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631- 589 -8100
25. -1 -9.9
BOX 9
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• � Dh!IIIr d Daih�se�W HaY� Seevk+e�:Gttmel. N Y 1061? � ' r '' c to�Avvlde Padt l t -
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CERMCATE OF
r—wj.L 1i0N PIMM FOR MP AM DUPOSAL SYS'1M : f
OO1YIPi?AN
Naas Q' Q:ba IM 0 " 1 Tax
��4��( �1' {
Date Subdivisibn _Approved Fee Enclosed Amr,,,nr
nPo '{1� AL Lot A.ea' O •`'l.) �' �'/-tC Foil
2
�y- ® N etldeitloo b EegikeO When FOI 'oomoleted
Nhbee d Hedtootats DeaiQq Fbw G; P D �d� PC
.
-Sepaw/q SO—WOM O Sour to Comm,( 12'5V; Ga0."g * TWA, 00 5?,& _� ���
To bs oielibi�ated b�� AdlhMe
Water P&& Fros N ;:A
eta Pth�ate Spppy DtMMel1 b —a,dd,.=
owe
... r
1 repr*rit. that 1 am woolly anA.eompNtety,►etponsible for toe, design and location of tM ' -posed ryst�m(s); 1) thit the siparate aw • ".dl tit •stem .
above desuibed- wili.be e6i ructed'.as shown on'tAe approve0 amendment tAera to it in accordance with the standards. rulesa, , repu ns o ° nam
County'Oepa►tment.,'of ►Iialth, an0,f�afoncomplelfontMreofa 'Certificate of, Construction ComplNncN'.iatistactory • to•tMCommissioneiofHwKhwill
M sub nftte0 to: the Oepntm@rt, and i w!lttan guarantee wili tie funiisMd the: owns, hissucccestora, MNf orrisiiens V the butl"i.• that wi0: bulkier will
phce . in good operating eari0ltlon any, part of; pkt svvager disposal syism tluiinq the pe►fo0 of two.(2 j �yept imm 0litely f011Owiny'tMdata.OR tM ifsu-
ante of the' appioval of the .Cartiflute o/ Constructon Complkince of original system or any, regks then o; 2) that the-drilled well ttaaC►ibed above
" e lowtid as O"Wim'on_tne;app► -lad plan, arid:tlat Ykl weltwill•t►e insta in. =61 nee with tAer, s and rpu aT Wn of the - Putnam
County Oepditmemt' o1 Health.
pate SienW P,t .,�5_ R.A.
�7..
AAAn r license No
APPROVED FOR CONSTRUCT10N TMs apptoval exikk,r two year ` m the date issued unless construction of the buildiny..has been undertaken and is
revocaba for Guse 01 may beifllended Or modiHad Whefl COnside/ iee f ry by t mmissioner of Health. Any change or altentlon of; construction
requires a Mw ermi Approved- for difpofal' of domestic san�l Y and ivate`-water supply only.'
REV.
Title
16/88 OiN
i
n.
APPENDIX C FINAL SITE INSPECTION DATE:
. Inspected by-
_ STREET LOCATION � ��� �.:4+' "r
V46�� OWNER
PERMIT # tM # OR SUBDIVISION LOT #
1. SEWAGE DISPOSAL AREA
a. SDS area located as per approved
b. Fill section - date of placement.
2:1 barrier LGTH
C. Natural soil not Stripped
d. Stone,brush,etc.,greater than 15'
e. 100 ft. from water course /wetlanc
II SEWAGE DISPOSAL SYSTEM
a. Septic tank size - 1,000
b. Septic tank installed level
c. 10' minimum from foundation
d. DISTRIBUTION BOX
1. All outlets at same elevation
2. Protected below frost
3. Minimum 2 ft. original soil be
e. juN rrcy box - properly set
f. TRENCHES
1. Length reauired - b� Ler
2. Distance to watercourse measured
3. Installed according to plan
4. Slone of trench acceptable 1/16 - 1/:
5. 10 feet from property line -.20 feet
6. Depth of trench < 30 inches from sur-
7. Room allowed for expansion, 100%
8. Size of gravel 3/4 - 17"" diameter cl,
9. Depth of gravel..in_"trench. 12" -minima
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 manhole to gr
5. First box baffled
6. Cycle witnessed by Health Department
III. HOUSE
a. House located pei
b. Number of bedroa
IV. WELL
a. Well located as i
b. Distance f ram SD.
c. Casing 18" above
d. Surface drainage
V. OVERALL WORKMANSHIP
a. Boxes properly q
b. All pipes Partia
c. All pipes flush
d. Backfill materia
e. Curtain drain in
f. Curtain drain ou
g. Footing drains d
h. Surface water pr
i. Erosion control ❑rovided
ted
nd trenches
installed
2 "Hoot
- foundations
ace
an
I
YES I NO O"ENTS
-, - 1"-, _ ..'
DIVISION OF HEALTH SERVICES
DESIGN akTA SHEET- SUBS'OFFACE SEWAGE DISPOSAL SYSTEM FnS NO.
Owner M,AG,Q i SAL LDft,4.�►J`T j/ .Address
Located at (Street)' �A rvj IT-[ Sec. 2r> Block' Lot
(indica e nearest cross street)
Municipality OgT-r AJ Watershed TQN
SOIL PERCOLA=CN TEST DATA REQUIRED TO HE SUBMIT= WITH APPLICATICNS
Date of Pre- Scaking Date of Percolation Test
HOLE ;
N(PMER C= PERCOLATION
Run - Elapse Depth to Water From Water Level
No. Tim` Ground Surface In Inches Soil Rate
Start -Stop Min_ Start- Stop Drop In Min /In Drop
Inches Inches Inches
1 14:0 5'
2 >-7(�
3 : o-7 - ; ,�� 30
5
t .
3 11:08' 11 -: 38 . SO Zq-
21
.3
4
NOIES: 1. Tests to be repeated at same depth'. until approximately equal, soil rates
are obtained'at each percolat or a,test hole. All data to' be s ibmittod
for review. w ,
2. Depth measurements to- beArmadey�fran top of hale.
rev, 9/85
I ►
DEPTH HOLE NO. HOLE NO. �i .. HOLE
NO_
----------- -- --
G. L.
'T4 PS o I L,
-rd F50. I �-
l �•
-
2'
1 L`' f 1°►
I L ISO 1Q 1✓1
3'
4' O A'i2 11
5'
�1�Ni7
71
9'
10' _ ..
11'
,
12'
131
'
r 14'
INDICATE. LEVEL AT .WHICH GROUNDWATER IS ENCIMINrEREO
INDZCA zEVEr. TO wMcx WATER LEVEr, RISES AFTER BEING ENOOUNTERm
- g-' o `
DEEP HOLE .OBSERVATIONS MADE BY.- DATE:
DESIGN -.
Soil Rate Used 1(0_20 Min/1" Drop: S.D. Usable Area Provided
No. of Bedreans Septic Tank Capacity gals, Type 6O/11G,
Absorption Area Provided By L.F. x 24" width trench
Other �i '� ��i�" , ^ %rr- �i� l✓ I %.1. ! -.. I ' ' t-�S , /'"
1�.
•v`�
• 'G..� ;r� t.1 ?�:;, ✓. Si 173tur �<
�^.
1. 1,
Address
SEAL
THIS SPACE FOR USE BY BEALTfir- lfftu
\
I' Soil Rate AQPraved �' • . ...
.
Date
__
_.
PUTNAM COUNTY DEPARTUENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: -Property of
Located at
(T)_ Section Block Lot
Subdivision of
Subdv. Lot Filed Map ;t Date
Gentlemen:
This letter is to authorize /4-q,, 1.7. ��.c /� c. 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 noted property in accordance with. the standards., rules.
or regu)_a.*tIi.ons. as prompla gated by the C ommissioner. of the Putnam.-County
Depa'r'tm'eAt of -Health, and to' sign. all necessary papers on'my. behalf.-in .
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the -Public Health Law, and the Putnam County Sani-
tary Code.
CO
z cis
Very truly yours------'
Signed
Oismr-6•1 of Property
_Ij
P.E. , R.A. , h,
Address
'
Teleph; ne
�Addr'ess
Town
Telephone-
I.
parnam County Department t of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE a4NER APPLICATION
FOR PERMIT. APPLICATION SUBMITTED- TO
PUTNAM COUNTY HEALTIJ DEPARTMENT
TO: Co7/ssio er of ealth In the matter of application for'
f
�ncZ2
epresent.'
- - - -- -
7 r
- - - - - - - -
that-I am an o i( r or employee of. the 'tion and am-.
ff'/;e e corpora , authorized'
t . 0 act for. ;61,4
17,
(na;m6 of corporation)
havin g offices at
A11�171 r5
Whose officers -are
President ^ 6Yeolq.
-7/—
ame an Tddre-ss)-.
Vice-President
_ - - - - -
Name and AU6� ss) - - - - -'
Secr,6tary
- -------- - --- - - ---- - - -
-
(Name and Address)- s
Treasurer"
- - - (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 requests
eeque'*t acts relating -thereto.
S.arrk to 'before 'me this day Signed
of 1924' Title
womm pme. srAT2 w m: w m.-,z
REG. 1493530G
OUAURM RN Mi
FN CON', milcloii DTMES Aut-1. "'_2 !36—
Corpor4te Seal
I— . .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 #�
WELL LOCATION
Street Address
p
Town/Village/City Tax Grid Number
CAI d 2,�
WELL OWNER
Name
Mailing Address
'�j
%Private
O Public
E OF WELL
- primary
CVCV-
- secondary
}RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
0 INSTITUTIONAL O STAND -BY
O ABANDONED
p OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVEDO ,G /EST. OF DAILY USAGEIJ :a( l
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION CI ADDITIONAL SUPPLY
13 NEW SUPPLY NEW DWELLING ) 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
13DRI VEN DDUG
C] GRAVED
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: 7,� TOWN /VIL/CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: 19
,LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
(SON SEPARATE SHEET
(date) Lgnature
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-, (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 oth w se co aminate surface or groundwater.
Date of Issue: �► 19
Date of Expiration 19 Per it Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Datei11.�
Re: Property of
Located at VAT L-AM�
(T)"��' Section 2✓ , Block Lot .0
Subdivision of
Subdv. Lot # � Filed Map #L[-.� ` :Date. — -
Gentlemen:
This- letter is to authorize- I- ,�,��`/
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 County
Departirient of Health,. and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani=
tary Code.
Countersigne
1.
R°'r* - 9
':.. C ► /
phone
Very truly your ,
Signed
`Ownex:�e P operty
1!1� r-, . 40L- t�5 1212,
Address
1P . -I L
•
J ►_-- _ g �
Telephone
RUrnam.- Qounty department of Health
Divisic Environmental Sanitation'..
AFFIDAVIT :.CORPORATE WNER APPLICATION
___ -- FOR - PERMIT. APPLTCAT•ION SUBMTTTED' -TO__
PUTNAM COUNTY I1EALTH DEPARTMENT
T0: Co 'ssio er of eal h - In the matter of application for
I g�� - — — represent.
77 '
that .I am an offi er or employee of the corporation and am; authorized '
to act for. Zo.-
(name of corporat�o7])
having offices at _ _ /_��7rj.C�_C
_.�• _ _ — _ Whose officers.•are
President U'Y� �. /litSo V_o, � '/� ),1 c-' /v /!�
ame and Address).
Vice - President
-'(Name and — Address) — ^ — — —
Secreetary _
t _- -_____ __ - - — ____—
(Name and Address)
Treasurer' _ '
— ^ — — — — — '(Name and Address)
and tlhat. I= am-and will be individually responsible fon any* or all ap:tp
of the- corporation With. respect to the approval requeste nd•all :sub
sequent acts relating -there to.
Sworni to before me this day Signed
of 19Ci Title
ru
o ary Publi � •
WMIDAM
NOTARTPUBM "A" OF MM MM
M {`498 &T '
OUA11RED IN DUTCRESS CCU T!
IN COMWIWOR M0 Alk.
Corpor4te Seal
I
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBkOOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
(914)278-6108 - (FAX) 278-2658
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
June 13, 1997
Robert Morris, P.E.
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS - Renewal
Car Dee - Lot #9
Patridge Lane
Town of Patterson
Dear Robert:
Enclosed are the following:
1. Four (4) prints of SS-9 "Proposed SSDS", revised 6-13-97.
2. "Construction Permit for Sewage Disposal System", dated 6-13-97.
3. "Application to Construct a Water Well", dated 6-13-97.
4. "Letter of Authorization"., dated 6-13-97.
Q
We would appreciate your review, approval and issuance of the renewal Construction Permit '_d_t
your earliest convenience.
co
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Ni ols, Jr., P.E.
HWN:TR:bd
9.4051
cc: Macal Devel. Corp.
SIMMONS
t - • , f � f: 3�� 1"m�r,c�, s «: �'� a � l� - 'k a "� �TM Y'' + L , � .
i •� lQllrA�[ 0001f1'1f D�Atll�fl' OF �r►LTS c ; + `'` � ., �' i � - Y
TZ OM.vld_�
F i
.x. a
!EllQ1.P01,OWAs D18tOiAL $YSl�It ?,', i
� Dpie oI- Pfef'ieo'Approvtl_
�!`ii Adiar To"° c
nArP c„t;divsi'on ;A�oroved Fee .Enclo'sed Amn„nt �% .
sr is t of A . D I G "F F� secua. D 5
hftaiR a[. DedFa t+fov G P D _��_ CPC® NoU0eilie la Qeq`�`yed �Yhs'P®G'afilMbd '
, M �So own � l (•nM S plle Taad<; � / L am!"`
',Tt+ amuse �afafd 4� 'P. Adlba+M '
P Addrein
W�Mr Sub's p� .
v ,
:
above ANCiibW willai• corlstrutt•0 of flwwn on th aDPMOwd am•ndm•nt than + C1 ohiiprr•t•nt tMt 1 am wholly anA eomp.N t •ly nfpooHbN fa tM d•tgn and ls ocatitoon t anof • o f•0 sb rn 1 ' taw d
i of ' f
ft•m tho the f• rat•,
d in accor"na�wtth th• i4*rd r, l� a u ns p
ity M Khwlll
0�' fubwiltt�d, to tMf 0•partm�nt, angr �'wrlttNi`ouarfnt•i wiy, M furnUMO tM owner hlt wcaaoi MNS oi`+tisiiont OY aM builds tlNt N10 builder will
platy M po0 opa►atMq owWltwn anY of �iW IMP", disposal system durilp' tM period of two (i)�yaa t _ m•dlately following tMOite'of'tM {a111•
ana- of tM approval: of tM fartttkaH. p1 Conftructfon ComplMhc• oft oriyfnal yst or an apaks t I Z) t tM diNNd well d•fo►l0ed above
i , wiN 0•AbaNd,at f11ow11 On tM pprovd plan and that fald:vrNl will M Insta In aeaoroan wit t stands ru an rquof Dint 0 , PutMm
' `'COY11ty Oapartaa•nt4 01 FlNlth - � � G r ' • . , {
r
, AdW
ApPROVEO;FOR CONSTRUCTION: Tl Nlapp Mal •xpk•t two yarsylrom thi dati i ufi co struttfon of bulldfno -ho been- une•rtakan and if 1.
revoeaba fovcam" or;m!Y t►•;am•rw•u;o► modt/i d when eonfidarb n•eitYry by Commisfiomr of M•attll `Any eliany ,or attMau"' oif construction
nauN•s a bw' permit: 'Apgov0 /oc'gifpost) o1 dom•stle sanitary ar supply ony.
Rev'. TItN ;
10/W 8 Oat• - -
m
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
own Village City Tax Grid Num er
WELL OWNER
Waine Mailing
Addr ss
p ✓
r va e
O Public
E OF WELL -
01 - primary
2- secondary
aRESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 BUSINESS O FARM p TEST /OBSERVATION
0 INDUSTRIAL 0 INSTITUTIONAL O STAND-BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /#
13 REPLACE EXISTING SUPPLY
aNEW SUPPLY NEW DWELLING
PEOPLE SERVED- i /EST. OF DAILY USAGE_,gLQ Sal
O TEST/ OBSERVATION Cl ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
13DRIVEN
DUG
GRAVEL.
0
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF 8UBDIVISI,
NO
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: ZA TOWN /VIL /CITY
DISTANCE-TO PROPERTY FROM NEAREST WATER..MAIN: -, nlZA
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
(BON SEPARATE SHEET
ignature
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 groun te-
Date of Issue: 19
Date of Expiration 19 Permit Issuing Offici
Permit is Non - Transferrable `White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
p U rr N,A. M. C O iJ �T T'SZ" 7� P ,A. RT L�)t1 TT T O E;'
-APPL•ICATION-FOR— APPROVAL OF-PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: V kk ,A ii �D�' lC ✓j> � 's � �� G,✓ I� i'' = `"'"'/'t, I
• 1 �'� � L'. J Imo`, •; �.r; :^ r ' `
► 0
2. Name or Project: rrWjjD rr2 �iGJDS 3.._•_LocationdW/C:
4., .Project Engineer: 12Y to. IJILFIDJ.� x _: 5. Address: N(AMODrt�- G'il
M1U.Ya�VtJ :�o�
0 :Y. 1050.9
License Number: Phone:'' _ CoJ00
6. T e of Pro ect: :.' :: /.. y' +. ' ' -. -t ...., . ' •'.. •
Private /Residential Eood;.Service ...-Coma erci,al
Apartments Institutional Mobile Home Park
Office Building t Realty Subd,ivisl.i Othe..r (specify)
7. Is this project;.subject' to" State Environmental-QuAlity Review (SEQR) ?•
Tyoe Status (Check One) Type I.'. Exempt ✓
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required?
9. Has DEIS been completed, and found acceptable ..by Lead'.
ead Agency ?, ...........
Name of Lead Agency /
11. Is this_..p_roje_ct.J'n an area under the control, of - local.._p.l.arini,ng.,._zon,ing.,:.,
or other officials, ordinances? ............ ti!d
12. If so, have plan- s'been..sub1itted to such. author .sties?......................
13. Has preliminary approval been 'granted by such authorities? Q/A Date Granted:
Id. Type, of Sewage Disposal: .Systen Discharge...... Surface Water v Ground Waters
15. If surface water discharge, what is the stream class designation ?........
6. Waters index nun, ber .(surface) ........ .. ....... ........................ N) /1&
:7. Is project located near a public water supply system? N U
3. If yes, name or water supply Q4" Distance to=water supply ,
9.. Is project site near a public sewage..- collection. or d.isposal system ?..... {�1p
,. Name of sewage system WA Distance to sewage system
1. Date observed: '23. Name of Health Inspector:. k4r,
Project design flow (:gal;lons,,per day) .....................
2.
25. Is State Pollutant Discharge E- l_i_mination.System ( SPDES) Permit required?.-.- �- -
26. Has SPDES Application been submitted to local DEC Office? ..... ....... �;)>p
27. Is any portion of this project located within -a designated Town or State -
wetland? ............. ....................... ............................... N) e)
28. Wetland ID dumber ......................... ............................... Q/X
29.' 'Is Wetland Permit required? ............. ............................. ti1�
Has application_ been made to Town or Local DEC Office? .................... 1J /Al
30. _Does project require a DEC Stream Disturbance•Permit? .
31. Js 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 industria4 activity? ........ YES or�t�0 n)y
32. Is project located-within 1;000'�feet of existence of abandoned'landfil1,
hazardous waste site, salt stockpile, landfill, sludge disposal,si,te or
any other potential known source or contamination? ...:....:....YES or NO
DESCRIBE:
33. Is there a local master- plan-or file.xith th'e Town or Village ?. ...............
34. Are community water, sewer facilities planned to be developed within 15 years? N*eQGW,0
3.5... Are any sewage" disposal areas in- excess of 15� slope? ......:................. _ go
36. Tax Hap ID dumber ................................................. �•��
37. Approved Plans are* to'•be< returned to: ................ . Appl icant Y/ Engineer
If the application is signed by a person other than the applicant shown in Item .1, the.
2ppli.cation must be•accompanied by y-a Letter of Authorization: Failure to comply with 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:r,ents made
herein are punishable as a Class A Nisder,eanor pursu t to Section 210.45 ,OF
the Pena 1 Lair.
SIGNATURES OFFICIAL TITLES:
4�11�j'LOo �1G�- G�1J .
�� 22 X11 o N a
'.AILING ADDRESS: 166
: i LI I�'_��3H 'AN3
RANDOLPH W. LAURENT, P.E.
HARRY W. NICHOLS JR., P.E.
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 & Milltown Road
Brewster, New York 10509
(914)278 -6108 - (FA)O 278 -2658
CONSULTING SITE ENGINEERS
RE: Individual SSDS
Car -Dee Building-Corp. Subdivision- Lot #9
Partridge Lane
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of-Drawing SS -9 "Proposed SSDS - Lot #9'
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 SOCIATES, P.C.
H rry W Nichols, Jr., P:E..
HWN:bd
94051 -9
cc: Mr. G. Macaluso w /enc.
I�PUTNAM COUNTY DEPARTMENT OF HEALTH /
DIVISIONaF ENVIRONMENTAL HEALTH - SERVICES -
TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
CONSTRUCTION PERMIT
Located at Town or Village
Formerly_
VQ i
Name MAC,,AL �1:L .Co�P�P Tax Map !29. Block 1 Lot 61. =-t--
Subdivision Name gLAgo
Subd. Lot # G,'
Mailing Address l:_ IQL.I V-c, Z EA&LM S , )4`� Zip 12551
Date Construction Permit Issued by PCHD
Separate Sewerage System built by 49�4ARQCg 2taEL, _ Address FACUIO?�= I
Consisting of 12!iQ Gallon Septic Tank and "&0 L r / OS. Tl? •
Other Requirements: Cy12'('%Al N t71 41►� , 2' (Z .O
Water Supply: Public Supply From
Address
or: C Private Supply Drilled by (I LL 12R I LU NC� Address
Building Type 12EStOEM-- DAL Has erosion control been completed? `( S
Number of Bedrooms Has garbage grinder been installed? 6
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 regulatigns of the Putnam Coty�y D,opaMnent of Health.
Date: J Certified by
Address
P.E. 9( R.A.
License # .moo 194-
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject to modification or change when, in the judgment of the Public Health Director, such
revocatio , odification or change is necessary. q
By: 1� Title: �!/` �C �� -� /^' Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
R
PUTNAM COUNTY DE$ARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
S!ie tAddress:
Taryn Drive
Town/Village:'
Patterson, NY lMap26
Tax Grid #
9.q
, Block I Lot(s)
Well Owners
Name: Address:
Shamrock Development Corporation, 313 Haviland Dr „' Patterson, NY
Use of Well:
1- primary
2- secondary
xx Residential
Business
Industrial
Public Supply , Air cond/heat pump Irrigation
Farm Test/monitoring Other(specify)
Institutional Standby
Drilling Equipment
Rotary
Cable percussion' xX Compressed.air percussion Other (specify)
Well Type
Screened
Open end casing xx Open hole in bedrock Other
Casing Details
Total length 43 ft.
Length below grade 42 ft.
Diameter _in.
Weight per foot 19 lb /ft.'
Materials: xx Steel ' Plastic Other
Joints: Welded xx Threaded - Other
Seal:. _2a Cement grout _ Bentonite _ Other
Drive shoe: xx. Yes No
Liner: Yes' No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
_ Bailed _.Pumped
xx_ Compressed Air
Hours
Yield 1.00 gpm
Depth Data
Measure from land surface-static specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
2.
Soft brown s o i l .W cobble s
2
12
Hard grey granite
12
20
Iso ft seams.'W/brown.sandy water
20
125
Hard grey granite
'125
185
Hard grey & black granite
185
550
ar. d grey & white gram e
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
550
Pump Type Capacity
Depth Model
Voltage 0105'
Tank Type Volume
Date Well Completed
8/27/97
Putnam County Certification No.
003
Date, of Report
9/11/97
Well Driller (signature)
wtttt
Well Drill
Signature:
,s to at least two permanent lanamarxs to De prr�gebaaj �eLp snupian.
a c IC ,; Address: PUTNAM AVE., BREWSITER, NY
i Date: 9/1:2/97
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
i
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road
Brewster, New York 10509
January 8, 1998 Tel. (914) 278 - 6130 Fax (914) 278 - 7921
Harry Nichols
Laurent Associates
Millbrook Office Centre
Route 22 & Milltown Road
Brewster NY 10509
Dear Mr. Nichols:
BRUCE R. FOLEY
Public Health Director
Re: Proposed Compliance
Macac Dev. Lot 99
(T) Patterson TMm 25.- 1 -9.9.
Review of plans and other supporting documents submitted at this time relative to the above
captioned project has been completed. Comments are offered as follows:
"The construction of this sewage disposal system may be subject to local wetlands regulations.
You should contact local wetlands officials in this regard."
1) Satisfactory results or a water analysis, for the parameters of table I
(attached) has not been submitted.
2) Photocopies of documents are not acceptable. Bacteriological test
submitted is a photocopy.
3) As - built is to note distances to the well from two fixed points,
preferably the corners of the building.
Upon receipt of a submission, revised to reflect the above, this application will be considered
further.
Ve truly yours,
Robert Morris, PE
Public Health Engineer
W
3. If the water supply is from a drilled well:.
a. Satisfactory results of a water analysis, for the parameters in Fable I below,
conducted and reported by a NYSDOH approved laboratory under the
"Environmental Laboratory Approval Program (FLAP)."
CONTAMINANT
MCL (1)(4)(5)
Coliform bacteria
Any positive result is unsatisfactory
Lead
0.015 mg/l (15 ug/1)
Nitrates
10 mg/1 as N
Nitrites
1 mg/1 as N
Iron
0.3 mg/1
Manganese
0.3 mg/l
Iron plus manganese
0.5 mg/l .
Sodium
No designated limit (2)
pH
No designated limit
Hardness
No designated limit
Alkalinity
No designated limit
Turbidity
5 NTU (3)
NOTES: (1) Maximum contaminant level.
(2) Water containing more than 20 mg/l of sodium should not be used
for drinking by people on severely restricted sodium diets. Water
containing more than 270 mg/l of sodium should not be used by
people on moderately restricted sodium diets.
(3) NTU means Nephelometric Turbidity Units.
(4) mg/l means milligram per liter.
(5) ug/l means microgram per liter.
q,q
Owner or Purchaser of Building Tax Map Block Lot
le4s D4
Building Constructed by Town[VIIIAge
Locati:oiy� Street Subdivision Name
Building Type Subdivision Lot#
I represt.,.nt. that I am wholly and completely re % sponsible for the location, workmanship, material,
construction and drainage of the sewage. treatment system- serving the abov&described property, and
that is has-been constructed as shown on the approved plan or approved amendment thereto, and �in
accordance with the standards, piles and :regulations of the Pufnam County Dqpartment 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. (late of appk oval of the "Certificate of Construction .Compliance" for the
sewage treatment system, or any repairs made by me to such system, except Where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
systcm.
The undersigned further agrees to accept as conclusive the determination of the Public H * ealth
Dircctoi 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: Year signaturee.�4
Fitle:
(jeneral tractor (Owner) - Signature
Corporation Name (if corporation)
Address
State 7i
Corporation Name (if corporation)
Address:
State
Form GS-97
TOTAL P.01
ml
7 ARTESIAN WELL
CONTRACTORS LET i T
ER ' ¢
Putnam Ave.. Brewster, NY 10509
r
(914)279.5041 Date ............ W1. 2/: 97 .................... ... :...........................
X- M ............. ....... SHAM RQC .K...DEVELO.PMENT....C.O.R.PO. RAT TON ............. ......................... ....... subject .................. ...............................
313 Haviland Drive Lot 9, Taryn Drive
................... P. at. terso. n..,.... NY........................................................__.........._............ ..........._...........'....... . ...................... . .-P.at. ter. so. n..... ............. : ......... ... ... ....
.............................................................................................. ...............................
EXACT LOCATION OF WELL W /DISTANCES TO TWO PERMANENT LANDMARKS.
...... ..._ ........ .............. _.�_` _ .....+........ ....................._........_ ................................................................................................................. ...............................
............................................................................................ .............................................................. ............. .............. ................................ ..........................................
...................................................................................................................................................................................................................................................................................................................... ...............................
NORTHEAST LABORATORY of DANBURY
(Formerly Tarlton Environmental Laboratory) CT Cert: PH-0404
39 -3 WELL.PLAIN ROAD -. DAN BURY, CT 06811 NY Cert: .11471.
(203) 748 -7903 - FAX (203) 748 -0652
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO•
MILL DRILLING, INC.
PUTNAM AVENUE
BREWSTER, N.Y. 10509
DATE SAMPLE COLLECTED: 1/2/98
TIIVIE COLLECTED: 10:39 A.M.
COLLECTED BY: R.. MILL JR.
DATE RECEIVED @ LAB: 1/2/98
TESTED BY: LAB# 11471
REPORT DATE: 1/8/98
51,pLE-81TE: MONAHAN, -LOT #9- -TARYN DR. � ATT RSON; N.Y.
SAMPLING POINT: HOSE BIB
SOURCE: WELL -NEW
TREATMENT: NONE
TEST PERFORMED RESULT: MAXIM" CONTAMINANT LEVEL
PHYSICALS:
pH 7.56 no designated limit
Turbidity. 1.6 NTUs 5 NTUs
CHEMISTRY:
Nitrite N
0.050
mg/L as N
I mg/L as N
Nitrate N
<0.50
mg/L as N
10 mg/L as N
Alkalinity
81.0
mg/L
no designated limits
Hardness
124.0
mg/L,
no designated limits
Iron
- .0.102
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
4.92
mg/L
20 mg/L **
Lead
..0.005
mg/1,, .
0.015 mg/L
m1= milliliter mg/L = milligrams per Liter
ND = none detected NTU =Units
* *Notification Level
RESULTS BASED ON SAMPLES SUBMITTED: 1/2/98
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS) ,
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
T
NORTHEAST LABORATORY OF DANBURY'
(Formerly Tarlton Environmental Laboratory) CT Cert: PH -0404
39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471
(203) 748 -7903 - FAX (203) 748 -0652 -
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING, INC.
DATE SAMPLE COLLECTED:
10/9/97
PUTNAM AVENUE
NORTHEAST LABORATORY OF DANBURY'
(Formerly Tarlton Environmental Laboratory) CT Cert: PH -0404
39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471
(203) 748 -7903 - FAX (203) 748 -0652 -
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING, INC.
DATE SAMPLE COLLECTED:
10/9/97
PUTNAM AVENUE
TIME COLLECTED:
3:35 P.M.
BREWSTER, N.Y. 10509
COLLECTED BY:
BOB
BACTERIAL:
DATE RECEIVED. @ LAB:
10/9/97
per 100 ml 0 per 100 ml
DATE(S) TESTED:
10/9/97
Chlorine Residual ND
TESTED BY:
LAB #111471
REPORT DATE:
10/13/97
SAMPLE SITE: SHAMROCK DEVELOP. CROP., LOT #9, TARYN DRIVE, PATTERSON, N.Y.
SAMPLING POINT:
TOP OF WELL
SOURCE:
WELL -NEW
TREATMENT:
NONE
TEST PERFORMED RESULT:
RECOMMENDED LIMIT
BACTERIAL:
Total Coliform (Bacteria) 0
per 100 ml 0 per 100 ml
CHEMISTRY:
Chlorine Residual ND
mg/L - - - --
m1= milliliter
mg/L = milligrams per Liter
ND = none detected
RESULTS BASED ON SAMPLES SUBMITTED:10 /9/97
SAMPLE, AS TESTED ABOVE: ❑X OTABLE or OT POTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
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
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