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HomeMy WebLinkAbout0752DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -35 BOX 8 1 17-211, 1 1 1 C. �r . . . . , f '- i �. ' } j 00752 I Division, 110 OLD ROUTE SIX Ci APPLICATI ,P!AR T� MXNTI OF HEALTH �, f Engirpninental Health Services TER;;;; {ARMEL, N.Y. 10512 (914) 225 -0310 .% CONSTRUCT A W ER WELL 1`4 PCHD PERMIT 0 WELL LOCATION Street ' Address / /[� rme,r MA Town Village City Tax Grid. tuber /1 WEI:L OWNER Name Malling 0. B Address Private 'O Public TJSE OF WELL lellii 1 "` primary - secondary RESIDENTIAL O PU .. C SUPPLY Q AIR /COND /HEAT PUMP D ABANDONED 0 BUSINESS El FARM O TEST /OBSERVATION O OTHER (specify 11 INDUSTRIAL 'ta' t3 INSTITUTIONAL .O STAND -BY Q AMOUNT OF USE YIELD SOUGHT , ^gpm' /UPFOPLE SERVED /EST. OF DAILY USAGE �%!6 Bal REASON FOR DRILLING 9REPLACE E%ISTING 'SUPPLY O NEW • SUPPLY NEW DWELLING O TEST /OBSERVATION ' 13 DEEPEN �'E ISTING WELL 12-ADDITIONAL SUPPLY DETAILED REASON FOR r b'-VTO. DRILLING,, _. ' WELLtiTYPE DRILLED DRIVEN . EIDUG GRAVEL. OTHER IS WELL SITE dSUBJECT TO FI:OODING? 4 YES ' N0, 'IF WELL IS LOCATED`,IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR:. Name ALBERT M. HYATT & SONS, INC. 'Address: Well BI'MAR IS PUBLIC WATER SUPPLY AVAILABLE IXM KNEW YORK Box 7168 - -YES NO PA ,NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY F DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �. LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED an gc�G BON T 'Ile :.4 (date) (signatur " PERMIT ~ TO CONSTRUCT A WATER, WELL This permit to construct one water well as set forth above is granted ande.r 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 s.hall- 1..:. ,P.ump- "the -well until the 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_pr'ovided by the Put m County Health Department. Date of Issue: �56Ay r- 19 Date of Expiration: 19_(0 Permit is Non- Transferrable Rev. 10/88 ermit ssui c White Dopy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner Orange copy: Well Driller A wfulums K . , . � - � �� . � - , ) � � %,,�, : , . . � o �". -,z;--.�, - , , -- *-'�- ,,, �. -� �. � ,-�,, -��', -`i$-,'R,Ii�:,,,�., ,�.,, .,., " " .c. .j,l xr- , . :, 20 1 Mamn Rw TV . - "� -�I�f"'--,l . - - ofxg - % % . � ... �- - - , , � , " �'�---' 4,00 '' � � `~�' , , 0 +*`.� �: " � t , , .. 7 ", I I , +, , �4** , � ..�,!,,,,,,.r"...,.-�l,.*,",,,.,--,.��l.;,� h ` �W, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # V J- - 41-1 �_j Located at 5`10 W T_Q rA' lLiT K'AD Town or Village Owner /Applicant Name �' H A k9 1; - b i,aN Af_ Formerly PATTfFfJ71N Tax Map 2-4 • Block Subdivision Name Subd. Lot # Lot � e Mailing Address �• D X71 ��� �� r� S A ��M N j —zip P o� g 0 Date Construction Permit Issued by PCHD Separate Sewerage System built by 0 1 �-nP6 o��l�` Address f d 'htaq Consisting of 1000 Gallon Septic Tank and 41A Lf- A-65 • f F-00i Other Requirements: Water Supply: CAT-A-44 %NH Public Supply From Address or: x Private Supply Drilled by CX) '5 T1NCi Address Building-Type,.- Has erosion control been completed? vE� Number of Bedrooms Has garbage grinder been installed? No I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: (J3 Certified by b, - P.E. X R.A. ..— gn Professional) Address 2° D �2t 22 `w5 J'T' 10 oy License # '�6 I2 Any person occupying premises served by the above system(s) 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 sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. 1 �j��C/�V�- By: Title: pYL;�--T Date: G / G L 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTN ' M COUNTY DEPARTMENT OF HEALTH DIVISION. OF; ENVIRONMENTAL HEALTH. SERVICES f GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM _. fLAY �LA�1- tp���0lr9i )0iri fi'Kel�44 , Y. Owner or Purchaser,,. of Building Tax Map Block Lot Building Constructed by TownNillage a Location - Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for .the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is 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 treatment 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 f4ther agrees to accept as conclusive the determination of the Public Health Director 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 the building 'li ing the system.... \ ; 4 Dated: Month Day ;94 Year Q 3 Signature: General Contractor' (Owner) - Signature Corporation Name (if corporation) Address: p10 $ox:: rDl �ALAAN State JJ i Zip 1© 666 0 jTitle: 1 c v _►�j Corporation Name (if corporation) Address: State P 1 Zip [0% Form GS -97 JUN -13 -2003 10:/25 AM HARRY W NICHOLS /*. - T, "T"I. 7 9 ••� cul PERMIT��.,. ' rvrMwd Mt Subdiwision Su Lpt ZM visiol pP , rL, . l: •, a3' .4 {•.i •.'h �'` > ", ..G"`:: {.,! ±M <Y`.'•.jf:; x {'!'SR����''�'r''F •i.': '''��i •.; `i• i���.,,. „L Y _ 1• JV' •K . f .r n. i• Al r°•a •,�a,(� S �[� / ••��,, 'ern i•r• y V •'. u. `; Ji.- ��L:',,•;;: �Sij' ��' P��4u} 3:_: 1Jy," :!WAr:13�i:W;tu:.•I'�......_... (:'•�v:.:'tr .'': J.. •,: ._ 914 279 4567 P.01 own-or 114 Tax 4. ..t•;;." ♦{ •.�r :• r.:{ d, �',(. ,�L,c:�c,o�;,•"'GIl�lP1•Y'MF4Ky ,rys +t....? :i%i��ti,;�, \,,L,,.�. ,�.��t; �. yid ?�i '"";�� �..'�. t•:•Y::•%'1' � � ;. <. �,' ,t:Y'; :5,; . .. il'::5; (�tia 1'�,1��:5.'e :'r.'i('I ei,.,., f':'��I rr� •. '''`�:',. .: t 1: �! Ij�" 5',•'.;;F� ',�• I'T,. `i• ,r ',} +r•` •:i,•' ' + } =.n.,y y.,v < °�,iU � , Y'i^ •.' �. •,I1 .. �� •, •� , L•• r\ `�4( r 1 .•ta x .5, w 5 t•,• . y I• y, rrt �^, Yr• 'i•'• .,y '.)i •' ti�r(t-�Ai'k�i '�'. ': i AY. ,..C:?) aqt h.r, .,.,...,\.:,�.( i '•ry It •:ice'., v•,r. P > rWK 9148786343 P.02 MAR -12 -03 08:41 AM PATTERSON TOWN HALL HRUcs R• F%BY * LOR3'c'1'A HOLWARIANv M.S.N. . .^ �` %• lrarc Xtaldi OWtuar . ,. .. .de000 PWk��._Xy�_� Dowtv if hrWM .., ..... „ _ . ,.� .._. , ..... MAR'DY= OF SAL __._... 1 ocam Road ,. _. .. j 13WNM, New York 10509 ! lt++fMn"w MUM 014)M-OX ►ap14) m • t }•..•' (PI�)7fi•issi WIC (014)371-4678 ?7i •eois _..... ; tG�'iitetti��O'(pll}1!i'•6014 t►eKscel pt�27i•deii I (1t�?Yf1•i6/i •::4 r' E : ORftRS NAM_ Rc ALA HAIL • T•' AX W NUMBER, .. ;• ` E911 ADDRESSI. ' ! rO*N: pkrS`g M lee AYLTHO1tM TOWN RI�CCIAis ? F i i rt� r; The Putnam County Depatrtment of Health will qot issue Carttficate of It :t '? �... Construction Compliance unless the above form is corn leted, I,e„ a lees! E911 �._ address is t�ssiEned by an authorized tows offltial. This vrm Is to be submitted with the application for d Certificate of Construction Co plbnee, ; it 4P Harry W. Nichols Jr., P.E. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION nCOMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # R'� /-'I' 41' A- 1'i' °�i Located at �RD To rALT KIAn Town or Village Owner /Applicant Name Formerly p4HDJ ►9 g - B044 - Tax Map 2-4 - Subdivision Name Subd. Lot # P ,kTT PTA 0N Block Lot 5 Mailing Address -P• 0' �4 261 HOW ill Zip MCC Date Construction Permit Issued by PCHD 1 f Z7 ! 0Z Separate Sewerage System built by Address M 'bpi 40 9RVA�'f t g% Consisting of t 0 D 0 Gallon Septic Tank and 4`0q LF A-65 • TWO Other Requirements: C./4TA-1R VII-41H Water Supply: Public Supply From Address or: X Private Supply Drilled by C%4 (6'rwol Address —Building-Type -Building -Type - 1 �' G Has erosion control been completed? - - - - - -. - - . - Y E 1 Number of Bedrooms % Has garbage grinder been installed? HD I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam Coulty Department of Health. Date: CO Certified by Address E0 5 a (2-r 22 �S ( gn Professional) 1 P.E. X . R.A. License # Z�6' II- y Any person occupying premises served by the above system(s) 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 sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. Gu- By; Title: p&"T Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form'CC -97 r i� i PUTN, j M COUNTY DEPARTMENT OF HEALTH DIVISION, OF, ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser; of Building Tax Map Block Lot Building Constructepd by Town/Village Location - Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for .the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is 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 treatment 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 Public Health Director of the Putnam County Department of Health as to whether or.not4he failure of the system to operate was caused by the willful or negligent act of the occupant the bu'l / \diin_g 'li ing the system.... e ,G��""` Dated: Month Day A) Year 6 3 Signature: Title: w 5 General Contractor `(Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) Address: pi0 $pK ���'(�- ��%^'� Address: State Zip 10 �a State T Zip [ O U 0 Form GS -97 Harry W. Nichols Jr., P.E. JUN -13 -2003 10:25 AM HARRY W NICHOLS 914 279 4567 P.01 1.1�, .e.y ^,.�r,e .Y. �� ...\/. `,",. :) ,;! J�I /�n�F `2`�:11,iirr. , r • ' 7 ♦ .�• t 14..x: t +•'• ?. s •.`i •�•xl.,'�: .'}`•: 1,:,f ;.4j `;, li -, v.r ...��LL '• -, Y .i a� 'r 1fl}Ju'� .Y.'S• r;r, f' '. i\!;.. 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''',�! ♦ :. r ; j1� r•n V , ',v' ;, i•• �l : ` ; .�: •}f.�.•7 i• V: 'n y, t,4 ; f"� v �.: : ,, .,5:r�.. . � ..•1'- ` •,> ', . : :n A..+p.l :• j i15�lf r/1 yi.r. a � f � ' , `•a M.f �rnS is y ,a C.. ,�.y�Cl' •�� i Yom- :'1' .Y•„ ,,••. •• {'.r •1' G a .yf � •I Nrsti,�a'4�•7ib.i'q'.]- �n?u��,, ! 5i .td.vh:7 \!f! }ia KTEI�L•Ai►'�:�e. `i'� .�W`.... aa'.�iCel "!57. !�.:x ^`.:i[.i...r,: + Y..d_,;. �. i _. _ ... _\.: ,.c:yt .. _.... S:'..Ca,.,a::4,F'9'',:�;. MAR -12 -63 68741 AM PATTERSON TOWN HALL 9148786343 P'02 4� ~ { ,)k(fk,-i•j. f.',.� BRUCE R• FOLSY * LO1t MA MOLWM. RNy KS,. Irblk Ifta/�h D/rreia►. .' � .. •,IWO�efair A�}iii1, R�d�ip���Nr,.. _r . , .�r w rr., .w •. ..�. pvecter'�.lat'�nt ��.. �:��1, ' r .. .. , ...• ,•.. .� .... .. .... .... -� • DEPARTIawr OF .. . �.... 1 Oeaars Road Brovatort New Y4 [os" i Lmp"*"w Nair piq M • 41}0 Faw14) V1 • ! . _. ... ! , :•',�� �• � °; . N�•twrkatod�)�a•tas� wtc nl�rn•a�i .rya Q ri•4ou �, . s<�'s;�N�.•plgrr•aau r�e..i Ot4n =�oa ► pthttr•�a+a 7,211 ADDRESS VRRIEICAT IQN � • • . .. � .... .� :vii 1 °'�. .. ; - . ... ., ..... , • . OWftRS HAMEc r ' i ... T�x� Mnp >1tfJ�IB]cRt... '� � � 1- 3.� .. ..... •.......:..:fy° . E91I ADbRT$S 00 AkA14 TO ~4-1111-r Rci At1TH0$1UD TOWN, - OMCIhi,: S.. ' (Signature) H + The Putnam CCnaty Depat�mwt of Health will not issue R Carffficate of K Construction Compliance unless the above forta is com feted; Le., a legal E911 ; { Y. address s SSipod by as authorized town official. This ona is to be submitted 'f ' with the application for at Certificate of Construction C' 0 pEiaace, : : PUTN, M COUNTY DEPARTMENT OF HEALTH DIVISION,, OF; ENVIRONMENTAL HEALTH. SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM _. I g.PA (%I rgi o;,* r. K,-;K 4j i 7i�7 Owner or Purchaserrof Building Tax Map Block Lot Building Constructed by Town/Village 59 r_P(p -cam ` fio N\P,14 i R oPO Location - Street Subdivision Name - Building Type Subdivision Lot # I represent that I am wholly and completely responsible for .the location, workmanship, material, construction and draWi ge of the sewage treatment system serving the above - described property, and that is 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 treatment 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 Public Health Director of the Putnam County Department of Health as to whether or. riot-the failure of the system to operate was caused by the willful or negligent act of the occupant the buildinng 'li ing the system..... � Dated: Month Day 620 Year Q 3 Signature: r General Contractor' (Owner) Signature _ Corporation Name (if corporation) � Address: P'0 Title• Corporation Name (if corporation) Address: State i' Zip t© �60 State l�f Zip Lo�iGv Form GS -97 a PUTN 4 M COUNTY DEPARTMENT OF HEALTH DIVISION, OE: ENVIRONMENTAL HEALTH. SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaserriof Building Tax Map Block P A-rnp - -6DH Building Constructed by Town/'Village 5�0 �NNk(\ to N\pt * R oPQ Location - Street Subdivision Name P--E5 '5 1! EFH L.,t Lot Building Type Subdivision Lot # I represent that I and wholly and completely responsible for -the location, workmanship, material, construction and dra)nage of the sewage treatment system serving the above - described property, and that is 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 treatment 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 Public Health Director of the Putnam County Department of Health as to whether or.iiot•the failure of the system to operate was caused by the willful or negligent act of the occupant the bu'l \ /d�Q*' 'li ing the system.... Dated: Month Day ;Vd Year Q 3 Signature: Title:fuw_► -CAS General Contractor' - Signature Corporation Name (if corporation) Address: PO fox- State Zip t©�G� Corporation Name (if corporation) Address: -o c �7 ^-7i S ,uM State Zip to�i6v Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PERMIT # CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM ;�V 9-9RAo R-. / A40 D i o j., + � - a 8' - o Located at 1510 FAW - Tb - M �'i kf,0 Subdivision name Date Subdivision Approved Subd. Lot # Owner /Applicant Name Rai M1 OQ E' 2) . H pi— Mailing Address 0 1 &%L Q-0 Amount of Fee Enclosed Building Type �Eweh(,e In on �� -oa< Town or Village Tax Map %4- Block Lot $ 5 Renewal Revision Date of Previous Approval �40M -4+ SMGT�\ ► t�y zip 10 50 Lot Area p- 0 No. of Bedrooms S Design Flow GPD (DDo Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Tp—Et-ki-* Other Requirements: To be constructed by Water Supply: C ")K M1N DW) % J is Public Supply From 1k gallon septic tank and W W— A bS Address Address or: Private Supply Drilled by EAA Address _ I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments sv tem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: A,,, //I�t,, P.E. R.A. Date %� p t Address �� So �' �� 1`r1 10 �' p� License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Appr�ved-fordisge'of domestic sanitary sewage only. B Title: l!��- - y: �+" .� �- Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy.-- DesignR ofessionaI Form CP -97 PUTNAM COUNTY-HEALTH DEPT. . 0 2 i Geneva Road (845) 27"130 Brewster, NY 10509 Date �. Received .of 4 n Y PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner M_rf, ......... j l�1.Q Address �.� w "�� 5 � %AL&my w) -I Inn Located at (Street) 6q0 Tax Map Block Lot -(indicate nearest,cross street) Municipality Watershed eA`5e �P-AI-4C�44 SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test W iQ u i NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test-hole. (i.e. s 1 min for 1- 30'min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Depth to Water From Ground Water Level > Percolahau. Hole.No Run No Trine Start. Stop Eta se Time Min:) Surface (Inches) Start Stop Arop In Inches Rate Miu/Inch :::. i A 4 2 3 4 .5 4 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test-hole. (i.e. s 1 min for 1- 30'min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0'. 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' ............ ..... 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO,_ HOLE NO. � .. HOLE NO...._ Indicate level at which groundwater is encountered'�%1 Indicate level at which mottling is observed NpNE Indicate level to which water level rises after being encountered l ,AA Deep hole observations made by: JeFf- � 11,L 450666 Date ►��1� Design Professional Name: W-W W, lk G MLi ; = Address: 2o5t) Signature: Design Professional's Seal Pa i q n . PUTNAM COUNTY DEPARTMENT OF HEALTH t 01- 071 • o'v DIVISION OF ENVIRONMENTAL HEALTH SERVICES y . DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Rkq V4 0.ow'b 6LA O lr 12 Address f7 Q VSpK "I ODD- -% SfZI`t, ,i 10S0 Located at (Street) Tax Map 2�� Block Lot CJs (indicate nearest cross street) Municipality Drainage Basin SOIL PERCOLATION TEST DATA. Date of Pre - soaking nel . is Date of Percolation Test Hole No. Run No. Time Start - Stop Eta se Time (�i41in.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Dro In Inc�es Percolation Rate Nlin/lnch Z® t �" ._ 2d'ly" 2 1101 -1'31 2C7 4 5 :W 12 1 1! 0z 'to '21- /`I 3 1; 3k - 2 : ®� 3n 20 — 23� 2 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percoiauon rakes a« WuLai11%,U ", percolation test'hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitte.d'for review. 2. Depth measurements to be made from top of hole. Form D'D 797 TEST PIT DATA DE$CPTIQN .QF,S.QILS g.REDAKTAST TEST HOLES D c PTH HOLE 140-1. •� HOLE N0, HOLE N0. TS Tb mm O 6 0' -- C., L .. • �• .. - y- ...:_ _ . 0.0 o i c a to I ewcl at which groundwater Is encountered ° ndica(e level at which mottbs is observed Indicate level to:rvtilch water lavcl rlscs agar being encountered deep hole. observations -made by:., JEf mooW Date 1-6115)fi. ---��• Design Professional Name; ht w, NJ (G 0 1 i address: _ f NEW )0, 0 co �- J W uj Signature. No. 5024' Desl g o Professional's Seat °A 9 °t ssie 14-16-4 WW) —Ted 12 PROJECT I.D. NUMBER • ,; 6M20 SEO R Appendix C . State Entilro�mintlil Guillty. Rvliw SHORT ENVIRONMENTAL ASSESSMENT FORM For UNUSTED AdPONS Only aeaT I_alaffJECT INFORMATION fro be comb'1eted by ADP11cant or Prolect aponsori' 1. APPLICANT )SPONSOR !. PROJECT NMIE J. PROJECT LOCATX k. �p �i Munklpallty f County 4. PRECISE LOCATION (6vW addmu and road Inlwaeatlona, prominent tandmaft, eta, or provide map) S. IS PROPOSED ACTION:, ❑ Now ❑ Expanslon x4lodlfloatloNaltwatlon 6. DESCRIBE PROJECT BRIEFLY. 7. AMOUNT OF LAND ECTt O. _ ...... _ ..._ . 0 " A •�'� Initially ' a0na UlunWely ., , aorw 6. M1 L PROPOSED AMON COMPLY WITH EXISTING ZONING OROTHER E)WN0 LAND USE RESTRIOTIONS1 Ya ❑ No It No, d"arlba brlafly ~ ` 9. VET 13 PRESENT LAND.USE IN.V OWITY OF PROJEOTT . . Realdwtlal O Industrial ❑ Com wolal ❑ Agriculture PwW westlOpen apaoa - ❑ OUW - • - - -- -. _: __....._. — _ . .0 10. DOES ACTION INVOLVE A POW A"ROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHEA 00VERNMENTAL AGENCY (FEDERAL, STATE {OR LOCAW 9Y" ❑ No It M Ilst agwroy(a) and pwmlthpprovala �vt\-Dlll. WIT. ��IvOLI� Ql�tr�� 11. DOES ANY ASPECT OF THE AM" HAVE A CURREIiTLY VAUD PEW OR APPROVAL? . 7N0 : U , Wi aWproa :_ .- _..... _ AGnY WW P" . 12. A RESULT OF PiiOPoBEO ACTION WILL EXITING PERIXIAPPROVAL REMRE MOOiFIG11TgN1 ea ❑ No 1 CERTIFY THAT TH6 INFORMATION PROVIDED ABOVE IS TRUE TO TKK 8 8T..OF.MY E Applkntlapono � vtiG D nar Data: y Signature: If the action is in the.Coastal Area, and you are a state agency, complete the . Coastal Assessment Form before proceeding with this assessment AVER PART II— FNVIRn1JUF1jTAI AA.gF.q -gUPNT rr, ha nemniatad by Aaanov) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.0- 11 yes, coordlnate'tM review process and use the FULL• EAF. O Yes ONO _. S. WILL ACTION RECEIVE COORDINATED REVtgW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involrid agency;, O Yes ONO C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritlen,.11 legible) C1. Existing air Quallty,._surfice oc.grour4wetpr quality or quantity,_nolse levels; existing trefllo p;ttar►S,.,"-wa� produotlon or disposal, potential for erosion, drainage or flooding problems? Explain bristly _ _.. . C2. Aesthetic, agrlculturai, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain bdelly: CJ. vegetation or fauna, fish, shellfish or %wIldilfe species, significant habitats, or threatened or endangered species? Explain bristly: G. A community's existing plans or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, suosarauent development, or related activities likely to De Induced by the proposed action? Explain briefly, C6. Long term, sr►ort terr►x currwlatMe, or other effects not Identified In C1-057 Explain briefly. -- • C7. Other Impacts (Including changes In use of either Quantity or type of energy)? Explain briefly. . 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? Yes O NO E- IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? O Yes O No If Yes, ixplairi briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect (dontifled above, determine whether It Is substantial, large, Important or otherwise sign IfIcant. Each effect should . be Mileage d._ln o0nne0tion With Its (a) setting (6e. urban cc rural); (b).,probablllty.of_gocOrrtag; (cy o ration; (d) irreversibility; .(a) geopraphlo scope; and (f) magnitude., if necessary, add attsohf►ents or reference supporting materials. Ensure that explanations contain sufficient dotal) to show that all relevant adverse Impacts have been identified and adequately addressed. It questlon D of Part II was checked yes, the determinatlon and slgnifidance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. O Check this box If you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. O Check thin boz :lf.you�have.determined, eased on the Information and analysis above and any supporting documentatlon, that the proposed action WILL NOT result In any significant adverse.. environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination :' Name of Md AVvxy tint or Type Namc of ar in Lead Apncy Title of Responsible r Denature of K y cure 0 Ftepuer perµ from responsible o rcer ate PUTNAM- COUNTY DEPARTMENT- OF- REALTY- ....... - DIVISIO..N;;O RONMENTAL HEALTH.SERVICES - . •,APPLICATION, FOR ."PROVAi OF PLANS FOR A WASTEWATER TREATMENT SYSTEM sees,. sees. .1 1. Name and address of appl)caat� 1?!A I'�'�•o!� D�''`` ,, :• , r '2. Name of project: " -� p ��i ► 0 .. 5 3, Locatlop TN: 4. Design Professionali wv _ S. Address:S 6. Drainage 7. Ty, e -of ProtECt :. P6atcJResidendia Food Service Commercial _- Apartmc}},t� , :sees ,..�.Institudoizal• . , , ,.Mobile Home. Park Office Building _ Realty S,ubdlvisloA ..:. 8. Is this project su*ct V, State /Ea*4atrtent4l Quallty Revlew Type Status (eieck.oae) ,. , 1 > '. p ........ ......1...1...........1.,...... I `y EXerr1 t., k. r 1 1..: Unlitted..,•L. 9. Is.a DraR.Envirotimental ImpacfStatement(DEIS) required? ..... /,Y.. /:•Y:..•..••.•, �,�•.. : � ... .. '1: � '•�.'� ' "`��' '''� .tip + .. .. -._. sees.._ -.. ... 10'. Has DEIS been "completed and found acceptable by Lead Agency? •' . , , ;, 11. Name ofLead`Age�:y' , '•.,:: ►1 •,: - N R `} _ ___ T2. Is this project iii'an area'under�tiic control of local planning,'zonln8, -o - th - E ro fir,. . : w•:•• •offcials <ordlrices? •1 wwgll :..:.., .. :'. •:sees:.,. r p' w /.IN1.,.H /waw.......1i11 . +�. •' ", `_. 13 If so hayeplans beeo.submitted to'sueti authorides? ' ` . �p f • . , - :.www..•I..ww�Iw.www•.wwwlr� �' .'.. 1.7, ti., . .. ..,. ,•a•.•`•..:•:. 14: Has preliminary �rova� b .grante�by, suc�.aut otides? 60 : Date granted: solos 1 S. Type of Sewage Treatment System surface water gxoundwater 16. If surface water c�iisc�c8e what is,tbaatreaia'classdesignation? ~ " tf . ... �,• r ! ; , •w�ww HH•11w H. 6 ,(•' }T -t •t +., .. •, . • .ter .• - '; 17. Waters in suit# , , .:. r , btr`(stirfacc)�effe ... :.:....1 :................... /....sees:..:... sees. .. sees ... ... ........... .. • ., ..:1.,! a . ..,. .. ... sees. .. ... .. . sees. _ '• ,. .. — 18: Is project located "near a puiilic water supply system?, 19. If yes, name ofwater'sup�ly� _ ': ,� Distatc• to water: su ISP roject site near a public sew ge.0.0 He cdoa or treatmeAt systettt? 21. Name of sewage system c1 �c Distan _ to sees. __::;_sees : • t ; ca ' sewage system : f 22. Date••testholes observed"`":4..5 . °• :. ,.,.:..•. 23. Name of Health Inspector 1044i\ { OkE1 ,sees. ...__...:. _.. .. A 24 • Project deslgn flow (gallons per day) :p.C� ... . 25. Is State Polluteiit Discharge Elimination System (SPDES) Permit required ?... N 1% rr_: nntwnn:A'-* '-tt`__:Z :; L_.._ _..L• �aa��i Is an portion of this r ct located wlthin-a designated,Town or State;wetlaid? N._p yp . ,.p. Wetlands ID Nui/fiber.. too :. Ito oil t ....... to It ..:.,...,.. too* ,...,. sot logo Its* . :,.:.: ..,..,..,1.1«�11910.:-Pei .s Is Wetlands Permit r4quired? ..: N: o Has application been made to. Town or Local DEC office? . ........................:...:.. N, Does project require a DEC Stream Disturbance Permit? .. ....$09.0..,.,,....0........... a,.. Is or was project site Ovid for agricultural activity involving application of pesticides to. orchards or other crops, solid or Hazardous waste disposal,'e = landfilling, sludge application or industrial activity? ..9:::......0....0......::.. Yes/No Is -project located wlthiti' 1,000 •feet'of existing •orab4ndoned landfill; hazardous waste.site, salt stockpile, landfill, sludge disposal site or any r� other potentially knowuource of contamination? .....:..00.,0.0.9..90.9....;0.; Yes/No :fir:::..;';:'- ,:,F..;,:..:;:... • DESCRIBE: - - Is there a'local master plan on file,with.the Town or Village? .......::............:... "' y�.:r Are community wgt;r:and/or sewer facilities planned to be developed within.: 15 yews in or adjacent to pqo ect site?................ Are any sewage treatment areas In excess of 15% slope? .. ,...,,.,._......,,,...,,.,x.., „. 6 Tax Map ID Number ,,..9..: Map_.,$Block 'tot' Approved plans .are-to b-creturned to ...0. _ Applicant � A,esignProfessional... , FE: All applications_ for review' and approval of a new SSTS to be located wid the.NYC,VKatershed shall :nt to the Deparunen*4'necd-not be sent ,in•duplicate to the DEP, although-the project may require DEP ,oval of the 'SSTS prior to foal approval by the Department., Projects within the watershed may also` ire DEP review and approval of other aspects.of a project, such as 3tortnwater-pl,axis -O't "the cr "cation :rvious surfaces, and the project:applicant should obtain the appropriate farms for. such activic'ies from. and submit -those forms to',DEP for rcview•and approval. - applicatioh'is signed by a person other than the applicant shown to Item .1 the application musi :companied by a Letter of Authorization (Form LA -97)9 Failure to comply with this provision be grounds for tie rejection of any submission.. , 1 hereby ajJlr_m, under penalty,of perjury, Thal injormallon provlded_on ro the best o m knOwled a and belle alsestatements made heieln•are, punishable ar Q jy $.. l�'. class ''A' misdemeanor ursuant 10;Seellon Z1O.0 o the Penal Law P of the & 91Fl1"LES; J. kvi y _ 146W V., r�lVf Ll�* Pt; P _�-U, r� ng Address: .... .0............0...9......0..09. 101' ° _ .. ��� �' `050' '• • . -• . • To: t\e S MID Attention: Harry W. Nichols Jr., P.E. rU—"A Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Aq" Telephone (845) 2794003 Fax (845) 2794567 Date: S M 01, Job No.: Project �00 ' Saor+PW®." p Gentlemen: We enclose ( ) copies of B/W Prints Reproducibles Reports Tracings Specifications Memorandum Copy of letter Description: Peg) om IIFIf 4�0tTS Revision/Date No. Sent Via: Our Messenger Your Messenger Copy to Blueprinter Hand Delivery First Class Mail Special Delivery V . Nichols Jr., P.E. \\ � - +�.a•"� \ice w \i \\ ```� ' \���� ` �__� -_ - - -- \ \� _ �\ \,Ni \` \ . i \ \ \ \ NN N *N `\ • q \ \ \ NN 19\ N \ w / I _ Q \ ;' �\ \\ \ IN Sp r N NN ol \\ ,: ' \ \ NI s �y \ \ N. Rt MA L= r Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 February 4, 2001 Mr. William Hedges Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSDS Repair /Addition Blanar Town of Patterson Dear Bill: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSDS," dated 2/04/02. 2. "Short EAF," dated 2/04/02. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 2/04/02. 5. "Design Data Sheet." 6. "Letter of Authorization." 7. Two (2) copies of Residence Floor Plans) _ 8. Review Fee in the amount of $100.00. We would appreciate your review, approval and issuance of the Permit at your earliest convenience. Very truly yours, Harry W. Nichols Jr., P.E. HWN:JM:jm (f 01 -071.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at 6�0 f p� 1-0 M�� �o m TN �Q� Tax Map # ��° Block Lot �S Subdivision of —' Subdivision Lot # Fil*ed Map # _ Date Filed Gentlemen: This letter,is to authorize �",, W , 0� (J tA0 LS, J�' .9 F- a duly licensed Professional Engineer )— or Registered Architect to apply for the required ,,wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance ,,�,ith the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems 1:1 corormiry with the provisions of-Article 145 and/or 1.4.E of the -Education Law, the Public Health I aw, and the Putnam C ary Code. NF FWro r Countersigned: P.E., R.A., # WF Mailing Address V � State tj Zip i o � 1 Telephone: Very truly yours, i C S gn ed: (Owner ocor roperry) Mailing Address: f` p ` State N Zip W5 b Telephone: ( ) (bq – ;U5 P J Fom) L:� t Second. Floor. w. Vi u: GEDAOO)4 3 0EDR009'2 1' X 161- G' --� —� j I :' • 3'X 10' O' 1 r • _A01 First Floor ; 1\ .I 1 DINING ROOK IE; -c'X I3,•a.. KIi CNEN ;t'.t'XIS'.a' r - �,, , it • .i f -(ASTER BEDROOK 11Yf:{6 ROOK. UP = 1 M� 0 1 N1 W ExIsr. WELL '71.82' wIl vi tr a EXIST'NG 3 � C. SR. a0 4 "d f-+IOOD 'SAL. AI. R� 1. 1 S @PTtc TAnIK 3 SrCENcE Q � "d SoI�D P ✓C i-�SCR 35 J. BOX CTYPj 2 , t9 25 4 23' 13 ~ _ -i . _ 3S' L 1 8 39! ZO P'/ GOLLb 9 4242, t �(TYP) t 10 Sol I S ' 17 10' j f6 19 3' 14 IS 1 0/,` ul 3 :o = p 1w �+! aN i �-,� /mil— in N Z k a �..- moos X5.65' H2501COVE 50.70' r4%%04 16 1'E M Tu MARKE RoA® ]DIMENSION CHART (in feet) Number A g I 28 21 37 3 21 42 4 21 46 5 24 52 6 2.9 57 7 34 G3 8 42 70 9 46 76 10 51 81 II 56 86 12 62 93 13 69 99 14 76 103 is 86 108 16 81 103 17 76 97 18 71 92 19 68 87 20 59 i8 57 75 22 47 65 23 43 59 24 42 55 25 38 49