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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -80 BOX 9 I ME oil m NEI ■�� , is .. . km! I ,6 ED 16, ,, , t 00772 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street ddress: Uq �I To �' illage: P ✓ T �' � Tax Grid # Map 21 Block � Lot(s)80 Well Owner: me: Address: Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _Other Casing Details Total length 0 ft. Length below grade 3 ' ft. Diameter in. Weight per foot lb /ft. Materials: Steel _Plastic _.Other Joints: _Welded Threaded _Other Seal: 'Cement grout _ Bentonite Other Drive shoe: •Yes No Liner:_ Yes • No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _Bailed _Pumped `Compressed Air Hours Yield � gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed�gll in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description '�.. 1'...Y ;..�- -, rrj -rs ft. ft. Land Surface ', '• � r If yield was tested at different depths during drilling, list: Feet ^ , Well Location Street ddress: Uq �I To �' illage: P ✓ T �' � Tax Grid # Map 21 Block � Lot(s)80 Well Owner: me: Address: Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _Other Casing Details Total length 0 ft. Length below grade 3 ' ft. Diameter in. Weight per foot lb /ft. Materials: Steel _Plastic _.Other Joints: _Welded Threaded _Other Seal: 'Cement grout _ Bentonite Other Drive shoe: •Yes No Liner:_ Yes • No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _Bailed _Pumped `Compressed Air Hours Yield � gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed�gll in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description '�.. 1'...Y ;..�- -, rrj -rs ft. ft. Land Surface ', '• � r If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type "� Capacity lip � Depth ZOO Model 7Eh710�¢•I y Voltage Z3D I•IP Tank Type'WX 3aZ Volume 8� Date Well Co pleted Putnam County Certification No. Date of Rep rt Well �I r (signa re NOTE: xac loca ion of well with distances to at least two permanent landm ks to be provtded on a sep ate sheet/ Ian. F ' Well Driller's �" 4r`i ' 4 t +'` ""' — Address: Signature: Date: White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 '-w a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P Located at 4 O P4L -a DP-1'-0 Town or Village Owner /Applicant Name Tax Map " Block )'— Lot X60 Formerly – Subdivision Name 0 l b Fl �_o Subd. Lot # 3 Mailing Address 4-c(, sa i�t" P-C) NP JQP�_ Zip 10604 Date Construction Permit Issued by PCHD 061 1'yI ©4 Separate Sewerage System built by la,,n Address 37 Oww, -wN Consisting of 1000 Gallon Septic Tank and 3 od ) 1 rce Je_ Pa-o L " Other Requirements: Water Sup&: Public Supply From or: ), Private Supply Drilled by'N"L -4 0� Address Address kik /" Oi14 Building Type ilk M Has erosion control been completed? YO Number of Bedrooms Has garbage grinder been installed? k 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 regulatior}s of the Putnam Counity Department of Health. Date: Certified by , Address P.E. P" R.A. License # ;' 6-1 1; - f 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 bject to modification or change when, in the judgment of the Public Health Director, such revocation mo z cati r change is necessary. By: Title: Date: 0 //10j White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street ddress: r V a." e— V. Tfillage: P lI i 611 Tax Grid Map 21 Block I Lot(s) 00 Well Owner: e: Address: Ko lc(� 466 rd P4. Armonk N•1 Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump . Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length D ft. Length below grade 3 ft. Diameter in. Weight per foot lb /ft. Materials: Steel _ Plastic Other Joints: Welded A Threaded Other Seal: Cement grout _ Bentonite Other Drive shoe: X Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _Pumped ' Compressed Air Hours Yield _/O gpm Depth Data Measure from land surface - static (specify ft) ?1 During yield test(ft) �- j- r Depth of completed Il in feet Z I— Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 01 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ;, Capacity lip si Depth 200 Model '76H10417, Voltage `Z30 HP l Tank TypeLJX 362_ Volume NNe, Date Well Cc pleted il V Putnam County Certification No. I G G j Date of Rep rt 1-- 'V G IW7 t r (signa re N OTE: Exact/location of well with distances to atj least two permanent landmkks to be provided on a separate sQheett Ian. Well Drillers Li", �e ��' l� `t i1'` �C-- Address: Signature: ' Date: oc. 7�3 'White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 � BRUCE R. FOLEY - LORSITA-'MOLINARI R.N., M.S.N. Public Health Director Amookie. Public Health Director 10 D&*tor Q/ Patl�nt Scrvtccr DEPARTMENT OF HEALTH 1 Geneva Road Browster, New York 10509 SavlroomeaW HW1h (914) 271.61)0 fix (914) 271.7921 Nurnlal Services (914) 271.6551 WIC (914) 271.6679 .Fa (914) 271.6015 Eu1y'Io1crv4ff6a *(914)111'•6014 Pradool (914)271.6012 Fut(914)171.6641 OWNERS NAME: 1� TAX MAP NUMBER: 2A, ° E911 ADDRESS: _ R -016 _ „ �1 UN F TOWN: ate' X AUTHORIZED TOWN 0MC1AL: �! � (Signature) )k`k� DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official:.This form is to be submitted with the application for a Certificate of Construction Compliance. F7, O W, S 42 16' 14:' E7 OD 4 _5 07 tz IV X 2i 20 a 19/ to ID ,9 18 17 I6 15 1+ 13 rm 0, &� o) 02 I Isr , 00/,'u i 1 C53 t )(00 Q1 08,02 - 1, . 13o.00" L 8 p, A 0 L E Y O lb wy DIMENSION CHART (in feet) Number A i 29 15 2 30 22 3 13 91 4 11 g� 5 10 91 G 10 89 .-7 10 88 8 -11 81 9 13 86 10 74 86 11 76 87 12 So 89 13 43 52 14 39 52 15 37 53 16 35 54 17 35 57 18 36 60 19 38 64 20 41 G5 2 1 45 73... -PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUIBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot Pz�VY \U Building Constructed by Tow ge 47tr,se)Lj All B iej E Location - Street Subdiv4sion 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 prarr-of said 'S3 stem coris1ructed 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 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:. ..._. Dated: Month 5 Day fie Year DS�" G� _." Geneial Contractor '(Owner) = signature Corporation Name (if corporation) Address: +e14 r3 _r4�� R04i A w01C4 State Zip S'o Signature: Title:..1 Corporation Name (if corporation) ICJ Address: / J State Zip L Form GS -97 ':9i .'L ..:A .. ..+ .. Name: Sample Date: Receipt Date: Report Date: Sample Site: L AQUA ENVIRONMENTAL LAB 56 Church Hill Road • Newtown, CT 06470 • (203) 270 -9973 Ross Alan 466 Bedford Rd Armonk, NY 10504 5/5/2005 11:00 AM 5/6/2005 11:00 AM 5/12/2005 4 Bradley Drive, Patterson, NY Report of Analysis Sample ID #: 56623 Sample Type: Drinking Water Sampler: RA Parameter Sample Result Units Limits Biological Coliform Bacteria absent none 0 e Coli Bacteria absent none 0 Metals Copper 0.03 mg /L 1.3 Iron 0.21 mg/L 0.3 Lead <0.001 mg/L 0.015 Manganese 0.03 mg /L 0.05 Minerals Alkalinity 80 mg /L No Limit Set Chloride 94.5 mg/L 250 Hardness 241 mg /L No Limit Set Sodium 9.2 mg/L 28 Sulfate 21.0 mg/L 250 Nutrient Nitrate as N 9.1 mg/L 10 Nitrite as N ND mg/L 1 Physical Color 5 Cu 15 Odor 0 0 -5 Scale 2 PH 6.9 SU 6.4-10 Turbidity 2.5 NTU 5 Comments: Based on the bacteriological examination, this water was safe for drinking purposes at the time the sample was collected. Report Approved bjL 1� -LA CT Lic PH -0787 NY Lic 11706 Page 1 of 1 ND = Not Detected * = Above Specified Limit SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 May 25, 2005 Re: Proposed SSTS: Alan 4 Bradley Drive, Lot # 3 (T) Patterson, TM # 24 -1 -8 ROBERT J. BONDI County Executive Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: 1. The results of the well water analysis have not been submitted. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve y yours, Robert Morris, P.E. Senior Public Health Engineer RM:kly Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 A May 16, 2005 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 27913567 Email: hnengineer@aol.com RE: Individual SSTS Compliance — Ross Alan Big Elm Subdivision — Lot # 3 4 Bradley Drive Town of Patterson, NY T. M. # 24. -1 -80 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As Built SSTS ", dated 05/16/05. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 05/16/05. 3. Three .(3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 05/16/05. 4. Laboratory Report, dated 05/12/05. 5. "Well Completion Report", dated 12/02/04. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated 07/11/02. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nich Jr., P.E. HWN:gav 00- 093.00 yU —'f vv t l . AQUA ENVIRONMENTAL LAB 56 Church Hill Road - Newtown, & 06470 - (203) 270 -9973 Report of Analysis Nanic: Ross Alan Sample.lD#: 56623 466 Bedford Rd Sample Type: Drinking Water Armonk, NY 10504 Sampler: Rn Sample Date: 5.,'M005 11;00 AM Receipt Date: 5!6/2005 ' 1:00 ANI Report Date: 5/12i2005 Sompic Site: 4 Bradley Drive, Patterson, NY P4rarneter i Sample Result Biological �- Coliform Bacteria e Coli Bacteria Aietats I Copper Iron I Lead Manganese Minerals Alkalinity Chlo6de Hardness Sodium Sulfate 1 ?nutrient Nitrate as N Nitrite as N Physical +, Color Odor PEI Turhidit}- Units Limits absent i none J absent none L- 0 0.03 mg %I. 1.3 0.21 tng %L. j 0.3 °01001 mg /l. 0.015 0.03 mg, 1. 0.05 80 I 1114 %L. I No Limit Set 94,5 I n1 if., I 250 241 I rngiL I No Limit bet 9,2 mgJ. I 28 21.0 ( mg L 250 9.1 mg/ L T 10 Nn ntgt 1 5 CG 15 0 0 -5 Seale 2 6.9 SU 6.4 -10 �I om rem Based on the bacteriological examination, dais waler was safe for drinking purposes at the tinge ch: sample was cullLcted.' Report Approved b..: CT Lic PH•0787 NY Lic 11706 PiloN r f7� i ND - tJut baecteo '= ;�iio'eSperi'.icdl.tmir � i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES�710 —® FINAL SITE INSPECTION Date: Zlfel4vy. Inspected by: Street Location - e :%r, Owner A /«-VA Town Permit # p — 13 ° 9!5- TM # -- l — SQ Subdivision Lot # 3 1. Sewage System Area a. STS area located as per approved plans .......... ................. b. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................. .. ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 1 00' from water course / wetlands ...... ............................... II. Sewage System a. Septic tank size ,000 ......... 1, 250 ......... other ................ b. ' Septic"tank irist evel ................ ............................... c. 10' minimum from fouridation .......... ............................... d. Distribution Bog 1 All outlets at. sameelevation water tested 2.�Protected-below frost..:.....: :.::� ............ 3... Minimum 2 ft. Original soil between box & trenches e. Junction Box properly set .......... ............................... 6. Trenches 1. Length required Soo Length installed 30,o 2. Distance to watercourse measured -1- ( o -t) Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 -11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped .... . g. Pumn or DosedpSystems 2. Overflow tank . . ............................%`� 3. Alarm, visual/ audio ........:........:.. ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... M. House/Building a. House located er approved plans ... ............................... b. Number of bed-rooms ................ IV. Well Well located as per approved plans ....... :........................ b. Distance from STS area measured oz ft........... c. Casing. 18" above grade ................ .............:................. d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a.. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :........................... i. Erosion control pprovided ................. ............................... Rev. ?2/02 I V ry u o� MMMMA M ii1� "Im no == Jr W FA FA MME davv .� PWAA iP2 Wr SITE INSPECTION FOR FILL PAD Y Date: / 1-7 d Inspected by: Fill pad located per the approved plan 7 S Fill Pad Length / / Required Length 112— Fill Pad Width Required Width 14/1 Fill Pad Depth 3 t O ! Required Depth Run -of -Bank Fill Quality , Slope from Top to Toe 7�e c,vm /efe� v�o ✓� 4r. Impervious Layer Installed �z°S Erosion Control Installed Ye! Sieve Test Results (if applicable) IVI,�' Additional Comments: r Reserved for Field Sketch if Applicable FEE -17 -2005 04:50 PM HARRY W NICHOLS ! a R.• 91'4 279-4567 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DINWON OF ENVIRONMENTAL HEALTH SERVICES QG --o c7,3 NNAL INSPFCTIMi For: Fill Date: Trenches _ PCHD Construction Permit # 3— Located: - (T) -u DO dwner /Applicant Name: ! s"f e 4-f a 1 TM fire Block / _ . __ Lot (90 Formerly: _ Subdivision Na 11'e: Subdivision Lot # Is system -fill completed? .l�: _ -7-C1 'Dal Is system complete') r Dal Is system coustzuated as per plans? Is well 'drilled? Da: Is well located as per plans ?: _ Are erosion* control M'easiires in plac'el I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance, with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. bate:. r Certified by: - E �y RA Desi rafessional Address Lic. # FOR: 13 ADAM 0•-GENE (NANS) 21 I l =1Mr : PUTNAM CC Form FIR-99 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health February 22, 2005 Harry Nichols P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr.Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Field Inspection — Alan Bradley Drive, (T) Patterson Lot 3, TM #24. -1 -80 ROBERT J. BONDI County Executive The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The fill pad 3 on 1 slope needs to be completed. 2. A pump test needs to be witnessed by this Department once the electrical inspection has been completed and notification of such has been submitted to this Department. 3. Retaining wall for the SSTS needs to be completed. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR: cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 tt , SENDING CONFIRMATION DATE : FEB -22 -2005 TUE 11:06 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME FEB -22 11:05 ELAPSED TIME : 00'41" ; MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... SdERLITA AMLER, MD, ME, FAAP ROBERT i. Rom Comndrr(ow ofH alto * Coun(y £oanun,c LORRITA MOLiNARI, RN, MSN - Axd- to CO- 41110aar of Health . DEPARTMENT or HEALTH I Geneva Road, Bi —strr, New Yolk 1(1509 I February 22, 2005 Harry Nichols P.S. Patterson Part; Suite 106 2050 Routc 22 Brewster; A-X 10509 .. kc: Field Inspection •- Alan Bradley Drive, Cr) Patterson I Lot "•;. TM "24. -1 -80 Dear Mr.NicholR; I The above referenced separate sewage trr- vlmc;u tt ^o:rm c?n be backfuled. The following comments must be corrected in the field. I 1. The fill pad 3 on I slope needs to be cwnplewd. 2. A pump test needs to be witnessed by this Department once the electrical inspection has been completed and notification of such bas been submitted to this Dopartmcnt. 3. Retaining wall for the SSTS needs ro he completed. Ifyou have any further questions, please contact nne nt (845) 273 -6130, ext. 2261. Sincerely. Gene D. Reed Sr. En irnnmru.tal Health Engineering Aldo GDR:cw • i I tp7lronn,mNl llnith (045) 218.6130 Fa(845)278 921 NardnB Berrrm (845) 278.655E 'NIC (845) 278.6678 F..(945)278-608 5 ' Gvlr lntar.enttonr4rrrdroo1 rR45)21FfAl•1 F'nr(045)27R.6648 I acknowledge recepti� of this report:: SIGNATURE: 02/96 Title: u o.; SHERLITA AMLER, MD, MS, FAAP Commissioner. of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health May 11, 2005 Harry Nichols P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Field Inspection — Alan Bradley Drive, (T) Patterson Lot 3, TM #24. -1 -80 ROBERT J. BONDI County Executive A re- inspection at the above referenced lot has been completed. There are no further comments to be addressed. at this time. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR: cw Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 i Early Intervention/Preschool(845)278 -6014 Fax(845)278 -6648 MAY -104 -2005 09:06 AN HARRY W NICHOL:= 914 279 4567 p, 02 aRV�ir . FOLEY Public Be lth- DirWor �- DEPARTNONT OF HEALTH 1 Genova- Road Brewstar, New York 10509 LORETTA MOLTNARl RN., M.S.N• dltortate Pub(!e Health Dlrecton Dfreel�r oj.PafterRt Servlae� ATTENTION: o ADAM STIEBELIt. G NE REED ,'J1 information below rnl4st be fW4 completed, prior to-.'d ny scheduling. DATE: ENGMC ER 01t FIRM: _.__ PHONKA REASON: - DEEPS: o PERCS: n PUNIY T)✓ST: ROAD/STREET: SUBDlYI510i�: t.�=,7 �--, _ _. _._.. LOTM: OWNER: NMI) P !QRITE RIA EQB JOIN1 RM NVY Abu M IMS I G OE SOIL 7,ES 'INC YrEs NO ❑ Proposed SM- within the drainage basin of West Branch or Royds Corner Reservoirs. 0 Proposed SSTS within 500 feet of_a reservoir, reservoir stem or,controt take, _ 0 Proposed'SSTS within 200 feet of a watercourse or a DEC wetltnd.' o Proposed S�TS design flow greater than 1000 gnllonsldajror MES Permit required, o Proposed SSTS _for :a Commerical Project. 1i is the responsibility of the design professional to provide the above information prior to soil testing. This D.epartrnent will determine the NYCDEP project status (Joint or Delegated) based on the response.. If you Answeredy -aY to- any-.of.the questions, NYCDEP must witness the soil testing. This Department will toordinate a mutually suitable time for field testing with the PCDOR, the Design Professional and NYCDEP. If a project has been determined to be.Delewed based an the above response and then subsequent information indicates NYCDEP i.r required to witness the soil testing; it will.be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DAT E: (F[ELDTEST) i -iQ•pa TAI 14111L GI ITNAM I MAY -04 -2005 09:07 AM HARRY W NICHOLS 914 279 4567 y 05/!84/Y005 07:35 914279403: P CARELLA ELECTRIC l ' 'ihe New York.Dowd of Pre Underwriters ' tlureau of 8l�ctruity 61 in ilia prucoee uE ideulj* a cowfieate of cumpliaivip for the eiectrita] itwW1Atl0n as pnsridad for i11 the cpplicatio A fnr !�� 1 ln=ipactiu� Now York Hord :of Fire Under writers sureau of .Fletpic7ity Tnepeclion activity pursuant to Application has..... 0*q*1w AM A belt&qte df . compliame iattina forth. the detail of the 41ecQr{cal a fain la being prepared,, :.: Wpector - r,ruiuN� Cllr•, iw�lRn P.03 PAGE 01 I MAY -4- 2005 14ED 09:25 TEL:845- 278 -7921 `1AME :PUTNAM COUNTY DEPARTMENT OF P. 3 I SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health January 27, 2005 Mr. Harry Nichols Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Field Pad —Alan Bradley Drive, (T) Patterson Lot #3, T.M. #24. -1 -80 ROBERT J. BONDI County Executive An inspection of the fill pad at the above referenced project has been completed. Comments are offered as followed. 1. Per our meeting in the field at the above referenced lot on January 21, 2005, it _was.agreed that some site work has not been completed due _tQ.access_issues (Re: 3 on 1 slopes and retaining walls) and will be completed upon this Department's final inspection of the SSTS. 2. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the separate sewage treatment system. 3. Please note that field measurements by this Department in no way suggest the exact size, slope, depth and location of the fill pad. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR:cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 JAN-19-2005 05:16 Pig HARRY W NIcHbLS 914 279 4567 P.02 rUTNA1q.;COTJNTY DEPARTMENT OF EMA.LTH DMSION OF ENMRONMENTAL HEALTH'SERVICES UQIJEST EOR EZIAL MERCLON For, Fill Date: Tfe'nches PCHD Construction Permit 0 *7� Located: A Z-42- (Ti 9v Owner/Applicant Name:. &,d st— TM Block f Lot Formerly- Subdivision Name: 81:4 t tn., Subdivisi on Lot 15'syste, m fill. completed?, Date' 18 system. complete? o Date: Is system C6nstr'ucted as per plans? Is well drilled? Date: Is well located as per plans? Are erosion control measures iri plac*69 I certify-that the system(s),, as listed, at the above premises , has been constructed and I have inspected and verifie'd their completion -in accordance -with the--i.ksued PC . Hb. Construction Permit and approved plans and the .Standards, Rules and RiguWI'04s of the Putnam County Department of Health. . baie- QMe b y RA ;2 Address: 4 Comments" _3 0 t2 If— a FOR: UAbAM KOExe Form FIR -99 - - � JAN-19-2005 WED 17:33 - TEL: 845-27877921. i-j01 11'::PL.1TNAM COUNTY DEPARTMENT OF P. 2 aHERI ITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health January 10, 2005 Mr. Harry Nichols Patterson Park, Ste 106 3050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection _ Alan Bradley Drive (T) Patterson, Lot #3 T.M. #24. -1 -80 A re- inspection at the above referenced lot has been completed. The following comments are offered. 1. Upon inspection it was noted that the fill pad appears to be less than the required size per the approved plans. 2. It appears a 3 on 1 slope has not been maintained. 3. The proposed retaining wall is not being constructed per the approved plans. If you have any further questions, please contact me at 845 278 -6130, ext. 2261. GDR: cw Sincerely, r '/J Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 SENDING CONFIRMATION DATE : JAN-10-2005 MON 12:38 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845-278-7921 PHONE 92794567 PAGES 1/1 START TIME JAN-10 12:37 ELAPSED TIME 00'40" MODE G3 RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED StIb',ItLITA-kKLEI1. SID, NIS, FAAP ILOUWA MOLINA 1U. RN.NISN ry larminry, 10,2005 Mr. Ilarry Nichols Patterson Park. Ste 106 3050 Route 21 Rrewste r. NY 10509 DEPARTMENT OF HUA!J_ l Geriev, V,,;A 7-11 Ike: Field Irinlicetim- - A!,V! Bradley Driv, r) ; o, 'f' T.A.'i'4A-80 Dear Mr. Nichols: A m-Inspection at the above. ectbienced 10L hU, The folInwingwituriculs are offered. I. Upon lnqpcctionitAR.qrl(llctitli:;[the than dic mquired size per the approved plans. 1. It appears a 3 on I slope hot, noE!,,cr .4. The proposed retaining wail is rut bvior. •r'!t7mlct:Nj Pre the annmved plans. if yon have any flurthcr questions, please rnncra --1 .0 �0 r.-Xt. ".51. Sincetely. Le. (',cnc Ha',I, T'nsitic-ring Aide C,DR,:cw 1 tri,V.1.11.1 Nurrina 10' iT,- - :11 i-;7� S.�i ... 1).EC-21-2004 11:24 AM HARRY W NICHOLS 914 279 4567 P.01 70 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAL'T'H SERVICES B301 MST FOR Flu C QN For Fill Date: OeLl 0:2 Trenches. PCHD Construction Permit # 13 `Yr Located: _Jrj to C, -_, (T) 117—Tis'a CS Owner/Applicant Name: .1 bij A4e&b .-__TM 131ock J, Lot Formerly: -Subdivision Name: Subdivision Lot # ls'systern fill completed? Date: is system complete? o Date. Is system constructed as per plans? Is well drilled? Date: Js well located as per plans? Are erosion control measures is place? I certify that the system(s), as listed, at the above. promises has been constructed and I have inspected and verified ;their completion in accordance with the issued PdHD Construction Permit and. approved.plags....�aad the.-Standards, Rules and Regulations of the Putnam County- Department of Health.. Date: D:72�4_701 Certified by: —,4.A, PE KA D Professional Address-: Lic. Co=ems, FOR: 13 ADAM �GENF_ 0, Form FIR•99 DEC-21-2004 TUE 11:41 TEL: 845-273 W 1 ... 4 1 0 M FINDINGS-. I1Trv� /r� sua cs 5 .5 .7 1y �/ /. ! . 7- !s '% -y ,rli �'dn�t S► / oe�P �e�r.�� L✓ `�'� --T " :. LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 March 22, 2004 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS:.Alan 4 Bradley Drive, Lot 3 (T) Patterson, TM #24. -1 -80 Dear Mr. Nichols: ROBERT J. BONDI County Executive Review of plans and other supporting documents submitted at this time relative to: the above- regarded project has been completed. Comments are offered. as.follows: -t. -The existing fill must be removed prior to the issuance of a new fill permit. Please contact this Department for an inspection when fill is removed. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM: lm Ve ly yours, Robert Morris, P.E. Senior Public Health Engineer LORETTA MOLINARI �j, ROBERT J. BONDI Public Health Director �� Y�� _ County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 April 30, 2004 Harry Nichols, P.E.- Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Field Inspection:. Alan 4 Bradley Drive Lot #3 .(T) Patterson, TM# 24.4-80 Dear Mr. Nichols: Per our conversation on April 27, 2004, it was agreed that upon receipt of a valid fill permit, any and all soils must be removed from the SSTS area down to original grade and inspected by this Department prior to the placement and/or spreading of new run of bank fill. Please be advised, at this time, the submitted plans for fill placement will be reviewed for the required fill permit. If you have any further questions, please contact meat (845) 278 -6130 ext. 2661. Sincerely, Gene D. Reed Environmental Health Engineering Aide. GDR:tn UPK*RV KMVI Q°P P -A A 4 Ev Irc. o1 6 LF ' Ex�ST1N4 �' i EXISTIhIG SSTS Q r All �g�✓AT odd' 3 � / '•' `t\j a Py. / \ i I I l e "le'f. WEu. IF �y o N N Q PUTNE 1 Gen 94 FROM: For your information For signature 0 -4 At For your files Referred for handlin Attached as reque Returned as requ ed It VVI- qA' Please see me Read and return y COMMENTS: ���� 011le 4171d I I 1 l.r. ... ..+.`+� it T - ��...' ^'•'�'_""+(`^. b' ...-y' P.. -�:. .b . -tn�c� • „�,:�d -oozy � •' -• ,� ..,~. °,.,�, ..�:.., a..:, Ar f o+t� IT :>•:.:.a..,�:= far,. -x -ter � .,;. .. - � �- «y ::rv- ,_.._. :� �.�.aM,::. i . ,•.w -es.,' ,"y kh ,,.�4L�/��V � -..,+a �..�m _ss..,?., x »..•„r*:•*�a..s.+..$"tC`� : J��:.k.. a.,.,:... FY�i.4 R..¢v'. -. .y b• �: f ,W.,.r •43 rw - +S r..:Wav- �e+�..'�«�+iw nt^':^.....�� -J °..� t: •'T" f .SPM1 +:f" .�t+••'�,+.• +rrnmu1+v^`•i'pe9'•.+� ^' n�'��_in+'i� "*+•�� less, ca -v. -" r s-+. �xr. ``�v�' t.:- .e �'TS -.. „'1"^" „Jw - ^,e< -'+•e�i+�w �� ,.y. r.- .«...���+ ' ��� :'''•� �• � �..��- ;__ . , t is �. ._s-- � . ..11n =�v�^ ++�»'�..n 4 .ralf...^' +.y '�Yw�a �9�w�•? •1 • .,may, �.M} •� V'� �� � � � - ... .. .o.:J.. +” ♦ "1. C' # h: -�:�- .ice... � ..s -,1� ,...+..�.+...•. I.. d � ~4 'i} -.��� � ^1_.s - t'.^a•n, A•. w. .0 �,�.•+�+C . BRUCE R. FOLEY Public Health Director LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914):278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 Harry W. Nichols, P. E. 311 Clocktower Commons Brewster NY 10509 Re: Field Inspection: Ross Alan Big Elm Road, Lot #3 (T) Patterson, TM# 21-1 -80 Dear Mr. Nichols: June 15, 2000 The following comments must be corrected in the field: • This is a follow up letter to inform you that a secondary sieve test has been performed on the above referenced. project: As stated in my previous letter dated June 2, 2000; -no- more than 10% by weight of the fill material should pass a #100 sieve. 17.89% passed a#100 sieve from, the sample collected at this site. The secondary sieve test results are 19.96% passing a #100 sieve. If you have any further questions, please contact me at (914) 278 -6130 ext. 2261. Very truly. yours, Gene D. Reed GDR:tn Environmental Health Engineering Aide 0 R BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N.- Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 -.7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 . Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 June 2, 2000 Harry W. Nichols, P.E. 311 Clocktower Commons Brewster NY 10509 Re: Field Inspection: Ross Alan Big Elm Road, Lot #3 (T)Patterson, TM# 23. -1 -80 Dear Mr. Nichols: The following comments must be corrected in the field: • Upon my inspection of the above referenced project, I found that the'fill pad is inconsistent with the approved plans in size, shape and depth. Furthermore, the fill material failed a sieve test. No more than 10 percent by weight of the fill material should pass a #100 sieve. 17.89% passed a #100 sieve from the sample collected at this site. If you have any further questions, please contact me at (914) 278 -6130 ext. 2261. Very truly yours, ,� Gene D. Reed GDR:tn Environmental Health Engineering Aide F1 PUTNAM COUN WDEPAR '' MENT OF HEALTH T DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE -SEWAGE TREATMENT SYSTEM Owner Address. 464 .4j,10i Located at (Street) ��rj /eLl 60'r t ve— Tax Map ,'Zf, Block Lot 0 (indicate nearest cYoss street) Municipality. 6a, a, ,-"v r_11 Watershed y'0 J" SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test -0 UTEN: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 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 ........... ....... .. ......................... ........... e . .. .. ... ...... ...... . . ... R ::>«: ::; >:: > <:::<: >::::: N »:<: >:<::: >: M: ......... pp .. ........ P 0 ..X. 9: .. ii.star t ....... ... ... ...... -3 3 1 4 5 7— 1 h0-'2-7- )6 '33 1'( 3 2 ffi: 3 7- j . 141� 3 3 V2 4 5 2 3 UTEN: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 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' 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. 2 .6 Indicate level at which groundwatet- is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered- Deep hole observations made by: Date Design Professional Name: Address: �)LA,, o A Signature: _ Design Profess al's w yo9. t 9 NF0 \" ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVI( CONSTRUCTION PERMIT FOR SEWAGE TREATMEN SYSTEM PERMIT # __ P t 3` JI S � ,� C �' Located at Town or Ve ,% / ✓��rtGh Subdivision name >_ Subd. Lot # Date Subdivision Approved 3 -©2 , C U Owner /Applicant Name %�O Ss Z1 a �3 Mailing Address Amount of Fee Enclosed Tax Map 2-& Block _I Lot 96 Renewal Revision Date of Previous Approval Zip /OS� Building Type J& S 1 L -ii cc I Lot Area 0, '71 No. of Bedrooms '3 Design Flow GPD c�OC Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of d00 gallon septic tank and T Other Requirements: To be constructed by I J' Address Water Supply: Public Supply From Address or: / Private Supply Drilled by �'� 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 treatment system 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: Address R.A. Date J -2L -,p �- License # 2T�% 2-4 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 ermit. App ed for discharge of domestic sanitary se age only. C � By: Title: Date: �i White copy - HA le; Ye ow copy - Building Inspector; Pink copy - O er; Orange copy - Design Professional Form CP -97 January 26, 2005 Putnam County Health Department 4 Geneva Road Brewster, NY 10509 ATT: Robert Morris, P.E. RE: Trench Permit - Lot #3 Big Elm Subdivision 4 Bradley Drive Patterson, N.Y. T.M. # 24.-1 -80 Dear Mr. Morris: Enclosed please find the following: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 279 -4567 Email: hnengineer@aol.com 1. Five (5) prints -.of .SS. -3 "Proposed SSTS -Lot #.3', rev. 01/25/05. 2. "Construction Permit - Trench ", dated 01/26/05. 3. "Design Data Sheet ", dated 01/26/05. Kindly issue the Trench Permit at your earliest convenience. Very truly yours, Harry W. Nichols Jr., P.E. HWN:gav 00- 093.03 UTNAM COUNTY DEPARTMENT OF HEAL [SION OF ENVIRONMENTAL HEALTH SERVI c;ONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P 0 cj S— Located at 4 Subdivision name r, —lL Subd. Lot # 3 Date Subdivision Approved 1---o2--3o Owner /Applicant Name Mailing Address Town or V' ge Tax Map ;'2,f, Block j Lot d Renewal Revision Date of Previous Approval Zip l0 S0- f Amount of Fee Enclosed 1 7— 4d Building Type I rA h . �,� Lot Area 611? No. of Bedrooms Design Flow GPD (,Os0d Fill Section Only —6� Depth _ Volume 70 e) PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of �' O Ud gallon septic tank and Other Requirements: To be constructed by `� Q Address Water Supply: Public Supply From Address or: Private-Supply Drilled by 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 treatment system 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: P.E. ZZ R.A. Date T Address �����rP,�� Sri !� �T- License # .12= 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 modifieO when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new jermit. Appro for discharge of domestic sanitary se age `e only. 2 Ot� By: Cep / Title: ' Date: & White copy - File; ell w copy - Building Inspector; Pink copy - Own Or copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT WATER WELL f� please print or type PCHD Permit # / ' 13 — c? t Well Location: Street Addr To n e Tax Grid # ��: ,� o ,�, 4— Ma- Well Owner: Name: fi®'�;s �-1 �. Address: ��� �2�aJ- Use of Well: _iZ12esidential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served - EEst. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling /New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ........ .......................... ............................... Yes. l,!:f: No Name of subdivision A Lei /31 Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No f/ Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate eet/nlan. Date: 5--�X—d Applicant Signature: L/ PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well 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. Well to be constructed by a water well driller certified by Putnam County. I Date of Issue g — 2,& - Ow Date of Expiration -Z e --0 Permit is Non - Transferrable Permi Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 0 August 26, 2004 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Michael J. Budzinski, P.E. Director of Engineering RE: Proposed SSTS - Lot # 3 Big Elm Subdivision 4 Bradley Drive Patterson, N.Y. T.M. #24. -1 -80 Dear Mr. Budzinski: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 2794567 Email: hnengineer@aol.com In accordance with recent review comments provided by the PCHD, we have revised the SSTS plan as follows: 1. Pump Chamber and Septic Tank have been relocated to east side of proposed residence, eliminating bends in effluent line. 2. - ---Single height retaining wall replaced with two (2) low profile natural stone walls. Section / Detail added to plan. Reflecting the above, we are enclosing the following: • Five (5) prints of SF -3 "Fill Plan", rev. 08/26/04. • Two (2) prints of SS -3 "Trench Plan", rev. 08/26/04. Kindly review the enclosed and if acceptable issue the necessary approval. Very truly yours, Harry W. Nich s Jr., P.E. HWN:gav 00- 093.00 August 18, 2004 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Mr. Robert Morris RE: Proposed SSTS - Ross Alan 4 Bradley Drive - Lot #3 Patterson, N.Y. T.M. #24. -1 -80 Dear Mr. Morris: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 279 -4567 Email: hnengineer@aol.com In response to your August 10, 2004 review letter, we note the following: 1. Proposed 45° bend noted on plan. 2. Septic tank and pump chamber are specified to be constructed for H -20 loading. 3. Retaining wall detail with wall heights added to plan. 4. Force main located outside conservation easement. Reflecting the above, we are enclosing the following: • Five (5) prints of SF -3 "Fill Plan", rev. 08/17/04. • Two (2) prints of SS -3 "Trench Plan", rev. 08/17/04. Kindly continue with your review and approval. Very truly yours, A - Harry W. Nichols Jr., P.E. HWN:gav 00 -093.00 LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 -'7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 August 10, 2004 Harry Nichols, PE Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: Ross Alan 4 Bradley Drive, Lot #3 (T) Patterson, TM # 24 -1 -80 Dear Mr. Nichols: ROBERT J. BONDI County Executive Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. Sewer line should not have any bends. All elbow angles are to be noted. 2. If the septic tank is proposed within 10 feet of the driveway, the septic tank is to be specified as H -20 loading. Furthermore, the corresponding detail Js to be provided. 3. The detail for the retaining wall is to be shown. The maximum height of the proposed wall is to be noted. 4. Please submit verification from the town stating that the force main line can go through the conservation easement. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly your Robert Morris, P.E. Senior Public Health Engineer ............. . . ......... Harry W.-Mch.of: r, F..E.. -Patterson Park; -Suite 106 2050 Route 22 Brewster, NY 10509 (84'5) 279-4003, Fax 279-4567 CONSULTING SITE ENGINEERS JOB No. Oo- 09 SHEET No. COMPUTED BY DATE CHECKED BY A W H DATE —JIL- 0 4 'R r-! V. 0 - 0z - of A, c, 14 -u6 &L G 6 X jAv-" VbAp 8 a e -130 T-110 m ELsu 7 5-2, as .Sgn k rl c- ffiE,4b P fM. -T--; S PlEa L r=, &,r,: r a 1) 1 v4& L'Z'N7 2— a D2m"R'. ROWVAL�z M-F �p) PE LL,� T/4 2-714. P U.A4 F> RA_r 4.0 Cr E, AA L,F, X7_'7JJ_FTl Z o b L, F, . ... ..... ... . 7 14 57;4-TIC _4 8-AR Pie lCTldj\4 jj-� ,41) TPR -ET A4 c%* :3993- tug-0-7/z 14 . ....... 1%7 A .... .... i Harry.W. Nichol 'r., I?.E.•........ JOB.I�.o0°-.0y ;.. _ `Patterson Perk, 106... �' ! __.2050_Rout6.22. "_..: .. .SHEET No. 2– ,OF— 'Z Brewster, NY 10509 COMPUTED BY �M DATE ($j X79 =4003, Fax 279 -4567 _ :.:..�__.....__.. . CONSULTING SITE ENGINEERS CHECKED BY . µWH DATE . .... Goulds S ¢ ee 3885 MODEL UAV MR,NEWIN MENNOWNE MENNO NE EMMENN,M MEMEMEN, r, August 2, 2004 .Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Harry W. Nichols Jr`., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 279 -4567 Email: lmengineer@aol.com RE: Individual SSDS - Lot #3 - Revision Big Elm Subdivision Bradley Drive Patterson, N.Y. T.M. #24. -1 -80 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SF -3, "Preliminary Plan for Fill Placement Only", revised 08/02/04. 2. Three (3) prints of Drawing SS -3, "Proposed SSTS ", revised 08/02/04. 3. "Construction Permit for Sewage Disposal.Systein ", dated 08/02/04. 4. -- "Application-to Construct a Water Well, "-dated 08/02/04. 5. Review Fee in the amount of j200.00. i 6. Pump Selection and Dosing Volume Calculations. At th6request of the Town of Patterson, NY, the septic tank and pump chamber have been relocated. Very truly yours, Harry W. Ni ols Jr., P.E. HWN:gav 00- 093.03 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 March 1, 2004 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 RE: Individual SSDS -Lot #3 - Renewal/Revision Big Elm Subdivision Bradley Drive Patterson, N.Y. T.M. #24. -1 -80 Dear Robert : Enclosed are the following: 1. Five (5) prints of Drawing SF -3, "Preliminary Plan for Fill Placement Only", revised 03/01/04. 2. Three (3) prints of Drawing SS -3, "Proposed SSTS ",.revised 03/01/04. 3. "Short EAF ", dated 03/01/04. 4. "Application for Approval of Plans for a Wastewater Disposal System ". 5. "Construction Permit for Sewage Disposal System ", dated 03/01/04. 6. "Application to Construct a Water Well," dated 03/01/04. 7. "Design Data Sheet ". 8. "Letter of Authorization ". 9. Two (2) copies of residence floor Plan(s), f r Bedroom Count Only". 10. Review Fee in the amount of $400.00. �� 11. Pump Selection an d Dosing Volume Calculations. If there are any questions concern ing the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. H)A N:gav 00- 093.03 14.16 -4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR F_00'7�) a 2. PROJECT NAME L—of S 3. PROJECT LOCATION: A 4 • 7MA PAIT RLrDID -1 V Municipality County I 4. PRECISE LOCATION (Street ldress and road Intersections, prominent landmarks, etc., or provide map) bica 5. IS PR POSED ACTION: ZLNew ❑ Expansion ❑ Modlflcatlon /alteration 6. DESCRIBE PROJECT BRIEFLY: 1ND�v�f���L 55��J 7. AMOUNT OF LAND AFFECTED: Initially C)` 1S acres Ultimately 4� acres 6. W14 PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? Ryes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? AResldential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: .61 �r 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes Eallo If yes, list agency(s) and permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ERNo If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? El Yes 29 No. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant sponsor n me: ° " O— J Jill— V 1� 64t'tr Date: 0 1 Signature: If the ..P U.TN AM C -O U N'I''Y._DEPARTMENT OF -HEAL-.TH • :.. -= • DIVISxON— OF.ENVIRONMENTAL- HEA.LTH•.SERVIC-ES` - APPLICATION FOR APPROVAL OF PLANS..�FOR A.VYASTEWATER'TREATIYIEN- SYSTEM'_`_° " ••'''' "': °' °'' ' :` _ 5 AH 1. Name and address of a licant: �� 2. Name of project: L�� �' '5�T� 3. Location, 4.:Des.igi Professional: R44 W - 0.! OW L6 5.. Address: x s 0 . 6-..DrainageBasin: 7. Type of Project :. - ;,;::..:: :.::. L`"•' ..:. . Private/Residential Food Service Commercial Apartments'-: Institutional Mobile Home- kark.. •._. _ Office Building Realty Subdivision __TOther (specify) 8. Is this project subject-to State Environmental Quality Review (SEQR)? TYP- e--Status ( check one) ..::....:.......... ................................... Type I Exempt . Type II ' = Urilisted r 9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... N.O. 10. Has DEIS been completed and found acceptable. by Lead Agency?...,........,:..,,, ::I.►R. 11. .. -Name of Lead Agency _12:.Is this project in an -area under the -control of local planning, zonirig, .or other ' officials, ordinances? ......:.......... ..............................: .::. ......:....... ..:: ...:. 13. If so, have plans.been submitted to-such authorities? Has'preliminary.approval been•grarited by such authorities? 00 Date-granted: - -• -15: Type of Sewage Treatment- System Discharge-.'...; ............. surface water• groundwater 16. :If surface water discharge; what is the stream class designation? .....:.:...::..::..... ! - 17. Waters index number (surface) ..... ...........:............. 1.8... Js project located near-a public .water supply system? ......... ....•......:....:..:.......:.., 19.• If yes} name of grater- supply IJ Distance to wter:supply' N� 2-0; Is .project site near a public sewage collection or treatment system? Name of sewage- system Distance to _sewage "system' { -- 22. , Date test -holes- observed i i ' �j �I 23; Name of Health Inspector i't1U &JPL(r- ,( ' 24. :....J. gn (g 1 Y) ........ .................I............. .. Fro'�ect•desi -flow allons er day) 25. Is State Pollutant Discharge Elimination :System.(SPDES) -Permit required?:.: 26. Has SPDES Application been submitted to local DEC office? ...........::.:...... :.... Form .PC -97 4-T.- Is- any portion: of this project. located -within a designated Town' or State wetland? . No — 28. Wetlands.ID. Numb. er ..................... ...::................... .............::.. .............................. _ 29. -Is Wetlands Permit required ? . .....:........................:... ..:........:........:....:..:.. Has application been made to Town or Local .DEC office? ............................ l\I¢c 30. "Does project require a DEC Stream Disturbance:_Permil? .. ............................... N� 31: Is or was project site used for agricultural activity involving application of pesticides to .orchards or other crops, solid ox hazardous waste disposal, landfillirig,'sludge application or industrial activity? ............................ Yes/No 32.• Is project located within 1,000 feet-.of existing or abandoned landfill, ... hazard ous.waste site, salt stockpile, landfill, -sludge disposal site.or any other potentially known source of contamination? .... : .......................... Yes/No [SQ DESCRIBE: 33. Is there a local master plan on.file with the Town or Village? .......................... 34.. Are community water and/or sewer facilities.planned to be developed:w.ithin 13 years in or adjacent to project site? ....... ................... :.................................... � 35. Are any sewage treatment areas in excess of 15.% slope? 36. Tax Map ID Number .......:.: ................ ............................... Map Block Lot 90 37. Approved plans are to be returned to ..... Applicant_ Design Professional .VOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall he.senc to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP' '' a:p�proval 'of the�SSTS griur- io final :approval 'by- the Department. Projects within..the. watershed..--may also require DEP - rev►ew. and 'approval. of other aspects of a project, such as stormwater. plans._or the creation of impervous.sarfaces, and the project applicant should obtain the appropriate forms..for such, activities from, == DEP and submit those forms to DEP for-review and approval. If the application is signed by a person other than the applicant shown-in Item l :,the application must be accompanied by a Letter of Authorization (Form LA -97): Failure. to comply with this: provision, .maybe grounds for the rejection of any submission. -° I hereby.affirm; .crnrler penally of perjury, tlrat.informrrtion provided on this form. is true`? to the -hest of my knowledge and.befief. False statements made herein. are punishable as -= a Class A misdemeanor pursuant to Section 210.95 of the SIGNA•TURES•-& -OFFICIAL TITLES: Mailing Address: .....:..:::.. �0 bJ� ...:' "7 ©jQl • PUTNAM COUNTY DEPARTMENT OF .HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner L- Ay Address 4t bafow W@ AWQP-0jj iosM Located at (StreetA b Mtn DFAN5i bU6A k Tax Map A% Block ! Lot (indicate nearest cross street) Municipality F P<-VT 5 "0 0 Watershed ef' ( &�W SOIL PERCOLATION TEST DATA Date of Pre - soaking 1 � �°� Date of Percolation Test 7 al ql 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 >bepth to Water From Ground A., '�NateX Level Perealatlon Hole hEo Run No '�me StarC Stop 1Ia Se Time �1klen) .. Surface (Inches) Start Staff...:.:.. .. ...... , . drop In Inches Rate Mm/Inch l......... 2 3 2 °� Z2s ?A 4 5 -. _. ? 3 �01 24 4 5 . 1 2 3 4' 5 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 N0. B ( M TS - S wj,1 uii�cc_� ��t� 4'_ SRNb- Lop�cn 5iii1 HOLE NO. 2 Indicate level at which groundwater is encountered No 06 Indicate level at which mottling is observed NA Indicate level to which water level rises after being encountered N A Deep hole observations made by: Date 7l i g Design Professional Name: VU % !(M - e Address: �4 5-0 "Jrf� Signature: Design Professional's Seal p� %EW -.� W W "o. 56124 °°°96FEss���� Ntk PUTNAM COUNTY DEPARTMENT OF HEALTH-. DIVISION OF ENVIRONMENTAL HEALTH SER'VICESj ,::: LETTER OF AUTHORIZATION RE: Property of ALA1-1 Located at TN pPTTTE�LS ©N Tax Map # 74 Block 1 Lot Subdivision of 1 �► �VM Subdivision'Lot # Filed Map # Date Filed-._. Gentlemen: This letter is to authorize a duly licensed Professional Engineer 'A or Registered Architect to apply for the•_req#ed wastewater treatment and/or water supply permit(s) to serve the above-noted property :in accordance' with the standards, rules or regulations.as promulgated by the Public 14ealth Director of.t&..._ ffiairi -: ;:,; County Health Department; and to sign all necessary papers on my behalf in connect-ion ,with' matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions. of Article 145 and/or. 147 of the Education. Law; the Public Health- Law, and the Putnam County Sanitary Code. -- - - M-. -. -Countersigned: / P.E., R.A., # Mailing Address State 1 Zip Telephone;`' Very truly yours, a Signed: (Owner of Mailing Address: 06MQ' IM ® rl� State Zi. r Telephone: (9 Form LA -97 } ��CUflU rl��Ur I CN 161. GEDI-i0ou 3. �'_. = -� OEJROOk 2 V II <'- I' X 16'- G' � Firs t F,aor 1 7-7— L' — — - 01 N1NG ROOL( XITCNE.^f G' X IS' - G• 2 UAS.TER GEDR,001- � -�" LIVI:iG ROOK. I+' -1' X t3' -G' j 1 <'- 0'XIS' -G' _�J r � r l ��CUI'�U r1UUf Firs[ Rlbor ol DINIXG ROO1! -� )- (ASTER BE'DROOK - 1 4'-I' X 13'- G' UP r J r K17CHEN LIVI:iG ROOM 14,- G' X I!, - 0' 16 ' FZ E� L..D�N Cam:,...... � ....._ ::............_. f � ~ :Z`«! ®/B O) b $ ■ �� \ � �� 38�87 17. Goulds ?-ubmer H Qw- age MODEL 0 L LOLOJU S�Io Aw 6 TP and THF 2 T Models 3 "B" Models 4 . . . . . . . . . . . 8 9 Goulds ?-ubmer H Qw- age MODEL 0 L LOLOJU S�Io Aw Har- ..W. Nichols Jr., P.E. JOB No. Do- 00 Patterson Park, Suite 106 2050 Route 22 SHEET No. 1 OF Brewster, NY 10509 COMPUTED BY P'I DATE ((545) 279 -4003, Fax 279 -4567 - CONSULTING SITE ENGINEERS CHECKED BY 14 W H DATE L I - 04 ST. AM C, 14EAD A-U.__ --- U.,4A p - TATI C_ thFAD _ -. - -- a p 1 p a L04C'T -h} ;2- 1'L - -yAi- y & L -:1a T_ -1'� 1 P t ;L- N _T = -- — 5 — - — IL°�3d�_FT,/ aL,E,, -- - .... .......... - -- - -- - -- - - - -- -- - - -- -- - - - -- -- - - - - -- - - - - - -- - - -- .... - - -... - - - -. _..... __...... . -- ........... _.._...._. _ ............... _.._.. _.__ ........... - - - - -- -- — a - - - - =— - -- -- _ TD _. - - - .... _....___.- W-71 F7 - - ..... ._ -- - - -- - .._... - - -- - -- -- . ........ __. _.._......._ ....._... __._ ......................... . _ I larry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 ;815) 279 -4003, Fax 279 -4567 ONSULTING SITE ENGINEERS JOB.No._.00- 093 SHEET No. 2- OF 5�f5'TCML UOlyiktEl — COMPUTED BY JM - -- - — -L F A65bgET -7 I- &I N S__ iZ 2l0 ( 'x 77 1,13 3 ' I - 04 CHECKED BY Mr _DATE DATE - 3 " I " 9'¢ �7S"�o d 5�f5'TCML UOlyiktEl — - -- - — -L F A65bgET -7 I- &I N S__ iZ 2l0 ( 'x 77 1,13 Mr b 05 li' IZI N6-� r -- - - - -- -- %41 ' - - - /_ I A o`u bina, er&We a wage Pumps 0 20 35 40 60 80 100 120 140 160 180 GPM I I I I - I 0 10 20 30 40 ml/hr CAPACITY 01985 Goulds Pumps, Inc. [qGOULDS PUMPS, INC* SIRC-CA FALLS NEW 'YM .13149 Effective July, 1985 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERT I SEWAGE TREATMENT SYSTEM PERMIT # f' i3 `� �- Located at Subdivision name Subd. Lot # 3 Date Subdivision Approved 3 -- , -, 1 Cl U Owner /Applicant Name R0 " Mailing Address Town or V. age J Q"L.1v v �3 Tax Map ;Z4 , Block % Lot 80 Renewal / Revision Date of Previous Approval 9 a 7 '- %- Zip 6" w. c� Amount of Fee Enclosed' Building Type ke - Je-i, li Lot Area 1,66 No. of Bedrooms Design Flow GPD 1900 Fill Section Only iv' Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of kzi�-C gallon septic tank and Other Requirements: To be constructed by I P) i) Address Water Supply: Public Supply From Address or: _� Private Supply Drilled by 'T j3 DJ Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the sgparate sewage treatment sy is em 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: Address R.A. Date 9- //-()0 License # fir, L 2-4 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment sstem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified Icn'sidered cessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permved o ischarge of domestic sanitary se a only. B Date: � By: Title: Oz1 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 _ _ ..� . ,3 Y _ - 7 -� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Well Location: Street Address: TownNiHfg-e Tax Grid # e- Noe-, A & S G L% Map Block Lot(s) � (� Well Owner: Name: Jddress: L'L Ar"'a", L k,-Ct " lce'4-J Use of Well: VResidential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served _ Est. of Daily Usage 8 66gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling i/New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type __j/ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes 4"" No Name of subdivision IR Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? ................. r ............... ............................... Yes No Name of Public Water Supply: A A TownNillage Distance to property from nearest water main: h Proposed well location & sources of contamination to be provided on separate sheetiplan. Date: q4t -u0 Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well 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. Well to be constructed by a water�"l f driller cegied by Putnam County. ( 111 Date of Issue Permit Issui ial: Date of Expiration Title: Permit is Non - Transfe White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 September 12, 2000 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS - Lot #3 Ross Alan Subdivisidn Bradley Drive Patterson, N.Y. 24. -1 -80 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SF -3, "Preliminary Plan for Fill Placement Only," revised 9 -8 -00. 2. Three (3) prints of Drawing SS -3, "Proposed SSTS," revised 9 -8 -00. 3. "Short EAF," dated 9- 11 -00. 4. "Application for Approval of Plans for a Wastewater Disposal System." 5. "Construction Permit for Sewage Disposal System," dated 9- 11 -00. 6. "Application to Construct a Water Well," dated 9- 11 -00. 7. "Design Data Sheet." 8. "Letter of Authorization." 9. Two (2) copies of residence floor Plan(s), for Bedroom Count Only." 10. Review Fee in the amount of $300.00. 11. Pump Selection and Dosing Volume Calculations. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni ols Jr., P.E. HWN:JM:his 00- 093.03 14.164 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 S EQ R Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT`FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR nn // a SS 2. PROJECT N ME SS ! S /TLG -hl-v a t ec� 3. PROJECT LOCATION:u _J PV f iv$ Municipality 47 County 1.,a 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, et ., o provide map) � c(�lvtsr.� 5. IS PROPOSED ACTION: 13w ❑ Expansion ❑ Modiflcatlonlalleration 6. DESCRIBE PROJECT BRIEFLY: �►� a��� Luecl t ST 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately �'� U acres B. WILL P%OPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? EK03 ❑ No It No, describe briefly 9. WrHrAAT)S PRESENT LAND USE IN VICINITY OF PROJECT? lResldentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVER 4MENTAL A ENCY (FEDERAL, STATE OR LOCAL)? CJ Yes ❑ No If yes, list agency(s) and permitlapproval� �Gwh �• ��ywt U� rJ'�.rfOr -, �CJU�I�L 11. ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? r_DDW RJ Yes ❑ No If yes, list agency name and permit/approval , YL�LW`l /�i�V VC✓Qil 12. AS A RESULT OF PR9POSED ACTION WILL EXISTING PERMITIAPPROVAL REOUIRE MODIFICATION? C3 Yes o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AppllcanUsponsor name: Date: _ g Signature: .v If the action is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate, the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency.' ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, nolse levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or, threatened or endangered species? Explain briefly: C4. 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, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1•C5? Explain briefly. C7. Other Impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether it Is substantial, large, Important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude: If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been Identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ 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. ❑ Check this box if you have determined, based on the Information and analysis above and any supporting documentation, 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 Lead Agency Print or Type Name of Responsible Officer in ea Agency Signature of Responsible Officer in Lead Agency Title of Responsible Officer Signature of reparer (if different from responsible officer) I Date 2 I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: Xocl , .-2 S /✓ AUv"l 2. Name of project: )TpaJ SSTS 4. Design Professional: r, 6. Drainage Basin: 7. Type of Project: 1/ Private/Residential Apartments Office Building i 3. Location T/j/ AQ a 5. Address:.-3i( L lam ��wz►. ��.G Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency Exempt Unlisted z-.1 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? 13. If so, have plans been submitted to such authorities? ........ ............................... -) 14. Has preliminary approval been granted by such authorities ?�Ls Date granted: 3 ` c� d 15. Type of Sewage Treatment System Discharge ................. surface,water z,-groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........................................... ............................... �- 18. Is project located near a public water supply sAy/stem? ....... ............................... 19. If yes, name of water supply /V Distance to water supply — 20. Is project site near a public sewage collection or treatment system? ................ /Ud 21. Name of sewage system /j- Distance to sewage system 22. Date test holes observed - -9 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................. ............................... 000 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... o 26. Has SPDES Application been submitted to local DEC office? ......................... 44- Form PC -97 z 27. Is any portion of this project located within a designated Town or State wetland? d 28. Wetlands ID Number ................................................:.......... ............................... 'v L4 IF 29. Is Wetlands Permit required? .............................................. ............................... �d Has application been made to Town or Local DEC office? ............................... A) 4- 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid. or hazardous waste disposal, landfilling, sludge application or industrial active Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any p other potentially known source of contamination? ............................... Yes/No NO DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... �r 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? .. ..............................o 36. Tax Map ID Number .......................... ............................... Mapes,f, Block I Lot 9 0 37.. Approved plans are to be returned to ..... Applicant �Z Design Professional NOTE:.All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be senfto the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). 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 Penal Law. I SIGNATURES & OFFICIAL TITLES. Sd`cp.�., ,,, %, 1 -zIJ — ��, e� 4 Mailing Address: ................................... 4 rci,.3er JV X 0 S--62 PUrNPM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENIM HEALTH SERVICES DESIGN DATA -SHEET - SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner .� ( Address a, L�.�_ /.J y r P Located at (Street) ; no. y (rte %� ec. a-`t, Block l Loth 111 (indicate nearest c ss street) Municipality 4 1 t:�_rs-o I. Watershed SOIL PERCOLATION TEST DATA - REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre - Soaking Date of Percolation Test 7 c 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 It it 5 5 1 2 3 5 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 DEPTH G.L. 1' 2' 3' 4.' 5' 6' TEST PIT DATP�`EQUIRED TO BE SUBMITIED WITH A'",\ICATION DESEEP —L OF SOILS ENCOUNTERED IN TEST BOLES SOLE NO. HOLE NO. L3 HOLE NO. On Tl 8' 9' 10' 11' - 12' INDICA'T'E LEVEL AT WHICH GROUNDWATER IS ENC)DUNTERFD �G4 e INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE 'BY:- DATE: DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capacity gals. Type 4i& , Absorption Area Provided By oz)- L.F. x 24" width'trench Other -\ Name �-tq, I- Ir �U icl a is. Signature Address SEAL =' No. 56124 aC� THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft %gal. Checked by Date, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: ' Property of �o S Located at BVq, k" , /-) k-1 t T/? & *_ Tax Map # Block 1 ' Lot 6 G Subdivision of Ala -I Subdivision Lot # i Filed Map # Date Filed -3-2---90 Gentlemen: This letter is to authorize Al-v_ a duly licensed Professional Engineer y L.-Ior Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with 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 in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County .Sanitary._Code. __ ......_..,___.. Countersigned: Lai P.E., R.A., # Mailing Address '7-4-)43'0 6 �dej_ State ✓ Y _Zip /o 516 i Very truly yours, Signed: 6�-J.D C� (Owner of Property) Mailing Address: L le- L State /) Zip Telephone: ?7.- -t 60- Telephone: 16 F6 It Form LA -97 APPLICATIONS Specifically designed for the following uses:.. • Homes • .Farms • Trailer Courts • . Motels . Schools • 'Hospitals • l.ridustry • Effluent Systems SPECIFICATIONS -Pump: Motor: • Single Phase: 1/3 HP, 115 or 230 Volt 60Hz, 1750 RPM '/z HP, 115, V,60 Hz, :�3500RPM . '/z HP thru 1' /z HP 230-V::6 0 Hz;> 3500 Built -in Overload with -Automatic Reset Class B Insulation 5` • Three Phase:''Yz'HP,th:ru'1'7z HP' ` 208/230 V,,* 460 V, 3500 Class B Insulation; Overload Protection `must be Provided in Starter Unit • Shaft: Threaded; :400 Series ; Stainless Steel , T' • Bearings ;Ball Beanngs�Upper.:_, . and Lower,` • Solids Handling Capabilities: • Power Cord 115 Foot Standard ...; 3/4" Maximum ° Length (Optional Lengths • Discharge Size: 2 "- NPT ' • Ca acities: U to 114 GPM P P Single Phase �' /3'and'h HP 16/3..: .e.;Total Heads: ":Up to 1,23 Feet TDH SJTO with`three „prong plug y • Mechanical Seal: 3/4 thru 1' /zF±HP 14/3 STO with Carbon- Rotary Seat/Ceramic- Bare Leads s , ; Stationary Seat Three Phase '/z thru 1; .HP 14/4 300 Series Stainless Steel Metal STO with Bare Leads �j`f Parts BUNA -N. Elastomers On CSA Listed Models' j4x20' eiiiperature 160 °F.(71 °C) Length ';S' and STW a`re i \ Maximum . Standard ``�` '' r' ”? _r .. • Fasteners: 300,Series Stainless a F Steel FEATURES 7F • Capable of Run ning:Dry Without w Damage to Components Impeller Cast tron,- sem''i open, non -clog with pump out vanes for ©1986 Goulds Pumps, Inc. .moulds Submersible. Eff I uent Pumps , ,� 3885 mechanical seal protection. Bal- anced for smooth operation. Bronze impeller available as an option. Casing: Cast iron volute type fo,- maximum efficiency. 2 ". NPT dis- charge adaptable for,, slide rail systems. Mechanical Seal: Ceramic vs carbon sealing faces. Stainless steel metal parts, BUNA -N elastomers. Shaft: Corrosion - resistant stainless steel Threaded design. Locknut on three phase models to guard against component damage on accidental reverse,rotation.;.• Motor: Fully submerged in h.igh- grade turbine oil for lubrication . and efficient heat transfer.:,: Designed for Continuous Opera- tion: Pump ratings are within the: ;' motor manufacturer's.recommended working limts,'can be`operated continuous,, Y without damage..:'; Bearings: Upper and lower.• -: ` heavy duty ball bearing con- struction. Power Cable: Severe duty rated oil and water resistant:: Epoxy seal on motor -end provides secondary moisture barrier incase of outer jacket damage and to.prevent�oil wicking: O -Ring: Assures-positive sealing against contaminants and oil ;' leakage Effective July 1986 Y;_ FEATURES 1. Impeller 2. Casing 3. Mechanical '/r Seal 4. Shaft 5. Motor 6. Bearings - 1750 Upper & . Lower T. Power Cable 8. 0 -Ring 1 N �_.,)uids Submersible Effluent Pumps UILCI r 1 ,('5J7 3885 PERFORMANCE RATINGS In gallons per minute Series No. I I L IWE031 I M 12L WE0312M IIHI 12H WE0712H 3/4 3500 90 87 83 78 73 67 61 52 43 W 17 6 VE1012H VE10328 VE1034H 1 3500 106 102 98 94 89 84 79 72 64 54 42 28 16 5 E1512H E1532H E1534H I'' /: 3500 114 108 104 100 96 91 86. 79 72 63 53 40 26 14 4 WE051IHH WE0512HH WE0532HH WED534HH '/1 3500 60 55 52 48 42 39 .'34 30 23 18' 12 . 3 1512HH 1534HH I'h 3500 83 73 77 68 72 63 66 58 60 52 54 45 47 37 40 33 24 15 4 C2" NPT 3'/4„ :0rder No.: SWE0311 L, SWE0312L;• ., ' SWE0311 M, SWE0312M, D' ' /,, 1h, V, and 1 HP = 15" except for model WE0712H & WE1012H = 18 "; SWE0511HH, SWE0512HH. 1'k HP = 18" Available Certifications: kiP. • Canadian Standards Association Pennsylvania Bureau of Mines for non -face applications - BOTE 91. 1�I SEPIEl11 FALLS NEW YORK 13148 SPECIFICATIONS ARE SUBJECT TO CHANGE WITHQUT NOTICE r HP 1/3 '/j '/r MODELS RPM 1750 1750 3500 5 100 70 80 Series HP Volts Phase Max. RPM Solids Weight 10 80 65 76 Amps. ILbs.) 15 60 57 71 WE0311L 115 9.4 20 36 45 65 WE0312L 1/3 230 4.7 1750 56 25 26 59 WE0311M 115 1 9.4 WEM12M 238 4.7 :` tr!''" 35 40 WE0511H 115 13.0 • - '. 3 40 26 WE0512H 230 -•6.5 545 10 WE0532H 208/230 3 3.4 ,, ru(j WE0534H 112 460 1.7 :I 55 -� WE051IHH 115 1 13.0 W E0512HH 230 6.5 65 WE0532HH - - '_' 208/230 3 3.3 70 W.E0534HH 460 1.7 3/4" 75 WE0712H 230 1 9.0 WE0732H 3/4 208/230 3 5.4 3500 V. " - 90 WE0734H 460 2.7 70 100 WE1012H 230 1 11.6 110 WE1032H 1 208/230 3 6.4 120 WE1034H 460 , ' 3.2 WE1512H 230 ". 1 13.3 WE1532H 208/230 3 '9.2 . `f 4a DIMENSIONS WE1534H 1-112 , ^ :4fi r; 80 WE1512HH 230 ,': 1 133 ; `(All dimensions in inches) WE1532HH 208/230 3 92 (Do not use for construction purposes.) WE1534HH 460 ' 46 121/e,r EFFLUENT EJECTOR SYSTEM ROTATION Effluent ejector system offers :Package Includes Submersible Effluent Pump," b' ease of ordering and installa- - WE0311 L. 12L or WE0311 M. 12M tion. A single ordering number. VE0511HH, 12HH,:>';: specifies a complete system ;,. Mercury Level Control Switch, designed for most residential `'A2S (115 V); A2� „(230 V) . and commercial sump and Basin A7- 1801ST"-' effluent pump applications. Basin Cover A8'.1822 ,• ' Check Valve A9 2P.. KICK -BACK 3/4 3500 90 87 83 78 73 67 61 52 43 W 17 6 VE1012H VE10328 VE1034H 1 3500 106 102 98 94 89 84 79 72 64 54 42 28 16 5 E1512H E1532H E1534H I'' /: 3500 114 108 104 100 96 91 86. 79 72 63 53 40 26 14 4 WE051IHH WE0512HH WE0532HH WED534HH '/1 3500 60 55 52 48 42 39 .'34 30 23 18' 12 . 3 1512HH 1534HH I'h 3500 83 73 77 68 72 63 66 58 60 52 54 45 47 37 40 33 24 15 4 C2" NPT 3'/4„ :0rder No.: SWE0311 L, SWE0312L;• ., ' SWE0311 M, SWE0312M, D' ' /,, 1h, V, and 1 HP = 15" except for model WE0712H & WE1012H = 18 "; SWE0511HH, SWE0512HH. 1'k HP = 18" Available Certifications: kiP. • Canadian Standards Association Pennsylvania Bureau of Mines for non -face applications - BOTE 91. 1�I SEPIEl11 FALLS NEW YORK 13148 SPECIFICATIONS ARE SUBJECT TO CHANGE WITHQUT NOTICE r Performance Curves METERS FEET METERS FEET 3 X 2 FQ- 0 MODEL 3885 SIZE 1/41' Solids� 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM L L -L j 0 10 20 30 ml/h CAPACITY MIGOULDS PUMPS, INC. SIRCCA FALLS WW YM 13148 CAPACITY C1985 Goulds Pumps, Inc. ) ml/h EHective July, 1985 - 90 25 - 80 70 W 1 20 - 60 0 50 15- 40 10 - 30 20 5 10 0- 0 METERS FEET 3 X 2 FQ- 0 MODEL 3885 SIZE 1/41' Solids� 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM L L -L j 0 10 20 30 ml/h CAPACITY MIGOULDS PUMPS, INC. SIRCCA FALLS WW YM 13148 CAPACITY C1985 Goulds Pumps, Inc. ) ml/h EHective July, 1985 Hany rW. Nichols Jr., P.E. 31 I,C!ock ,Tower - Commons �.. {,. ; °.; Route 22;• :. , , Brewster, NY. 10509 Telephone-(914) 279 -4003 Fax (914) 279 -450�";:' .JOS No. . .. 00- 093,03 SHEET No. OF--2. COMPUTED BY JM DATE CHECKED BY �wN DATE 17 -00 SCALE { •s-��: .:..... �;- -: - -;._. � �..� �?.''_�_�I���y�.�.:.� ..: 2.��..� °.....:..._.. __:.....__...:. ' .. :..... _:fir... �.. � (� -. :.�.. �. -.. _ _ ... _..._. _ __.... _... __..._. _. -7_._ ..... -_._.. ..._....- ..._._...... _ .. _ _...._ _. _ :. 3 _ _ ... _ .3.. 'YNAU'�A.1 . • MOM Harry W .'. Nichols Jr:; P,E..:', 311 Clock:Tower. Cominons _ Route,22 Brewstei; NY 10309 Telephoiie'(914) 2794003 Fax (914) 279 -4567' • Boa No.. 06 - O`l3.03 SHEET No. O= _ COMPUTED BY DATE CHECKED BY IV DATE S~ j7-OB SCALE .._..�:..�� T.�.� `..\.��..�.,1�4`.�i�_._._. -�00 .....r''... � �Sr fir',- .1.�•.� i --, C'. , � r � �� ..� .. Ow�ae /AP�Ilo�it Node �ecc i¢� i.r Renewal_ O. � - . Date of Pmvkm Approval M Adi`ws ZS Lem "I �G�P /�' Ar"Ak_& 10SOy Town ZIP ` Date Subdivision) Q /pnrroved Fee Enclosed .Amr,i,nt, 3ad''`"r Bwwb 7h, �:S G�P�T`7 at l Lot Ate. Ppl Sectlon _ Dept* .?z_v a Nusbar of d I , oflBatson b Begn)eed Wbis Fm b, co�letea Ha�po�s Deal�a Flow G P D . SOU PC®N " Salwaft Sewmy SydM to oaaII'M at Gam Septic Tflsk:as�l liGb L:F' �%t .fi- � To be aa.aticcea by TBjJ. Adaltan " Water saPPtr `PdmUc Sop* Feosn Addsea a TBI� saa.�. asK— :.�e —,— Pdvaee Sltppb DelOed by Olbeir Regabelpasta I mpreant:that 1 am wholly and completely responsible for the design,and kfcation of the proposed syttem(s); l) ,that the separate sewer a dis sal system above described will be constructed as shown on, disapproved amendment there to antl';in accorclanca with the standards, rules an regulations o a ham County Department :of . NMlth, and that on Completion thereof a (Certificate :of,Constructlon,Compliance" satisfactory to the Commissioner of Maalthwill be submitted to: the OePW.ment, and a written gyagntee. wits be •furnisfimi the owner, hit sun oassors; heirs or aWins by the builder, toes tend pulMar will plate in good operstkq condition any 'Part of said sewage dis- 'I system.duriny,tne Parlo`d•of two (2) yaan ImInWiately following thedate of the luu- once of .the approval of the Certificate of ;Construction Compliance •of the Origin' afsystem or.any repsks theretol2)4hat the drilled wets deserlbed above will be located as shown on the approved plan and that saki well wili be Installed,, i ccordance,;whh` the standards,'ru and rep anions .of the Putnam County Departenen�t of Health. Datr S —,' ` / .Sqn P.E. RA. _ Adds Coss No APPROVED FOR CONSTROCTIONeThisapprovalex piss two years', data issued unless construction of the �klihq has been undertaken and is revocable for cause or may be amended or modified when considered ne -Man y Ali the. Commissioner. of MYlth. Any change or alteration of construction requires �a - now er permit. Approveeddffor disposal of�ddomestic sanitary b e, and /or .D water supply, 'only. Date- , L1'/J�2: f�/ J BY. Title -a. MAY -25 -2000 07:35 AM HARRY W NICHOLS 914 279 4567 p,02 PUTNAM COUNTY DEPARTMEN'x' OF HEALTH ' DIVISION OF ENVIRON7IENTAL HEALTH SERVICES BLQUESTEO EINAL.INS?ZCT4N For: Fill 41_� Trenches _ 1 PCHD Construction Permit # 13 4 __ Located tj G Owner /Applicant Name f2o 5-r' ��Q,, TM_Block_Lot 8� Formerly Subdivision Name 13 system fill completed? Date, 7-:Z-f-0_0 Is system complete? Date Is system constructed as per plans? Is well drilled? Bate Is well located as per plans? , Are erosion control measures in place? I certify that the system(s), as listed, at the above premises has been constructed stud I have inspected and verified their completion in accordance with the issued PCM Construction Permit and approved plans and the Standards. Rules and Rquietions of the Putnam County Department of Health. Date: 5'-.4' --#o - —Certified by PE t/ R.A Def)h Professional - -- Address 3 / ( C c� ��°►- 1 ,�..ti�,..�yr Lie. q - S� 12g Comments: Form FIR -99 MAY -25 -2000 07:35 AM HARRY W NICHOLS 914 279 4567 P.01 'e v Harry W, Nichols Jr., P.E. 311 Clock Tower CommOrn Route 32 - - - — Brwrater; NY 1=0 MOM (914.279AOiOO fax (014) 279.4607 Fm. Tot LT G c % \ c d Proms Y„ Fax 278 - ? R ?a Pagast Phones Revs Fdr 7,,.-- ._. CCt © Urgent Q For Rovl *w d Please Comment ®'hlea w Reply Q Plea" Reoyole e Commee t r. DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL J PCHD PERMIT WELL LOCATION Street Addr ess Village City Tax Grid Number o .Z WELL OWNER Nafie Mailing Address OPrivate 6Lkn In, rw V O Public USE OF WELL M RESIDENTIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED 0- primary 0 BUSINESS ❑ FARM ❑ TEST /OBSERVATION O OTHER (specify 2- secondary 0 INDUSTRIAL U INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE______gal O REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION 11 ADDITIONAL SUPPLY REASON FOR DRILLING 12 NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL DETAILED REASON FOR ULw bt/Pjf/ j4 Se-rye, tie:✓ 1-,5 ;d_'&4c_e_, DRILLING WELL TYPE DRILLED DRIVEN ®DUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. 3 WATER WELL CONTRACTOR: Name T -819 - Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __X,NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF yS JON SEPARATE (data., CONTAMINATION PROVIDED SHEET PERMIT TO CONSTRUCT A WATER WELL to 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; (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 otherwise coon m1nate surface or groundwater. Date of Issue: - 19-- -ti- -<�- -' Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller APPLICATIONS Specifically designed for the following uses: • Hdrries • F", ms . • Jraile r Courts. '`Schools • "Hospitals •. 166stry • jEffluent Systems r. .-Y--SPECIFICATIONS Pump: s Handling Capabilities: Maximum • isc argeSiz6:2",NPT ies' U *._-apac.i t pto114GPM • ,.36tal Heads., Up to 123 Feet TDH • Mecha. n ical Seal: "C''b h-Rotary Seat/Ceramic- -ar b y S f eat . .; 300 Series Stainless Steel Metal 'tt "Pa s BONA N bast omers _!a, Maximum u rn Fa§teners: .300 Series Stainless Steel r 4, , � D Without Capable of li unning Dry to Components Goulds Pumps, nc. Motor: • Single Phase:' /3 HP, 115 or 230 Volt 60Hz,_J750 RPM "r. '/z HP, 1_15. `60 Hz, :3500 RPM. 1/2HP thru'�JYz HP23P:Y,:'..6Q Hz',', 3500 RPM Built-in _OZ`i8ad with A . utornatic Reset Class B ln*§Ulati6n,-.'.I�..--.,��..,;.',,.,.,... • Three hasp:�., 4 . rujl ?.H P 208/230 V, 460'V60 K� 3500 RP! Class Blns6 Overload latioh� Protectioin''"i0i st-be Provided i n Starter Unit • Shaft: Threddedi ., 400 6iri Stainless • Bearing 11, Bearings U and Lower ' y • Power Foot.S4andard Lengtri `(Optional Lengths Availabl Single P..T16%3.. SJTO with.'_f.hi.;,e.q.'prong pjug. 3/4 thru 11/2 HPF 14/3 STO with Bare Three STO with--, Bare. Leads On CSA Listed Models 20- Length *-,,'-.8JT,W,afi'd-:'S'tW,*4rP.,-',,z,.�,.._,* FEATURE non-clod Ior Goulds Submersible. Eff I uen't Plum* PS 1�_751 3885. mechanical seal protection. Bal- anced for smooth operation. Bronze impeller available as an option. Casing: Cast iron volute type for maximum efficiency. 2" NPT d is- charge. adaptable for,.slide rail systems. Mechanical Seal: Ceramic vs carbon sealing faces.. Stai nless.steel metal parts, BUNA-N elastomers.' Shaft: Corrosion-resistant stainless steel. Threaded design. Locknut on three phase models to guard against component damage on accidental reverse ,'.rotation., Motor: Fully submerged in high- grade turbine oil for lubrication.and efficient heat transfer Designed for Contin.6ous 00era- tion: Pump ratings 6 ' re within the motor manufacturer's recommended working limits, can be operated continuously without damage. Bearings: Upperarid lower heavy.cluty ball bearing con- struction. Power Cable: Severe duty rated, oil and water resistant..' . Epoxy seal on motor -end provides secondary moisture barrier in :case of outer jacket damage and .to Prevent. oil wicking.-. 0-.Ring: Assures positive sealing against contaminants and oil leakage. Effective July 1986 RANDOLPH W. LAURENT, P.E. HARRY W. NICHOLS JR., P.E. June 23, 1995 LAURENT ENGINEERING Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Big Elm Subdivision - Lot #3 Bradley Road Patterson, N.Y. ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 8 Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAIL 278 -2658 CONSULTING SITE ENGINEERS Dear Bill: Enclosed are the foll owing: ' 1. .. Three (3) prints of Drawing SF -3 "Preliminary Plan For Fill Placement Only Lot #3" dated 5- 24 -95. 2. One (1) print of Drawing SS -3 "Proposed SSDS -Lot #3 ", dated 5- 24 -95. 3. "Application For Approval of Plans For A Wastewater Disposal System ". -•- -� - - -' 4. - �� "Construction Permit for Sewage Disposal System ", -dated 5= 24 -95. 5. "Application to Construct a Water Well ", dated 5- 24 -95. 6. "Design Data Sheet ". 7. "Letter of Authorization ", dated 5- 19 -95. 8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 9. Pump Curv e. 10, Money Order in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earlies onvenience. ' Very ,fruly you , LAURENT E GINEERIN G ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:bd FEATURES 1. Impeller 2. Casing 3. Mechanical Seal 4. Shaft 5. Motor 6. Bearings - Upper & Lower 7. Power Cabl 8. O -Ring 1 2 MODELS Series I HP I volts 1/3 1/2 3/4 :1 1 -1/2 115 230 115 230 115 230 208/230 460 115 230 208/230 460 230 208/230 460 230 208/230 460 230 208/230 460 230 208/230 460 Goulds Submersible Effluent Pumps 3885 PERFORMANCE RATINGS In gallons per minute WE0511 H Series WE0512H WE0712H No. WE0311L WE0311M WE0532H WE0732H IWE0312L WE0312M WE0534H WE0734H EFFLUENT EJECTOR SYSTEM HP 1/3 1/3 112 Package Includes:° Effluent elector system offers RPM 1750 1750 3500 ease of ordering and installa- WE0311L,12L or WE0311M,12M,::- r 81A.wy ., •;.•,. a r; �. 5 100 70 80 Phase Max. RPM Solids Weight 10 80 65 76 and commercial sump and i Amps. effluent pump applications. (Lbs.) 15 60 57 71 9.4 Check Valve A9 -2P :.. O d N SWE0311L SWE031'M KICK -BACK 20 36 45 65 4.7 1750 56 25 26 59 1 9.4 30 50 . 4.7 35 40 13.0 3 40 26 6.5 0 45 10 3 3.4 . LL 1.7 1 13.0 A 60 6.5 .. 3 3.3 ►- 70 1.7 3/4" - 75 1 9.0 3 5.4 3500 90 2.7 70 100 1 11.6 110 3 6.4 -_._ 120 3.2 1 13.3 3 s.2 DIMENSIONS 4.6 80 : 1 13.3 (Ail dimensions in inches) :. 3 9.2 (Do not use for construction purposes.) 4.6 12'1/2' EFFLUENT EJECTOR SYSTEM ROTATION Package Includes:° Effluent elector system offers Submersible Effluent Pump ease of ordering and installa- WE0311L,12L or WE0311M,12M,::- r 81A.wy ., •;.•,. a r; �. tion. A single, ordering number WE051 1 HH, 12HH specifies a complete system designed for most residential Mercury Level Control Switch A2 -5 (115 V), A2-6 (230 V) f and commercial sump and i Basin A7 -1801S ;� >: effluent pump applications. Basin Cover A8 -1822 Check Valve A9 -2P :.. O d N SWE0311L SWE031'M KICK -BACK 3/4 3500 90 87 83 78 73 67 61 52 43 W 17 6 VE1012 VE1032 VE1034 3500 106 102 98 94 89 84 79 72 64 54 42 28 16 5 WE1512H WE1532H WE1534H 11/2 3500 114 111 108 104 100 96 91 86 79 72 63 53 40 26 14 4 111111 121111 1/! 3500 60 55 52 .48 42 39 ' 34 30 23 18 12 . 3 �nn Lei :1512HH :1532HH :1534HH 1' /r 3500 83 73 77 68 72 63 66 58 60 52 54 45 47 37 40 33 24 15 4 r o.. W'/ 1/2, 3/4 and 1 HP = 15" t for model WE0712H & WE1012H = 18 "; except SWE0 311M, SWE0312M, a� P SWE0511FiH, SWE0512HH. 1'/z HP = 18" Available Certifications: ZO Canadian Standards Association nil Pennsylvania Bureau of Mines for non -face applications - BOTE 91. SENECA FALLS NEW YORK 13148 SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE. PRINTED IN U.S.A. r 'r7s Performance Curves METERS FEET 0 10 0 METERS FEET' -j 0 H M M MODEL 3885 SIZE 3/4" Solids� 20 30 40 50 60 70 80 90 1 100 110 120 GPM L I I 10 20 30 MI/h CAPACITY [gGOULDS PUMPS, INC. SBECA FALLS WW *YM 13148 CAPACITY 01985 Goulds Pumps, Inc. ml/h Effective July, 1985 - 90 25- 80 70 w x 20 - 60 0 50 15- 40 10- 30 20 5 10 0- 0 0 10 0 METERS FEET' -j 0 H M M MODEL 3885 SIZE 3/4" Solids� 20 30 40 50 60 70 80 90 1 100 110 120 GPM L I I 10 20 30 MI/h CAPACITY [gGOULDS PUMPS, INC. SBECA FALLS WW *YM 13148 CAPACITY 01985 Goulds Pumps, Inc. ml/h Effective July, 1985 Gentlemen: This letter is to authorize NAref Y 1A) 01-S. Trz- a duly licensed• professional engineer or registered architect f (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 PU" 'A A COUNTY DEPARTMENT OF Hr • 2H Putnam County Sani= DIVISION OF-ENVIRONMENTAL HEALTH SERVICES Date J� 19. Re: Property of IZ0�51IJ Located at ei0tA 2TN! I/AQS, (T) jfj,=N rYL��or� Section Block Lot Q Subdivision of �;;(4 Subdv. Lot # 3 Filed-Map # 146"7'• Date Gentlemen: This letter is to authorize NAref Y 1A) 01-S. Trz- a duly licensed• professional engineer or registered architect f (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 C o un 0 Very truly yours,* Signed hew 1 5�1 Owner of Property Address 0� Telephone-��� a Z� Address �Mo�lk 0,-5 0'q Town (�3'0 -22) _ �� I Telephone PUTNAM comm DEPARTmir w OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA-SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner T�s '4 L fl Address 4,-, Lam. AJ A,, L Located at (Street) u.��p C �,.� Ij jec. a-`t. Block Lot o (indicate( nearest c ss street) Municipality / dll;Grja h Watershed C�-o (o ►� SOIL PERCOLATION TEST DATA -REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre - Soaking , Date of Percolation Test HOLE NUMBER CLACK 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 17 4 3 3 r , --7 4 4 5 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 frcrn top of hole. rev. .9/85 _ DEPTH G.L. 1' TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES E OLE NO. HOLE NO. ^� HOLE NO.' " i vPso� I 2' 3' 6' V . 8' 9' 10' - 121 13' 14' 414 't, INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED /U DEEP HOLE OBSERVATIONS MADE BY: /Li. �v �t �� DATE: 7 S DESIGN Soil Rate Used Ce _� Min /1" Drop: S.D. Usable Area Provided No. of Bedrocros Septic Tank Capacity gals: Type Absorption Area Provided By fod- L.F. x 24" width trench Other Vn -��- -- Name �„v�� ICS, v �_ Signature. Address 1 SEAL to so c� -• )44F tis No. 56 24 �A USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date a PUTr7A.M CO CTN T'X" »EP.A R'rt�)uN T (D)' JCX).A.X.'TX-X APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL.SYSTEM 1 . Name and Address of Applicant:- Aotr 14 N, Z5 1?y rrA A4 L !lam Rd /OSog 2. Name of Project: 3.._,_Location ®/V /C; ��F�sn�•� 4. Project Engineer: r660. ,Ch Ply ' P• 5. Address: /'li//,6 ,okP OA�'� [e,,h -e- NY License Number: 5Co/ Z Phone: 6. Type of Project: _I/ Private /Residential:: Food.Service ....Commercial Apartments Institutional Mobile Home Park Office Building) ,s Realty Subdivision_, Other (specify) 7. Is this project subject'to State Environmental-Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt ✓• Type II. Unlisted. 8.. Is a Draft Environmental Impact Statement (DEIS) required? ............. ho 9. Has DEIS been completed and found acceptable by Lead Agency? 10.. 'Name of Lead Agency N /�9 11. Is this project in an area under the control of -local planning, zoning, or other officials..,.. ordinances? . .......... ............................... A/0 12.. If so, have plans been .submitted to such, author .sties ?,.................... 13.. Has preliminary approval' been* granted by such authorities ? Date Granted: 14. Type of Sewage Disposal. System. Discharge...... Surface Water ✓ Ground Waters 15., If surface water discharge, what is the stream class designation ?........ N 4 :6. Waters index number (surface) ....................... .................... N1 �. Is project located near a public water supply system? .................. No S. If yes, .name of water supply Distance to water supply- 9.,Is project site near a public sewage collection or disposal system ?..... Na '0. ,Name of sewage system %V�i`� Distance' to sewage system 1. Date observed: -2J -8.1 23. Name of Health Inspector: 13Ud;:._1117 �. Project design flow (gallons per day) ..................................... oG 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. ''U 0 26. Has SPDES Application been submitted to local DEC Office? ti.. .............. 27. Is any portion. of this project located within a designated Town or State wetland ? .................... ............. ............................... 28. wetland ID Number ........................ ............................... i. ti.... ,f 29. -Is Wetland Permit required? .............. ............................... ' Has application been made to Town or Local DEC Office? 30. Does project require a DEC Stream Disturbance Permit? ................... 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 oc industrial activity? ........ YES or NO / C. 32. Is project located-within 1;000•feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge.disposal site or r any other potential known•source of contamination? ..............YES or N0 ./U c DESCRIBE: 33. .Is there a local master plan or file•with the Town or Village? �-> 34. Are community water, sewer facilities planned to be developed within 15 years? 35. Are any sewage disposal areas in excess of 15% slope? ........................ l Vd 36. Tax Hap ID Number .......... Co9 , " �- �' _ 37. Approved Plans are'tobe returned to: Applicant engineer If the application is signed by a person other than the applicant shown in Item.12 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 Hisdefreanor pursuant to Section 210.45 of the Pena 1 Law. J 4 31GNATURES & OFFICIAL TITLES: 4.". 'AILING ADDRESS: \Exi�TiNc / SSTs` 3� r� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT ice, PERMIT # l '1- I y 3 1 1 0 �1 Located at 4 Town or Village��'��� Subdivision name ' I o f, -1 Subd. Lot # Date Subdivision Approved Owner /Applicant Name P-05 6 ALLAH Tax Map 7,4% Block ` Lot V Renewal X Revision X Mailing Address .4 (; �, 55PPO" �-Dp"Q Amount of Fee Enclosed * 40000 Date of Previous Approval 01- % -00 Ak�-M0NV-- NY Zip 106D� Building Type 9061 DG1-4 6C' Lot Area G % 'A� No. of Bedrooms f5 Design Flow GPD (000 Fill Section Only Depth Volume Separate Sewerage System to consist of 1 C cM gallon septic tank and Other Requirements: To be constructed by ITU Address Water Suunly: Public Supply From Address or: Private Supply Drilled by T*'p 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 treatment system 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: , /I,� --t y P.E. A R.A. Date 0'IJ - 0 ` " 0+ N� Address 9_01� 0 tX V t o'�'0� License # rD C � 1-4 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 w consider necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew pe it. Approv or dischar f domestic sanitary sews a only. Au-1a By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ please print or type PCHD Permit # J Well Location: Street Address: p� � Town/Villa _ Tax Grid # P: © H �9 map", Block Lot(s) Well Owner: Name: Address: I oaf, 1AL-AP 4Gco D6WOK P4P@ Pc Mot IoSo� Use of Well: V�' Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought (5+ gpm # People Served 45 -S Est. of Daily Usage o a gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No A Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision X16 l;LVA Lot No.� Water Well Contractor: Tbf Address: Is Public Water Supply available to site? .................................. ............................... Yes No X Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separa sh et/plan . Date: 0'� - o �' o� Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and 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 or their designated representative 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. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well 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. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water 11 'ller cert'fied by Putnam County. Date of Issue i V Permit Issuin g O Date of Expiration 1&/g 4 Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97