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HomeMy WebLinkAbout0842DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25. -1 -9.3 BOX 9 . I 1, , 9 kc 16 116L, �. , ; . , ■ ; PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION -OF- ENVIRONMENTAL HEAL -T -H- SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE ENT SYSTEM PCHD CONSTRUCTION PERMIT # p 11 - 14 Located at pAp- rW©rn0; 1 --NN4a Town or Village Owner /Applicant Name BEN+ 00-94� PA Tax Map 1-6 ° Formerly Subdivision Name Subd. Lot # Block I Lot. �`� CAFL - PE 5 Mailing Address 6000 P-4AI'Ei P041 F"AP '912- Ew5r5r- hpr , � Zip 165,00) Date Construction Permit Issued by PCHD Separate Sewerage System built by gr- �' � EpTI �' Address Consisting of Gallon Septic Tank and r7OO LF A84 712-UtiC114 IBSoY Other Requirements: Water Supply: Public Supply From. or:_ Private Supply Drilled by iNR- 44 Of-Oi - Building'Type-_ j2E51pe N(,E. Number of Bedrooms Address Address I v2 040 F-P POYNr C-7 0041- Has erosion control -been completed? Has garbage grinder been installed? Im No 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 regulations of the Putnam County Department of Health. Date: V:W 11 Certified by P.E. K R.A. (Design Professional) Address to HIuTOWN Avh,D 69,6w51-67z- N' /0" License # �� 1 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 subject to modification or change when, in the judgment of the Public Health Director, such revocatipn, dificatio change is necessary. By: Title: 0 4 — Date: �6 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: Town/Village: Tax Grid # Partridge Lane Patterson Map Block Lot(s) 7 Well Owner: Name: Address: Kenneth Daros Maple Row Crompound,NY/ Use of Well: _� Residential 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 X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Total length 20 ft. Materials: Steel _ Plastic _ Other Casing Details Length below grade 18.i. Joints: Welded X Threaded Other Diameter 6 in. Seal:. X . Cement grout _ Bentonite Other Weight per foot . 17 lb /ft. Drive shoe: —x Yes _No Liner Yes X No Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? Screen Details First NONE Yes No Second Hours Well Yield Test Bailed _Pumped x Compressed Air Hours 6 Yield 6 gpm Depth Data Measure from land surface - static specify ft) During yield test(ft) Depth of completed well in feet 20 225 225 Well Log Depth From Surface Water Well Formation If more detailed ft. ft. Bearing Diameter(in) Description information Land Surface 10 descriptions or 10 225 6 Granite Quartz sieve analyses -. - are available, please attach. If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump Type Sub Capacity during drilling, Depth 18 0 Model RJ list: Voltage 2 3 0 Hp 1/2 HP Tank TypeAmtrol Volume_ Date Well Complete Putnam County Certification No. Date of Report We I Driller (signature) 1/6/99 15 2/2/99 PG'`' NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/ flan. i Well Driller's Nam Wra Bros. Address:162 Baker Rd. i Signature: Date. Roxbury, Ct. 2/2/99 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 L NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/ flan. i Well Driller's Nam Wra Bros. Address:162 Baker Rd. i Signature: Date. Roxbury, Ct. 2/2/99 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 L UZI Kill lilil,52! M PUTNAM COUNTY-HEALTH DEPT —�'�. 't' aBRva Road: (914) 278=6130 n x av�- '�,.P ,.. '`tea aim x Brewster, NY10509 <.., �cY`- 3 "�. 1 � �Sry� �Sl`.3�1 -! %1'.'S., 4�� yrn 5n� �; ' y.i`I --,� �`�'�3 LTTt„ � ,T, � �'4 x�' }'�'n ,.Li'Y:'• -. }.1 ,�; CT,..,aC �,r.. � M � 1iy��IT- i'-0 >G'�'�Sl �'. '.. } '. .. .�}. .. K„ ..(' "'�r"!j .� � 5 ;...W �2� i � � 4 M•C,� 3 :, � x �.•:�� �x .� �.: �..- �. - , Dollars �-�,� ��� � �� ;, -Pi7T1vAM- COUNTY DEPARTMENT' OF- HEALTH DIVISIPN OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or P oiler of Building Tax Map Block 'Lot Building Constructed -by TownNillage ?AP-TP-Al? (A F_ CAS- DFF. Location- Stfeet Subdivision Name Building Type Subdivision Lot # I represent that I am --% l —and rornnIetely �esponsibl� for the workmanship, -Material, and construq�ion of the sewage treatment 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 offlealthand he & antee -to the owner; his successors, heirs or assigns, to place in qood 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 treatment system, or any -- repairs -made- byme-ta.sucl;. system, - except where.the`failure to�erato:properjy:is:caused by the willfitj�oi negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the evidenced determination of the Public Health Director of the Putnam County Department of Health, as to whether or not the failure of -the.,s3! -�a_4perate was caused by the willful or pegliigent act of the occupant of 1 ie'building utilizing the system. Dated: M th Day _3 l Year Signatures ;� Title. General Con "cto (Owner) - Signature 01 6TATra )'�AU, <��v a7�-, C � Corporation Name (if corporation) Corporation Name (if corporation) Address: fb Address: -9q State Zip State f_�4__?-- I '1 4­ Zip 0� ( v V-'u 1 Form GS -97 't - I.; 1�_ � - K., .11 �, �,A,`, . . , � . .. - , ,�', . 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" . ., .. , - . . .1 - i. � � , : � , ,.�. , Z. . ., ,- I , ,'.-, '. I ,,.,:'.l . . : . �. r , �7.1�1 ,...�� ,� - .., , . , , , .:-: , I �: ,z ., ,­� i . . - I i. ., 1. ` �-;- ., � , , ? - - , , 0: �.. :, � I "", ". ., . �., A� ., - �`: :. ,,, :, * , , - � -,I'.' , � , I ,;� - - , .. � ., . . . . ., .. �..r I � :. : - , ... .1�1 .44- . . ... � ! � -, . ,., - �_ . . . 0 . . :%, i ;,. .... I - - , 1, -: - .�;... r - � ;, -'.7 _1 : " , � � .. - v ... t., . . ,; t\ " . . .1 � , . ;. . .� . . " -'. "I - . 14 , � � - , . ' ,� '.. ., �. " " �'.;,�f . I . ;, . r, t�7 , . . - _'.�"' "! ' ' '� _. .0 � .7, .� 'V' � '�' ' � I', 'I', )" , . h . . ., . 's X,,,,,� . ..". 4 : , �; '! , ., . ,�, . . , 11 �� . , � , : _:"`:�, ".j , I... , � *., f � . :, I . , , ..... . , "I'll", IP =1111 . oil 0 Most. man 0, vWwwwo x WASAT 4y, too SAW, Y Tor: so on r, t it" long .. ...... .. SAW TV, 4 . TP Qn- AXAMP Q w ""If—$ Q Qfq- '- March 31, 1999 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Compliance. Partridge Lane Lot #3 - Car -Dee Subdivision Town of Patterson Dear Mr. Morris: Enclosed are the following: 1. Four (4) prints of Drawing S -3 "As -Built Plan," dated 3- 31 -99. 2. - " certificate of Construction Compliance for Sewage Disposal System," dated 3= 31 -99. 3. "Guarantee of.Subsurface Sewage Disposal System," dated 3- 31 -99. 4. Well .Completion Report, dated 2 -2 -99. 5. Water Analysis Report, dated 3- 31 -99. 6; : Application Fee 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:JM:his 94051 -3 — ^ LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10609 HARRY W. NICHOLS JR., E. P. / `.i .._..___ / (914)278.6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS March 31, 1999 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Compliance. Partridge Lane Lot #3 - Car -Dee Subdivision Town of Patterson Dear Mr. Morris: Enclosed are the following: 1. Four (4) prints of Drawing S -3 "As -Built Plan," dated 3- 31 -99. 2. - " certificate of Construction Compliance for Sewage Disposal System," dated 3= 31 -99. 3. "Guarantee of.Subsurface Sewage Disposal System," dated 3- 31 -99. 4. Well .Completion Report, dated 2 -2 -99. 5. Water Analysis Report, dated 3- 31 -99. 6; : Application Fee 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:JM:his 94051 -3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROI'MENTAL HEALTH SERVICES FI \'AL SITE INSPECTION _ Street Location = BjR- rR/]2fTF5 LAKg Town p,4T:r gsoM TIM f �. S, 1 — % 4 � . ' 1. Se}vage System Area ; 0 a. STS area located as per approved plans ........................... b. Fill section - date of placement s. 3:1 barrier Lgth. NVidth Av D th c. Natural soil not stripped .. ...........................g... p............ d. Stone, brush, etc., greater than 15 from STS area.......... o e. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size 1,000 ........(61P ......other ................ b. Septic tank installed level c. 10' minimum from foundation .......... ............................... S d.- Distribtuion Bo. . -All outlets at same elevation -water tested ................. y .2. Protected below frost .................. ............................... 7,3.yMinimum 2 ft- Original soil between box & trenches o Junction Box - properly set ....................... ............................... 1. Length required 6'Oo Length installed 5-00d 2:` Distance to watercourse measured r :Z o Ft.......... 1.Insta ordinQ ..... ..........:.................... 4. Slo re .)a acce4ab 16 -1/32" /foot ............. s 5. 10 ft. from property h e - - foundations .......... 6. De f tryp c o s ace .................. A. 7. Ro a si ..........:.............. .� 8. S ve13 /4 -1 %2" diameter clean .................... 9. Depth of gravel mArerkh 12". minimum ........... :.: 10 Pipeea p ......................................... 4- g. Pum or Dose ystems Size of pump c am er ................ ............................... 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. HouseBuildin a. Ho4s e ocated der approved plans ....... ...... ....... ............ b Nt�ri ben ofybedtrooms . :....................... IV. «el a_-Well located as per approved plans . ............................... b. Distancetfrom_STSral a_measured +qae) ft ........... .: Casing 1 °8 above rade 1 ........... ............................... u ace drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted.... ................ ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box .. ....................6.......... 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 ..............4 h. Surface water protection adequate .. ..............................6 Date: 99 Inspected by: Owner VAgo5 Permit _ P — / 4 —244 Subdivision Lot _� " c a - nFr IV IIYES NO COMMi NIT S e� X n� NORTHEAST LABORATORY OF DANBURY 39 •CT•Cert: PH- 0404' _I MII.L PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471 (203) 748 -7903 - FAX (203) 748 -0652 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: LAURENT ENGINEERING BREWSTER, N.Y. 10509 DATE SAMPLE COLLECTED: 3 /22/99 TIME COLLECTED: 5:00 P.M. COLLECTED BY: K. DAROS DATE RECEIVED @ LAB: 3/22/99 TESTED BY: LAB# 1,1471 & 11301 REPORT DATE: 3/29/99 SAMPLE SITE: DAMS, 6 PARTRIDGE LA., PATTERSON, N.Y. SAMPLING POINT: KITCHEN TAP SOURCE: WELL TREATMENT: NONE TEST PERFORMED RESULT: MAXEVIUM CONTAMINANT LEVEL BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml PHYSICALS: Color 0 Odor ND pH 6.29 no designated limit Turbidity 0.19 NTUs 5 NTUs CHEMISTRY: Nitrite N <0.005 mg/L as N 1 mg/L as N 11301- Nitrate N 0.48 mg/L as N 10 mg/L as N - Alkalinity, 29:0 mg/L no designated limits Hardness '40.0 mg/L no designated limits Iron <0.03 mg/L 0.30 mg/L Manganese <0.01 mg/L 0.30. mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 3.5 mg/L 20 mg/L** Lead <0.001 mg/L 0.015*** m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTED:3 /22/99 SAMPLE, AS TESTED ABOVE: ❑X OTABLE or OT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Iftium tin ' ,.. Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037•'(860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 J JTNAM COUNTY DEPARTMENT OF HEALTH SION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM #NP'19' I Located at\f-A(- 1°R-104F, L-NNt Subdivision name 6AP-' Dt�- �- Subd. Lot # Date Subdivision Approved 11-m-81 Town or Village PArrEA-60N Tax Map Block Lot Renewal Revision Owner/Applicant Name F-rf4 7h -v ���� lE Date of Previous Approval �odCo IP�L�Gj iZ1A'/►�Pcp 8lnl� N`� Zip Mailing Address Amount of Fee Enclosed Building Type doGook Lot Area 0-91 �4'No. of Bedrooms 4 Design Flow GPD 860 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage S sy tem to consist of 1210 1'6 Tp-ENL H gallon septic tank and Other Requirements: 11�70r �� Ag To be constructed by T • P ° Address Water Supply: - Public .Supply From or: �(, Private Supply Drilled by 1" V 0 Address Address 4500 LF I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments sy tem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval.of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address 1O HIo l4/N fZQWb P.E. X R.A. Date 10 41 q8 T-b7Z NY 16M License # 56) %A APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe Approve r discharge of domestic sanitary se age only. By Title: C Date: 11 "!� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL - - please print or type - v PCHD Permit # [ ` Well Location: Street Address: Town/Village Tax Grid # n PAR- IDQF- 1-A`Nf- rN'rTEPA�DN Map l-bt Block I Lot(s) 11,'Ob Well Owner: Name: Y94NoK } t� -ERI�i D�P44) Address: (006 594L.� ` IDC46 W 6PV-KA5�L t-� wqo� 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 15 +- gpm # People Served y Est. of Daily Usage 000 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _ New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type X Drilled Driven Gravel Other Is well site subject to flooding? .................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes Y No Name of subdivision C-AP-- DES Lot No. 3 Water Well Contractor: f I P) 1D Address: - Is Public Water Supply available to site? .................................. ............................... Yes No K Name of Public Water Supply: Town/Village -� Distance to property from nearest water main: Proposed well location & sources of contaminatio to be provided o separ she t/plan. Dater . °o� - . Applicant Signature.:, PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wL;II certified by Putnam County. Date of Issue �l G Permit Iss ' Nc/ icial- Date of Expiration 1� Title: , Permit is Non - Transfer ab e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 �,' c A 1 ASSOCIATES. ENGINEERING hull BROOKE OFFICE-CENTRE Route 22 d Milltown Road ,�\ Brewster, New York 10509 is A. (914278.6108 - (FAX) 278 -2558 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS October 20, 1998 Mr. Robert Morris; P.E. Putnam County Health Department,. 4 Geneva Road Brewster, NY 10509 . RE: Individual SSDS Kenneth & Kerry Daros Car.Dee B1dg.Corp. Subdivision Lot #3 Dear Mr. , Morris: Enclosed are the following: 1. "Short E.A.F," dated 10/20/98. .2. Five (5) prints of SS -3 "Proposed SSDS," dated 10/20/98 3. "Application for Approval of Plans For a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 10/26/98 5. "Application to Construct a Water Well," dated 10/20/98 6. "Design Data Sheet" 7. "Letter of Authorization.'' dated 10/20/98 8. Two (2) copies of Residence Floor Plan(s), For Bedroom Count Only." 9. Money order 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:JM: hs 94051 -3 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM -For UNLISTED -ACTIONS Only :'art 1 PROJECT INFORMATION (To be completed by Applic�3nt or Project sponsor) SiC:atue 11' the action is in a Coastal Area, and you are a state agancy, complete a C t ! Assessment F before o g with this assessment ^ fl 2. PROJECT NAME: 3. PROJECT LOCATION: Municipality County 4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map) 5. PROPOSED ACTION IS: 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT N AFFECTED: Initiall cres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? I&Yes ONo If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 1 O.,DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAQ? % OYes &o If yes, list agency(s) name and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? bYes (RNo - If yes, list agency(s) name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE SiC:atue 11' the action is in a Coastal Area, and you are a state agancy, complete a C t ! Assessment F before o g with this assessment ^ fl CaD /J /0/� STREET P{�ATION REVIENF4 BY _ 1, G: Y APPLICATION PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH DIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENTS TEMS - VIEW SHEET FOR CONSTRUCTION PERNIIT NAME OF OW R 1 AS, MB, BH RAIE MAP # PERMIT_ PWS LETTER R OF AUTHORIZATION N DATA SHEET (DDS) )RATE RESOLUTION LEAF -TWO ,OCATED IN NYC WATERSHED LANS $UBMITTED TO DEP IELEGATED TO PCHD )EP APPROVAL, IF REQ'D ►EEP TEST HOLES OBSERVED ERCS TO BE WITNESSED ,X- APPROVAL SSDS ADJ. LOTS VETLANDS (TOWN/DEC PERMIT REQ'D ?) )ATA ON,DDS PLANS & PERMIT SAME RE 1969 NEIGHBOR NOTIFICATION ,ETTER BI /ZBA 00 YR. FLOOD ELEVATION ITHER REQ'D PERMITS) REQUIRED DETAILS ON PLANS EWAGE SYSTEM PLAN - (NORTH ARROW) SDS HYDRAULIC PROFILE iRAVITY FLOW : ONSTRUCTION NOTES Y ROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. 'PROPERTY METES & BOUNDS OUSE SETBACK NECESSARY (TIGHT LOT) OUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE' NO BENDS; MAX.BENDS 459 W /CLEANOUT . FILL SYSTEMS C AY BARRIER - FT. HORIZONTAL;SLOPE 3:1 TO GRADE ILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE &DIMENSIONS VOLUME ILL-IN EXPANSION AREA TRENCH . JkF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED DESIGN DATA: PERC & DEEP RESULTS L! 2' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT C FOOTING /GUTTER/CURTAIN DRAINS SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME,ADDRESS TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE �,OCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: j ON PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS _15 -WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 0/o,10'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' - <1% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION 1. 2. 4. 6. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - APPLICATION FOR APPROVAL OF PLANS FOR . A WASTEWATER TREATMENT 'SYSTEM: Name and address of applicant: jL� N N ' H KER'�� PA Pb (oo(o ' EAG L ID �Ll PGi F_ ' �ZO AP Name of project: 1NDNc606(, 'J�Pc7 3. Design Professional: Rk* W 1 i4\L*016 WL15' 5. Drainage Basin: 7. Type of Project: iz Private/Residential Apartments Office Building Location TN: I��TTEP -h�N Address: �1-0 MILL'foWN PAP 10 Food Service - Institutional Realty .Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... .... ..... ........................ Type I' Exempt X Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No 10. Has DEIS, been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances?: :.:..:::...::.: NA NA 13. If so, have plans been submitted to such authorities? No 14. Has preliminary .approval been granted by such authorities? NO Date granted: N A 15. Type-of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface Water discharge, what is the stream class designation? ........... .......... NA 17. Waters index number (surface) .......................... 18. Is project located near a public water supply system? o 19. If yes, name of water supply NA Distance to water supply NA 20. Is project site near a public sewage collection or treatment system? ................ No. 21. Name. of sewage system NI, . Distance to sewage system 4A 22. Date test holes observed 23. Name of Health Inspector M, R JV 2A -6y_1 24. Project design flow (gAons'per day) Boo 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 140 26. Has SPDES Application been submitted to local DEC office? Np Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? N0. J 28. Wetlands ID Number ........................................................... ......................:........ -NA. 29. Is Wetlands Permit required? ............... No Has application been made to Town or Local DEC office? N 30. Does project require a DEC Stream Disturbance Permit? .. ............................... Ne 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 0 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 DESCRIBE: N0. 2 33. Is there a local master plan on file with the Town or Village? ......................... YE6 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? No 35. Are any sewage .treatment areas in excess of 15% slope .. ............................... M� 36. Tax Map ID Number .................. .................. ..................... Map qJS. Block I Lot at 1; 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC- Watershed shall -be sentto 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 toDEP 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 Secti9r; 210.45 of the_PenalAaw. _ SIGNATURES & OFFICIAL TITLES: L0�` S/Z i Wd' .9Z '1-00 86 RAP- k H(U ftA A., .E ' A5 14bEK Mailing Address:..... 50A- }9.144.4.3H -ANN mlI_uTO�N jl-aAp AIN000 1JtIwnd NS �- 1,4� to jol �a PUTNAM COUNTY DEPARTMENT OF HEALTH -- DIVISION OF ENVIRONMENTAL.HEALTH SERVICES _ _.DESIGN DATA SHEET -SUBSURFACE .SEWAGE TREATMENT SYSTEM Owner F _ Srf$ p �P/X/on/ Address 6 FwsT & Located at (Street) A i P & 1 wF Tax Map' Block Lot .____ ndicate.n,earest cross street) Municipality WIV D 0L47* i9S7" Drainage Basin S-011, TIERCOLA L Date of Pre - soaking Date of Percolation Test IQ: Hole No. Run No. Time Start - Stop Ela se Time I in.) Depth to Water rom Ground . Surface (Inches) Start Stop Water Level ; Drop In Inches Percolation Rate Min/inch i io1 i3 a3 I ' Pb C" 2 o,3d —A// -I I9 L3 , 26,, 3 10;5 -D- ll; l! a a3 ' G ,, 4 5 1 ld,® --1d 3g, 3a a3 as " a l5� 2.... - 2 / ®:3g- ll;of. 3a a3 ! ►�! ► 13; 3..�. . 30 is' 4 5 .1 2 3 4 5 _L NOTES: 1 2. Tests to be repeated at same deptn unto approximately equal percolation rates arc UUM111CU (XL 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. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH' HOLE NO. HOLE NO. HOLE NO. G.L. 0.5' 1.5' 2.0' 23 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' 10.0' Indicate level at which groundwater is encountered _fV Indicate level at which mottling is observed t Indicate level to which water level rises after being encountered _ Deep hole observations made by: Design Professional Name: �kflWr - gg V Assacfif s Address: im.")ld3 D, �^,�� ���✓i E' ►_.,.,,� �.� _ .q,.., „Y..� -rah® 9 Signature: Design Professional's Seal A✓ Date pF NEW y09 . �p NICH `' ZQ V� W LU \O;p No. 56124 \'°9oFESS►oNP` M1 • . rn t T� A✓ Date pF NEW y09 . �p NICH `' ZQ V� W LU \O;p No. 56124 \'°9oFESS►oNP` -- -------------- T1 BEDROOM 3 13'-0" x 10*-0•. BEDROOM 2 13' 0" SECOND F LOO ll 4828 =.-1344SF A: T C)l KITCHEN ptlat 14 k DINING ROOM MORNING ROOM 13' 0" 12••0" � ji T_ IN OFE N ABOVE LIVING ROOM UP . . . I '&-a FAMILY A00064 FOYER 'l- I FIRST FLOOR IX 0­n 17' 0•* 4829 = 1.1440 l: BATH F 7 < BEDROOM 4 DRESSING. WALK* -IN CLOSET MASTER BEDROOM. OPEN 17%o x 18*•8** SECOND F LOO ll 4828 =.-1344SF A: T C)l KITCHEN ptlat 14 k DINING ROOM MORNING ROOM 13' 0" 12••0" � ji T_ IN OFE N ABOVE LIVING ROOM UP . . . I '&-a FAMILY A00064 FOYER 'l- I FIRST FLOOR IX 0­n 17' 0•* 4829 = 1.1440 l: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of "OmaH -t- V -6W OA .O� Located at pA'R�'P-10(a (_Jk4l: T/V FATTEP -5o H Tax Map # Q's, Block Subdivision of 0R4L- pEa ?)UiU01W (,'Mi' Lot Subdivision Lot # ''� Filed Map # 2 Date Filed 1111518 Gentlemen: This letter is to authorize 1+�'*Y A/& ��L1 -�oLy, JP' P's A duly licensed Professional Engineer K or Registered Architect to apply for the required wastewater treatment and/or water supply permits} to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems inconformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary-Code. Countersig P.E., R.A., Mailing Address t, \\.Cif 2. ,..' /MM/A State N Zip 10509 Telephone: ��l� J �'�6 - 6106 Very truly yours, Property) (Owner of Mailing Address: �a State Zip �SCj zl� � , I Telephone: °"L �lG 4�51'03� C� Ul Mr ! � _S GS 23.27 IN TM • . / �.� — •:.fin'._ �:�; \ I :1 a K � O AL ' r i < t, vzh 1, '--W�V, -TA _L t «Bag) 1v. �int�-: e'--r . a� 1 ��w Ct; r 101ZIA11[ OOOIf!'Y DBlAlil�il' OF �ALTH w �`" �' � DlsriiiiM d�i��h16WId SiedeM. -Qt�1. N:Y 111.'' , p hwl� PM�It / Y T 1 >iEWA�- D0tOt3AL:8Y3'1'®I[ ` s Kre Tax DntO ett'Pretlaq� Appeowl 1:­" 2 !/ M1i�aa :. ii division A Fee nclosed :E � ��'� { Dti� T Lot °Ana T k G Fm Section o* vata�s N�Mc 1 Hie t: Deat�n Flow G PD PCHD NetlOaiiei M l:ea W6sP ®b ayNted Se�to,Swwnp S7!Iwt a ooiolat 1�� Srptlo Teak r � v G t T b eslim _y f Adihri�� Wapr So>t PaMeS Ftr• Ad�eeo DoMed y ' �OYa a1at��e� touity Ow±i1 a' 'sYArnitt0;'.1 . - pop Yt 11000., ana of tM,. ii wwpR lope d` CeuMy D.Wrt A .V 'j`;� APPROVEO''F ravO�aON'Ip1.4 raquMas a my , 1.088 t)atfa I shown on tha approw0 amarldmant tner� to and.in aceorAaiwa with tM ttaMarAs, ruht a ►pq e> o, munafn 1 thit on Co eoriipNtionttnaaof a t:NtNkat of Construetloq'ntplisrk ' Ytidrretory to.tha Cominii"nor of MNlthwill n0` a ;w►tltiii awragtN wi11N0%vfurnisMO tM ownM his:fucaao►s, °Mirf or'asi�nf,Oy tM Wiildir ,that Yi0't►ufMtar will Iny ;part of JtaW aawa�a Airpotal systani ourirly tM parbA of two,(t) yaari, titNy followirq tMaiH ef,;tM Nau- ut� Of GopRrudion ,t:omplianp of th` inaL;sY�taT'a any rapiMS tM[ 2) t t tM 4rNNA wall WfaiOW above wA ion and :that raid virNl will `O instils s acoonci.' _Nh't anA�iu ulai nA r u ns of "ahi, Putnam t AA. _ tree' "curs- 'ahe�n an Asti =7 . un _ ` 'eoristru ion Hof, tha ,euildina ,hit •t1 9 'urida►takin and is DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Brewster, New.York 10509 (914) 278 -6130 APPLICATION -TO CONSTRUCT A WATER WELL PCHD PERMIT WELL LOCATION Street Address owns Village City Tax Grid Number o —I WELL OWNER a Mailin Addr ss O �j )UPr vate O Public USE.OF WELL g - primary 2- secondary ® RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT gpm /# O REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLING PEOPLE SERVED -. /EST. OF DAILY USAGE , ,gal O TEST /OBSERVATION 12 ADDITIONAL SUPPLY 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING I 1� WELL TYPE DRILLED DRIVEN []DUG []GRAVEL'. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot o. 'J WATER WELL CONTRACTOR: Name "r.r7.% Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES r� NO NAME OF PUBLIC WATER SUPPLY: C/A- TOWN /VIL /CITY DISTANCE__T0. PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED, ON SEPARATE SHEET 41C (date) ignatu e PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant any and all water or waste products from such well property and in such a manner as not to degrade or Date of Issue: 19 Date of•Expiration lel 19� shall take appropriate action to assure that drilling operations be contained on this otherwise contamiAate surface or groundwa�t_ax Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller %rl\ RANDOLPH W. LAURENT, P.E.- 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 - (FA)Q 278 -2658 CONSULTING SITE ENGINEERS RE: Individual SSDS Car -Dee Building Corp. Subdivision - Lot #3 Partridge Lane Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -3 "Proposed SSDS - Lot #3 ", 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 ". i 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. Nichols, Jr., P.E. HWN:bd 94051 -3 cc: Mr. G. Nhcaluso w /enc. i 48. _ -- gA7H:; BEDRO01.1 X 1 .% .` J� . �,• DRESSING. WALK BEDROOM.! 0. - 13,-0, x 10"•0' I`'` - CLOSET - - MA-STER BEDROOM • BEDROOM 2 OPEN 1 S T U D `f'- _ � `lei' \fE' i'I ��' �� i�� r• �..�' , `• • G'O*R �s �j `� A 482.8 �.•-1.344SF - -= 48' .. KITCHEN •1 01NIN0 H00M p �� MORNING A001.1 13 O" x 12'•0" .r� ' _1 OrEN ' ABOVE LIVING MOOIA �.► ' fAI.:ILY n001•4 17••0"' x 1 t..0.. 13' 0" x 17' 0.. fOYEM �- I.RST FLOOR ... 4828 1 i Dllh I D 6. 7. License Number: �l0'12 Phone: Type of Project: is , _ . T Private %Resi dent ial* Food _Service, : ....CorYnerci.al Apartments Institutional Mobile Home Park Office Building Subdivision. Other (specify.) Is this project subject' to State Environmental Quality~Review,(SEQR)? T.yoe Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement. (DEIS) required? .. .. fJ19 9. Has DEIS.been completed and ..found. -acceptable- by Lead Agency? ......:.... )/% 10. Name of Lead Agency 11. Is this project.. in an area under the control. of -local planning, zon.ing;_, -.•. ...... _..._.__._or other offfcial's, ordinances ?" ......... tilil I 2. If so, have 'plans been .sut}�itted to such . authorities ?.. ... ......:.......... ►� /� 13: Has preliminary approva'1 been granted by such authorities? 0A Date Granted: �4. Type of S,Ewage Disposal: System, Discharge.:.. • Surface Water v Ground Maters 15. If surface water discharge, .what is the stream class designation ?........ �11� :6. Waters index number (surface.) ............ ....... ........................ ;7. Is project located near a public water supply system? ►JO 3. If yes, nave of water supply tij /a Distance to=water supply 9. Is project site near a public sewage. collection or disposal system ?..... L.la .;Name -of sewage system IJIti Distance to sewage system 1.. Date observed: 23. Name of .Health Inspector: �.^ • �� . .��i�'' =y i :'. Project design flow (gallons per day) ..................................... �DD APPLICATION. F FOR_ APPROVAL O OF PLANS FOR A W WASTEWATER DISPOSAL SYSTEM - i . Name and Address of A Applicant: h hl%!;�.;` i '�c.')C / /� %'►' F`= ��!��'�'� `'"rr"f.l 2. Name of Project: 1 1�1�'UPDGJr, t2 3 3:,_•_LocationaKV/C: 4��"( 4. Project Engineer: R'iD,4�'i� u u1. k11 L LN0J�� "( �. 5 5.. Address, :,.,i`'�ll�i,>�i pa m� 6. 7. License Number: �l0'12 Phone: Type of Project: is , _ . T Private %Resi dent ial* Food _Service, : ....CorYnerci.al Apartments Institutional Mobile Home Park Office Building Subdivision. Other (specify.) Is this project subject' to State Environmental Quality~Review,(SEQR)? T.yoe Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement. (DEIS) required? .. .. fJ19 9. Has DEIS.been completed and ..found. -acceptable- by Lead Agency? ......:.... )/% 10. Name of Lead Agency 11. Is this project.. in an area under the control. of -local planning, zon.ing;_, -.•. ...... _..._.__._or other offfcial's, ordinances ?" ......... tilil I 2. If so, have 'plans been .sut}�itted to such . authorities ?.. ... ......:.......... ►� /� 13: Has preliminary approva'1 been granted by such authorities? 0A Date Granted: �4. Type of S,Ewage Disposal: System, Discharge.:.. • Surface Water v Ground Maters 15. If surface water discharge, .what is the stream class designation ?........ �11� :6. Waters index number (surface.) ............ ....... ........................ ;7. Is project located near a public water supply system? ►JO 3. If yes, nave of water supply tij /a Distance to=water supply 9. Is project site near a public sewage. collection or disposal system ?..... L.la .;Name -of sewage system IJIti Distance to sewage system 1.. Date observed: 23. Name of .Health Inspector: �.^ • �� . .��i�'' =y i :'. Project design flow (gallons per day) ..................................... �DD 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.._ 26. Has SPDES Application been submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State wetland? ...... .............................:. ........................... N) 1) 23. Wetland ID Number .....' .................... ............................... IJ /b 29. :Is Wetland Permit required?` ............... .............................. :Has app! icat- i.on..been made to Town or Local DEC Office? ..........:....... qAl 30. Does-.:projec.t- require a DEC Stream Disturbance .Permit? 31..Is.or was project site used for agricultural activity involving application of 'pesticides to orchards or other crops, sol.i`d or hazardous waste `disposal; lan•dfilling, sludge app "lication or industrial-aictivity ?. YES.or NO - 00 3.2._ Is project located-within I- ,006-feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or ' any other potential`knokn•source of contarninatfion? .... ..... YES or N0. :I�IrJ DESCRIBE: 33. Is there a local master ,plan or f11e.:Hith t1 ' Town or Village? .:.:....:. 34. Are community water, sewer facilities-planned to be developed within-1 5 years? kLN3 A 3,5 Are any sewage- di- sposal: areas in.- excess of. 154V* slope? .... '..•. 430 36 . Tax Nap ID Number ...... .......... 37. Approved Plans are to-•be: returned to: ................ ' Appl i ca* nt Y/ Engineer If the application is signed by a person other than the applicant shown.in Item. 1, the.. application must be•accoimpanied by -a Letter of Authorization: failure to comply with -this Provision may be grounds for the rejection of any submission. I hereby affirm,, under penalty of perjury,• that information provided on this form is true to the best of my knowledge and be 1 ief. Fa Ise state.,,en.ts made herein are punishable as a Class A Wsde-reanor pursuant to Section 210.45 of the Pena 1 Law. / SIGNATURES OFFICIAL TITLES: JAILING �' !Q0. r V11s ✓ 5 i`I `J DESIGN DATA SHEET- SUBSUFACE SENTAGE DISPOSAL SYSTEH FILE N0. C wher ►✓IAG Ii 1 V I.of�f Eh1-1" COt�. Address Located at (Street) '�,�'TI ���,kl Sec. ?h . Block �_ Lot (indicate nearest cross street) Municipality 09-rTe7Zs ,Aj ` Watershed �i%ZO7 -VA/ 2 3 r 4. ' 5 NOtIS: 1: "Tests to be repeated' at ram° depth, `,until .apgraximately .equal soil rates are obtained at each perpolation- te`st,,+h&l ' l '.All: data to` be subatt�d for review. ` 2. Depth measurements to be made frCm 'top` -:of' hole. re7. 9/85 SOIL PEROOLn.TION TEST akTA RDQiT= TO BE SU&SC= WITH APPLICATIONS Date of Pre - Soaking r✓ Z7 ��� Date of Percolation Test rV A ` HOLE _ . ... . NLP BM CL= TIME PERCOLATIC N PERCOLATION Run Elapse Depth; to Water Fran_ Water Level No. Ti.rn? Groond Surface In Inches Soil Rate Start -Stop Min. Start'. Stop Drop In Min /In Drop Inches Inches Inches ' 1 jf 2 5 : I01 '.. 5 3(o 17' �7-t 27 �o 3 5.3'1 - 5 : }' I 2 _ . Z� _5 . 2 3 r 4. ' 5 NOtIS: 1: "Tests to be repeated' at ram° depth, `,until .apgraximately .equal soil rates are obtained at each perpolation- te`st,,+h&l ' l '.All: data to` be subatt�d for review. ` 2. Depth measurements to be made frCm 'top` -:of' hole. re7. 9/85 DESC F=ION OF SOILS hN_uururt W _LN nvl •rz> DEPTH HOLE NO.—. HOLE HOLE NO. G.L. 1 'j"0 21 a 31 s 41 5' 6' 7t 8t 9'. 10' 12 .. 131 - - 14' INDICATE LEVEL AT WHICH GROUINATER IS ENCOUNTERED INDICATE LEVEL T0. WHICH WATER_LEVEL ..RLSES AFTER BEING ENCOUNTERED �N 19 DEEP HOLE OBSEMTIONS MADE BY: DATE: DESIGN Soil. Rate Used (0 7 Min/1" Drop: S.D. Usable Area Provided No. of Bedroans Septic Tank Capacity / 254 gals. Type <52:W6- Absorption Area Provided By DD L. F. x 24" width trench Other {, L Nzsne 1 H o ► y 4? Signafur Address I 'l�'L' DI i �,�il iii r,1 I � SEAL' •W�'"i ,1 � �Odi• I f' t '��� ru • - � ' — ,�..�..� -1. U ,� �, u:r -- f•``-� � � oaf . THIS SPACE FOR USE BY HEALTH. DEPARTt� ONLY: �' r �. l �4 > Rate- Approved sq. f t,%g _ Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of Located at 'Block Lot (T Section Subdivision of Subdv. Lot h- ,.�.�Filed IMap Date II Gentlemen: This leitter is to zauthorize /4Qy'rI,, C�: �!�.� -(� r- 1 r j , a duly licensed professional engineer or registered architect (Indicate) to apply for a Construction Permit for a separate—sewage system, to* serve the above rioted property in accordance with the standards., rul e s• or regulations as.-- promula gated by the Commissiorler of the Putnam County Department of Health, 'and to* S3.g4 & 1:1 necessary papers on my behalf.- in. connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147•-, Education Law, the -Public Health Law, and the Putnam County Sani- tary Code. Coun P. E. I Address - / "--I I Z_�) Telephone Very truly yo Signed 0 1 of Property Address Town Telephone R.itnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE a4NER APPLICATION FOR PERMIT.APpLICAT•ION SUBMITTED- TO PUTNAM COUNTY HEALTH DEPARTMENT T0: Co 'ssioner of ealth - In the matter of application for 1C4_}: �'; represent that.I am an offio,,er or employee of the corporation and am: authorized' to act for, !�'�'// lv m���• C' (name of corporation) _ having offices at _ _ , �� /�9r�� ' Y�,�`iJ��°S ���31 ' _Whose officers -are President Vii(" /.v./ ames7 an��ddres�'. Vice - President ' —(Name and AddressT Secretary — (Name and Address) Treasjirer' _ -(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 reoes:te rid -all .sub -` seque it acts relating -thereto. Sworn: to 'before me this L f day Signed of 19 C?jj. Title o ary, Publi BO�V J. DRYS REG. E40ESW QUALIFIED IN DfCHESS MY COMI.SSSIN MKS A''.0 -. Corporate Seal I 'htr�ary 32 " -?-o ;Vwvel to v�gVe� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �3 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 2 AIF.::�>S Address Located at (Street) HA)1j L jyn Tax Map a S-. Block �_ Lot q.,3 (indicate nearest cross street) Municipality -PA -rtrr vAl Watershed r,4gT -Bg AUe_,{ SOIL PERCOLATION TEST DATA Date of Pre - soaking 1 o // -s"19S Date of Percolation Test 1-0 % 16 / 9 R 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 1 0, A6 6 6 3 na 3 - ! 3 4 5 o - o; 1 3'0 2 3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Sheet I of�_ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD.ACTIVITY REPORT, ,nature and Tit I acknowledge receipt of this report: SIGNATURE: - - RECORD OF PRONE CONVERSATION— Time: i Date: Person calling: — , 4-e Phone #: 02:� : CLacvV�✓��' Reason O Inspection: Deeps and /or ergs- Pe rc Scheduled Field Meetin.p - Tir Da 1 1V Tentative /to be confirmed () ( ) Town:, Road /Street: ._`�Gt.r �^,`��,,.ve Tax Map #: �� — j of , Comments: Lof 3 owHeV` GA F R-D� ! < TEST PIT PROFILES ;Hole # _ Lot # Hole # Lot # Hole # Lot # - - Depth to water 1U,�2 yl e _ Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling. Depth to mottling G.L. Depth to rock/imp. O Depth to rock/imp. Depth to rock/imp. 1.0 G.L. G.L. G.L. 3.0 0.5 �•- ". S 0.5 0.5 0 1.0 1.0 1.0 7.0 2.0 2.0 2.0 9.0 # 3.0 ,e P`ow n 3.0 3.0 0 4.0, �° 4.0 4.0 5.0 5.0 5.0, t s 6.0 6.0 6.0 7.0 e 5 7.0 7.0 8.0 8.0 8.0 i 9.0 9.0 9.0 10. � 10.0 1070 Hole # Lot # Depth to-water-- ._ : _... - _.. Depth to mottling Depth to rock/imp. G.L. 0.5 1.0 2.0' 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 Hole # Lot # Hole # Lot # Depth to Water"- bb epth to water Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp. t G.L. G.L. 0.5 0.5 1.0 1.0 2.0 2.0 3.0 3.0 4.0 .4.0 5.0 5.0 6.0 6.0 7.0 7.0 8.0 8.0 9.0 9.0 10.0 10.0 i.n RECORD OF PHONE CONVERSATION Time: ©� Date: Z2 f Person calling: ry, z A//�C—h Phone #: ;L % 8 Reason ( ) Inspection: eeps nd /or Peres: Scheduled Field Meeting Time: �1d2 Date: Y N Tentative /to be confirmed O ( ) Town- -'--Road/Street: Tax Map #: