPTTC TANK -, SIZE, DETAIL O CATCH BASIN, 35' STORMDRAI 1, PIPED WATER
JELL DETAIL, SERVICE LINE IF OVER 10' TO WATER LINE (PITS -20')
ONSTRUCTION NOTES (GRINDER RATE) IlVTERMTTTENI DRAINAGE COURSE
DESIGN DATA: PERC AND DEEP RESULTS 20Wr. RESERVOIR, ETC.m 150 FT. GALLEY SYSTEMS
WO -FOOT CONTOURS EXISTING & PROPOSE,] SEPTIC TANKS
RIVEWAY & SLOPES CUT'° 10' M FOUNDATION; 50' TO WELL
DOTING/GUTTER/CURTAIN DRAINS WELLS
AENTI: 15' WELLTO P.L.
ofd
Y
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Dote
Re: Property of Do[aves G- ree 69CEWSPh-Al eyiLt&-p�5
Located at —1 V�5-f� bot o'les
(T) '22-77Lf0 brkc7tion a. 12- Block 71 Lot - ya
Subdivision of 1 V1s �DIO�!eS
Subdv. Lot # Filed Map # (p Date
T. MICHAEL pALY, P.E.
Gentlemen: CONSULTING ENGINEER
P. 0. BOX 243
This letter is to authorize SHEIYAEie6i�: #�:— °°
a duly licensed.professional engineer V or arehit
gisb
(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 Code.
Very. truly .yours,
/ Signed
Countersign Owner of Property
0 P.E. , R . , #� �'? 0V
Address
T. MICHAEL DALY P.E. �Y iG� +�GI I � � m ah b r D S'
Address CONSULTING ENGINEER Town
N. 0. BOX 213
iNr�1f�'rOCIC, N. Y. 10.587 q[ "6
Tel phone
Telephone
r
2.
275. 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 ,3t
wetland ?..... ..... .. ........ .r ..................... K'b
28. Wetland ID Number. .:..• ...................
29. Is Wetland' .Permit requ.i red?
Has. application been made to° Town or Local, DEC Office ?,
30. Does project- r- equire a�.DEC Stream Disturbance Permit? ...................
't1 d
31. Is or was'project site. used for agricultu�raliactivity involving"
of pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial,;actiwity ?.......... YES or. NO
32. Is project located with:i,n 1;000 feet of- existence of .abandoned landfill;
hazardous.waste site. salt stockpile, landfill, sludge disposal site ror.
.
any other potential .known source of . contamination? .., ...... .......YES:, or NO
tA 0
DESCRIBE: ti
.33. Is•there.a local.master plan or. file with the Town or Village? ....
Are.community .water, sewer.faci1ities planned to be developed within 15,years?
35.'Are any sewage_.disposal areas 1n- excess of:15% slope? .... _
36. Tax Map ID Number ... .... .:......................................
37. Approved Plans are to be returned to: ................ App scant '" Engineer
If the application is signed by a person other than the applicant shown in'Item 1,' the
appli cation- must•,�be`.accompanied by.a,Letter.=of sAuthorization. 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. Fa Ise statements tirade
here in :are punishable as a Class A Misdemeanor pursuan o,,Sect ion 210, 45 of
the Penal Law.
SIGNATURES. &OFFICIAL TITLES:
! i
MAILING ADDRESS:
51oc(G Ail
PUIYM COUNTY DEPAMMENT OF HEALTH
DIVISION OF .. ::,HEALTH'SERVICES:
- DESIGN DATA SHEET- SUBSUFACE SEWAGE.DISPOSAL SYSTEM FILE.ND6
Owner ')nL ni S GPxEI, PWAA Address r QAf- bUT -14mw- Iii• iD5%
Loted at . (Street) V IOM IO0ME5 . 7, 3� lZBlock �_ Lot
ca
(indicate nearest cross street)
Municipality �g'�D �.! Watershed
SOIL PEROQLATION TEST DATA RDQJMM TO BE.SUtN� WITH APPLICATIONS
Run
Elapse
Depth to Water Frcm
Water Level
No.
Time
Ground Surface
In Inches
Soil Rate
Start- StarStop Min.
Start Stop
Drop.1h
Min /In Drop
Inches. ..... .Inches ..
Inches
. 3
'SS
2
3
(o
3
(v
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 measurements to be made fran top of hole.
rev. 9/85
iI a1•
G.L.
1'
2'
3'
4'
5'
6'
71.
8'
TEST PIT DATA REQUIRED TO BE. SUBMITTED WITH
HOLE NO.
14!
INDICATE LEVEL,AT,WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO,gMCH WATER LEVEL RISES AFTER BEING ENCOUNTERED
.DEEP HOLE OBSERVATIONS MADE BYc¢�p�(G CEFZMA1ti/ DATE: `7- t'1 S LEI 6
DESIGN
Soil Rate Used fa"' Min/1" Drop: S.D. Usable Area Provided
No. of Bedrocros- Septic Tank Capacity IZj5n gals. Type
Absorption Area Provided By 400 L.F. x 24" width trench
�n
Nam T. MICHAEL DALY, P.I. , Signa
Address P. 0. BOX 243 SEAL - {
OCK, N. Y. 10587 4f
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: p°QAF�s'sto�p�'�
Soil Rate Approved sq.ft /gal. Checked by Date