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00717
°Rev. 3/86
CAOF
CERTIFICATE
-r•.. h — —
hLTH
N.Y 10512 " 4
Engineer Mast Provide � r
P C:H D. Permit q��� •�� , ��
►L SYSTEM : �C�,r� ✓S ;?
Town ok Village:
;/ '4.Y✓d ti/ �j /✓�_ , q Tai
Located u 1Kep, Biock Lot
.pp ame Sabdv
Owner/ llcant Name Former) Sabdivlelon'N
IUlailing Ad".. J3 y3 ZIP > os u Date Permit. Issued
Separate Sewerage System bullt by 4 ✓� r ✓r 194 A_or7 i Address
Consisting of Gallon Septic Tank.and
.1 ,l F 2 .
Water Supply: .. Public. SU" Iy From
Address
oi: Private Supply Drilled by PG ° %
Address �J/`G » �✓ 0✓ y .
E�
Bnudi;,g ✓�1� /4.CP" Has _ rosloa Contro ,Completed?
Number of Bedrooms %�/ Gazt.4 .G n installedY_
U �
�i
Otber.Requirewents
OF NE
I'certify that the systems) as listed serving the above premises were construct ee
',of standards;,
lf�AtdOt� s .the plans of the completed work ( copies
'th.'
which are attached), .'and in, accordance with., thi rules and regulat s,'' accordance iled plan' and the'.permit issued by the
Putnam. County Department Of deal c�
%d. C' rifled by
Oats �
f
v
..
_ P.E. � R.A.
1;
.../
y_
d
No
Address
Licenw
Any person occupying prom by th bove: systems) shall promptly take su t
conditions •resulting from, such, usage. •, Approval of the separate ;aavverpgs system fh
may no o secure the corroction of any unsanitary
wZAB ' soon as a pubf;: sanitary sewer becomes
available and the approval of the -private "water'supply shall.become,null and volo, who
subject to modifiratlon or change when; In the, judgment M the.Cominisslonar of, Neal
ai becomes available. . Such approvals are
i►Si modification or change Is n cesury.
tL Title
ti
_PUTNn.M COUN`T'Y DEPARIMMr OF IIEALTR
DIVISION OF ENVIRONMI -MAL REALTfI SERVICES
Owner or PurcIlaser of Building
�i
Building Constructed by
Location - Street
RTlicipality
Section Block Lot
Subdivision Name
Z
Subdivision Lot #
GUARANIEE 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 Environiriental Health Services of the Putnam County _
Department of Health as to i- .he.ther or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building uti- .izing
the system.
Dated this ;Z-el day of
4T'19 q e/ Signature
rev. 9/85
Hilt
/— Q4 o /% 6Z -;t - h L
CorporaEion Name (if Corp.)
Address T G
Y a C4- Ir9 7r 1,1 Sp0
r iaLioDc)-G /C-&
ly .c
WZLL tjVrlrUDi.LV" nc.rVni
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: TAX GRIO NUMBER:
Flintlock Ridge Patterson NY Lot #6
WELL OWNER
NAME. ADDRESS:
Arnold Gr>ee
Q PRIVATE
❑ PUBLIC
USE OF WELL
1- primary
2 - secondary
9 RESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED
❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY Q
MOUNT OF USE
YIELD SOUGHT gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
IN NEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST / OBSERVATION
❑ REPLACE EXISTING SUPPLY ❑ DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 365 ft.
STATIC WATER LEVEL _30 ft.
DATE MEASURED 88 _
DRILLING
EQUIPMENT
[3 ROTARY a COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION O OTHER (specify):
WELL TYPE
O SCREENED O OPEN END CASING. -U OPEN HOLE IN BEDROCK ❑ OTHER
CASING
DETAILS
TOTAL LENGTH —f 1 fit
MATERIALS: [$ STEEL O PLASTIC O OTHER
LENGTH.BELOW GRADE 6o ft
JOINTS: ❑ WELDED MTHREADED ❑ OTHER
DIAMETER `.6 in.
SEAL: aCEMENT GROUT O BENTONITE OOTHER
WEIGHT
PER FOOT AA Ib. /ft.
DRIVE SHOE 91 YES O NO
I LINER: ❑ YES 0 NO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (ft)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
O YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH fL
BOTTOM
DEPTH It.
WELL YIELD TES? It detailed pumping
P P 9
MMOO: l2FPUMPED tests were done is in-
OKCOMPRESSEO AIR formation attached?
O BAILED O OTHER ❑ YES O NO
It more detailed formation descriptions or sieve analyses
WELL LOG are available, please attach.
DEPTH FROM
SURFACE ,
water
Bear-
ing
Well
Dia-
meter
FORMATION DESCRIPTION
G70E,
tt.
fL
WELL DEPTH
ft.
DURATION
fir, min.
DRAWOOWN
ft•
YIELD
gpm•
Surface
2C
Erillinp-in
overburden clay & bldrs
t
ock at 20'
365
6
345
20
20
61
il..ing
in rock set casin route
.
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE Well Xtrol 250
CAPACITY 44 GAL.
PUMP INFORMATION
TYPE submersible CAPACITY 7_ __-
MAKER ,.r -n-11 ri DEPTH ;�pQ!
MODEL 7EH07 412 VOLTAGEZ-3-0-HP3�A
WELLDRILLERNAME P.F. Beal & Sons , Inc . DATE 8/31/88
ADDRESS PO Box B SIGMMRE
Brewster, NY 10509 '—`
BREWSTER LABORATORIES
Box 224 - BREWSTER, N.Y.
(914) 225 -2072
- WATER ANALYSIS REPORT -
SAMPLE NO. 7063
SOURCE: Greenspan Builders
Flintlock Ridge
Patterson, NY
vv�rrv.�v. a'au7 uJ �. GJ 1�VV
BY: P.F.Beal & Sons, Inc.
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
Lot 6
This result indicates the source of the sample was
of satisfactory sanitary quality when the sample was collected.
August 30 1988
Roy Bi kwit P.E.
actor
hose bibb -well
0 per 100 ml.
.? n `77N— - '�'^�r- -±: -,-, F-r`° c^a --+F ^� �^.ry- '• rz?^„�^"s 'I
Lr
t; / �� (b PDTNAM CODNTY DEPARTMENT OF HEALTH I
/ 3 Diylsbn of Envhbamental Health Servleeo., Caemel, N.Y 10511 ; . Eaghteei to Piovhie Peeotlt M
t (on CERTIRCATE OF CQWUANCE
CONSTRUCTION FOR SEWAGE DISPOS IRV
f,OCitOa It • Own Ott.. ,VlOage
Sabdiybba Nsme OG Sabel. Lot N Lot' '
R&Won �' Renewal p
Owner /Applkant
_ Date of Ptevlone Approval' '
MaWng Address , �/ Town
BalldinQ Type Lot Aeea FBI Secdon.Onlr Depth Volume
Number of Bedrtioma Design Flow G P D G tl PCHD Notlfi -d Is Regalred When MR le 'mPleted
Separate Sewerage System to eenslat of GhOon ttc T an'd / G
To.be oonatrgcted by ��'l dh / Address
Watec SnPPb i1c Supply From Address
or= 0k;iite Sappiy.DrlIlW by'
Other -
er ReQatremente -• . ` .. "
I rebreierit that i am wfio0y and comple(ely responsible for the des�gn'and location of the D ►o (fit. °ty��wy " `that tlie} separate sewage dis oral. s stem
above described will be constructed as shown on the approved amendment there to antl in ac w' staa� rules an regu a cons O e.:, u nam
"County, Depa►tment',of` Health; antl that'on completion thereof a Certifwate,•,ot Constr i�il'' (RMp� s y.to,the Commisslonei gf'Healtliwlll
bs wbmittadao the Department and' a written,quaiantee will be furnished fns owne his s, hairs` - n y,,the.buildii. that laid builder will
place in goo dperating eonddion any pG►t of said sewage tlispofal, system- during ,f per f f yea%J "rise "tely, following, thedate of -the isau-
ance of the epp►ow,l, Of tM, Certificate, of Coristr`uction Compliance. of the original e p� a is is li 2) t t.th6 drilled weltdescribed above
will be louted�as shoWn,on the aPProved: plan ind that said well wilt be installed, m acc` Wi., di, s. `d, regu as ons of the PuWan
+r
County Department of Health
Date Heel- . P.E.
i►ddress License No Z
APPROVED FOR CONSTRUCTION ppr
This,aoval.expues two years from thq date issue s budding' has been' Undertaken and ii
revocable for cause or'msy amentled of modified when considered nscessa►,�r :by the Co F ��tt�t`' y Change or alteration .of. construction .
requires a ` ew permit" por disposal �o,(fdy}o�mestic sanitary sewage; ;and /or' priva
lRev.
,' Date
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�J�!'
PCHD PERMIT
WELL LOCATION
Stre t Ad r ss
7e h(1_1 *
Town Vil
/�
ge City Tax Grid Number
WELL OWNER
Name M
r_n dd
'ling Address
i �O
�O jv�'G�i
rivate
Public
USE OF WELL
1 - primary
2- secondary
rBUSINESS SIDENTIAL
0 INDUSTRIAL
O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
❑ 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 ,7od gal
REASON FOR
DRILLING
WNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY
OREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
O TEST /OBSERVATION
DETAILED
REASON FOR
DRILLING
WELL TYPE
BILLED
ODRIVEN
ODUG O GRAVEL
O OTHER
I
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name
Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
G
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: ^
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
.� O ON REAR OF THIS APPLICATION N SEPARATE SHEET
(d e) —7-71 _ (si WapreX ®.®
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 Dep rtment.
r
Date of Issue: 3�
ermit Issuing icia
Date of Expiration: 19�
Permit is Non - Transferrable White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
2/87 nrancre
PL]7NAM CO= DEPARTMENT OF
DIVISION OF ENVIRONMENTAL. HEWCH. SEMCES
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner �i^�a� ��r''! �o�iv� Address
Located at (Street) a' ✓�'Gz '�'� (/% Sec. /S Block Lot _� Al
(indicate nearest cross street) ,
Municipality 4 ,�� ®/i Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre- Soaking / Date of Percolation Test
HOLE
NUMBER CLOCK
TIME
PERCOLATION
PERCOLATION
Run
Elapse
Depth to Water From
Water Level
No.
Time
Ground Surface
In Inches
Soil'Rate
Start -Stop
Min.
Start Stop
Drop In
Min /In Drop
Inches Inches
Inches
3167 /c3k`
3y
4
5
1y y� 3e2-
4
5
1
2
3
4
NOTES: 1. 'Tests to be:,repeated'at same depth until approximately equal soil rates
are obtaineffat:,each percolation test hole. All data to'be submitted
for '-review., .
2. Depth measurements to be made frm top of hole.
rev. 9/85
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.
1'
2'
4'
5'
7'
8'
9'
10'
11'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RIS AFTE %R BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: Lm // %%r DATE: ZZ o
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided 2�00 U
No. of Bedrooms Septic Tank Capacity. ✓�s� gals. Type C- 0.0/
Absorption Area Provided By 4-:!;V LF. xd 24" width trench
Other
�E Y
Aj Name C50 i Sig
Address �9`7x /t'+�i/IC/CS�� /�. S
THIS SP FOR USE BY HEALTH
Soil Rate Approved
0 1
NT ONLY: �
sq.ft /gal. Checked by Date
APPENDIX B
PUINAM CCURUY DEP=4JaU OF HEALTH - DIVISION OF ENTv-MCDZflM!AL HEALTH SERVICES
fk DIDD-TIUML WATER SUPPIT;f & SUBSURFACE SZ- DISPCEA-L SYSTEMS
RE"v7=R S= - CONSTRC=ION PERMIT
DATE R.;V----.v7EI)
BY:
Clone of 0nar) (Street Lecaticn)
DCaD
Pe---ait AnIolicaticn,
Corporate Resolution
Plans - Three sets S/s
L'ngineers Authoriizaticn
Design Data Sheet MCS)
I S
Ceep Hole 1,-c
Consistent Perc Results (3)
Perc Hole Depth C-
__T6
Varianc-- Recuest
G --- A L
Leca-1 Subdivision
Subdivision A-ccrcval Checked
Ex-ac-crwal SSO-c Adj. Lots Cher :-,=--
Wat-land (Tcw-n/DEC Ps=ti-- R & D)
Data Cn DDS Planes & Fermi S,17,:a
REQU= DETA 1=1 S ON PL-: VS
C&-e -c Svcz=-,n Plan - (rorth ar--n74)
-e
F1
Se-race Sys tan E-1-rdrau-1 -ic Pr f
Fill Profile & D--irnensl*cns
J Box; Trench/Gal lery; R pit d=-,-:J,
Septic rra-nk - Size, Gail
Well Detail, -cervice Line is cv=---
Czr.structticn Notes (crind-er rate)
Design Data: pert and deep res-ult'S
Two-Foot Contours Existing & P-rccosed
Driveway & Slopes Cut
Foo=a/C-atter,0,2r----'Ln Drains (d-ischarge OK)
Perc & Deep Holes Loc-atted
Represaritative of prLTL=--y and expansicn
Expansion A-re--;shcw,-i;zravit-v flcw,suff. sLzc-
If Pxnped Pit & D iL Shcwn &
House - Vo. of Bearoans
Wells & SSMS's Win 200 ft. of Propcsed Syst
P-rcperty motes & Bourds
House Setback Necessary (Tight lot)
House Sever - 1/4"/ft. 4"0; Tyke pipe
No Be-ids; Max. Be-rids 45" w/cleanout
SEPAMION DISTANCES SPECIFIED CN PUUNI
Fields
101 to P.L., Dr-iveway, Large Trees,TC-0 of
201 to Foundation Walls
1001 to Well; 2001 in D.L.O.D, 150' pits
1001 to Stream, Watercourse, Lake (inc. e:,-
15' to Drains-Curtza-L-i, Leader, Footing .
35'to catch ba-sin,stormdrain,niced watercc'
101 to Water Line (pits-201)
50' intenuittent drainage course
Sentic —
10' fran Foundation; 501 to w7-11
151 Well to PL 9
CC1V--V-7rS
YES
I NO
la
I
=,encn pr:v-cec:
to ccntour-z II
I s A A
F= SYSTEMS
claVca.rriex
10 ft.
fill notes I
OV,
I
new scec.F.
decth cauces
100 v--. flood elev.
200 ft. rese--voir, etc.
1:41
150 ft.
te-
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