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Home My WebLink About0841DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25. -1 -9.2 BOX 9 oom 11 A . or '` or 1 _�l t REV 3/ 6 a Division of En -Must; Wg' 1 -d SE-4f, -EM' COMPLIANCE AGE.bIg DISPOSAL NTIJANIMAM SYSTEM T'im M&O B166k 91 ppi 77 A 1z WU ii Dati v AP kddii V.. -Y, "WT Si C, I Co 14 f ns twg 6 GiElon 'Water Sbpply: Public .Supply From i. 2- Aa� Sapply'Drllled by m Ing, i'm n Nambei of Bidd Be n Othert$egnlrements Pz the r. isi were con of i certify ' Sys, Ti which wA., intacc9rdance iwith thii itimd ild I�ie ouliiy tiDimpaxtlie�i- h 4dtnaij 6 f Ajg��t. V Dole Address ' 6Any,Poijon in lysfin( s), shall ,pf-pnp, Iy' I jd�lt ions ri"Ofing frorK, wch u Approval "-o .::the ,',sPPa!a w�wwormqe_ iy t.,avaumbia-'and the-approval bf,thw, Ofi W vst6JwatsUpOIV.Shmll, become subject f* I "Ori',:An� th'al judgment -'". or or. M o. 11 A P ti % "Pese It:h tdd .work copies "".qii s ' A� 9 . plena of e ', - � compl, i� c ccor R� e an, i;d6.`the'perfftft,issued by the cor n �ch.pctlpj,ss; may -b4 hiosisary to tetue IJ I f it on o any union ary IMII become -mull, an#',,,vola-*5, loon ai, nifjs6,,iiwiwJbocom*5 U IiIE vva Su C . h ,approvals are M Deaf on r, c ionge Is: necorsuCy. TItN of ,cAi��.G�. wbLL uvriPLE11UV KErviii * * DEPARTMENT OF HEALTH " Division Of Environmental Heal -th - Services. _.. PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only •—�1�^ WELL LOCATION STREET AOURESS: TOWNIVILLAGAIGHY O a TAX GRID NUMBER: - fri e r9 0 A WELL OWNER NAME: A00RESS: f1fP81VATE e: 1A aoCa -f O PUBLIC 16 RESIDENTIAL O PbBLIC SUPPLY O AIR /CONDJHEA7 PUMP O ABANDONED ❑ BUSINESS ❑ FARM O TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL O STAND-BY. 0 USE OF WELL 1 - primary 2 - secondary MOUNT OF USE YIELD SOUGHT ____ _ gpm. /N0. PEOPLE SERVED / EST. OF DAILY USAGE 6_ gal. REASON FOR DRILLING REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION []ADDITIONAL SUPPLY NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING.WELL DEPTH DATA WELL DEPTH _ u�_. ft. I STATIC WATER LEVEL 46 ft. DATE MEASURED DRILLING EQUIPMENT ❑ ROTARY COMPRESSED AIR PERCUSSION O DUG O WELL POINT ❑ CABLE PERCUSSION O OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING IH OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH.. 0 _ tL MATERIALS: MSTEEL O PI ASTIC O OTHER LENGTH BELOW GRADE it. JOINTS: O WELDED THREADED . O OTHER DIAMETER in. SEAL: KICEMENT GROUT O BENTONITE OOTHE WEIGHT PER FOOT 17 lb./It. DRIVE SHOE YES ONO LINER: OYES 0 SCREEN DETAILS DIAMETER (in) SL07 SIZE LENGTH (It) DEPTH TO SCREEN (It) DEVELOPED? FIRST O, YES O NO HOURS SECOND GRAVEL PACK 13 YES 0 NO GRAVEL SIZE:, DIAMETER OF PACK in TOP . DEPTH tL BOTTOM DEM M. WELL YIELD TEST It detailed pumping MQHOD: O PUMPED tests were done is in- 1 COMPRESSED AIR , formation attached? D BAILED 0 OTHER i D YES O NO WELL LOG It more are avaii2bte. detailed formation descriptions or sieve analyses please attach: •. DEPTH FROM SURFACE Wale( Bear. irg Well 01a-. In t�RMAT10N DESCRIPTION GOOE It. It, WELL DEPTH It. DURATION hr, min. DRAWOOWN It, YIELD Arm. Land e 0 . 6 �v TY O CLOUDY HARDNESS O COLORED ANALYZEDI O YES ONO ANALYSIS ATTACHED? l7YES 0 N [MAKER R O CLEAR . TEMP. STORAGE TANK: TYPE ;SO tO 11- (-troI CAPACITY GAE,. 8'O P IHFgHATION cSU oie ml+ L e CAPACITY 7— /6 DEPTH VOLTAGfi��HP!�a W L�Ei� l M IYATT &SONS, INC. DATED A00RESS `':Well Dri,ll.ing SIGNATURE ate. 311. +.R .R. Box 17114 i aC3m NEW YORK 12563 �6 F(JI't�`tf COUNTY D.c. -rM/DM OF !-ZA.LZ"H DMSZO-4 OF Et1VIR0M 7", Ar, AF Pp-LT'i SERVICES O•emer or Purchaser of• Buildi-ng Build i nds� /�,�� Location - Street t•S.uLi c i _c�.l i�G�`d� l,::! S-) Q J- ---':A,' .41.- Building Type Section Block 7,ot 6� - L;�OE Sul division Name- 7i Sub5lvision Lot ' CJJAR.FNL E OF SUTC-SURFAM S:,a'tL.GE DISFC1c.Pr SYS r •1 I represent: That 1 an wholly and co.�pletely responsible for the location, Wor-aranship, i,aterial, construction and drainage of the s&, :age disposal systen serving the above described property, and. that it has -bean constructed as sham o. 't_he •aporoved •plaft or anoroved arrr;endment thereto,-: in accordance with the standards, rules and regulations .of the :Putnam Co%nty Deaxbrent of Health, anc. ,he-reby gur-.. -ntea -to t1he ct,nexr, his Successors, heirs or assigns r to place in god•_ operating condition any part of said system constructed by me which fails tc operate for a p`riod of t-wo years im lately following the date of approval of the "� erti.tica.te of Construction Comollance" for the se5•rcge dlspaSal system or an,, rec.:ixs "Fee- •by - -me 'CO -such system?,e }:cept whexc the fay_ lure 4 o- operate properly i caused by --he willful or negligent act of the eccupa.nt.of the bai.lding utilizinc the system. The undersigned further agrees to accept as conclusive the determination o-': the Director of the Division o` Envi.xon�-,EntaJ- Health Services of the Putnara Count, Der.,ar.tr;ent o-I�- Health as to v�hether or not• the failure of the system to operate was caused by the willful or negligent act o- the occupant of . the t�ui�.ding utiliz i ne the system. I /I Dated this day of �V a,� 19q-7 , Si.gnature Title Cener-'c. -� '7. ^.t-t act o- (CrM1;:e�r) - Sicn t -T- Z-A "d 1) D,( L/.e lej -y-"Us74f .. PC 7W 7 Y Corrxoraticn Nam_ (iY: Corm. ) 4-5x es s r� PtTMIN-1•1 COUrMC DEPP_rMEW OF fU;'nLZ l , DIVISIO N Or ENVJROZQ 1iLA.L HFD1,`7i SERVICES owner or Purchaser of, tuildi ng T�m Build ir�� Location - St.reeL t•5 7r , Ci palilly Building Type Section Block Lot Subd tvi s a.on tare Zi . Su.ixiivision Lot C- J.PRk_7'xDE OF SUE-SU.c:.Cv Sa,Z- -CB DISMS -kT, SYS r •i 7 represent that X am wholly and co:-apletely responsible for the local on, anr- �Panship, material, construction and drainage of the sewage disposal systaF. serving the above descries property, apd. that it has •bean ocnstructc-d as sha•,n cr the approved. -plan' or aoorov.ed amendment thereto,-..and-.'in accordance with the standards, rules and regulations of: the .Putnal;t Cou my Ee_caxtrent of Health, any hexel-,y gua—, antea to the c,,,ne -r, his successors, heirs or assigns,. .to place in goq• operating condition any part of said syste: constructed by me which fails tc operate for a period of JL o years L- ed.i..ately following the date of approval• of thc. "Certificate of Constn�cta on Cc<<oliance" for the sewage disposal system or a,1`. - -recairs- :~,ace by- r,-P-- to such systan, except_- where the failure to operate properly i-- caused by the will;_u'1 or negligent act of. the cccupant.of the baillding utilizin the sys t. n i. The unders i anc-d further agrees to accept as conclusive the detenrm�r? tion e the Director of the Division of Environ-ic -ntaJ_ E alth Services of the Putnam Ccu.nt•, Der- r.tri.ent of Eealth as to Vnether or not. the failure of the syste-i to oprnrate caused by the wi11fu1 or negligent act o�: the occupant of the �u#ding utilizin:: the sys tti7a. ;Can?ex-�all ted this day Of �_ )_i9'% t Sicrature Title ont_':ac`tor \Crn%e - Sigrrat;_::e /_,T_. en _Y_4vs741 . k7w 2 y y Cor_corat_ion t ;,a (ir: Corp.) :,_ : Tess � NORTH AMERICAN O. LABORATORIES, INC. LAB ID NUMBER: CLIENT: CERTIFICATE OF LABORATORY ANALYSIS SAMPLING LOCATION: COLLECTED BY: DATE COLLECTED: DATE RECEIVED: DATE OF REPORT: ANALYTE Total Coliform E. Coli 96 -8563 Debre Colett 11 S_ unset Ridge Carmel NY 10512.. Kitchen tap: Partridge Ln, Patterson NY N. Nittolo 12/30/96 12/30/96 01/02/97. RESULT* UNITS Absent Absent TIME COLLECTED: 12:40 PM MAX -CNTMT LEVEL" METHOD ANALYZED Must be "Absent" SM18(9223) 12/30/96 Must be "Absent" SM18(9223) 12/30/96 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. rYr- 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 lVlllA�[ CODMT{DSl�lll0�fl OF�ALiB Dt•lii •[�akadttawltl BMllh S•edeM. Llurl. N;Y 161? te,FawNa F•t�lti a C810�[CA18 OF 1 -� 77 } Oiif /A�■i�t ir.. p aaa,wd_a �eaiiae ❑ J —r— �� •t Peevle�a_I►ppeovd ra•s �,�,,...��,�i� 1-EGLAII a2� T°"° �� ' �� , 125 I Dame Subdivision °Anniived j I - "��1.' �� Fee Enclosed' 4mr;;,,r41 dU Iot Ana ,/, - °4�j� G � PUI Sectle� o.�, Y `Yolttee Ntiar 1 DaaiFb I+)ow G P D P ®NetlOedMr 4 �bq�4a! W6ta F ®Ia at�pNb�d S;peab S.wa Sra. b ew.rlt.t s• - �` T� oaoiU�alad bj = - Adden u Wdlar Slts *+� Stt;Ft v Z / Y A�i-S -jam 1., ✓� .+ , .c s N .1 yr } ky.: 1 1'►�pra•Mt that 1 +aT wholly and eompNttly nfponfibN for tM Wsiyn and button of tM propof•d fyit�T(f) 11 that tM Nparita. Mwa i. dit OYI a tt•m aeow doswib" wNl bi oDnatruet•d as mown on tAi app►owd am•nOm•rit th•►n'to ai d in accordanp w{tn:4M •tanA�rtls, rules an rpu a ons O �,. M County tiaONtlrlaflt Of tl•altly and tMt on`eompbtbn tUa�oi a .C•rtifkat% of Conftruetlon, Complianu +ratfdactory to tM Commlalonir o1 FIMKhwill b, fremltti0 to th 0•partmnt aid i written twannt�i will M ;furnNhd tM owmr hi>< fucpaaf, „MNa a atifMa by::th• buildN that i.a t♦u110�i will t iA po0 opMitiM OariOitbnxany pint of jiaa faurq• difpoYl s<yit.n du►Np the p•rio0 of two (2) rNnmaditatNy folbwin�etMASt• of tM {faY- anq of the, iPparal _ of LtM sCNtNkati of ComUudion `Compli�nc• of ; A orptMl 1,171 Y�t•m {ci ahy Mp Nt •to 2) tlMt, tM Ar:{INO wNl.diw►IOaO above wIN;M bcatp0 q Mcww on tM app ov�A,Wan and gnat na wNI w- illpi insta ih acoorda wK M 'sta ►d>ti:' u iiul rpuTa�ons of -the `PWOSM COwity t�tm•nt 01 MNlth. : , } . ` '" - "� �" -e. y ... : . `_ ' Siyn•OV P E _ RA. _. tilt• F Addy . Ir D1'% �% r N LIk•fq• NO #PPROVEO'FOR CONSTRUCTION Tnif a0W vi °ixpirK.awo y kt►i' fromft�a dat tau unNS C estiuctbn of tM b "uil0iny la`s.b•an ,un0•►takin and {s< rwroCabN fo►. -uut• oc -;maY b• a�MrWid" or modifi�0 whin cohsa•►W n•e•tfary by tM sCOTTiffiOMr of NONtn Any clrn� oValt•ratbri of oorstrucWon pp,�� n0uq mit, ow0' o► "ditposar of dompk »nitagr..ta •- w•t•r'!0'pply only 11Cv• aid �.> �`" 10/88 f+ 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 Xn�o_w WELL LOCATION Street Address Town Village City Tax Grid Numbel�r)� 1 L/ WELL OWNER 'Naipe Mailing Address ®Private D Public SE OF-WELL .primary 2- .,secondary ® RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY. O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION U INSTITUTIONAL O STAND -BY O ABANDONED ❑ OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED4 -r /EST. OF DAILY USAGE a1 13 REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION 13 ADDITIONAL SUPPLY KNEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL REASON ,FOR DRILLING ` ' DET,AYLED { :. REASON- DRIhLING 51 WEZL TYPE< • DRILLED DRIVEN DDUG GRAVEL. OTHER IS WELL_.SITtSUBJECT TO FLOODING? YES NO IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: WATER WELL CONTRACTOR: Name Lel Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 1% NO NAME OF PUBLIC WATER SUPPLY: Lk TOWN /VIL /CITY DISTANCE..TO_PROPERTY.FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION ON SEPARATE SHEET ( ate) 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: ,l��'7� 19 Date of Expiration I'// 19� Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink'copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 48. BATH BEDROOM DRESSING. 9'•8— x 12'-0— WALK' IN BEDROOM 3- < 13,-O,lx 10' -0'* CLOSET L,6L L jr 7- mA_STEF4 a ED.ROOM .. BEDROOM 2 OPEN 17%0 1 V•8 1.3, 0,* x 1 S. T U D't-, -3 .-1 44S F -S. EGO ND:.-FLO*'.OR - 4$Zg 48 17 r, J, -OF HE) L;li _ , A 7� E. r MORNING ROOM DINING ROOM 13* 0** x 12*•0 r. LIVING MOOIA IR ST FLOOR t OFEN AISCIVE I fOYEr% IN Date now FAMILY M(>OM 1:)' 17- 6" 482.8 1 .1 ild q P LAURENT ENGINEERING �j ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE.. Route 22 3 Milltown Road Brewster. New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 -(FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. \ CONSULTING SITE ENGINEERS Date: 8 -17 -94 To: Putnam County Health Dept. 4 Geneva Road Brewster; NY 10509 Attention: Mr. William Hedges Gentlemen: We enclose (4 ) copies of: IM B/W Prints ❑ Reproducibles ❑ Specifications ❑ Memorandum Job No.: 94051 Project: Proposed SSDS - Lots #2 & #3 Car -Dee Corp. Subdivision Patterson, N.J. • Reports ❑ Tracings • Copy of Letter ❑ S Description: - Revision /Date No SS -2 "Proposed SSDS - Lot #2" Rev. 8 -17 -94 SS -3 "Proposed SSDS - Lot #3" Rev. 8- 17 -94. Revised per your comments. Sent Via: • Our Messenger • Your Messenger Copy to: ❑ Blueprinter ED Hand Delivery ❑ First Class Mail Q ❑ Special Delivery Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per.A 111! — Harry W. Nichols, Jr., P.E. PUTNAI`i COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date �� iU ��• Re: Property of Located at (T)�'('��}�j��,� ection 2 Block i Lot i Subdivision of Subdv.- Lot -Filed Map y 1"�.J Date Gentlemen: J • This letter is to authorize Nar•r, 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 'regulation's as promulagate.d' by the Commissioner of the Putnam County Depar`tmerit of Health,. and to sign, all. necessary papers on'my behalf..In. connection with thi.s,matter and to supervise the construction of said system or systems i-n conformity with the provisions of Article 145 or 147, Education Law, the -Public Health Law, and the Putnam County Sani- tary Code. _ -!f„..;:- /a Countersigne `cy c -�j_`; � Na.561�4 A � P . E . , R . A . , �✓� � ;,�;�, -: %ate � - ,� yi G � � � �. I--y Very truly yours-_—` Signed ��✓' �i' . %--� 0 o Property Address Address -rte ��pi1;l�'l,'"rr? . tj 7 r � r B Telephone Town 'Telephone ` mmm 6a0 = DEPARTMM OF 'HEAI DIVISION OF ENVIRORMERTAL HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. 7. - er f`/1 be . li '�1/ �tKrT Ci�'.Address �j - ; p _ Located at (street) 0?�I? -T I'Lllx Sec. -0,�5 . Block _� Lot `f :2 (.indicate nearest cross _street) Municipality 7-Te7-7�1V Watershed (i 7-,!ON 2 Z:o 4 5 0►] NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be sutmitttd for review. 2. Depth m.asure-nents to be made fran top of hole. rev. 9/85 SOIL, PERCOLATION TEST aATA RDQU= TO BE SUB�SI= WITS APPLICATICNS v Date. of Pre- Soaking i::;?/ZI ��g Date or Percolation Test 5 21 1 ff8 ; - BOLE . NU-MER C.'L= PERCOLATION Run Elapse; Depth to Water Fran Water Level No. Tug Ground Surface In '.Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches inches Inches - 1 y� 2. :55- 2:19 3' 2:- i 7 'X?- -7 3 q. 2 Z:o 4 5 0►] NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be sutmitttd for review. 2. Depth m.asure-nents to be made fran top of hole. rev. 9/85 ..�.K...._. u .. • ... a..... ......0 a aa. t yti.t..t]11VLV V DESCJ -QTION OF SOILS ENCOUNTERED IN TE:c?' HOLES DEPTH HOLE N0. ,.' MOLE N0. HOLE NO. G.L. 2' 3' . - 51L1Y 5f}Nn SILT 5'14ND 4' G tzAv EL- 6' 8' 9' = - 13' - INDICATE LEVEL AT MdlCH GROUNM;Q= IS ENMUNTERED -. INDICATE' LEVEL TO WMICH WATER LEVEL RISES AFTER BEING ENMUNTERED _ DEEP HOLE OBSERVATIONS MADE BY: DATE:,, /L lag DESIGN =_ Soil Rate Used Min/1" Drop: S.D. Usable.Area Provided No. of Bedrooms Septic Tank Capacity / 220 gals..Typq't- /1lG Absorption Area Provided By L.F. x 24" width trench i Other 9� , I,j How : �C -Signature Address 11r1(ZDVG I G h)''i�tZC Y 2746it" L )j -�o ND. 55124 THIS SPACE FOR USE BY HEALTH DEPAR1iERT 'ONLY: Soil Rate Approved sq: f t•,%gaI ; Checked by Date pU'rNA.L-1 COICJ1*-T'r -5C DEPA+nDCL-f ErT'r O)` I-XE.A.XLTla: -- APPLICATION• - FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: day) ..................................... �JOD (��Olv o License Number': I d5o Phcn'e: 211? _ 610b . 13. Has prelinfinary approval•been granted by such authorities? 0A Date Granted: 14• Type of Sewage Disposal: System Discharge...... I ..Surface-Water ✓ Ground Waters 15. If surface water discharge, what is the strean class designation ?........ /A S. Waters index 'number .(surface) ................................. nl /� 7. Is project located near.a public water supply system? ......... .......... N 0 3. If yes, name of water supply._ I�IiA Distance to water supply , 9. Is project site near a public sewage col lection. or disposal ,Name of- sewage system Q/A Distance to sewage system system ?..... . W 1. Date-observed: �— 12 '� �� . 23. Name of Health Inspector: 2. Name of Project: rr"0(JD!JIrr2 3.•_•_Location(]W/C; 4. Project Engineer: W. fJl GNDDfl .Tr2_ _:. 5. Address: N. day) ..................................... �JOD (��Olv o License Number': I d5o Phcn'e: 211? _ 610b . �j .6_ Type of 'Pro e'ct: - P.; Fr-ytvafe %Residential Foo�i:Ser..vice Coriercal ' — A_art�;�ents InWtutional Mobile Home Park - :Q,f:.fice' Building.. Realty .Subdivision ,Other (specify) 7 IsR:th' t ee o State Environmental Qual i ty,, Review, (SEQR)? Tyne 'S�tatus�(Check One) Type I.. Exempt ✓ _. - Type II. Unlisted 8. Is a9Dr, tfEnvironmentaI Impact Statement (DEIS) required? . Q0 9. Has DEIS been completed and .found acceptable by Lead'Agency? . /n 10. Mame of.,Lead Agency 11 .. -Ts -this project- in an area under the ccntrol.-of -1,ocal_-p.l arming,- zoning., - or other officials, ordinances? ....:... .............................. tilil �2. -If so, have plans been .sub,.titted to such .authorities ?.. .. . . . . ....... . • , , , . tJ /� 13. Has prelinfinary approval•been granted by such authorities? 0A Date Granted: 14• Type of Sewage Disposal: System Discharge...... I ..Surface-Water ✓ Ground Waters 15. If surface water discharge, what is the strean class designation ?........ /A S. Waters index 'number .(surface) ................................. nl /� 7. Is project located near.a public water supply system? ......... .......... N 0 3. If yes, name of water supply._ I�IiA Distance to water supply , 9. Is project site near a public sewage col lection. or disposal ,Name of- sewage system Q/A Distance to sewage system system ?..... . W 1. Date-observed: �— 12 '� �� . 23. Name of Health Inspector: k4z, • ±�1 . ?- '.�1J %" 1 -! :. Project design flow (gallons per day) ..................................... �JOD 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. �o 26. Has SPDES Application been submitted to local DEC Office? ............... ►.VA 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... nlil 23. Wetland ID Number ....................... .....................•......... Q A& 29. `Is Wetland Permit required? .............: ................ ..........: :.... R1n . . Pe Has application. been- made to Town or Local DEC Office? ................:.. 30. Does,.:project require'a DEC Stream Disturbance Perm t? ......... p 31. Is or was project site used for a.gricultural activity involving application _ of pesticide$ to orchards or othe'r crops, solid or hazardous waste -M spo'sal landfilling, s I udge 'dppl i cation or industrial*activ.ity? ::.... :. YES =or NO -00 f 32. Is project located—within—l—,000—feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known - 'source"of contamination? ..............YES or NO 1d DESCRIBE: . 4 ` 3.3. Is there a local master plan or file:with the Toun or Village ?, fh 34.._ Are community water, sewer facilities planned to be developed within15 years? 1J�1KrJ�10� 3.5_.. _Are. any.- .sewage,-d- isposal - areas- -in 36. Tax Hap ID Number .. ...... ..........,�— 37. Approved Plans are- to' -be: returned to: ................ • AppI icant _Y"' Engineer Xf the application is signed by a person other than the applicant shown in Item.1, the.. 2PPIication must be - accompanied by y-a Letter of Authorization. Failure to comply with-this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of. perjury,- that information provided on this form is true to the best of my knowledge and be 1 ief. Fa Ise state,,ents made herein are punishable 'as a Class -A Hisde,-,eanor Purs ant to Section 210.45 of the Pena 1 Law. n 31CNATURES OFFICIAL TITLES: 14 149 r- r-_. r fZ GIN r� i� v'v � N� �wToWN rr -flAr� .AILING ADDRESS: f�'i%UtJs�T f2 , N,Y �050q % rr RANDOLPH . HARRY W. • July 20, 1994 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 LAURENT ENGINEERING — ASSOCIATES, P..C.- MILLBROOKE OFFICE CENTRE Route 22 8 Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS RE: Individual SSDS Car -Dee Building Corp. Subdivision - Lot #2 Partridge Lane Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -2 "Proposed SSDS - Lot #2 ", 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. chols, Jr., P.E. HWN :bd 94051 -2 cc: Mr. G. k caluso w /enc. Aitnam County Department of Health Division of Environmental Sanitation AFFIDAVIT CORPORATE a4NER APPLICATION FOR PERMIT. A PPLICATION - SMITTTEI} TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Co assio er of ieal h - In the matter of application for 1, —rr� °2.1 Yl(� Zia- 0 represent. �/ that .I am an offi er or employee of the corporation and am: authorized ' to act for. _ Gi ��.� ��C�(G C� rig 1� �� l�� _ (name of corporation) _ _ having offices at /,77 r3� �C/I�P�S _Whose officers -are President z/.2 ` � Name and Address) Vice - President _ = = —(Name and Address) ^' Secretary • _ _ — _ — _ (Name and Address) — _ _ Treasurer' •• • .... — .._. — — — .,._..... ..(flame and Address)_ and that I- am-and will be individually responsible for) any* or all aptp of. the- corporation With respect to the approval reques:te rid•all .sub -r . sequeit aets .relating -thereto. ' sw ra to•before me this '. day Signed 1 , of 19 Title o.ary �Pu l i f 1§01W I DAM IIatwp=c, 6TATh` w m' FORE REG.149853X QUA! IFlED f.N Df'Ci•�eSS ��C:� ?`! VY CONINIII&SION DTiR S ALL. 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