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Ylw dt DrlaLaat•uttl 8er16 SaedDM: C7ateaei. N.Y ICU GO SWATZ OF OOAQUANCB
- _
1 ►ep►eeant`that I' am wholly and completely responsible for the detign and IbCation' of I the proposed system(s); 1) Ghat the .M gate fovea a
above deipibed will, be constructed as shown on'tneapproved amendment there to and in accordance with the standards, rules an rpu a oral IT
County. DsWmant :of. 'mwott%- and that on completion thereof 0 - Cartif icete of Construction Compliance•' Ytkfactory to the Commissioner of Healthwill
be submRteO to, tye Oapartmant, and a' written guarantee will bi furnished the owner, his successors. Mks or assigns by the builder, that Yid bulkier will
place in good, oguretklg condition any part of Yki saw age dispotaI syitpni. duflrp the period of two (21 Y 1 Immediately Yolklwlnta tMdate of the 111u-
ante of 1M';appfoiral of tM`Grti/kate of 'ConAwction.,COnipllanq of tO iginal system . or any repair$ *to; that the drilled well desal0e0 above
Mim W beat" as,Ylawn on the apaowd,plan and that yid well will be Instal . n accordance wit he fta rd16 le old rNu MWn of the Putnam
County Oepaftm ek Of • Mealth. r
OLti ✓'�..,� Signor ";
P.E. R.A.
Address
Ucenl No-
APPROVED ROR CONSTRUCTION: This app' va expNes two years from the date -I .un construct n of the building has been undertaken and is
revocable for ca11N or may be amended or modified when considered neteslary.'by the Commissioner of. Health. Any change or alteration of construction
requires a w permit.. Approved f disposal of Oomegic sanitary,' age ate water supply only.
Rev. � �. r Title
1vtoo Oate_�Gyz
am
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT -A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address 1 o Village City Tax Grid Number
WELL OWNER
Nam Mailing Address
AO W122
DID ' ? % �
MPrivate
O Public
SE OF WELL
], - primary
2 - secondary
8 RESIDENTIAL O PUBLIC SUPPLY
0 BUSINESS O FARM
0 INDUSTRIAL IU INSTITUTIONAL
❑ AIR /COND /HEAT PUMP
O TEST /OBSERVATION
❑ STAND -BY
O ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT je� _ gpm /# PEOPLE SERVED,''.- /EST. OF DAILY USAGE al
❑ REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION Q ADDITIONAL SUPPLY
O NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED _
13DRIVEN
ODUG
GRAVEL.
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES Y"" NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name T.•�.�i Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ENO
NAME OF PUBLIC WATER SUPPLY: L / A-- TOWN /VIL /CITY
.DISTANCE..TQ_PROPERTY.FROM NEAREST WATER._MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(date) J, J, sig ature
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirt -y (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 su h a manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19— T ---
Date of Expiration 19 Permit Issuing Offici
Permit is Non - Transferrable White copy: HD File Pink opy. Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
i
NORTH AMERIG' . _ LN
HOUSING
A
48'
L Li BATH
-- —
t OWING ' '
1 ^' MASTER BEDROOM
10 p
'd" a 11'.x" KITCHEN 11"1"
•
- 11'
,. BATH I I
Y
i~ LIVING ROOM BEDROOM 12 .
18'5". n•..•" .� BEDROOM.3 % tt..2... n•.r. ,.
_ UP DN
_. PLAN 1 4824 =1152 SF
—�.—
_P,JT.P1.Av� COUNTY .DEPARTMENT. OF HEALT •
HOU SE FLANS APPROVED FOR
BEDROOit COUNT O1,11 YJ
• 1
48' ff- DR001iS
I
M. 6AT14
DINING R O O M MASTER E E R OOM
10' .0". t]'t'• KITCHEN 1 1... ... +" ".,"'4 °� -::.y �p j® .r✓�.
t 1'B"
If BATH
28'
�`
LIVING ROOM BEDROOM w2
18'•5" . t]'a" BEDROOM r] 10'•5" a 13'•1-
AON UP
PLAN 11 4828 =1344 SF
ALL FLOOR PLANS AND ROOM SIZES ARE APPROXIMATE
NORTH AMERICAN HOUSING CORD/ (301) 948 - 8500• (301) 694 -9100 • (301) 442114 0
'tans, I Prices And Spedriications,Subject To Change Without Notice Copyright 1985 (Sae Reverse Side)
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: -Property of 1,
Located at
Section Block Lot
Subdivision
Subdv. Lot r'
Gentlemen:
Filed Map # Date-
This letter is to authorize
a duly licensed professional engineer or registered architect
(Indicate)
to apply for a Construction Permit for a separate -sewage system, to
serve the above noted property in accordance with the standards., rules.
or regulations.as promulagated by. the Commissioner of the Putnam Country
D '11. necessary papers on 'my behalf. in
epar. ent of*ftealth-, and to a
r� co=66tion with this matter and to supervise the construction of said
' _syst6m or systems -in conformity with the- provisions of Article 145 or
_1 471 Education Law the -Public Health Law, and. the Putnam County Sani-
1
tar ta`ry Code.
X,
Countersigne
_U
P.E. , R.A. , f"
Address.,
/ I leo O:T g
Telephone
Very truly y o u r
Signed
Oumi� of Property
Aadr'ess
Town
-Telephone
• LAURENT ENGINEERING
ASSOCIATES; -P.-C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
RANDOLPH W. LAURENT, P.E. (914)278 - 6108 - (FA)q 278 -2658
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
July 20, 1994
Mr. William Hedges
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS'
Car -Dee Building Corp. Subdivision - Lot #1
Partridge Lane
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing SS -1 "Proposed SSDS - Lot #111,
dated 7- 20 -94.
2. "Application For Approval of Plans For a Wastewater-Disposal
System ".
3. "Construction Permit for Sewage Disposal System ", dated
7- 20 -94.
4. "Application to Construct a Water Well ", dated 7- 20 -94.
5: "Design Data Sheet ".
6. "Letter of Authorization ", dated 7- 20 -94.
7. "Corporate Affidavit ", dated 7- 18 -94.
8. Two (2) copies of Residence Floor Plan(s), for "Bedroom
Count Only ".
9. Check in the amount of $300.00, review fee.
We would appreciate your review, approval and issuance of the
Construction Permit at your 'earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. ichols, Jr., P.E.
HWN:bd
94051 -1
cc: Mr. G. M)acaluso w /enc.
p C7`T N,A, M C O U N '2' i»✓ is P,. �2T M 1G r7'T O >r'
APPLICATION. FOR. APPROVAL OF- PLANS. FOR A WASTEWATER DISPOSAL -SYSTEM
Name and Address of Applicant:
2. Name of Project: 1�1UPD 1;1� �i�►75 3. _. Location /C
4. . Project Engineer: 5. Address.: i�(11,Lfi�i�OD�
M1W To1VQ roAn
• .•. _ .... ... , t T T� , N Y 1050
License Number: Phone: 21 _ GIoB
6. TYp�e of Pro ect•
✓ Private /Residential• -Food .Service. -'• ....Qoa iercial
Apartments Institutional Robile:Home Park
office Building : Realty Subdivision Other (specify)
7. Is this project subject•to State Environmental - Quality Review (SEQR)?
toe Status (Check One.) Type I..- Exempt ✓
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? ,,.........., KAI)
4. Has DEIS.been completed and found acceptable by Lead•Agency? N)
10. Name of Lead Agency K)
11. Is this project in an area under the control of local planning,_ z.on_ing,
or other* officials;' 6rdfhances? _ ....:. ............................. ti?il
12. If so, have plans been..subsnitted to such. author .i ties" ...................... t�/A
13. Has preliminary approval been 'granted by such authorities ?. Q/A Date Granted:
14. Type of Sewage Disposal.Systen Discharge...... Surface Water ✓ Ground Waters
15. If surface water discharge, what is the stream class designation ?........
6. Waters index number ( surface). ........... ...............................
7. Is project located near a public water supply system? nJ0
3. If yes, name of water supply U_ /A Distance to=water supply ,
4. Is project site near a public sewage collection or disposal system ?..... Uo
0. Name of sewage system W/A Distance to sewage system
I- Date observed: 2 — �� 23. Name of Health Inspector• ! ,UZ . !�' . }%�!..�� I<.;n
Project design flow (gallons per day) ..................................... 6D/
. 2.
25. Is. State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. �p
26. Has SPDES Application been submitted to local DEC Office? K) /A
27. Is any portion of this project.located within a designated Town or State
wetland ? .................... ........................... ............... N.) Q
23. Wetland ID number. ......................... ............................... ►J /d
29. •Is'.WetIand Perm, it. requi red? .............................................. tiro
Has applicatiorn_ been made to Town or Local DEC Office? .................. !J A.
30. Does. project require a DEC Stream Disturbancp Permlit? Fc�0
31. Is or was 'project. site used for agricultural activity involving application
of-pesticides to orchards or other crops, solid or hazardous waste disposal;'' -
laAdfilling, sludge application or industrial activity? : ...... : YES or NO ^)y
32. Is project located-within 1;000-feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known -source 1: contamination? ......'.........YES or NO 'kld
DESCRIBE:
33. Is there 'a local master plan or r"ile.with' the Town or Village?: ............
34. Are community.water, sewer - facilities planned to be developed within 15 years? UN I:fNvr-100
.3.5....Are any sewage disposal areas in- excess of -15%� slope? ................ .. :w: .c; !Q0
36. Tax Hap ID dumber ...... ..... ........ ......• .
)
37. Approved Plans are'to "be returned to: ........ Applicant i,: = _Enginee r
If the application is signed by a person other than the applicant shown im-Iten'.1_;:.;.the.
application must be - accompanied by-a. Letter of Authorization. Failure to ;cwomply�� ith this
Drovision 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 be 1 ief. False state:rents made
herein are punishable as a Class A Hisde,-,eanor pu suant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES:
MIMM "
':AILING ADDRESS:UJT
DES: 1. Tests to be repeated at same depth until approximately egi3al 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
IM4 O0UN1Y- DEPARTMLW OF BEAL
•
DIVISION OF ENVIRORHMM HEALTH SERVICES
DESIGN DATA SHEET- SUBSUFACE SEWP,GE; DISPOSAL _SYSTEM, _ - - -
-- _ -.- .:, FILE No.
Owner
/I �cG� ii b l r.�OPti%I �.i Address j_��
oN✓IP ..,.
, a l�M �s j. l �� f3
Located at (Street-). PA I'G�tZt; 76 r>'` � I mo, .. .: ;Sec. 25 . Block / LO
(inch ate nearest cross street)
Municipa-Lity !:�f T-rf ZEN
Watershed
C907,ON
SOIL PERCO=CN TEST DATA RDQJ= TO HE SUBMITTED KM APPLICATICNS.
Date of Pre - Soaking 5f2f Igo' Date of Percolation Test
5. 2! lee.
HOLE
'
Nal M
.- CL= TIME PERCOLATION
PERCOLATION
Run
Elaose Depth to Water From
Water Level.
No
Time. Ground Surface
In Inches
Soil Rate
Start -Stop Min. Start Stop
Drop In
Mini /In Drop
Inches -Inch6-s
Inches
2-7
3
11
30
2
:55 - 2-Z5 30
2 :30
q
5
2
3
S
DES: 1. Tests to be repeated at same depth until approximately egi3al 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
G.L.
1i
-TO PSol L - rDPSoI L
2'
5I LTY 514N17Y (o)i LA SILTY 5PrN5 T0� M ,
41
�► �, GIG 5 ,
6'
7,
10'
12'
JAI
INDICATE LEVEL AT WHICH .CROUP IS ENCOUNTERED
INTDICATE LEVEL TO.. WHICH WATER LEVEL RISES: AFTER BEING F.NOOUNTERED
DEEP HOLE OBSERVATIONS M_n.DE BY: DATE.:
DESIGN _
Soil Rate, Used. Il- 15 Min/1" Drop: S.D. - •Usable Area Provided
No. of- .Bedroans �7 Septic Tank -- Capacity Od0 gals: Type COME.
Absorption Area _Provided By `;',_7(0 L.F. x 24" width trench
Other : U • t"✓ _ .
Signature h:iC:�y
�• ,1) t.11t+-�n� -S `�'CL• • % r , V
" "' _ �(^ •v •��`
ess
rte+
f � 0 _T r4S SEAL cd
N
o.. 5 N 124
THIS SPACE FOR USE BY NTH DEPARI[Ma ONLY:
Rate Approved sq.ft,%ga]_•; -Checked by Date
putnam County Department of HeaIth
Division of Environmental Sanitation
a
AFFIDAVIT - CORPORATE a4NER APPLICATION
FOR PERMIT. A PPLICAT•ION- -SUB MI-TTED• -TO
PUTNAM-COUNTY HEALTH DEPARTMENT
TO: Co bssio er of iealth - In the matter of application for
x _�.- `4L�q1�?;_.___ —_ represent
�/
that.1 am an offi er or employee of the corporation and am: authorized'
to act for. Gi 1 !i /�' (U • i�-� 7` p <
(name of corporation) _
having offices at — �. `1Z. 31 /�
Whose officers -are
President oi-6q . /6l
.., ame and address
Vice -,Pies den t
-.....�.- ..: •- _'••......_ ._..._ _ - -(Name and Address) _ _ _ _ _ �. ,......�: i. , •
S;ec;retar
Treas�ire�r:
' (Name and Address)^
and that I= am-and will be individually responsible fon any'or all aptp
of. the- corporation with respect to the approval regl'es:te .rid -all sub-
sequeit acts relating - thereto.
Sworn to'before me this J. day Signed �---',
of 19 Title 7j =-�-
i
o ary Publi -
10 J. DAMS
J1OTMPiJW.=ETATSOF:O; M?X
REG.14935305
QJ4URM N DUT CHESS LC ,-Y
t
Corpor4te Seal •
/ FQ11ilAM CO DI�A>tTlr!$NP"OF RBALTH
` / `7 `3 ` Dlvl�lae d iv6H Seevloe�:: Crnmel. IRS. J@d13
CERTMATE OR•C0111PLIANCB
-> N» FOIL sswAf� OtsrosAl. SYSIEM L-
00
' ` r
4C _ l Or. p. / Tax. Map r Rldek ` Jat q .
_ j L -
/ Reoeaal_� ,Itevlalea p `
Ow adAp GMW Nattte v W. G's
Dated,! l
Pamalft Adaa �UG } Town
Date Subdivision Approved Fee: Enclosedf0 Am
Fm Section -O nb vabme
Lot Area � '. :,
Fbw .G P D iy d km b RegWred When FM b twasPlebed
Ntabar d Baieoome . .
Sepaeats Serraear Syikm to ooe�Nt d7 iZ(seOa Seplb Tank
To 6 caeaa.atea by wr.�s " 0 X— t" Address- 1 S otrwi Lr t! I Cr sT�, -`..V� Cr
Ad
wow sue: t std haim Aar.
ue,_pe9vate Sapglj, De91ed b9 r• ` sari.
Ober Reoaleementa
t rip►esanf tnat 1, am wholly and eompNtely rotponsible for thi design and location of the proposed system(s); 1) that the separate sewage disposal s stem .
ebo,re dSStribed: will be opnsfructed ap shown on tee +Dprored amendment then to and in accordance with the standards, rules a regg wns o - nem
County 'Department
of :/WItA, _and that oneompbtion thereof i "Cart ifx is ot• Construction Compliance" satisfactory ao thr'CommisNonei of Neilthwill
be submot" to- the Department and "a wiit'ten guarantee wall "Oi furnislNd the ownor, his succsssors _heirs.- aagns,by -the bui". fhat said bulkier will
place iA 000d'oper the eoti0itbn any part`oP saW swags tlifposal system during too period of two (2) yoi Ommadiately following thedate of,the ipu-
Shot of the approval -of the- Certificate of Constructioe Compliance of thi `iginal system or any repairs then o;2) that the drilled,well c6sEril)W above
wfll'M• wcaeea;SS sAawnn on,tne'app►o,red plan and that. aid well will w Instal_ accordance with the itanela' iu a , reau a1i%ns of. the Putnam
County,DiWrtiiwntto�l- `N7wltli.
Gate " -f / ` . Sgned p E v' R.A. _
Addle tlf.� rev O ir:ense No • �la ) ��
APPROVED FOR CONSTRUCTION This approval expires two years from the date`iswed unless construction of the b ilginq- .has;Desn:undertakM and is
,,. -
revocable for cause••oi. maybe amended vr- modifieA when considered noeessary Oy tee commissioner of Heanh. Any charge or. alteriWn'.of Construction
re0uins anew , ..water supply only.
ReV.� By Yitln
10/88 -Date
F.
I
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509
(914) 278 =.6130
APPLICATION.TO CONSTRUCT.A WATER WELL
PCHD
PERMIT # -
;WELL LOCATION
Stnreet A dres Town Vil
I Ty �t,
age City Tax Grid Number
WELL OWNER
Name / M i� ing, Address
((,, �t tt► ate.
rivate
Public
� E OF WELL
primary
'2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY O P AIR /COND /HEAT PUMP O ABANDONED
BUSINESS ❑ FARM O TEST /OBSERVATION O OTHER (specify,
0 INDUSTRIAL U INSTITUTIONAL. O STAND -BY O
;AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED 3-4 /EST. OF DAILY USAGE 60 al
,REASON FOR
DRILLING
E3 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION GLADDITIONAL SUPPLY
&NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
',DETAILED
REASON FOR
DRILLING
t c
WELL TYPE
• DRILLED
ODRIVEN
ODUG
C] GRAVEL
C]
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES L/NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: (�,.� — (J.�, (1L.Iv1 Ce►-
Lot No.
WATER WELL CONTRACTOR: Name T f3 Q Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ENO
'NAME OF PUBLIC WATER SUPPLY: /�- TOWN /VIL /CITY
..- DISTANCE TO.TROPERTY_FROM_.NEAREST WATER MAIN:
LOCATION SKETCI,� SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
1
(date) (s nature)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirt3- (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 contaminate-surface or groundwater.
Date of Issue:
Date of Expiration 19_,�7 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
APPEJ*DIX C+ FINAL SITE INSPECTION DATE:
Inspected by:
STREET LOCATION OWNER
PERMIT # '� S , — TM # OR SI I V I S I ON LOT
1. SEKA(f DISPOSAL AREA
a. SDS area located as
b. Fill section - date
C.
Natural soli not st
d.
Stone,brush,etc.,gr
e.
100 ft. from water
11 SEWAGE
DISPOSAL SYSTEM
a.
Septic tank size -!�
b.
Septic tank installs
c.
10' minimum from fot
d.
DISTRIBUTION BOX
1. All outlets at sz
2. Protected below f
3. Minimum 2 ft. on
0
e elevation -
ost
i na 1 so i 1 bete
e. JLNCTICN BOX - properly set
I:. TRENC HES
1. Length required - ,� L
,2. Distance.to watercourse measured
-3. Installed according to pian
4. Sloe of trench acceptable 1/1 .-
5. 10 feet from property 1� ^e - r2O fee,
6. Depth of trench < 30 inches fr
7. Room allowed for eyeamsi on. 100%
`8. Size of carav 4 - diameter c'
9. Depth _of gra each 12' mininx.
10. Pipe ends-capped
g .
PUMP OR DOSE SYSTEMS
1. Size of pump chamber
2. Overflow tank
3. Alarm, visual /audio
4. Pump easily accessible marY)o l e to gr
5. First box baffled- - - -- - -__
6. Cycle witnessed by Health Oepartrnent
11. MOUSE
a. House located pei
b. Number of bedroa
J. WELL
a. Well located as I
1b. D i stance f ran SD:
c. Casing 18" above
d. Surface drainage
OVERALL WORKKg4SHIP
a. Boxes properly gr
b. All pipes partial
c. All pipes flush %
d. Backfill material
e. Curtain drain in
f. Curtain drain out
9. Footing drains di
h. Surface water pro
i. Erosion control pi
,� "e
)ox ana trencnes
igth installed
ft.
- foundations
Tans
xmd well acceptable
:ed
backfilled _
inside of box _
ntains stones < 4" diameter _
led according to plan
1 protected & dir to exist watercourse
are away from SDS area
+-ion ad ate
i dec r'
YES I NO I OOM•tENTS
to ..
•�l
gyasi -1
5
r.2 ... 310
c
I�XES_ 1. Tests to be repeated at sa*rti depth until: appraXimately -e awl _soil rates
are obtained at each percolation test hole. All data to 5--submitted
for review. -
2. Ikpth n�asuramants to ba made fran top of hole.
PUTL\L M ' C JLNTY DEPAR2MEIU OF HEALTH
• DIVISION
OF ENVIRU-vL,, ENTAL HEALTH SERVICES
DESIGN DATA :SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTII4 FILE ISO.
owner Gr/Gy - � �y
Address
Located at (Street) .
Sec. •Block Lot 7.
.:...(indicate
_T_
nearest: cross street)
Municipality :. , .... _:. ,
_...:.:......_.. ...... Watershed GfvTO��... -
:..-.SOIL. PERCOLATION TEST DATA :RIUTR® TO BE SU&�LiTPF.D WITH APPLICATIONS .
Date of Pre-Soaking...
Date -of •Percolation Test _ ....
HOLE. - - .......:... ..:.........
NUMBER CLOCK TLNE
PERCOLATION PERCOLATION ."
Run ._...._......... - _........_ .Elapse -
Depth to -Water.Trcrn .._ 1qater:'Leve1
No. Time
Ground Surface..,- In Inches Soil, Rate
'Start -Stop .. Alin.
-Start :: -Stop Drop In Min /In Drop
Inches 'Inches Inches
*
1 2 /;��� ,30 .:_
Zss:. 31.
5
r.2 ... 310
c
I�XES_ 1. Tests to be repeated at sa*rti depth until: appraXimately -e awl _soil rates
are obtained at each percolation test hole. All data to 5--submitted
for review. -
2. Ikpth n�asuramants to ba made fran top of hole.
., � - �C..7.�' N ,A. N� - . C C� �C7 t�7- '�C"X` �D � � .la, R.'� M �E �T '�C '• O �' - 7E� � ,� :C_;, '.1,' �-:
— APPLICATION FOR APPROVAL, OF .PLANS. FOR A WASTEWATER DISPOSAL, SYSTEM
Name and Address .of. Applicant: dot@. CA-SC "�. kC\
2 Name of-Project: ..���tp ��� _ , ati.o�J /C: �v441 Wv50c,
.. �= 3. Loc
4: .Project Engineer:v�_.�tGi /rr___, .5�` Address riillbrooke Office Cent:
er, NY 10509 .
License Number.: (e 12d - Phone: (914). 278 =6108
T ce Project:
�Private /Residential Food.Ser.vice Cor•nercial
.Apartments Institutional H6b:i,le :home: Park
OfT.ice Building. Real ty.Subdivision: Other.,.(s.pecify)
V.. Is this project subject' to State Environmental•Quality Rev w.(SEQR)?
Tvoe Status (Check One) Type I.. EXemot
Type II. Unlisted.
S.
Is a Draft Environmental In. pact'.Statement (DEIS) required? . ..........:.. ✓"0
9.
Has DEIS been completed '.and found acceptable by Lead Agency?, ......:....
i 0 .
Name of Lead Agency.
mil/ .....
li.
Is this'project in an area under. the control of -local planning., zoning,
or other
�0
officials, ordinances? ......... ...............................
_
2.
Lf so, have plans been:sut:mitted to such authorities ?.. ...... :..........
A11A.
_
3.
Has preliminary approval bee�i granted by .such. authorities? Date Granted: —'
;.
Type of Sewage Disposal; System Discharge ......• Surface Water Ground Waters
�.
if surface water discharge, what is the stream class designation ?.........
>
W aters index number (surface)
Is project locaLed'nea.T a public water supply system? ................
- d
if yes, nac,e'of 'water supply Distance to water supply
TS project site n_ar a public sewage collect-ion or.disposal systi::-i ?.....
d -
-
Of sewage system 1" /� Distance to sewage system
Date observed: %�
_ 23. tta�,,e of Health Inspector: r.
�L %�vJz "5 -��.
P`Oiect design rlo'; (gallons per day) ......................
2,
G5, Is State Pollutant Discharge_Elimination•System ( SPDES')- Perm it required ?.. c/
26. Has SPDES Appl icati.on been subiitted ;to' local DEC -Office? . . ........... . N A
27. Is any portion of this - project located within a designated'Town or State
wetland ?...... ..............
28. Wetland ID Number . ..... ..............................i
29. 'Is Wetland Pe m, it-required-7 .............. ................................
Has 'application been made t Town r Local DEC Office ?• ......: ...... _
3o, Does project require a DEC Strewn - Disturbance Pe „it? ....................
31. Is or was project, site used for- a'gr-icultural activity involving 7appl ication '
OT pesticides, to orchards-or other crops., solid or hazardous waste disposal,
land-IN lling, sludge application or. industrial activity? .. YES:'or:h'0:. 6
32. Is project located'xithin 1;000-feet of `existence of abandoned landfill,.'`
hazardous waste: site, salt .stockpile,, Ian dfill; sludge.disposal site or- �Q
any other potential known•source of contamination ?......'. ......... YES or..h`0
DESCRIBE:
33. Is there a local Waster plan or file•with the Town or- Village? ...........
34. Are co,_--*iunity water, sewer facilities planned to be developed within 15 years ?. No
3S. Are any sewage disposal areas---in-excess of i5- slope? ... _ ..... �D
`6. Tax Nap TD Nu,,ber ....... .............................:. .. 'a.s4'�
37. Approved Plank are'to*be returned to: .................. . Applicant 'd, Engineer
If the application:is signed by a person other than the applicant shown in Item•1, the.
°pplic<tion must be-accompanied by y-a Letter of Authorization: Failure to comply with this
-)rovision.may be grounds for the rejection °of.any submission.
X hereby affirm, under penalty of perjury;- that information provided on this
fo. „ is true to the best -of Gy fnow7edye and be_7fef. False statements •made-
herein are punishable as a Class A Kisderreanor pursuant to Section 210.45 of
the Penal Law.
iGN/1 T URES OFFICIAL TITLES:
�lillbrool-:e Office Centre
,ILING ADDRESS: Brewster, NY 10509
111qAm CCUNTY DEPARIIKERX, OF BEl _
DIti�SION OF ,FlFrALT4i SE,,,/ICES
DESIGN DATA SHEET- SUBSUFACE SE AGE DISPOSAL SYSTEM FILE NO.
O>,mer �::vyt/: `q; Address
Locate`i at (Street) 1��.�1�.��� i��►.� .::sec: 25 , Block xot �I 1
(inmate nearest cross street)
mm-dcipality 1A•7 -r!07 AJ Watershe3 GiZOTQN
SOIL PERCOLA CN TEST DATA PZQ=ED TO BE SUBMITTED re= APPLICATIONS
Rate of Pre- Soaking
Date of Percolation Test21 Lee
HOLE.
NiP43FR ; CI�OCg ' T1ME ' PERCO ZION PERCOLATION
Run Elapse Depth to Water Frcm Water Level
No. Time . Ground. Surface In Inches Soil Rate
Start -Stop Min. Start stop Drop In Min /In Drop
Inches Inches Inches -
i 2(0, :5:3. 2-7 _...._.....__ 3 .. 11
2-
2 : 55 - 2: 17_5 30
3 2 2b ` 2: 30 Zla 2 15
4
5
2
3
4
r
5
i
NO'L'FS: 1. Tests to be repeate3 at sarre depth until approximately equal soil rates
are obtained at each percolation test hole. All data to'be subnittt!d
for review.
2. Depth nea.sureTents to be made fran top of hole.
Irev. 9AW;
G.L.
lr
-TO Psort. " rpPSol L ,
1.7Y 551UPY l AkA s)L;TY 5&N5 L, Oq M
31
5r
6'
gr
10
11' L .
12' -
13
14r
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED N. � ►4 .
INDICATE LEVEL TO WHICH LATER LEVEL RISES: AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY : A � � �I
.. __ zaks DATE- l2
DESIGN
Soil Rate Used" ' it14�-? Min/1" Drop: S. D. Usable Area Provided
No. of Bedroms Septic. Tank Capacity lOdO gals. Type (O4* NG•
Absorption Area Provided By '537-76 L.F. x 24" width trench
Other
- r I I4- Zk }�`� '1a) ti 1 I G�-i DL-5 "rG Signature > /. diary
Address SEAL x ki
.Y
No. 56124
THIS SPACE FOR ' USE BY REA= DEPPIMMU ONLY:
Soil. Rate Approved sq.ftAg 1-; Checked. by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date Tai
Re: Property of T Ste, 4 vL- 1 L
Located at
La
0c,
Lot '!, I
V
Subdv. Lot # Filed Map Date
Gentlemen:
This letter is to authorize Harv"vr/. tc, }
a duly licensed.professional engineer 6; or registered ai '
(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 brehalf in
I•..._ -
--connection. with. -this matter-and-to supervise the construction of said- - --- --
system or systems in conformity with the provisions of Article 145 or
147, Education.Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
J�
�14.. Sign
Counte signed:
P.E. , R.A. , #
Address
5,,44 �,sj
21- 8 -610B
Telephone
13 1^ jk� �jl �
Town L of
r-?4) o?V-76%
Telephone
Section
25`,
Block
Subdivision of
Car - d-eP_
A U
IJ CII' c-
0c,
Lot '!, I
V
Subdv. Lot # Filed Map Date
Gentlemen:
This letter is to authorize Harv"vr/. tc, }
a duly licensed.professional engineer 6; or registered ai '
(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 brehalf in
I•..._ -
--connection. with. -this matter-and-to supervise the construction of said- - --- --
system or systems in conformity with the provisions of Article 145 or
147, Education.Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
J�
�14.. Sign
Counte signed:
P.E. , R.A. , #
Address
5,,44 �,sj
21- 8 -610B
Telephone
13 1^ jk� �jl �
Town L of
r-?4) o?V-76%
Telephone
NORTH AMERICA . T
HOUSING JAM
E5I'OWNE
SPLIT FOYER
.48244828
aoc
. . . . . . . . . . AF
y A, K.
L.. ........
48'
48'
M. BATH
M. BATH <
DINING Room
"I MASTER BEDROOM
M W.6 x 13'. 1
KITCHEN
I I '-6C,13
—j
0
DINING
BATH
1 LIN
28'
ILI
MASTER BEDROOM
KITCHEN
LIVING ROOM
BEDROOM -2
10',1 13',,-
14**• X i I'A"
.G
16*.5" . 13--1"
BEDROOI.I r)
TH
UP DN
I �LN
PLAN 114828 =1344 SF
24'
LIVING ROOM
BEDROOM .2
BEDROOM .3
10' 6" A 8'-0*'
UP DN
177 7—
-PLAN-[
4824,-1152_SF__'_
48'
ALL FLOOR PLANS AND ROOM SIZES ARE APPROXIMATE
NORTH AMERICAN HOUSING CORP/ 145 point of rocks, maryland 21777
(301) 948-8500 (301) 694-9100 c (301) 442-1410
Plans, Prices And Specifications Subjcct To Chang,: Without Notice cup)-fight 1985 (Sec Rcvcrse Sidc'
M. BATH
DINING Room
"I MASTER BEDROOM
M W.6 x 13'. 1
KITCHEN
I I '-6C,13
—j
0
BATH
1 LIN
28'
ILI
LIVING ROOM
BEDROOM -2
10',1 13',,-
16*.5" . 13--1"
BEDROOI.I r)
UP DN
PLAN 114828 =1344 SF
ALL FLOOR PLANS AND ROOM SIZES ARE APPROXIMATE
NORTH AMERICAN HOUSING CORP/ 145 point of rocks, maryland 21777
(301) 948-8500 (301) 694-9100 c (301) 442-1410
Plans, Prices And Specifications Subjcct To Chang,: Without Notice cup)-fight 1985 (Sec Rcvcrse Sidc'
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Harry Nichols, P. E.
Laurent Engineering
Rt. 22 Sir Milltown Rd.
Brewster, NY 10509
Dear Mr. Nichols:
I3'gr,
.. BRUCE R. 'FOLEY," R.S.
Acting Public Health Director
December 13, 1996
Re: Lot # 1 CarDee
Mecal Development Corp., Partridge lane
(T) Patterson, TM #25 -1 -9.1
Construction Permit #P -15 -94
A field inspection on the above mentioned parcel on December 12, 1996 indicated several
major deficiencies.
Excavation .of the- foundation, driveway and .the .SDS area -has caused the following concerns: - -
1. The SDS area has been cleared and ROB material has been placed. However, it is
obvious that this work was done with heavy. equipment, during periods of heavy rain.
It appears the soil structure has been compromised and the bank run appears to be
mixed with a large amount of on site soil
2. Although silt fence and erosion control measures are clearly noted on the approved
plan, no erosion control measures have been constructed to protect the regulated
wetland or adjacent properties including partridge Lane.
Therefore, I am requesting the building inspector to place a "Stop Work" on this
parcel until the following items are corrected.
1. All soil which has been transported off site, or within the 100' buffer of the wetland
be removed and these areas restored to original condition.
2. All erosion control measures required to insure adequate protection of the wetland
and adjacent properties be installed and approved by both this Department and the
Town of Patterson.
z " Mr. H a r r y Nichols - 2 - December 13, 1996
3. The area of the proposed sewage disposal system be inspected by both this office and
your firm to determine the extent of the damage. This may include new deep test
holes and percolation test in the original soil.
4. The ROB soil, may require sieve analysis to insure the quality is acceptable to both
your office and this Department.
No construction or activity, other than these items mentioned above, will be allowed until the
reinstatement of the construction permit by this Department.
If you have any questions, please contact me at your convenience.
Very truly y-
William Hedges
Sr. Public Health Sanitarian
WIVJP
cc: BI (T) Patterson
McCal Dev. Corp., 175 East Holmes Road, Holmes, NY 12531
r �
O
B
,1
�1
ID
(x
1 tn
DIMENSION
CHART
(in ft.)
No.
..
1
25
/5
2
28
r,
62.
4
37
67
5
�3
ZZ
!o
¢9
7&
7
55
eo
8
ZZ
53
-N 70000'5
9
Z2
37
15.00".
35
//
32
43
/2
40
50
67
89.. .
Al
97
I
.a
a
a
- a
W
PUTNAM COUNTY DEPARTMENT OF HEALTH
COMPLAINT OR SERVICE REQUEST RECORD
No. 803 -96 -19
CONFIDENTIAL'
REQUEST FROM 'P M /Bill TELEPHONE
ADDRESS
ENVIRONMENTAL HEALTH: Home Sewage Rodents
Migrant Camp Other
Refuse Public Water Food Service
COMPLAINT OR REQUEST HRXX Bridle Ridge R.S., TM #25- 1 -9.1, has started construction.
No silt fence, dirt washing off site. Also - ROB being placed by pushing onto site.
SDS has been disturbed.
Haviland Road to Bridle Ridge, first lot on left. Partridge Lane.
ACTION TAKEN BY
FINDINGS
4 iii
P `d i it
7GYB•7i 7�
w i�ti J /1-71 d� - — (r:s
FOLLOW UP INSPECTION (s
DATE I FINDINGS I /-,,;G
G
/La d� r ATE z'sl.`Y
oe
PROBLEM ABAT �D //
DATE l' PERSON NOTIFIED
i
— -rw
ESTIMATED TOTAL MAN HOURS SPENT
;77
PATTERSON_
DATE _.... _ _ 12/ 12/96 - -
- _ -- - REFERRED. TO
Bf H.
TAKEN
BY BH
TELEPHONE CALL
X IN PERSON
LETTER
CONFIDENTIAL'
REQUEST FROM 'P M /Bill TELEPHONE
ADDRESS
ENVIRONMENTAL HEALTH: Home Sewage Rodents
Migrant Camp Other
Refuse Public Water Food Service
COMPLAINT OR REQUEST HRXX Bridle Ridge R.S., TM #25- 1 -9.1, has started construction.
No silt fence, dirt washing off site. Also - ROB being placed by pushing onto site.
SDS has been disturbed.
Haviland Road to Bridle Ridge, first lot on left. Partridge Lane.
ACTION TAKEN BY
FINDINGS
4 iii
P `d i it
7GYB•7i 7�
w i�ti J /1-71 d� - — (r:s
FOLLOW UP INSPECTION (s
DATE I FINDINGS I /-,,;G
G
/La d� r ATE z'sl.`Y
oe
PROBLEM ABAT �D //
DATE l' PERSON NOTIFIED
i
— -rw
ESTIMATED TOTAL MAN HOURS SPENT
;77
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Harry Nichols, P. E.
Laurent Engineering
Rt. 22 & Milltown Rd.
Brewster, NY 10509
Dear Mr. Nichols:
BRUCE R. FOLEY, R.S.
Acting Public Health Director
December 13, 1996
Re: Lot # 1 CarDee
Mecal Development Corp., Partridge lane
(T) Patterson, TM #25 -1 -9.1
Construction Permit #P -15 -94
A field inspection on the above mentioned parcel on December 12, 1996 indicated several
major deficiencies.
Excavation-of the foundation, driveway and the SDS area has caused the following concerns:
1. The SDS area has been cleared and ROB material has been placed. However, it is
obvious that this work was done with heavy equipment, during periods of heavy rain.
It appears the soil structure has been compromised and the bank run appears to be
mixed with a large amount of on site soil
2. Although silt fence and erosion control measures are clearly noted on the approved
plan, no erosion control measures have been constructed to protect the regulated
wetland or adjacent properties including partridge Lane.
Therefore, I am requesting the building inspector to place a "Stop Work" on this
parcel until the following items are corrected.
1. All soil which has been transported off site, or within the 100' buffer of the wetland
be removed and these areas restored to original condition.
2. All erosion control measures required to insure adequate protection of the wetland
and adjacent properties be installed and approved by both this Department and the
Town of Patterson.
t
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
Harry Nichols, P. E.
Laurent Engineering
Rt. 22 & Milltown Rd.
Brewster, NY 10509
Dear Mr. Nichols:
BRUCE R. FOLEY, R.S.
Acting Public Health Director
December 13, 1996
Re: Lot # 1 CarDee
Mecal Development Corp., Partridge lane
(T) Patterson, TM #25 -1 -9.1
Construction Permit #P -15 -94
A field inspection on the above mentioned parcel on December 12, 1996 indicated several
major deficiencies.
Excavation-of the foundation, driveway and the SDS area has caused the following concerns:
1. The SDS area has been cleared and ROB material has been placed. However, it is
obvious that this work was done with heavy equipment, during periods of heavy rain.
It appears the soil structure has been compromised and the bank run appears to be
mixed with a large amount of on site soil
2. Although silt fence and erosion control measures are clearly noted on the approved
plan, no erosion control measures have been constructed to protect the regulated
wetland or adjacent properties including partridge Lane.
Therefore, I am requesting the building inspector to place a "Stop Work" on this
parcel until the following items are corrected.
1. All soil which has been transported off site, or within the 100' buffer of the wetland
be removed and these areas restored to original condition.
2. All erosion control measures required to insure adequate protection of the wetland
and adjacent properties be installed and approved by both this Department and the
Town of Patterson.
I
;.b r3.
P
Mr. Harry Nichols
-2-
December 13, 1996
3. The area of the proposed sewage disposal system be inspected by both this office and
your firm to determine the extent of the damage. This may include new deep test
holes and percolation test in the original soil.
4. The ROB soil, may require sieve analysis to insure the quality is acceptable to both
your office and this Department. .
No construction or activity, other than these items mentioned above, will be allowed until the
reinstatement of the construction permit by this Department.
If you have any questions, please contact me at your convenience.
Very truly y�,-
William Hedges
Sr. Public Health Sanitarian
W ip
cc: BI (T) Patterson
McCal Dev. Corp., 175 East Holmes Road, Holmes, NY 12531
s PLTTNAM COUNTY DEPARTMENT
OF! HEALTH
R v / 86 Dlvbdon of fitvlronmental Heakb Services, Carmel; N Y 10512
Engineer Mnet Provide
` P C H D Pernik
CATE OF CON5TRUCTION COMPLIANCE FOR.SEWAGE DISPOSAL SYSTEM F a D
M
ill Ta: ap B ackr VMS
wne ap t 4Nam Y `S1?urZmQr1Y Snbdivlslon Nam �° - Sabdv: Lot M
MaWng A _ _ a�V k �P _ Dste'Permit Issued'
Sepsuate,$ewenge SyetemAbnut i s 4 r
Conslttlog of ' � �I�� 4 ` > y �' rGiQon Septic TaW� and: —, ✓ '�':� s � �•
.r..
Wader Supply Pabll c Snpply "From «S es _
or: Pilvste Sappl - DrWedtby
w.
• / "P `/,� Has Erosion Control BeenaCompleteaY Li•� -S
BalldlnB.Type
Number °ot Bedrooms Has GaibagecGrinder Been InetalledY
Dtber Regnlrements 4
3 cazt'ify that the system'(e) as listed serving the eboveYpremiaes,rere conetructedresaentially ae eho on'the plane of the completed rorlr (copies
of which' are. attached) ;and in accordancerith the standaida, rule. and latioge do accordance:r th fi d *plan, and the permit iasued by the
Putnam County Depertment`Of Health
Date - Certifletlfby
Liaria NO
A
eR
d--re / O
Any, person oecupyinq pnmiws 'Joy ed by the ab0've system('s) shall promptly,take such - action es may W nepspiy to n tM coi►edion of any unsanita►y
Y
conditlons resuH!ne from such us pe ADProval o� tM sspatrate siwer :H stem shall bieoine n IF rid void at t at Pub(': pnitary awsr becomes
ivalwtilo and the approval; 'of the "p►ivats;vvater supply sMlf.becomeI null• nar: oid vvMn a.pub watw fupply bewntis avatNbN SSueh',approvals are
subjeeC ,tom tiotfo of cMnge when In tM judgment Df It CO f of MNith Ocatbn. ri►odlflutbn Or eAinOe
Date f 8Y %�� Title
ti
-f.
NORTH AMERICAN
LABORATORIES, INC.
CERTIFICATE OF LABORATORY ANALYSIS
LAB ID NUMBER: 97 -2584
CLIENT: Joe Cuscina
Taryn Ln
Patterson NY 12563
SAMPLING LOCATION:
COLLECTED BY:
DATE COLLECTED:
DATE RECEIVED:
DATE OF REPORT:
Outside tap: Taryn Ln
W. Cuscina
05/15/97
05/15/97
05/19/97
TIME COLLECTED: 2:00 PM
This' sample, as submitted -to the laboratory, and' as compared to- the -New York State limits for drinking
water quality for the tests performed, was:
✓ ACCEPTABLE. NOT ACCEPTABLE.
Maryann Fasano, Assistant Laboratory Director
NYS ELAP #11218
CT Lab Approval #PH -0171
* Underlined results are unacceptable according to health department and /or US EPA codes.
** Maximum Contaminant Level (maximum permissible concentration allowed by health department and /or US EPA codes).
618 Clock Tower Commons, Brewster, NY 10509 -9241 / 914 - 278 -7600 / Fax 914 -278 -7754 / E -mail: NoAmLab ®aol.com
ANALYTE
RESULT* UNITS ' `
MAX CNTMT LEVEL *.*
METHOD
ANALYZED
Total Coliform
Absent
Must be "Absent"
SM18(9223)
05/15/97
E. Coli
Absent
Must be "Absent"
SM18(9223)
05/15/97
This' sample, as submitted -to the laboratory, and' as compared to- the -New York State limits for drinking
water quality for the tests performed, was:
✓ ACCEPTABLE. NOT ACCEPTABLE.
Maryann Fasano, Assistant Laboratory Director
NYS ELAP #11218
CT Lab Approval #PH -0171
* Underlined results are unacceptable according to health department and /or US EPA codes.
** Maximum Contaminant Level (maximum permissible concentration allowed by health department and /or US EPA codes).
618 Clock Tower Commons, Brewster, NY 10509 -9241 / 914 - 278 -7600 / Fax 914 -278 -7754 / E -mail: NoAmLab ®aol.com
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'Owner or Purchaser of Building Section Block Lot
U
ETuilding Constructed by
Location - Street(
_A9-17_E,CS0
ML icipality
Building
PAV a)�a
Subdivision Name
Lo -r -i /
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM
I represent that I am wholly and completely responsible for the location,
workmanship, material, construction and drainage of. the sewage disposal system
serving the above described property, and that it has been constructed as shown on
the approved plan or approved amendment thereto, and in accordance with the
standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good
operating condition any part of said system constructed by me which fails to
operate for a period of two years immediately following the date of approval of the
"Certificate of Construction Compliance" for the sewage disposal system, or any
repairs made by n►e to such 'system, except where the failure to operate properly is
caused by the willful or negligent act of the occupant of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environinental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building utilizing
the system.
Dated this -S day of 13 19 Z Signature
// Title % ���'T� F �� s -'XC' Ayg,
�i A,, W)u e- P-
General Contractor Owner) - Signature
Corporation Name (if Corp.)
Corporation Name (if Corp.)
7j-,o p ess
Address /2 _S- 3
rev. 9/85
mk
A% on
WELL COMPLETIUN tcP_-P_
* # DEPARTMENT OF HEALTH
Division Of_' Envi`ronmental Health - Services
�� PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
�-
WELL LOCATION
STREET AOURESS: WN I TAX GRID NUMBER:
a 1 rr} IG, -1 - q,
WELL OWNER
NAME: ADDRESS:
T f% �„ ��' Q V `l
® PBIVATE
O PUBLIC
USE OF WELL
1 - primary
2 - secondary
10 RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED
❑ BUSINESS O FARM ❑ TEST /OBSERVATION ❑ OTHER (specify)
O INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT gpm. /NO. PEOPLE SERVED_/ EST. OF DAILY USAGESdr�, gal.
REASON FOR
DRILLING
OREPLACE EXISTING SUPPLY []TEST /OBSERVATION � ❑ADDITIONAL SUPPLY
IONEW SUPPLY (NEW DWELLING) ❑DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH S —ft. I
STATIC WATER LEVEL eft.
DATE MEASURED 3
- DRILLING
EQUIPMENT
V ROTARY O COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
O SCREENED UN OPEN END CASING ❑ OPEN HOLE IN BEDROCK O OTHER
CASING
DETAILS
TOTAL LENGTH fit.
MATERIALS: 01 STEEL O PLASTIC ❑ OTHER
LENGTH BELOW GRADE 2 b ft.
JOINTS: ❑ WELDED Gil THREADED ❑ OTHER
DIAMETER in.
SEAL: 8 CEMENT GROUT ❑ BENTONITE OOTHER
WEIGHT. PER FOOT iL_ IL /ft.
I DRIVE SHOE: ® YES O NO I LINER: G YES % NO
SCREEN
DETAILS
.
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TU SCREEN (It)
DEVELOPED?
FIRST
O YES ONO
HOURS _-.z.
SECOND_.
_
_... _.. _.
GRAVEL PACK
O YES
❑ NO
GRAVEL
SIZE;
DIAMETER
OF PACK In.
TOP
DEPTH fl.
BOTTOM
DEPTH It.
WELL YIELD TEST ' If detailed pumping
METHOO: O PUMPED i tests were done is in-
O COMPRESSED AIR ,'armation attached?
O BAILED O OTHER ❑ YES ❑ NO
�p��LL LOG it more detailed formation descriptions or sieve analyses
lly are available, please attach.
DEPTH FROM
SURFACE
FORMATION DESCRIPTION
0008
It
WELL DE
It.
DURATION
hr, min.
DRAWOOWN
It,
YIEt.O
gCm.
Land ce
1eaare.'0
3
An Lkh + r
3 CY)
9!
4 P
–LOS
WATER O CLEAR TEMP.
QUALITY O CLOUDY HARDNESS
O COLORED ANALYZED? OYES ONO
ANALYSIS ATTACHED? O YES O NO
STORAGE TANK: TYPE
CAPACITY GAT,.
PUMP INFORMATION
TYPE
MAKER
MODEL
CAPACITY
DEPTH
VOLTAGE HP
WELL DRILLER NAME 6q i W edl GO DATE
ADDRESS RSA - Q;M SIG�rA
C LA�j V E6 �Z
1 3
3/89
✓f PVTKAM COIIhiPYDEPARISUM OFMALTS
of HaaE6 Sr" Caalwel. N.Y. 14912 CERI TES larrvlie Pwtfrk M
}
an . OF COMPil m
N PstS6ST'F't)= SEiYAtiE SYSTEM. Poa�lt
{
`�.vt�t
. ,� • �c6. 1 `�" "t. `'�'iz. t�a,/trt dv. " _ - - , Yetr� ,ar vmlr�a
S.bID.W.;N. I =r i c t a a ./ Tta MaP � r � Let -
aUt r
ap
grilse /A}�ort Nina 4 � +i!��t -D►- � —' `�. , : � � � � ,
`
Mdbg Area . , :' G
� Date of Approwl
natg SubdiQ sign Approved Fee Enclosed [ Arum ,t
t _.. FM Vellum eg
-
No�bar_a[ Beiastia Bl Daa{Qn Fbw G P D 0, 4 204deed Wbea b NPIeted
z. _
1466
i� PCHD xaemt.uee P1Q
:Sslaats SatraeaEe Sj06mi. a.ert at GaDoi'Septic Tank eoa ' / t Y+aM G 1
Vsi,be o��tted b7 ' f 4 p tf' Atldeeae:: i l�.►+ti �r� id �r r� .t+ei 6
Wator;S!!p4 Pvb&,S"* F"m . -
airt Petillte SW* II!jW by
Addren
- .
1 npreseht that 1 am wholly and compiately responsible (or the desgn and IouUon of 'tea, proposed system(s), 1') that st ►ate sewage dispoYi :stem
above . described will be constructed as'show'n•on the approved iinehdmegt then to 'and' in accordance with. the stmdards.; Ulas a _ rpn ns o na
County. OOponth4nt of Health, and that on completion thereof a "Certificate of` Construction Compliance" satiifilctairy to the Commissioner of HealthwHi
a =tlr submRteot• to the •Oeportmenl. M0 ,.written guarantee. wi11 'be furnished the owner, his;fucauors,: Mks or agigns by the builder, teat said builder will
pac..wr good operating condition any pait'of acid siirrege ;displisel systsim aufirg the period of two (2) Yfw►s'immdiataly following tM.Wta of tea issu-
tlnoa at 'the approval: of the. Gartifkate of. Construction. Compliance o1 'the .iginal system..or any repairs ther, o; 2) that thi drilled wail-described above
wNl l► located ea tliawn Oo'tM.approved pNh:apd that feid.well ,will be "Instal aeeoroance With the :standar rules regu a="s of the ,Putnam
County Oepertment of Health; v
Otte ( '� �. /.[i - 5�l�er }0
_ .Addreu 1 C +� Y oG . , 'tJ 'S icense NO°""
APPROVED kOR CONSTRUE ION This approral.expins twoyeais •fropixthe date'iswed 'uoNss construction `of tM•b ildingl s been undertaken and is
'revocable for cause or ,nay be, amended or modified when considered :necessary by the. Commissioner of 'Heatth. Any charge or alteration of construction
requirea a Mw. permit Approved toi dispoYl'ot domestk santtary saw" a^"f water wpply only:
GeV � .y ,jam
y
H.
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # -711
WELL LOCATION
Street I dresp
& 1 Y 4
Town Vi1 age Cityt
G (�C
Tax Grid Number
WELL OWNER
Name
Jac
M i} in (g Address
am ��
)
Jz� 1 (d�
rivate
B Public
SE OF WELL
1 primary
2- secondary
RE- SIDENTIAL
BUSINESS
0 INDUSTRIAL
.O PUBLIC SUPPLY
O FARM
O INSTITUTIONAL
Q AIR /COND /HEAT PUMP ❑ABANDONED
O TEST /OBSERVATION O OTHER (specify
O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST.
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION
NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL'
OF DAILY USAGE 60 al
L1 ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
y t- 1&4� 4 c
WELL TYPE
DRILLED
DRIVEN
. []DUG GRAVEL OTHER
,,IS WELL SITE SUBJECT TO FLOODING? YES
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: ►-
Lot No.
.WATER WELL CONTRACTOR: Name T �.� Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _4/ NO
'NAME.OF PUBLIC WATER SUPPLY: ZA TOWN /VIL /CITY
'DISTANCE TO PROPERTY FROM NEAREST WATER.MAIN: /U /A-
LOCATION SKETC & SOURCES OF CONTAMINATION PROVIDED
&(ON SEPARATE SHEET
9-
(date)- (s nature)
f
PERMIT TO CONSTRUCT A WATER WELL `-
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, 'and provided that within
thirt3, (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 contaminate- _s-ur.face or groundwater.
Date of Issue: �j 19
Date of Expiration 19 l % Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy:.Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
.rte- •T- •._'i7T'•rr .L- !ilia,,. .
� ..rfyvr.L aim ^ -ii_ � n�.....''TT..►r� -- �r-- --_._
PUTNAM COUNTY HEALTH DEPT.
016283
4 Geneva Road (914) 278 -6130 `
Brewster, NY 10509
Date_
,• Rene ti
14
• '�i7 ( � r�A . j'l 11 l 'o ! _I
Cash 0� Cr 1.0. c� �It
LAURENT ENGINEERING
ASSOCIATES, P.0 :_
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
(914)278 -6108 - (FAQ 278 -2658 .
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
May 22, 1997 .
Robert Morris, P.E.
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS Compliance
J. & W. Cuscina
Car Dee Subdivision - Lot #1
Partridge Lane
(T) Patterson, N.Y.
Dear Robert:
Enclosed are the following:
1. Four (4) prints of Drawing S -I "As -Built Plan ", dated 5- 22 -97.
2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 5722 -97.
3. "Guarantee of Subsurface Sewage Disposal System ", dated 5- 13 -97.
4. Well Completion and Well Log Report, dated 5- 21 -97.
5. Water Analysis Report, dated 5- 19 -97.
6. Money order in the amount of $200.00 payable to Putnam County Health Department.
If there are any questions concerning the enclosed, please call.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nichols, Jr., P.E.
HWN:TR:bd
94051 -1
cc: J. & W. Cuscina w /enc.
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N7o S'o' /o "G✓
s
♦ 3.7'Mae ?-1W
L
2
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♦ t
o
Go.vGRB
.46i00•Y�
Ni< U.eS t✓GA
NE�✓oER SOi✓
Certifications Indicated hereon signify that thl
existing code of practice for Land Surveys as
IV70 •oi� S0 ~�✓
Professional Land Surveyors. Said cerlificatk
the survey was prepared, and on that party'
agency and /or lending Institution listed he
institution, for mortgage purposes for said
07 I +
/ �
FO✓NO
Certifications are not trans:erable to addition;
"H/ N7L' •33 /p'h/ �i0
Only copies from the original of this survey i
/S /, DS
/V %S• 09 �D
this Land Surveyor's Inked or his embossed
C`,i✓7it L/Ni' RE.f/.,+.r✓3 of
Z
copies.
s >.va�✓wd- Gu'�RA«Y ow uvt
In addition,'unauttorized alteration or addlt
- STRtAM
I
�j
Surveyor's Seal is a violation of Section 7
G04MSR OF •y„r/G hyr ,
J
Education Law.
The location of underground Improvements
3, O ' �✓oRT�'
2
i
a
certified.
Certified to: h/En/o/ �^'c i036P
'
,QO.✓gLG GOLOSAN
�
NAT /Oi✓.4L TiTGE /
o.✓�r sse' ey i
PAWL /i✓q S/C // /N
LX.oMC
r -t
'
n
R -ES /O ENCLi
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Field survey performed: 06G6.�IB6
�rq„rr
I
and map prepared: OEG6�sBE.¢ 2
SiS s.
u"°`c
�",,.,
srwhE y �a0lJ4-> re ao7Y- : iiPR�L
' .... - x -. _
_.._ ._._ - -
'--.
iA1!_o M.OP RE ✓ /3c0: qPR /L /%i 19i
,4GRB5
_.r
..._
\�
I
0
David L. Odell, P.L.S., N.Y. State L
I c \
O
YY
�+
SURVEY O
1.69 /6
PREPA
t
�
IAIM 110L
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