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HomeMy WebLinkAbout0822DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -2 -55.3 BOX 9 6 r o 1 116 r•l 2 IL , �I 1: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: To illage: — "" " Tax Grid # - - Map 2-4, Block Well Owner: Name: 112 Ad ess: Lot(s) 55. Use of Well: _ Resid ntial Public Supply Air cond/heat pump Irrigation 1- primary Business Farm Test/monitoring Other(specify) 2- secondary Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _y Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Total length ft. Materials: Steel . _ Plastic _ Other Casing Details Length below grade __IAft. Joints: _ Welded A Threaded _ Other Diameter in. Seal: Cement grout _ Bentonite _ Other Weight per foot lb /ft. Drive shoe: Yes No Liner:_ Yes X No Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? Screen Details First , _ Yes No Second Hours 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 well in feet 37 yel�_ / /b Well Log Depth From Surface Water Well Formation If more detailed ft. ft. Bearing Diameter(in) Description information Land Surface descriptions or sieve analyses are available, please attach. If yield was tested Feet Gallons Per Minute Dump /Storage Tank Information at different depths ' -' Rb 4 am Pump Type 511 Capacity 1A during drilling, Depth 6 Model f 3F 2 4( Z list: Voltage 23 0 HP 2 ��J- Rij - - ____ Z/,) Tank Type Lu t -70Z_ Volume Date Well Completed Putnam County Certification No. Date of Report Well Driller ignature) q NOTE Ex aft location of ell with dista=s to at least two permanent 1 ' dmarks to be provi o a separate. eet/plan. Well Driller's Name Address: ILI I Signature: Date: rV all- jr J'W' White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; erange coW el rer / Form WC -97 DIMENSION CHART (in feet) Number 1 °.59 - 6 . 2 72 78 120 117 , 3 . 4 122 125 132 5 ' ' 128. . 6. _ ,•13;j 138 . 7 140 144, 8 . 146 151 152 157 9 .. 10 158 .163 I1 .164. " 170 12 170 177 ]3 183 .'I 182 .190 14 j97. 15 189 203 . 16 195 17 ,165 182 38' 159 176. 19' 152 169' 20 145 163• 21 138 157 12 ' _ -132 I50 .� 23 125 143 '24 119 137, 25 112 106 131 . .. 125 ` 27 .919 119 • 28 - 93 113 29 87 . 107 30 •81 '101 31 ;98. 96 P � �n �1• i _ rte• 6k W, { rim TNAM COUNTY DEPARTMENT OF "HEAI ION OF ENVIRONMENTAL-HEALTH SEF CERTIFICATE OF CONSTRUCTION COMPLIANCE PCHD CONSTRUCTION PERMIT # h `17 -a 0 Located at �tO (n 1J'a TN Owner /Applicant Name �4 v eel ,� ►-lc r Formerly FOR SEWAGE TREATI.A,... a U l A7 i AZATA Town or Ytll9e Tax Map 2.!!J— Block Z Lot Subdivision Name 1- wv I-ca- /?v�- Subd. Lot # Mailing Address 3'7 )3 1 o a c.,, er R o a �J rc.c. �.r �. � Zip Date Construction Permit Issued by PCHD ) l - Ce -0 o Separate Sewerage System built by log,,, Lr Address -3 rdU`,., ,,,,- o fi►-cijs+ Consisting of 1 SOD Gallon Septic Tank and Q ; a� Other Requirements: Water Supply: Public Supply From. Address or: r/ Private Supply Drilled by a �, /� t �`,er, e c6.1 tUed Co. Address ( Q 91t Ae Z ��►--�, ,... Building Type Has erosion control been completed? Number of Bedrooms IT Has garbage grinder been installed? /(/C) 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 regulaVgns of the Putnam County'pepartment of Health. Date: /D -; �- 01 Certified by Address P.E. Z/ R.A. License # SCe / 2-2f Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are ubject to modification or change when, in the judgment of the Public Health Director, such revocation, o fic or change is necessary. B Title: Date: 3 )or 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 Address: � To n/Village: Tax Grid # Map °L�} ,Block 2„ Lot(s) 55.�j Well Owner: Name: Ad ess: l L All 1e, 6^1d i Use of Well: 1- primary 2- secondary - Resid ntial Public Supply 4' 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 121 ft. Length below grade ft. Diameter _ in. Weight per foot lb /ft. Materials: Steel —Plastic _ Other Joints: –Welded Threaded _ Other Seal: -7< Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes X 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(f4) Depth of completed well 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 ft. ft. Land Surface Pap n. Y If yield was tested at different depths during drilling, list: Feet Gallons Per Minute ump /Storage Tank Information Pump Type 51 L Capacity I Depth 2 �'0 Model '(3 6' 2-04(Z Voltage --'3 o HP 2 Tank Type luq - 3Oz_ Volume Date Well Completed / /1 Putnam County Certification No. 4 ti ; rJ Date of Report. {� I 1 D 'f Well Driller ignature) iVU'1'L/ Exact location otuveii with aistances to astwo permanent 1, arl.iumarlcs to be pro, Well Driller's Name / Address: Signature: Date: �L White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; on a separate eevptan. `A ,. copy - Wel dril er Form WC -97 -PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SU13SURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Towrifyill Location - Street B4�-k 14,oal+ OIL Building pe.' /e.✓ �-�- Subdivision Name 3 Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, constructiorf and "draina'ge of the sewage treatment system serving the above - described' property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition.. any parr- -of said '-s-ystetn constructed by me which fails+ to operate fora 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 10 Day -2�- Year pol Signature: Title:" ) General C ntractor (Owner) - ignature . Corporation Name (if corporation) Corporation Name (if corporation) Address: 3j Address: 3 . �3l0o►�,�r ewc�Gv State ALY Zip 10 SD State Zip 1.0 S'o Form GS -97 NORTHEAST LABORATORIES, INC. 129 MILL STREET - BERLIN; CT 06037 -9990 NORTHEAST LABORATORY OF DANBURY <�v �N aocoRO�N [Danbury-Sample Drop Off Site: 100 Mill Plain Road Suite 342,. Danbur -CF] - ° — -- TELEPHONE: Toll Free (in CT) 800 - 826 -0105 (Outside CT) 800 - 654 -1230 Berlin/Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 E -Mail: NELABSCT@AOL.COM www.NortheastLaboratories.com REPORT TO: 1NN EK U1JKULh r A"JL - W to 1 r, W W n i m m v A" juanj rem I HYATT PUMP SERVICE DATE SAMPLE COLLECTED: 7/22/03 229 SOUTH RD. TIME COLLECTED: 10:30 HOLMES,NY 12531 COLLECTED BY: Madeline NONE STATED DATE RECEIVED @ LAB: 7/22/03 11:03 am TESTED BY: LAB #11471 8c 11393 DATE TESTED: 7/22- 8/1/63 TEST PERFORMED LAB I.D. # D0302086 LEVEL (MCL) OR REPORT DATE: 8/4/03 SAMPLE SITE: 1NN EK U1JKULh r A"JL - W to 1 r, W W n i m m v A" juanj rem I SAMPLE POINT: TAP LOCATION TACK ROOM SINK SOURCE: WELL DRINIGNNG WATER TREATMENT: NONE STATED MAXIMUM CONTAMINANT TEST PERFORMED RESULTS METHOD # LEVEL (MCL) OR DATE TESTED -STANDARD BACTERIAL: • Tofal Colifo n Absent (0) -per 100 1&!::: SM 92226 ,.: , . 0 per 160 Ml(ABSENT) .. ; ". 7/22/03 (Bacteria) PHYSICALS: • Color (Apparent) None Detected EPA 110.2 15 units 7/23/03 • Odor None Detected - 3 Units 7/22/03 • pH 7.17 - ASTM- D1293 -99 No designated limits 7/23/03 • Turbidity 0.26 NTUs EPA 180.1 5 NTUs 7/23/03 CHEMISTRY: • Nitrite Nitrogen <0.005 mg/L as_ N EPA 354.1 1.0 mg/L 7/22/03 _ • Nitrate Nitrogen * 0.42* ing/L as N EPA 353.3 10 mg/L 07!25/03 • Alkalinity • 72 mg/L SM 2320B No designated limits 7/22/03 • Hardness 90 mg/L EPA 130.2 No designated limits 7/23/03 • Iron 0.05 mg/L EPA 236.1 0.30 2 mg/L 7/28/03 • Manganese <0.01 mg/L EPA 243.1 0.30 2 mg/L 7/28/03 2 Combined -limit for Iron plus Manganese = 0.50 mg/L • Sodium <Q 4.9 mg/L EPA 273.1 No designated limits 3 7/28/03 • Lead <0.001 mg/L EPA 239.2. 0.015 mg/L * ** 7/31/03 • Chlorine Residual <0.05 mg/L - --- 7/22/03 • Conductivity 172 umhos/cm EPA 120.1 No designated limits 7/25/03 • Potassium 2.2 mg/L EPA 258.1 No designated limits 7/30/03 • Sodium Bicarbonate None Detected' SM2320B No designated limits 8/1/03 • Calcium 34 mg/L 3500CaD No designated limits 8/25/03 • Magnesium 1.2 mg/L SM 3500 MgE No designated limits 8/25/03 ml= milliliter mg/L=mii igrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count " "Notification Level ** *Action Level <Q= Analyte detected below quantitation limits. Data deemed estimated 3 =Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than. 270 mg/L of sodium should not be used for' drinking by people.on moderately restricted, sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. All holding times (were) met. Tested by Spectrum Analytical Laboratories, Inc. Lab #11393 SAMPLE, AS TESTED ABOVE: MOTABLE or DOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE �IL�iu ciwu �(, Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 BRUCE R FOLEY LORETTA MOLMARI•R.N., M.S.N. Public Health Dlrecta, - v � 04 ,4uoclalc Publl�:.NfOlrh .[?(rrcror,•- - w �' - Dirccror of Palfcnr. Scrvkcr DEPARTMENT OF ' HEALTH 1 Geneva -Road­ _. __ ...... Browster, New York '10509 Earlroamcaut Hu1tk (914)271.6170 Fcx(914) 271.7921 Natalat•Strrica (9J4)27F •6152• •WIC (91 <)27F =6671 M(M)27:40:5 LutyTaIcri4Na- (914)11x• 6014 Preschool (914) 27: -6022 Fax (914)17r- 6641 E911 ADDRESS •VE IFICATION FORM OWNERS NAME: 1-40rCIL I--V� TAX'P.I�I[TMBER:: _ . S _...:_ .__.........._. .. E911 ADDRFM.. _ .. ,/� ! `/ TOWN - -- - i' [l - e-we-tj /V , t i __ AUTHORIZED TOVIJ_D.FMCiAL:. - - -- (Signature) The!* Putnam County Department of Health will not issue a Coat f cate of -• - • - - - - Constructioh Compliance. unkss the above form is. completed; a legal E911 address is assigned by n authorized town official. This-form-is to be submitted with the application for a Certificate of Construction Compliance. I (E911YERFFK - -... _ g November 10, 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) 279 -4003 Fax: (845) 279 -4567 Email: hnengineer@aol.com Re: Individual SSTS Compliance - Laura Parker Parker Subdivision, Lot # 3 36 - 40 White Hawk Trail Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of 'Drawing S -3, "As -Built SSTS," dated 10/27/04. Z. " Certificate- of--Construction -Compliance- for -Sewage Treatment-- System; " - - - - -- dated 10/12204. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 10/22/04. 4. Laboratory Report, dated 08/04/03. 5. "Well Completion Report," dated 09/01/03. 6. Application Fee in the amount of $300.00 payable to Putnam County .Health Department. 7. E911 Address Verification Form, dated 11 /01 /04. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN:gav 00- 154.nov PUTNAM COUNTY DEPARTMENT OF HEALTH / DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Col -� o E) Date: �%C .�� Inspecte y:.% Street Location lJ f Owner "`G►� Towns,. Permit # — TM # 3 Subdivision Lot # 1. Sewage System Area a. STS area located as per approved plans ..................... I........ b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil qot stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a. Sep-tic tank size - 1,000 .... .....1,250.........other....�'� b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. .2..Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... f. Trenches I . Length required Length installed 3y8 2. Distance to watercourse measured 4 -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 - 1 %" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped .................: .:. -- - g. PumR or Dosed Systems Size ot pump comber .............. ............................ 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........... III. House[Buildin a. House located per approved plans ....... n.......... . b. Number of bedrooms ........... a?. -a?.!.� :•:: IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured 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 & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 6/97 I rune a 1 v M r.s _ /r IN �� (©E= imm Imm imm imm imm ION 100 SWAM rune a 1 v M r.s _ 0 w DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 TeL (914) 278-6130 Fax (914) 218-7921 Date: �� ! � A -0 To:' I)akt"Y A)i cllwr /Z. Cl 1 l-e 1111-L v� iii From: Shawn Rogan Public Health Technician For your. information For your review As discussed Notes/Messages Fax #• L^) gi5-% 7 No. Pages (Including cover sheet) BRUCE . R. FOLEY Public Health Director Please respond Attached as requested Please call In the event of transmission /reception difficulties, please contact this office at (914) 278 -6130 egt ,2159. H • A PUTNAM COUNTY DEPARTMXNT OF HEALTR DIMION OF ENMONMMTAL HEALTH 9ERVICEs ATTENnON D ADAM GENE 1QiESTEA For: Fill All Wonnadon must be dilly completed prior to sqy Trenches — inspections being made, 00- PCIdD Consuuction P rmit # Lowed: (T) Ql� �ar•*�d ti _ _ Ownah pplicaat Name; La. `TNI _4_ Block -Z_ Lot ,= 3 Formerly: Subdivitioa Name: �--- • .. Subdivision Lot # - —`- Is system fa eompleled? Date: Is 3ysterae041ete? _ V. Date: 1 ` ©Q r. 1s syatem coastnicted a: Dar plssasT Is wen drilled? f �..*.�... Date: _ _•',j ...� Is wen located as por plans? V- t Are orosioa control measures in place? I c * that tha systagil as Bated, at the above premises bas been constructed end I bave inspected and verified their eompledon ht accordance with the issued PCHD Construction Permit sad approved plaa wad the Standards, Rules and Upladons of the Putnam County DgWmact of Health °O CatiWd by: PE RA . • - _ ._ .. . _ __ Professional - Address. Lic. Comments: Form M -99 , --COt MEALTH--DEFT.. -P 7T rl4 PI ..'UTNAW JNT 02" v 4Z.-I re "B;iiO ' a4- r,, NY 10b08 v `. to bQ z-1 1.1, The"SLI 7 om- - N .p , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # �` 7 -0�) Located at V O 1 I h 4A W- TILA I L Subdivision name pN Q- Subd. Lot # Date Subdivision Approved B)00 Town or Village Tax Map A Renewal p�TT'�R -Sort Block 0.4- Lot " ✓� • •! Revision Owner /Applicant Name LAJJ -A p Date of Previous Approval Mailing Address 45� o15g- 1 N� Zip Amount of Fee Enclosed tibrioi Building Type FOtPW I Off+ Lot Area '151 t No. of Bedrooms �P Design Flow GPD 1 000 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1y00 gallon septic tank and At5 Other Requirements: 0051 N(a � (V KOH t 0E0 CIdKMH VM114 To be constructed by TS O Address Water Sunuly: Public Supply From Address or: �4 Private. Supply Drilled-by ... .7%V 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 treatmentsystem 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. X R.A. Address 1,1061D K VL- 'di p-- tii �� License # _ Date 101t )to 5'6/Zq 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 SpRsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit p oved fo charge of domestic sanitary sewage o 1 . By: Title: Date: ro Vj White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 ".%VL PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL ('� please print or type PCHD Permit # vQ Well Location: Street Address: TownNillage Tax Grid # MiV5 liAWIL -N-ML- PIN� ()h1 Map 24 Block I Lot(s) 151;,� Well Owner: Name: Address: �-X'J P �bj BLJ10 (t el�- i Use of Well: 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 Ii`3' gpm # People Served '9 '6 Est. of Daily Usage Gs o!) 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 X. ........................... ............................... Is well located in a realty subdivision? ........... Yes )� No Name of subdivision r Lot No. Water Well Contractor: 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 separate she t/plan. Date:. � 1� _ Applicant Signature:- I&M4. V 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 y revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate we l driller qgrtified by Putnam County. Date of Issue J. I Permit Iss ' Official: t-),An Date of Expiration Title: Permit is Non- Transfe a e 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) 279.4567 To: Attention: �bIFW7 G ntlemen: We enclose ( ) copies of B/W Prints O Reproducibles O Pecifications O Memorandum _ Description: Date: II� i�OQ Job No.: O Reports O Tracings O Copy of letter O Revision/Date No. Ls Aar vi olo fill �00 (►� P -�y,�o cA�15�U Vno� 'Q �ncn r� �o j � I o0 Sent Via: O Our Messenger O Blueprinter O Your Messenger O Hand Delivery Copy to iohols Jr., P.E. CD r.n CM b C) O First Class Mail O SpeciaEDeli r� , O r M CD M V+= ...-,-o= N •� C7 —C Very r ly�ypurs, iohols Jr., P.E. 1 V Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279.4003 Fax (845) 279 4567 Octo er 23, 2000 Putnam County Health Department 1 Geneva Boulevard Brewster, NY 10509 ATT: Robert Morris, P.E. RE: Proposed SSTS: Parker White Hawk Trail, Lot #3 Town of Patterson, T.M. #24, -2 -55.3 Dear Robert: In response to your review letter dated October 19, 2000, we offer the following: 1. Curtain drain has been added to the plan & standpipes are shown & detailed. 2. Design flow has been increased to 1000 g.p.d. Enclosed are five prints of the revised drawing. We believe the above adequately addresses your concerns and we request the issuance of the construction permit at your earliest convenience. Thank you. Very truly yours, Harry W7Nichol s Jr., P.E. HWN:JM:his 00- 154.00 BRUCE R. FOLEY Public Health Director LORETTA. MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services 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 (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Parker White Hawk Trail, Lot #3 (T)Patterson, TM# 24, -2 -55.3 Dear Mr. Nichols: October 19, 2000 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: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1) Curtain drain standpipes are to be shown and detailed. 2) The design flow is to be increased by 200 gal/day, i.e., two separate habitable areas sharing the same SSTS current codes requires the design flow to be increased by 200 gal/day. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:tn Ve truly yours, Robert Morris, P.E. Senior Public Health Engineer fLe I 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 (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: Parker White Hawk Trail, Lot #3 (T) Patterson, TM# 24. -2 -55.3 Reservoir Basin Dear Mr. Nichols: October 19, 2000 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on October 3, 2000 is complete. The Department will notify you by_November 3, 2000 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions asset forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation Letter to: Harry Nichols, P.E. - October 19, 2000 -2- of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. RM:tn Ve ly your Robert Morris, PE Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address O'jLI 6L00Mg3- P-00 hgw� j" Ip;p� Located at (Street) iii -'rC Tax Map L4 Block 2 Lot (indicate nearest cross street) Municipality fyi — ET-60H Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 1 ljq NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Depth to Water G ou d From r n Water L vel e Percola on.: h Hole No RunNo Time Start Stop EIa s6 Time . �1VIm) Surface (IQches) Start Stop X?ropp In IncLes te Min/Inclr 2 224' ZSN v 2"� 2rj 3 4 5 1A4 1'14 3 2 ��, �,� 2A' 24 4 5 2) ZA'Ii. 2 ►:� - 'r� o �� 2�'r2 j j2 yR 3 V 2-4'/4 1'14 2-4 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. n � HOLE NO. � (� j Oj�ao!', m�'avm sA►sc� eF of��C NwTU4 HOLE NO. Indicate level at which groundwater is encountered (11"tE � A) Indicate level at which mottling is observed' Indicate level to which water level rises after being encountered Deep hole observations made by: DENNi� P-W JE- Date G i l Design Professional Name: 1+414 •w, N�(,RVt ; jf-�5 Address: 15url'e A fA *T t0A UIP K rVL 10� Signature: Design Professional's Seal 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: ( STREET LOCATION: REVIEWED BY: RM, GR, AS, SEDATE: Y A DOCUMENTS (__) PERMIT APPLICATION f�WELL'PERMIT OR PWS LETTER ( (_ PC -97 LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) 'OCORPORATE RESOLUTION (SHORT EAF )PLANS -THREE SETS HOUSE PLANS - TWO SETS (__)( VARIANCE REQUEST SUBDIVISION (�" f0 EGAL SUBDIVISION SUBDMSION APPROVAL CHECKED (_)L_)PERC RATE (_))FILL REQUIRED DEPTH U CURTAIN DRAIN REQUIRED GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP �CrDEP EGATED T O PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED RCS TO BE WITNESSED - APPROVAL SSDS ADJ, LOTS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA 100 YR. FLOOD ELEVATION W/I 200' SOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS W � SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT TOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES (TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# IDATE OF DRAWING/REVISION ►DATUM REFERENCE, ►LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. )PROP OOR AND BA4MENT ELEVAT S )WE W/IN 200' OF SSTS )PROPERTY METES & BOUNDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01 /00 TAX MAP #: (CONFIRIAED) Y (REQUIRED DETAILS ON PLANS CONT'D OUSE SEWER -'/4" FT. '4 "0'; TYPE PIPE CAST IRON N BENDS; MAX BENDS 450 W /CLEANOUT RENEWALS C_ _)SITE NOTE (NO CHANGE) FILL SYSTEMS J__)10'HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE 1 1FILL SPECS/ FILL NOTES 1 -5 L _)FILL PROFILE & DIMENSIONS FILL IN EXPANSION AREA FILL GREATER 7HAN2 FEET CLAY BARRIER U FILL CERTIFICATION NOTE (� DEPTH GAUGES (� VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS (� SEPARATION DIS CE FROM TI TAN—OE OF S PE ED� ( P THE ROVID RALL OURS 0% EXPANSION PROVIDED ETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL EOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS (_&e�)10' TO P:L. DRIVEWAY, LARGE TREES, TOP OF FILL F)5BO' 20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. expan) 0' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER TO WATER LINE (pits - 20') ( 50' L ITERMTfTENT DRAINAGE COURSE ( 0200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS __)10' MIN TO LEDGE OUTCROP ' � SEPTIC TANK C--4610' FROM FOUNDATION; 50' TO WELL WELL X�D.,rMENSION�S TO PROPERTY LINES LCATION OF SERVICE CONNECTION (_nCLJMIN 15' TO PROPERTY LINE SLOPE L_)SLOPE IN SSTS AREA (920 %) (_) EGRADED TO 15 %, IF REQUIRED r DOSE/PUMP SYSTEMS PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (� DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) (_) PIT AND D -BOX SHOWN & DETAILED (_) 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN TANDPIPES, 5' BOTH SIDES, DETAIL 15' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % - <1% (_) 20' MIN to CD DISCHARGE /100' with 182 cons day discharge 10' MIN to NON - PERFORATED PIPE Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279-4567 September 27, 2000 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Lot #3 Parker White Hawk Trail Patterson, N.Y. TM #24. -2 -55.3 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -3, "Proposed SSTS," dated 9- 27 -00. 2. "Short EAF," dated 9- 27 -00. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 9- 27 -00. 5. "Application to Construct a Water Well," dated 9- 27 -00. 6. "Design Data Sheet." 7. "Letter of Authorization." & Two (2) copies of Residence Floor Plan(s), for Bedroom Count Only." 9. Review Fee in the amount of $300.00. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic ols Jr., P.E. HWN:JMhis 00- 154.03B 14.16 -4 (9/95) —Tex1 12 PROJECT I.D. NUMBER 617.20 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) SEAR 1. APPLICANT /SPONSOR �� p A 4��� . r I F2, PROJECT NAME DoT '� IN �gININI. '5y°� - C-)/xR -H 3. PROJECT LOCATION: I�vT A1— G Municipality (/� 1 ) >1�'� w County l 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) S. IS PROPOSED ACTION: 4New ❑ Expansion ❑ Mod ificatlon/alteratlon 6. DESCRIBE PROJECT BRIEFLY: ii- IU1viCT�L �''r'`7 i'� �►t� 61�� al'!��1�Nr . 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ZYes ❑ No If No, describe brlefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open apace O Other. Describe: '0'D) yG')1 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ X0 Yes 11 yes, list agency(s) and permitlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ® Yes ❑ No If yea, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Yes ❑ No I CERTIFY THAT THE INFORMATION ABOVE Is TRUE TO THE BEST OF MY- KNOWLEDGE rPROVIDED Yv `�� gnu '_ `� K`4CK .9 1��I"o Appllcant/sponsor name: 9i Date: (/ Signature: F 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 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: i *JPA PA - P-- Wwiz p— NY 2. Name of project: La—1 t j N DNI ML 6 '91_�7 3. Location TN: 4. Design Professional: 1t�� � �` NIGI -��is, JP-"5. Address: 5JTF ) O� f'!tfTE�-60 f -Ar_�K_ 1z;0V1 22 6. Drainage Basin:,�Hc,l -�N-' 7. TVDe of Proiect: )( Private/Resideritial Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this.project subject to State Environmental Quality Review (SEQR)? Type Status ( check one) ....................... ............................... Type I Exempt Type II Unlisted :X 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... N Q 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency N f, yA 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? NQ 14. Has preliminary approval been granted by such authorities? No Date granted: NA 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... y A 17. Waters index number (surface) JA 18. Is project located near a public water supply system? I -AD 19. If yes, name of water supply Distance to water supply NA 20. Is project site near a public sewage collection or treatment system? ................ N 21. Name of sewage system Distance to sewage system kA 22. Date test holes observed (P y 23. Name of Health Inspector 24. Project design flow (gallons per day) . .............................. ............................... AQ0 25. Is_ State Pollutant Discharge Elimination System.(SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... 'N h Form PC -97 z 27. Is any portion of this project located within a designated Town or .State wetland ?_ `` t�— 28. Wetlands ID Number ........................................................... ............................... Lo (-NL 29. Is Wetlands Permit required? .............................................. ............................... hl D Has application been made to Town or Local DEC office? N R 30. Does project require a DEC Stream Disturbance Permit? N� 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 activity. ..... Yes/No N� 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination. Yes/No b 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 within 15 years in or adjacent to project site? 35. Are any sewage treatment areas in excess of 15% slope? . ............................... NlZ 36. Tax Map ID Number .............................. Map '2-4- Block Lot P' 37. Approved plans are to be returned to ..... Applicant Design Professional _ NOTE:. All applications for review and approval of anew SSTS to-be located within the NYC Watershed shall be sent to 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. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... 15U i l � �Oi- � C 1r'�'-- � �,o�4 pl- 0P -9 \4 6i �--, '0 b�I 10 '0` . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL. HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of k"r a Pap Ker Located at lei i� Ifi/�y,i� fi1tL T/V Tax Map # '�-�° Block Lot Subdivision of F't'(��� Subdivision Lot # 1 Filed Map # �r�� Date Filed Gentlemen: This letter is to authorize"((1 -(�- t`I �.l✓ 1-�a(� �', Q a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary paper's* 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 Conitary Code. Countersigned: P.E., R.A., # Mailing Address State i- � Zip I050� Telephone: q �1) 2� 61 - 4 00 ' 1 Very truly yours, igned: (Owner of Property) Mailing Address: 39 31o0 ry\a,U kd State Telephone: _ I If a- T2) 7 3 g S Form LA -97