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HomeMy WebLinkAbout0763DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -55 BOX 9 L i J 61 i W 1 1, I 1 ` L Rev: 3/84 Located at:G r G. Owner /applicant Name Mailing Address 1� 1�Yii V/ /� lIG.E G� Cwt 4 0 Separate Sewerage System built by h S�' f" Address 'Consisting of l_1 Gallon Septic Tank and 9 Water, Supply; PabBe Supply From' Address ' pp Y jL . or: ��� Private Supply DrlDed by Address i��� -. 3s 'I I %�a . �r v (r�4 4L X Building Type Kr:;� I de.+, I9 c ( Hoe Erosion Control Been Completed? Has Gbg.G'Been installed? of Bedrooms 'Other Regalremente I certify that the system(s) as listed serving the above premises were const ted eseentially as shown on the plena of the completed work (copies . of which, are.'attached)„ and in accordance with the' standards; rules, and reg 1 tion_s,' in a cordance with thplfiled lan, and the permit issued by the Putnam County Department Of Health Date - Cars Wed by Address Z. 5 4 1 I �ilr� i�= � W �' lT s�� License No._`� mss[ Any person occupying premises served by the above systern(s) shall promptly take such action as may be necessary to aicure the correction of any unsanitary conditions resulting from such usage Approval of .the separate sewerage system, shall become null and void as soon'at a pub(;: sanitary sewer becomes available ' and the approval of ,the _private water. supply ,shall, become null ana ";yoleh when s public 'water 'supply becomes available. Such approvals are subject ttoom�odiftufion or change when, in'lth.a judgment.4f the CommWioner of.Mealth, such revocation, modification or change is necessary. -2 z Gate _L By ��'� �'' Title w ti fi 4 .� WLLL UU1vLrLL11U" itCrvnl DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADDRESS: INNl I I Y TAi GRIO NUMBER: WELL OWNER NAME: ADDRESS: e0, S A e. u PRIVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary m RESIDENTIAL O PUgj� SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED O BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT _--cf— gpm. /NO. PEOPLE SERVED / EST. OF DAILY USAGE 0 gal. REASON FOR DRILLING .[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY ffNEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH __s; � ft. STATIC WATER LEVEL _ 0 ft. DATE MEASURED DRILLING EQUIPMENT O ROTARY COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE O SCREENED O OPEN END CASING OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH ft. MATERIALS: 9f STEEL O PLASTIC 0 OTHER LENGTH BELOW, GRADE � ft' . JOINTS: O WELDED CVTHREADED ❑ OTHER DIAMETER -7 in. SEAL: O CEMENT GROUT '0 BENTONITE U6TH R WEIGHT PER FOOT 17 Ib. /ft. DRIVE SHOE YES O NO LINER: DYES NO SCREEN, DETAILS DIAMETER (in) 'SLOT SIZE NGTH (ft) EPTH TO SCREEN (ft) DEVELOPED? FIRST YE O NO HOURS - - GRAVEL PACK OYES O NO �` GRAVEL SIZE: AMETEK OF PACK in. T OEPTN tt. B 1TTOht D PTH ft. WELL YIELD TEST ; It detailed pumping p p 9 METHOD: O PUMPED i tests were done is in- O COMPRESSED AIR , formation attached? O BAILED O OTHER ; ❑ YES ❑ NO 1i��LL LOG 'are more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FrROM SURFACE Water Bear- ing Well oia- meter FORMATION DESCRIPTION CODE tt ft. WELL OEM It. DURATION hr, min. DRAWOOWN ft. YIELD gpm. Land (� Q �' ec �e,e~ , oc' 6• � a ra_u CJ WATER VCLFAR TEMP. QUALITY O CLOUDY HARDNESS O COLORED ANALYZED? O YES ❑ NO ANALYSIS ATTACHED? O YES O NO STORAGE TANK : TYPE CAPACITY GAL.. PUMP INFORMATION �5/ TYPEI.?6/0 If CAPACITY MAKER DOH MODEL VOLTAGE ��HP WELL DRILLER NAME DATE Ao4VERT M. HYATT & SONS, slGt�r7tiURE %-- Wgll Drilling Rte. 311 R.R. 2 c?ox 171Al[ ,- r YORK PUINAM COUNTY DEPARTKENr OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Owner or Purchaser of Building Building Constructed by Location — Street Section Block Lot Subdivision Raffie Municipality Subdivision Lot # Building GJARANrEE 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 detenu nation of the Director of the Division of Environcrental 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. / �� "I,- .11 Dated this ,*" %� davffh 19 Signature Contractor (Owner) - $ignature Corporation Name (if Corp.) Address rev. 9/85 mk Title ';�_r.S"I - /p. /114- Corporation Name (if Corp.) AIX Address s ANALYSIS DATA SHEET TYPE: PW LOCATION: Keasbey, Couch Rd., Patterson, NY REPORT TO: Hyatt Pump ADDRESS: RR2, Box 141C CITY, STATE, ZIP: Holmes, NY. 12531 DATE COLLECTED: 02 -15 -93 TIME COLLECTED: 9:30 AM COLLECTED BY: Hyatt d REPORT DATE: 02- 18 -93' SAMPLE: 93 -0575 SAMPLE SOURCE: Outside fauc_et,__ DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform Absent COLILERT 02 -15 -93 THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET THE REQUIREMENTS OF NEW YORK STATE DRINKINGWATER STANDARDS. Laboratory Director NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914-278-7600 / FAX 914- 278 -7754 L_ t C'C cr=- C= f_C-` 'ter - 1 �� t ryL'" i r'it':L � �.� � -'ter: �� ter•:- _ - r- 4 C. j CCc C= C. 10 - --- _- C =�.C�• Li � _ -_ - it -==- - ' =L :- =___ � I Eie 7. r- •- nc_Ci. �L� E. F.cc: Z. 7. E:-� - -- L--s ALLL— .`I..._i 1 r•�� =- _= t� crC =CVc'' D i E^.c _ I AI.L all c_ �_ —_ = �__ =_ °- �_•_`_= wig � - _ =�==' °- • I 1;i �+i Ccc f ' c: a Gi = `'1 l: �_C� CL �C-- 5 �.:nris < 2 : L ^ ' cC:CrC:rc l Tian C-12cn.=rce away Cwt r_ ca S! CCES czaa. � r MEOW" L !r DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address C Town/Village/City Tax Grid Number WELL OWNER Name al ing Addres a5 6. � S CIPrivate D Public USE OF WELL 1 - primary - secondary (.RESIDENTIAL D BUSINESS D INDUSTRIAL rr O PUBLIC SUPP Y O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, D AMOUNT OF USE YIELD SOUGHT -!5 gpm /# PEOPLE SERVED 3 • /EST. OF DAILY USAGE nQ,. Sal O REPLACE EXISTING SUPPLY O TEST /OBSERVATION 0 ADDITIONAL SUPPLY 91NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL _ REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE MPRILLED O DRIVEN ODUG O GRAVED O OTHER 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 I_V5 7 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >C NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE *' TO PROPERTY FROM NEAREST WATER MAIN: ryA/A LOCATION SKETCH & SOURCES OF CONTAMINATION PROVID (SON SEPARATE SHEET 7,15 -�j2 ` (date) s nature 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. During all well drilling operations, the applicant h t any and all water or waste products from such well property and in such a manner as not to degrade or Date of Issue: ��t�� /� 19 G° Date of Expiration 191 shall take appropriate action to assure t a drilling operations be contained on this otherwise contaminate surface or groundwater. Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller i i i PUTNAM` COUNTY H�pLTH DEPT r Q 1$19 ' 110 Old Rf 8 Cte: Phone 914 225 0310 L Carmel,�New York 1051'2 ,Date' 19 JOHN N. CALBO Building Inspector TOWN OF PATTERSON PUTNAM COUNTY PATTERSON, NEW YORK 12563 July 28, 1992 Mr. William Hedges Public Health Sanitarian Division of Environmental Health Service Geneva Road Brewster, New York 10509 Dear Bill, According to Patterson Town Code, the property known as Tax Map # - 15 -1 -3, New TM # - 24. -1 -55, is considered to be a buildable lot. . Sincerely, Jo N. Calbo __. B44ding Inspector JNC /cs Telephone 878 -6319 LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 RANDOLPH W. LAURENT, PE. (914) 278.6108 -(FAX) 278.2658 I HARRY W.NICHOLS, JR., PE. CONSULTING SITE ENGINEERS List of Contiguous Property Owners Lands of Thomas & Edith Keasbey Couch Road Patterson, N.Y. 24 -1 -54 Thomas & Edith Keasbey 24 -1 -56 Couch Road 14 -1 -6 Patterson, NY 12563 24 -1 -57 Norman & Mary McGrath 164 West 79 Street New York, NY 10024 24 -1 -48 Heinz Luschinsky RR #2 Box 225 Patterson, NY 12563 24 -1 -53 John Urban 46 -10 Union Street Flushing, NY 11355 14 -1 -7 Virginia Hall 14 -1 -8 Couch Road 14 -1 -9 Patterson, NY 12563 14 -1 -10 Lloyd G. Bayme 929 Ocean Parkway Brooklyn, NY 11230 FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT Thomas & Edith Keasbey Couch Road Patterson, NY 12563 Dear Mr. & Mrs. Keasbey Date July 28, 1992 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: Thomas & Edith Keasbey Address: Couch Road Town: Patterson, NY Tax Map : 24 -1 -55 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call Mr. Hedges or Mr. Morris of the Health Department at 225 -0310. Very truly yours, B Title Agent- Laurent Engineering Assoc, P.C. RECEIVED BY: Address: Tax Map: JK;cj FORMAT NEIGHBOR. NOTIFICATION CONSTRUCTION PERMIT Norman & Mary McGrath 164 West 79 Street New York, NY 10024 Dear Mr. & Mrs. McGrath Date July 28, 1992 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: Thomas & Edith Keasbey Address: Couch Road Town: Patterson, NY 12563 Tax Map: 24 -1 -55 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call Mr. Hedges or Mr. Morris of the Health Department at 225 -0310. Very truly yours, B Tit le Agent- Laurent Engineering Assoc., P.C. RECEIVED BY: Address: Tax Map: JK;cj FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT Heinz Luschinsky RR #2 Box 225 Patterson, NY 12563 Dear Mr. Luschinsky Date July 28, 1992 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: Thomas & Edith Keasbey Address: Couch Road Town: Patterson, N.Y. Tax Map: 24 -1 -55 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call Mr. Hedges or Mr. Morris of the Health Department at 225 -0310. Very truly yours, B Title Agent — Laurent Engineering Assoc, P.C. RECEIVED BY: Address: Tax Map: J.K;cj FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT John Urban 46 -10 Union Street Flushing, NY 11355 Dear Mr. Urban Date July 28, 1992 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: Thomas & Edith Deasbey Address: Couch Road Town: Patterson, N.Y. Tax Map: 24 -1 -55 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call Mr. Hedges or Mr. Morris of the Health Department at 225 -0310. Very truly yours, Title Agent -T gurant Fngi nearing AccnC, P.C. . RECEIVED BY: Address: Tax Map: JK;cj FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT Virginia Hall Couch Road Patterson, NY 12563 Dear Ms. Hall Date July 28, 1992 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: Thomas & Edith Keasbey Address: Couch Road Town: Patterson, N.Y. Tax Map 24 -1 -55 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call Mr. Hedges or Mr. Morris of the Health Department at 225 -0310. Very truly yours, B Title Agent- Laurent Engineering Assoc., P.C. RECEIVED BY: Address: Tax Map: JK;cj FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT Lloyd G. Bayme 929 Ocean Parkway Brooklyn, NY 11230 Dear Mr . Bayme Date July 28,' 1992 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: Thomas & Edith Keasbey Address: Couch Road Town: Patterson, N.Y. Tax Map 24 -1 -55 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call Mr. Hedges or Mr. Morris of the Health Department at 225 -0310. Very truly yours, By Tit leAgent- Laurent Engineering Assoc,. P.C. RECEIVED BY: Address: Tax Map: JK;cj P --03.1 -94 -1 39.6 RECEIPT FOR CERTIFIED MAIL NO INSURANCE COVERAGE PROVIDED . NOT FOR INTERNATIONAL MAIL (See Reverse) 9e"�b4 f(i Se "o hl CIS o> d P aS a and ZIP Code I Sr ! C 10 d Postage $ y '-75 , Certified Fee ' r OO Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to whom and Date Delivered B� CIA Return receipt s6owing'i6'whom, 45 Date, and Address of Delivery a TOTAL Postage and -Fees- $� m U. I g PostmarWor Date f E rj� U. a p 0 3 y '14.1- -.- 7 s RECEIPT FOR CERTIFIED MAIL, , NO INSURANCE.COVERAGE PROVIDED NOT FOR INTERNATIONAL MAIL (See Reverse) S nt to rQ Q 4 m 4 Street and No. Q co ► I l )eS C P. :,State a d ZI Code row, f O Postage `7� (A 6 Certified Fee Special Delivery Fee l Restricted Delivery Fee Return Receipt Showing to whom and Date - Delivered N Return receipt showing'to whom, w Date, and Address of Delivery A TOTAL Postagerand Fees $:oj LL c Postmark or Date ri ao :r E _ f' O LL N P 526 170 574 RECEIPT FOR CERTIFIED MAIL No INSURANCE OE PROVIDED NOT FOR I RNATIONiERNA710 . NAL MAIL (See Reverse) 1204 N e Se to co Str t and Due -Gact d P Q• t to and ZIP Cod;' mac, * Postage S r75Certified Fee Special Delivery Qd r Fee Restricted Delivery Fee Return Receipt showing to to whorn and Date Delivered om Return te eceipLshOwing+to whom, r O0 m ridress` -o p bve TOTA ostage and Fee ees s _ 4 1 M Postmi a'rk pr Da`te- C 1L 0 t ' IL f� P 0 31 9 -41 -3 9 7- P 526 170575 RECEIPT FOR CERTIFIED MAIL RECEIPT FOR CERTIFIED MAIL NO INSURANCE COVERAGE. PROwOED, NO INSURANCE COVERAGE PROVIDED NOT FOR INTERNATIONAL MAR NOT FOR INTERNATIONAL MAIL (See Reverse) qap� � a Sent to j (See Reverse) N i►!V C�. pie. i i mStreet and No. co d W., State and ZIP Code I r l Postage S O + d Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt showing to whomy,and_Date Delivered J C� oo Bet rn Receipt showing to whom, t i " Mat Addrese,of- Delivery i TOTAL Postag"ndFees I g Tostmark,or Date a ` E N i N r Sent t r Stre and No. on L, - 10 tin P.O. State and ZIP Code hi Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to whom and Date- Delivered 7, i00 Returndeceipt shoWing'to, whom, W a TOT ostage.and Fees ?,',, $ c Postmirk�or -'Date rn a v Ch co aD a 0 E 0 U. rn CL P 031- 9.4.1 394 RECEIPT FOR CERTIFIED MAIL NO INSURANCE COVERAGE PROVIDED NOT FOR INTERNATIONAL MAIL (See Reverse) n no Uzl Sent to Str et and o. P .,. a ano Code OS (o3 Postage $ Certified Fee r Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to whom and Date Delivered /i 00 Return receipt showing to whom, Date, and Address of Delivery TOTAL Postage,and; Fees $� Post f rk or Dates 4, Date,fand,Af3dress of Delivery v Ch co aD a 0 E 0 U. rn CL P 031- 9.4.1 394 RECEIPT FOR CERTIFIED MAIL NO INSURANCE COVERAGE PROVIDED NOT FOR INTERNATIONAL MAIL (See Reverse) n no Uzl Sent to Str et and o. P .,. a ano Code OS (o3 Postage $ Certified Fee r Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to whom and Date Delivered /i 00 Return receipt showing to whom, Date, and Address of Delivery TOTAL Postage,and; Fees $� Post f rk or Dates 4, PUTNAM COUNTY D E PARTMENT O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL f SYSTEM 1. Name and Address of Applicant: ✓1 V1�Srnit cat r`7"fi� �t°GZSYJ�L.� C67u0_-k POV* --A 2. Name of Project: ��/�POSel S0, y5 3.._ Location T/V/C: (� S 4. Project Engineer: i2ixvv(DIak �- a1AV r-F�• 5. Address: 'f:a:- 4C��G� t�c,r�i �y�7�rc9►71®>(sS�,P.c �f A Szm N` License Number: Phone: .-bl ofd 6. Type of P o ect: _K Private /Residential Food 4ervice ....Commercial , Apartments Institutional Mobile Home Park Office Building, Realty.Subdivision Other (specify) 7. Is this project subject to State Environmental.Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted _Y� 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. _ w o 9. Has DEIS been completed and found acceptable by Lead Agency? ........... _�(/A 10. Name of Lead Agency 11. Is this project in an area under the - control of -local planning, zoning, or other officials, ordinances? ........ ............................... 12. If so, have plans been.' submitted. to .. such - author sties ?..,............ 13. Has preliminary approval been granted by such authoriti s ?- °'Date Granted: 14. Type of Sewage Disposal_ System. Discharge..,... Surface Water Ground Waters 15'. If surface water discharge, what is the stream class designation ?........ I-l/A 16: Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. U b 18. If yes, name of water supply 1.1 /A Distance to water supply _ 19. Is project site near a public sewage collection or disposal system ?..... N D. 20: Name of sewage system N /A Distance to sewage system I21. Date observed: %-11 -I -_ 23. Name of Health Inspector: i/.1. t- �F_flL�C —.tea 24. Project design flow (gallons per day) ...... ............................... ;?�00 • 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. 11�1 n 26. Has SPDES Application been:submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... NO 28. Wetland ID Number ........................ ............................... 29. -Is Wetland Permit, required? �... ........................... 0... 0.......... Has application been made to Town or Local DEC Office? .................. ;N% 30. Does project require a DEC Stream Disturbance Permit? ................... 'N r7 31. Is or was project site used for agricultural activity involving application of pesticide$_ to orchards or other crops, solid or hazardous waste disposal,``'`` landfilling, sludge application or industrial activity? ........ YES or NO 32. Is project located within 1.;000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ....:.........YES or NO toll DESCRIBE: 33. Is there.a local master plan or file with the Town or Village? ........... 34. Arecommunity water, sewer facilities planned to be developed within 15 years? •NCB 35. Are ,any sewage disposal areas in excess of 15% slope? ........................ Z? 36. Tax: Map ID° Number ......................................................... 37. Approvedr4.Plans are to be returned to: ............U.... Applicant DC Engineer If the application is signed by 'a person other than the applicant shown in Item 1, the. application must be accompanied by!a- Letter. of Authorization: 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. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Pena I Law. SIGNATURES & OFFICIAL TITL MAILING ADDRESS: I G lr r e't Nardi?' i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date ?- Re: Property of ') homa S q i (-A-n Kea & Located at C6rZ,�C --t, Section 2,4 . Block Lot 5� Subdivision of Subdv. Lot # Gentlemen: Filed Map # Date This letter is to ,authorize�Ql. e �/� i'� W L /eL=,v` a duly licensed professional engineer or registered architect (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. OF N , A,, *ILL C o u n t eIA ItB &.- P.E. , J!i. , # 7-1 /61 N e y e. Address ?049(910 0 Telephone Very truly yours, Signed OwnYr of Property — t R+ D 2-ok ?2,z UOCL a-, Address ""-RX 1 Z�7o3 To Q 14- 97 W 616 Q Telephone OF 2 •O ID 0 • k. DESIGN DATA SM T- SUBSUFACE S5gAGE DISPOSAL SYSTEM FILE ICU. Owner l Y1/) r n S �' E) i-i% Kt°y S Lee Address ���(,1 <' (n 12 3 located at (Street) �" Loca �'�1 �C`:in �'G /X. � Sec. :7-4, Block Lot 55 (indicate nearest cross street) _� Municipality Watershed ( V-0 �-rn SOIL, PERCOLA ON TE'S'T DATA REQUIRED TO BE SUBMI= WITH APPLICATIONS Date of Pre- Soaking 1-7 -10 !9,z Date of Percolation Test -7 - 5 HOLE N[F1HM CROCK TIME P�.�f" tCOL,ATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 2 � P> 4 �r- 2 2 + --Y 2 3 ti 4 5 1 - : o0. o 2 3 4 5 2-7 3 - 3 �•. 2.. ' •2 2 2 � P> 4 5 NOTES: 1. Tests to be repeated at same depth until appraximately equal soil rates are obtained at each percolation test hole. All data to'be sutmittd for review: 2. Depth measurements to be made fran top of hole. TEST PIT DATA REQUIRED TO BE SUBMITTED. WITH APPLICATION OF IN TEST HOLES DEP'T'H HOLE NO. ( HOLE NO. 2 G.L. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' b I ?" HOLE NO. a 14' _. INDICUE LEVEL AT WHICH GROUN9,gATER IS ENCOUNTERED INDICNTE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �.� . J-aU (N �l.� . Pc G�c'S DATE: 7- 2 DESIGN. Soil Rate Used jI-Ir�2 Min/1" Drop: S.D. Usable Area Provided No. of Bedroams f Septic Tank Capacity ( 25© gals.' Type C��C Absorption Area Provided By 5a p L.P. x 24" width trench Other Address +/ ;\ J4 q SEAL THIS SPACE FOR USE BY fiEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date 2 of 2 PUn,41M .COUNTY DEPARTMERr OF HEALTH . DIVISION OF ENVIRCNMENTAL HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE S5gAGE DISPOSAL SYSTEM FILE NO. . '1=5 Owner `t i S Address C,,:7 Located at ( Street) Cev elt-, 90A,4 Sec. 24 . ' Block I Lot O� (indicate nearest cross street) Municipaiity f G[" 466,0-n Watershed C"10 SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATICNS Date of Pre- Soaking -7 -10 '-1 2 Date of Percolation Test -z- HOLE NtbMM CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fresn Water Level No. Time Ground Surface In Inches Soil Rate Start Stop.Min. Start Stop Drop In Min /In Drop Inches Inches Inches 24 27 3 ( D a 3 5: 5- �,,. aa . 4 2,50 3 5'.-7yl 6' 4 5 2-7 : . 2 Vj TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS EZKXXMMM IN TEST HOLES DEPTH HOLE NO HOLE NO. HOLE NO. G.L. t f 2' Sal,- A, W 3 Ac 1 41 51 61 71 81 91 10 12' 13' 141 INDICATE LEVEL AT WHICH GROUNUKATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING. ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �fd DATE: -7 -01 DESIGN Soil Rate Used I Min/I" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity 1,2 gals.' ' Type(/p,10 Absorption Area Provided By 3,-0 L.F. x 24" width trench Other I' Tom,-o � i-)A �-/;f -,Y,, Name Ltf FA,-A.-Assec �-',C Signatur �a, e-5?TJ 41 Address -7 r i e_j V -e- SEAL THIS SPACE FOR USE BY'HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft/gal. Checked by I 9`11k Nc Date -90 ;590 - TOPOGRAPHY J p PREPARED FDR THONAS 8 EDITH KEA. t TOWN OF PATTERSON PUTNAM COUNTY, NEW Y JUNE 24, 1992 OF SCALE.• l " --JO' 587.53 Underground u/i/i/i, J _ f174 6 y , /i if any, no/ shown, KYLE L. A LER, P. L. N.Y. Lic. No. 49887 i WILLOW ,/4 i SBSrr ` KAYLER SURVEY /NG, P.C. 57578, 7. o / - SURVEYORS AND L "AND MANAGEMENT PROFESSIONALS / GO GLENEIDA AVENUE CARMEL, NEW YORK 10512 15 B6.J4 (914) 228 -4048 dp- mol 51-040 ¢�-.- _ T.M. 24. -1 -55 5 -1 -3) ------------------ - - -- / 1 - - -- -A ReSloEtvice / _ - -- - - - - -- °- cri .o • �� � �� ". c . b:F.EL.CoO - - --- - �� - _ -- -jils I4914.LI$ -ED - --------- - - ---- ,/� -cr.� g¢2 SUNC -i1 -_��_� �5q�FA09RLiP_fION ✓ /� t, f•1 r 'V o V' 2 4- IT A4 •Y (�y/v�p" Q I atTr G h.t �P �rT. o \�\ �¢ kr•� rY. I t f }} GO UG'H elf I J)54S tJT !<07 � y yyy d' PROP.FIU•GK.4t9G �' 599 Aff'" c. 10 LI'. a 2.0 /� . O'f�AOE % 1250 bALLON r �� Z ��. N rf N \9 V SEf'fIG TANK