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BOX 10
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11:
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11:
PUTNAM COUNTY DEPARTMENT OF HEAL
DIVISION -OF ENVIRONMENTAL - HEALTH SERVICE
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # P ) I -6 �_
Located at 5-3 Lod 0q r d- 1) r I u e Town or Vile
Owner /Applicant Name Tax Map Block % Lot
Formerly
Subdivision Name
Subd. Lot #
Mailing Address Zip Z. 5 C.
Date Construction Permit Issued by PCHD /0 - -,7-5 — 0 5—
J
Separate Sewerage System built by Address Al(e,K
Consisting of 1 00 U Gallon Septic Tank and '325—
Ir �
Other Requirements:
Water Supply: Public Supply From Address j
or: POOOOO' Private Supply Drilled by Da v d W e -t !j Address R b
Building Type 7�1��. Has erosion control been completed? (� -
Number of Bedrooms Has garbage grinder been installed?d
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 regulatiogs of the Putnam Couja y Department of Health.
Date: 'S -0 7 —u 8 Certified by
Address t" 6 , ho x y
P.E. L," R.A.
License # iZa t 2t
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
White copy - HD
e_ is necessary.
Titl Date:
- Building Inspector; Pink copy = O er; ange copy - Design Professional
Form CC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES j
Well Permit � _
WELL COMPLETION REPORT
Well Location
Street Address:
6� 14o',% err �da�
First
Town li4kr§e:
�a` ,ev�D(., �`�
i
Tax Map #
ZS'1'
Map Block Lot(s)
Well Owner:
Name:
Alamo
Address:
Bj-0,j RoaJ t Arwiv,7k, All,
Use of Well:
Residential
_Public Supply
Air cond /heat pump _Irrigation
1- Primary
Business
Farm
Test/monitoring —Other(specify)
2- Secondary
Industrial
Institutional
Standby
Drillina Eauioment
Rotary Cable percussion Compressed air percussion —Other(specify)
Well Type _Screened _Open end casing JL Open hole in bedrock _Other
Total Length 60 ft. Materials: Steel Plastic Other
Casing Details Length below grade�b ?" Joints: Welded Threaded Other
Diameter _in. Seal: Cement grout Bentonite Other
Weight per foot lb /ft Drive shoe: X Yes _No ILi ner: _Yes No
Diameter (in) ISlot Size Length (ft) IDeptto Screen (ft) IDevel oped?
If yield was tested
at different depths
during drilling
list:
Gallons Per Minute
Pump Type(,
Depth 19s
Voltage 2 0
Tank Tvoe X-TI
NOTE: Exact Location of well with distances to at least two permanent landmarks to be provided
age Tank Information
Capacity 10
Model D! J0S
HP Z
Volume %e,
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Rev. 3/06
Screen Details
First
_Yes _No
Hours
Second
Well Yield Test
_Bailed _Pumped Compressed Air
Hours (,o_
Yield gpm
Depth Date
Measure from and surface-static (specify ft
Q
During yield test ft
2,0S
Dept o completed well n ft.
2D5__
- --
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.Surfav,-
. -_. -- ---------
--'- -- - --- ._._.. - -•
- - - - - -- ----- -_. -..
._--- bg. ..------- •----- --- •-- _. - -- - --
6` - a
If yield was tested
at different depths
during drilling
list:
Gallons Per Minute
Pump Type(,
Depth 19s
Voltage 2 0
Tank Tvoe X-TI
NOTE: Exact Location of well with distances to at least two permanent landmarks to be provided
age Tank Information
Capacity 10
Model D! J0S
HP Z
Volume %e,
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
Rev. 3/06
MOLINARI'' M.S.N.
BRUCE K JOLEY: LOR1rTTA . RN., .
Public Health Dlriclor y� Q� Auocwr. Pablk Health' Director.
W Dirt "ctor q/ Patlsru Se rvk4r ' < ..
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
EaMamcotcl HWtb (914) 271- 6130 Fax (914) 271.7921
Nurclol S4rrlca (914) 271.6551 . WIC (914) 271.6671 .Fie (914) 271.6015 .
E,rty'rtervio86o'(914)171'• 6014 Prwbwl (914)2714M Pa (914)171'• 6641 -
E911 ADDRESS VERIFICATION FORM
OWNERS NAME:
TAX MAP NUMBER:
E911 ADDRESS:
TOWN:
AUTHORIZED-TOWN OFFICIAL;
��►�Gj e lee,
(Signature)
DATE::.
The - Putnam County Department off Health will not issue a Certificaw of.
Construction Compliance unless the above form is completed; i.e.; a legal--E911
address is assigned by an authorized town official. This form is to be submitted
With the application for a Certificate of Construction Compliance..
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF. ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF S013SURFACE SEWAGE TREATMENT SYSTEM
Gi 32- r
Owner or Purch r of Building Tax Map Block Lot
Q I movie
Building Constructed by Town/Village
- 1 UDC r '11"'tV�
Location - Street
J
Building Type.'
Subdivision Name
Subdivision Lot #
I represent that I.. am wholly and cbmpletely' responsible for the location, workmanship, material,
constrixtiorr and�dfain "age of the sewageireatment system serving tlie'above- described property, and
that is has been constructed as shown on the approved plan or approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition..
any 'part-Df said stein coff9ructed by � me which fails to operate fora period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system, .except where the failure to
operate properly is caused by the.willful or negligent act of the 6ccupant of the building utilizing the
The undersigned further agrees to accept as conclusive -the determination of the Public Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of the building utilizing: the
system.
Dated: Month Fe, Day ` Year . cx8 Signature: '
Title:" «.� le r - --
Tr
Geneial Contractor (Ibwner) - signature
Corporation Name (if corporation)
Address: A /k , pr j 4--m
State N . Zip 12—
,
Corporation Name (if corporation)
Address: , U c _D; i v;�ti
State Zi
a—... P _t 3
Form GS -97
AQUA ENVIRONMENTAL LAB
56 Church Hill Road • Newtown, CT 06470 • (203) 270 -9973
Report of Analysis
Name: Ross Alan Sample ID #: 88495
27 Thornwood Rd Sample Type: Drinking Water
Armonk, NY 10504 Sampler: RA
Sample Date: 5/13/2008 11:45 AM
Receipt Date: 5/13/2008 12:30 PM
Report Date: 5/30/2008
Sample Site: .54 Homer Drive, Brewster, NY
Parameter
Biological
Coliform Bacteria
e Coli Bacteria
i Inorganic Compounds
Chlorine, residual
Sample Result
absent
absent
ND
Units
none
none
mg/L
- --
Limits Method
- -- j -
0 SM9223B
- -0 SM9223B
-+
No Limit Set 4500CLG
-- - - - - -- - - - -- - - - - --
MDL
I -
0
I 0
! 0.05
Analysis Date
5/14/2008
5/14/2008
5/14/20.G8.
Metals
----
�
-
Copper
0.03
mg/L
1.3 ! .200.7
0.01
5/13/2008
i Iron
0.18
mg/L
1 0.3 i 200.7
j 0.01
5/13/2008
I,
Lead
0.021 *
mg/L
0 -015 200.9
! 0.001
5/15/2008
Manganese
0.01
mg/L
0.05 200.7
0.01
5/13/2008
Minerals
I' Chloride- -
201.2--- -°
mg/L
I 250 - 300.0 " !-
5
5/14/2008
Hardness
263
mg/L
No Limit Set 200.7
5
5/13/2008
Sodium
74.0 *
mg/L
28 200.7
1;
5/13/2008
Sulfate
Nutrient
19.3
mg/L
250 300.0
I
2
5/13/2008
><"tra
,.5
mgt
1^ 30C'.0
1
5/13!2008
Nitrite as N
ND
mg/L
1 I 300.0 1
0.1
5/13/2008
_ -_-
- - -
Physical
Color
10
Cu
15 110.2a
0
5/14/2008
Odor
0
0 -5 Scale
2 140.1
0
5/14/2008
PH
Turbidity
6.6
3.0
SU
NTU
6.4-10 4500HB
5 _ J 180.1
0
0.05
5/14/2008
5/14/2008
Comments: Based on the bacteriological examination, this water was safe for drinking purposes at the ND = Not Detected
time the samected. Above specified Limit
Report Approved by: CL CT Lic PH -0787 NY Lic 11706
Lab Director ?7
Analytical results relate to the samples as received at the laboratory. Report shall not be reproduced except in
its entirety without written approval from the laboratory.
Page 1 of 1
AQUA ENVIRONMENTAL LAB
56 Church Hill Road • Newtown, CT 06470 • (203) 270 -9973
Report of Analysis
Name:
Ross Allen Sample IDth 88715
27 Thornewood Rd Sample Type: Drinking Water
Armonk, NY 10509 Sampler: RA
Sample Date:
5/20/2008 11:30 AM
Receipt Date:
5/20/2008 12:05 PM
Report Date:
5/22/2008
Sample Site:
54 Homer Dr, Brewster NY
_ND = Not Detected
' — Above Specified Limit
Report Approved ..ras...... CT Lic PH -0787 NY Lic 11706
Lab Direct Ur
Analytical results relate to the samples as received at the laboratory. Report shall not be reproduced except in
its entirety without written approval from the laboratory.
Page 1 of 1
Parameter
Sample Result
Units
Limits
Method
MDL
Analysis Date
Metals
Lead
0.003
mg/1-
0.015
200.9
0.001
5/20/2008
_ND = Not Detected
' — Above Specified Limit
Report Approved ..ras...... CT Lic PH -0787 NY Lic 11706
Lab Direct Ur
Analytical results relate to the samples as received at the laboratory. Report shall not be reproduced except in
its entirety without written approval from the laboratory.
Page 1 of 1
E
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f
DIMENSION CHART
(in feet)
S 220
.UI WALL "
0
i
.q
ti E
3.
Number
A
8
1
360.00
28 . 5o
2
45.00
2-7.50
3
5 0. 00
2 5 . 00
4
5 5. 00
25 . 00
5
GO, 00
25 - 00
G
GO . 50
20. 00
73.00
35.00
8
80.50
42. 50
9
88 • 00
50.00
10
95.00
57. 00
11
102.50
04.00
12
IO9.50
71. 50
13
11 Co . 50
78. 50
14
124 .00
8ro. 00
15
151 .00
93. 00
ICo
157.0o
lol.so
17
1560. 50
104, 50
18
134. 00
10 5. 00
19
12-7.00
015. 0O
20
120-00
9 2. 00
21
1 1 3. 00 --
-- 8 5 .: 5-0. -
22
105.00
-7,0). 00
23
5-7. 50
72. 50
24
00.00
GCV . 00
25
62.50
coo . 50
2&
7 C0 . 00
55. 50
2 7
ro9 00
51 .00
2&
0 1 50
47 , 0p
29
54 .50
45-00
S 220
.UI WALL "
0
i
.q
ti E
3.
50-00
57-00
64 . 00
71.50
78. 50
arc. 00 i
9 3. 00
10(.50
104.50
105.00
98. 00
02. 00
85. 50
79, 00
72-50
GG.00
Co O . 50
55. 50
51 .00
q.7 .00
43•�
FX15T. WEl-L1
N - 1'D*-24'50'E
ICo.52'
WELL
°
No
83
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N 64° 45' 20 E
IO. Gtr ,
QJ J.13ox(rYPi
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6l SEPTIG TANS
20
To: PC
Attention:
N
�irL1i�ar G( �hglhrCr�k
Gentlemen: We enclose(/ ) copies of
• B/W Prints O Reproducibles
• Specifications O Memorandum
Description:
Harry W. Nichols Jr., P.E.
P.O. Box 252
Brewster, NY 10509
Tel (845) 855 -9275
Date: '7 - -2-1 —00
Job No.:
ZS, 3 Z I .-6
• Reports
• Copy of letter
Sent Via:
D 90 Messenger
El Your Messenger
Copy to
• Blueprinter
• Hand Delivery
O Tracings
or�
Revision/Date No.
0 First Class Mail 0 Special Delivery
O
Very truly yours,
Harry W. Nic s Jr., P.E.
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health -
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
July 16, 2008
Harry Nichols, P.E.
P.O. Box 252
Brewster, NY 10509
Dear Mr. Nichols:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
Re: Construction Compliance for Gagliardo
Homer Drive
(T) Patterson, TM # 25.32 -1 -5 & 6
This Department is enclosing and returning the well completion report to you for completion of
the "Pump Installer Name and Address" and "Pump Installer PC Certificate # ".
Should you have any questions concerning this matter, please feel free to contact this office.
Respectfully,
MJB:kly
Michael J.
Director of
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
Harry W. Nichols Jr., P.E.
VAV P.O. Box 2.52
22 Brewster, NY 10509
Tel (845) 855 -9275
Date: .7 - H - 09
To: Job No.:
Oc 4 C) o-I - oS`i'
I (J �i�l y �, g 0'a o� Project 1r I d I v t dyC d SSTs C� 4 -(� y L w,
W zr S�3 lid", e
"k �
� oRttention: /k r -t� 1 Jd v d z-i Q-
Ili. I
VC-C- t o r O � I = mil) 4t eCr C �►`� �i St 3 �-
v 1 _
Gentlemen: We enclose (f) copies of
O B/W Prints ❑ Reproducibles a orts O Tracings
O Specifications ❑ Memorandum ❑ Copy of letter ❑
Revision/Date No.
— —G
Description:
Sent Via:
Our Messenger
❑ Blueprinter
O First Class Mail
O Your Messenger ❑ Hand Delivery ❑
Copy to
O Special Delivery
E ruly yours, W. ols Jr., P.E.
i
July 7, 2008
Michael J. Budzinski, P.E.
Director of Engineering
Putnam County Health Department
1 Geneva Road
Brewster, NY 10509
Harry W. Nichols Jr., P.E.
P.O. Box 252
Brewster, NY -10509
Tel (845) 855 -9275
RE: Individual SSTS Compliance — Gagliardo
53 Homer Drive
Patterson, NY
T.M. #25.32 -1 -6
Dear Mr. Budzinski:
Enclosed are the following:
1. Five (5) prints of Drawing S -1, "As -Built SSTS," dated 02- 08 -08.
2. "Certificate of Construction Compliance for Sewage Treatment System,' dated
02- 07 -08.
3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated
02- 09 -08.
4. Laboratory Report, dated 5 -22 -08 and 5- 30 -08.
5. "Well Completion Report," dated 10 -02 -06
6. Application Fee in the amount of $300. payable to Putnam County Health
Department.
7. E-9 11. Address Ven ication Form," dated 02- 06 -08.
If there are any questions concerning the enclosed, please call.
Very truly yours,
Harry W. Nic Jr., P.E.
HWN:his
04- 054.00
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Harry Nichols, P.E.
Patterson Park, Ste 106
2050 Route 22
Brewster, NY 10509
Dear Mr. Nichols:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
May 25, 2007
Re: Field Inspection — Gagliardo
Homer Drive
(1) Patterson, TM # 25.32 -1 -5 & 6
The above referenced separate sewage treatment system can be baclfilled. There are no further
comments to be addressed at this time.
.._. ___..._..... .. __._
-you -h-a Vie- any. LUrther'U�I.�LV ffio-s�-pleasV contact ma CiL `V4✓l L/8 -61✓0 eAt. 2rL61....•�._'.__. ...._ _..._.._. __......_._... ..._- _.___. __...
GDR:kly
Sincerely,
MIN - Z I
Gene D. Reed
SR. Environmental Health Engineering Aide
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Harry Nichols, P.E.
Patterson Park, Ste 106
P.O. Box 252
Brewster, NY 10509
Dear Mr. Nichols:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Re: Field Inspection — Gosselink
Old Milltown Road, (T) Southeast
T.M. # 57: -2 -10
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
May 25, 2007
The above referenced SSTS can be backfilled. The following comments need to be
addressed:
1. A pump test needs to be witnessed by this Department once the electrical inspection has
_.beer} -completed and - notification of such has 0-cerrsub111itted to this Department -
If you have any further questions, please contact me at (845) 278 -6130 ext. 2261.
GDR:kly
Sincerely,
Gene D. Reed
Senior Environmental Engineering Aide
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
PUTNAM COUNTY DEPARTMENT OF HEALTH �
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ��GN' s o/V/-
y
FINAL SITE INSPECTION
Date: - IMP P
Inspected by: `
_... __ --
Street Locatio Own - _ _ -_ - -- -
V� er Cry ��
Town Ck-�o/V Permit # - </— 0 '�
TM # S. 3 2 - / - Subdivision Lot.*
1. Sewage System Area
a. STS area located as per approved plans .......... .. ................
b.. Fill section - date of placement
3:1 barrier Lgth. Width . Avg.Dpth
c. Natural soil not stripped.. .....................
.............................
d. Stone, brush, etc., greatr than 15' from STS area..........
e. 1 00' from water course / wetlands ...... ...............................
IL Sewage System
a. Septic tank size - 1,000 .......... 1, 250 ......... other ................
b. 'S eptic'tank installed level ................ ...............................
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
1. All outlets at same elevation -water tested .... :.............
2. Protected below frost .................. ...............................
3. Muumum 2 ft. Original soil between box & trenches
e. Junction Bog - properly set .........................................
6. renc ies
1. Length required %'Length installed ?�
2. Distance to watercourse measured Ft..........
3. Installed according to plan ......... ...............................
4. Slope of trench acceptable 1/16 - 1/32" /foot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface ..................
7. Room allowed for expansion, 100 % .........................
8. Size of gravel 3/4 - 11/2" diameter clean ...................:
9. Depth of gravel in trench 12" minimum ...................
10•- Pipe ends-capped—'.-
ncis_ca n?d-._.:.......... ................. ..................:........._:.
g. Pumu or Dosedp §ystems
1. Size of pump chamber ................. ...............................
2. Overflow tarik ............................. ...............................
3. Alarm, visual/ audio ................................................. ..:
4. Pump easily accessible, manhole to grade .................
5. First box baffled .......................... ...............................
6. Cyycle witnessed by H.D.estimated flow /cycle...........
IIL House/Buildiii
a. use located per approved plans.......... .. ,..
b. Number of bedrooms ............................ ... t...i- '�.........
IV. Well
Well located as per approved plans . ......:........................
b. Distance from STS area measured s- oo • - ft...........
c. Casing. 18" above grade ................ ............. ...................
d. Surface drainage around well acceptable .......................
V. Overall Workmanship .
a. Boxes properly grouted ................... ...............................
b. All pipes partially backfilled ........... ...............................
C. All pipes flush with inside of box.
d. Backfll material contains stones <4" diameter............
e. Curtain drain & standpipes installed according to plan..
f. Curtain drain outfall protected & dir.to exist watercourse
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate ..............................
i. Erosion control provided .......... ...............................
Rev. 12/02
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Harry Nichols, P.E.
Patterson Park, Ste 106
2050 Route 22
Brewster, NY 10509
Dear Mr. Nichols:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Re: Field Inspection
Homer Drive, (T) Patterson
T.M. # 25.32 -1 -5 & 6 .
The following comments must be corrected in the field.
ROBERT J. BONDI
County Executive
ROBERT MORRIS, PE
Director of Environmental Health
January 3, 2007
1. Large rocks in SSTS area to be removed.
2. Silt fence on downside of house behind dirt pile must be erected and maintained as
- -per - approve u-1 _ 14��
3. C.I. pipe and septic tank need to be installed.
S' D
Please contact this Department upon completion of the above comments and prior to backfilling.
JD:kly
Si e l y,
r�
J S h Digit
nvironmental Engineering Aide
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention[Preschool (845) 278-6014 Fax(845)278 -6648
JAN -02 -2007 12:08 PM HARRY W NICHOLS 914 279 4567 P.01
PUTNAM COUNTY DEPARTMENT OF WEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
RRQUEST FOR FINAL INSPECTION For: Fill
Date: 1 12 /0:2 Trenches
PCHD Cbnsttucdon Permit #
Located: P`' �j
2inft ~ �c tee... - ('1'} i Lea &Y -re ti
Owner /Applicant Name: ?%& J'� Q c dg ie od d _ TM 2-7, 3 2 Block . I Lot S" 9 4
Formerly: Subdivision Name: r-
Subdivision Lot #
Is system fill completed?
Is system complete?
Is system constructed as per plans?
Is well drilled? a
Is well located as per plans?
Are erosion control measures in place?
Date:
Date:
Date:
I certify that the system(s), as listed, at the above premises has been constructed and I have inspected
and verified their completion in accordance with the issued PCHD Construction Permit and
approved plans and the Staudards, Rules and Regulations of the Putnam County Department of
Health.
- _ 7
De p Professional
Address: 5' Lic. # (?� Ir
Comments:
FOR: C1 ADAM
(N )
Form FIR-99
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Harry W. Nichols Jr.; P.E.
Patterson Park, -Suite 106
2050 Route 22
Brewster, NY.10509_._
Telephone (845) 2794003
Fax(845)279 -4567
Date:
To: Job No.: P
0
Project
LL
Attention:. E
5
Gentlemen: We enclose ( copies of
VB/W Prints Reproducibles Reports Tracings
Specifications Memorandum Copy of letter
Description: Revision/Date No.
C
e-
S Ts'
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'r r PCAVL h lS y.. t
< 44 G
al
Sent Via:
4/0"ur Messenger
Your Messenger
Copy to
Blueprinter
Hand Delivery
La
First Class Mail
Special Delivery
Ve Vuly yours,
arty W. Ni o1s Jr.., P.E.
PUTNAM COUNTY DEPARTMENT OF HEALTH
SION OF ENVIRONMENTAL HEALTH SERVICE
p- -- -- -.. - -
�CO- �)- NSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # ( t— O�
Located at Town or age
Subdivision narnego5isMaJe, Subd. Lot # Tax Map Z5',3'2..Block Lot S �-
Date Subdivision Approved & / J-7 /0' — Renewal Revision
Owner /Applicant Name &A g i; wyjG Date of Previous Approval
Mailing Address /�-JI �,� `��rr��a�. /� �� Zip
w
Amount of Fee Enclosed 5 4-dd f
Building Type R.c.S 1 zh + << Lot Area D,-J'-j S No. of Bedrooms Design Flow GPD (a 0 y
Fill Section Only Depth Volume
PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of JC10I� gallon septic tank and
Other Requirements:
To be constructed by T 13 P Address
Water Supply: Public Supply From
Address
3 -7
fl oil 1V
— -- or: �/ - Prwate Supply L�ril?ed by -Address_
I
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment system 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
R.A. Date 4bld�
License # S`� 12d
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 n onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new pe pproved discharg o domestic sanitary sewage only. /
By: Title: ( Date:
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 PCHD Permit #
Well Location:
Street Address: TownN" age Tax Grid #
14e," 3ZBlock ' 5 �¢
er to )-I v e___ g t ors CA1 Map 2-C, Lot(s)
Well Owner:
Name: f
Address.
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 � gpm # People Served 1-5- Est. of Daily Usage CHUG gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
t/New Supply (new dwelling) Deepen Existing Well
Detailed Reason
�c
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No _jam
Is well located in a realty subdivision? ...�.. �..1 ..... ........................... Yes ` No
,... ..
G
Name of subdivision k0 S /¢ � «z ro�4 Lot No. _ i(
Water Well Contractor: Address:
Is Public Water Supply available to site? ................................: ............................... Yes No
Name of Public Water Supply: A1 /g- Town/Village -�
Distance to property from nearest water main:
Proposed well location & sources of contaminatio be provided on separate eet/ an.
/0�
-.°. 4t J-9 A plicait Si naturc: . !� '° &a
Duw• f 1}Y g �
LFA
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED _FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. y revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water we driller c ified by Putnam
County. Date of Issue J o/1 Permit Issuin 9k11
Date of Expiration ' d
Permit is Non - Transfer able
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
SHERLITA AMLER; MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Harry Nichols, P.E.
Patterson Park, Ste 106
2050 Route 22
Brewster, NY 10509
Dear Mr. Nichols:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
October 17, 2005
Re: Proposed SSTS: Gagliardo
Allen Road, Lot # 4
(T) Patterson, TM # 25.32 -1 -5 & 6
Review of plans and other supporting documents submitted at this time relative to the above regarded
project has been completed. Comments are offered as follows:
1. The drop boxes are to be shown, a minimum of 20 feet from the house foundation. Please clearly
dimension the 20 feet setback on the plan.
2. Please be advised that if the house plans are changed, revised house and SSTS plans must be
submitted.
3. Trenches are shown within 10 feet of the property lines.
4. Plan is to note house location to be surveyed located prior to construction.
5. Please check trench lengths and primary area expansion trench
6. All trench lengths must be noted on the plan.
Upon receipt of a submission, revised to reflect the above comments, this application will be considered
further.
RM:kly
Ve tru your
Robert Morris, P.E.
Senior Public Health Engineer
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
October 20, 2005
Mr. Robert Morris, P.E.
Putnam County Health Department
One Geneva Road
Brewster, New York 10509
Re: Proposed SSTS: Gagliardo
Homer Road
Patterson, N.Y.
T.M. #25.32 -1 -5 & 6
Dear Robert:
Harry W. Nichols Jr., P.E.
Patterson Park - Suite 106
2050 Route 22
Brewster, NY 10509
Tel: (845) 279 -4003
.Fax: (845) 2794567
Email: hnengineer@aol.com
In response to your review letter dated October 17, 2005, we note the following:
1. Setback dimension from foundation to drop boxes clarified on plan.
2. Comment noted.
3. Trenches revised to be minimum of 10' from property line.
4. Note added to plan requiring surveyor to stake house location.
5. Trench lengths in primary and expansion areas checked.
6. Length of all trenches noted on plan.
Reflection the above, we are enclosing five (5) prints of the following:
• SS -1, "Proposed SSTS," revised 10- 20 -05.
Kindly continue with your review and issuance of the Construction Permit.
Very y yours,
Harry W. Nich is Jr., P.E.
HWN :jm
04- 054.000
PUTNAM COUNTY .DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
RE: Property of
Located at
LETTER OF AUTHORIZATION
Lem l Gr 04
T/W J_�1-_ r- soh Tax Map #
Subdivision of /I_.0
o- ,v c
ZS, 3 2 Block
Lot S
Subdivision Lot # Filed Map # Date Filed 8/1,5105-
Gentlemen:
This letter is to authorize / I /
a duly licensed Professional Engineer or Registered Ar itect to apply for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in. accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater tretment and/or water supply. systems in
conformity with the provisions of Article 145.and/or 147 of the Education Law, the Public Health
La-- -
w; and the Putnam County Sanitary Code. . -
r
Countersigne
P.E., R.A., #
Mailing Address ;L05'0
h
State Zip / O SU
Very truAdProperty) Signed:
Mailing Address: 1 f 0.J
State ./l% y Zip I ZS-C,_
Telephone': t5'- —7'7 - -100 3 Telephone:
Form LA -97
BRUCE R- FOLEY
Public- Health... Director — – - - --
LORETTA MOLINARI R.N., M.S.N.
- Associate Pubic Nealrh Director
Director oj. Pallenl Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
ATTENTION: ❑ ADAM STIEBELING GENE REED
All information below must be L14 completed prior to any scheduling. DATE:
ENGINEER OR FIRIti1: CJ' Ur., iqjp PHONE #:
REASON: '
DEEPS: - PERCS: g1C PUIVIP TEST: ❑
ROAD /STREET: C�r D-12 -))A _
TOWN: — a / ( �r�� TAX MAP #: ;2- 5J'3 2- _1 5!E4?
SUBDIVISION: LOTH:
OWNER:
� :: 1: 1 ►1 : ►11 9 ►1 �i�[tZ1 I I� 1
YES
NO
o.
o
.36-
o
er
o
16
Proposed SSTS-within the drainage basin of `Vest Branch_or- B.oyds Corner.Reseevoirs. -
Prq;posed:SSTS- v:i thin -500- feet -of -a- rose► -roir reserwuir-srern`or- copfrollake:�
Proposed SSTS within 200 feet of a watercourse or a DEC wetland..
Proposed S -STS design flow greater than 1000 gallons /day-or SPDES Permit required.
Proposed SSTS for a Commerical Project.
It is the' responsibility of the design professional to provide the above information prior to soil testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the
response. If you answered y= to any of the questions, NYCDEP must witness the soil testing. This
Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design
Professional and NYCDEP.
If a project has been determined to be Delegated based on the above response and then subsequent
information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility
of the design professional to'schedule re- witnessing of the soil testing with NYCDEP.
%% FOR COU&TY USE ONLY `
DATE: �/�3 ® 3w 3a TIME: /
COMMENTS:
(FIELDTEST)
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM /
Owner L l�,ti '46 Z7�0 Address W,5:O4a-IZ -p2z l V4
Located at (Street) Tax Map 1C, 32Block Lot 5- G
(indicate nearest cross street)
Municipality �'/�T7" 'i7so�% Watershed .L%/�57 1�1z/�IJG I-f
SOIL PERCOLATION TEST DATA
Date of Pre - soaking _ 7 Z 13 l a:J1 Date of Percolation Test _�YfT�Z
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
u_
3
2
137-
3
' ��- '0
141
3
J// %
4
5
2
- 1�
3 c�
,Z - Z6
/5-
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
. TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. _ - �. HOLE NO.
G.L.
0.5'
1.0'
1.51 .
2.0'
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
6.0' ,
6.5'
7.0'
7.5'
8.0' :b2
8.5'
9.0'
- - 9.5'... _- - - -- - -- -
10.0'
4-o 1/
Indicate level at which groundwater is encountered s-/ o N 1�-
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: ez L2� ; L �l %G .. Date
Design Professional Name:
Address:
Signature:
Design Prof6ssional's Seal
2
4
'PUTNAM COUNTY DEPARTMENT OF HEALTH
M '
DIVISION OF ENVIRONMENTAL- HEALTH. SERVICES
INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM
SECTION A. GENERAL INFORMATION
Name of Project
Site Location
�,t,SCounty Pu�.i�ll�/�/I
Building construction begun ® Extent
Is property within NYC Watershed ? ................. EYes
0 No
SECTION B. TOPOGRAPHY (Please check all appropriat boxes)
1. F--J Billy- a Rolling J7 Steep slope Gentle.slope Flat
2. a Evidence of wetlands Low area subject to flooding a Bodies of water
Drainage ditches Rock outcrops j- 4,`e a it S
3. Property. lines or corners evident....��.T<t?�fw1� ......... Ye s No
4. Do water courses exist on or adjoin the property? ............................ Yes No
5. Will these affect the design of the sewage system facilities ?............ 0 Yes No
6. Do watershed regulations apply in this development ? .......................
czlly es a No
7 Will.extensive grading be necessary? ................. ............................... Yes No
iV fili be necessary for SST -? : ............................................... .� Yes � No'
8. <<'ill c���zs e
9. Do filled areas exist within the SSTS area?..* ......... .................... ...... Yes No
If yes, what is the condition of the fill?
SECTION C. SOIL OBSE ATIONS
10. appearance of soil: Sand 0 Gravel Loam lay Hardpan a Mixture
11. Observed from: a Borings Bank cut Backhoe excavations
12.
13
14
Soil borings /excavations observed by JA t on -7 d
Depth to groundwater N O on
Depth to mottling ' /V D AI g on
15. Are test holes representative of primary & reserve areas ...................... :..............
16. Soil percolation tests made by r7 t DL �j �, �� on
17. Soil percolation tests witnessed by % �,� t'> p.L �, ��, on
-ors
SECTION D (on back)
Form ST -1
SECTION D. DRAINAGE
18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Q Yes N
19. Will groundwater or surface drainage require special consideration? ...................... Fl Yes N
20. Will gullies, ditches, etc,, be filled and watercourses be relocated? ............ .I.............. Yes No
SECTION E. REMARKS
21. If a common water supply is proposed; has an inspection been made of the
existing or proposed source and facilities? ................................ .....................:......... F-1 Yes �No
Inspection data
22. Do adjacent wells and /or sewage systems exist? ........ .:.��..�,Z /. ye �> .............. Yes No
23. Additional comments
�
24. Site observer /inspector and title ,Gip. t5d
25. Date(s) of ;observation(s)inspection(s) -7 /Z /67
TEST PIT PROFILES
Hole # Lot # Hole # Lot #
Hole # Lot #
Depth to water Depth to water
_ Depth to water
Depth to mottling Depth to. mottling
Depth to rocklimp: Depth to rock/imp..
Depth to rock/imp.
G.L. G.L.
G.L.
.
a
0.5 .0.5
0.5
1.0 1.0
1.0
2.0 2.0
2.0
3.0, 3.0
3.0'
4.0 4.0
4.0
5.0 5.0 .
5.0
6.0 6.0
6.0
7.0 7.0
7.0
8.0 8.0
8.0
9.0 9.0
9.0 /
10.0 10.0
10.0 j
PUTNAM..:C:�?:UNT: DEPARTMENT O IEALTI
:
DIVISION OF ENVIRONMENTAL HEALTH SERVICES - -:
DESIGN DATA SHEET - SUBSURFACE SEWAGE' TREATMENT SYSTEM
Owner': P�#'�� GunllctVJ6 Address- AI -I-VN
Located at (Street) Tax Mans.,az Block_i_ Lot• -5_ K
_ ...R..::. .
(indicate nearesteross street)
Municipality. Watershed . EAS% Z&A j e- t4
SOIL. PERCOLATION TEST DATA
Date of Pm-soaking, ` '07- i -is _ n¢ . Date of Percolation Test 4'- 0 4
.. ...vv:..x.:•:rv••r. -.
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NOTES: T. Tests t0' be repeated at Same aepul anal apprv]cuiiatc,y c�uni Yciwiuuyii iuw� cud vvwuicu a� u,,,,. .
miri >for - 3Q:mininch; s Z min for l -6Q minrnch) All_data t� bek percolation lest hole. (t i
submitted for review.. `
rtP�l ' 2. Depth measurerpents to be.riiade.from-top of hole;
Form DD -97
TEST PIT DATA
2
D exe% s, CJ, 4'- D'
8.0'..
83..
9.0'
10.0'...
Indicate:-level at which° Mgr .4undwatez: -is,encountered::.- .
Indicate levcT at which.mottling is observed e.-
Indicate•level to which water leveF- rises-after:being encountered
Deep hole observations made by: Date. -cq
vesign -rrotessional Name:.
Address:
� ®lLdLI
,C
DesigB Pro.f'essiOnal's Seal
2.0'
2.5'
--� :
3.5'r
A n1
2
D exe% s, CJ, 4'- D'
8.0'..
83..
9.0'
10.0'...
Indicate:-level at which° Mgr .4undwatez: -is,encountered::.- .
Indicate levcT at which.mottling is observed e.-
Indicate•level to which water leveF- rises-after:being encountered
Deep hole observations made by: Date. -cq
vesign -rrotessional Name:.
Address:
� ®lLdLI
,C
DesigB Pro.f'essiOnal's Seal
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH. SERVICES
APPLICATION FOR APPROVAL OF PLANS FOR
A WASTEWATER T.REATMEN SYSTEM
1. Name and address of applicant:
411*�VTC.41 _/V_1./
2. Name 'of project: PI'a -5 3. L . ocation T/,V'
POS4 S,5 _&_1 eY'so L,
4. Design Professional: �X Al 11 "5. Address:.
L Din I V
6. Drainage Basin:
7. Type of Pro-Ject:
v,'—Private/Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building. Realty Subdivision Other (specify)
8. Is this project subject to State Environmental Quality Review -(SEQk)?
Type Status (check one) ....................................................... Type I Exempt
Type.II Unlisted
9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... '-1V6
.10. Has'DEIS been completed and found acceptable by'Lead"jkgen*cy? ............... -/J/,+
11. Name of Lead Agency AJ
12. Is this project in; an area under the control of local planning, zoning, or other.
officials, ordinances? ............................................ .......
13. If so, have plans bee'n submitted-to such authorities? ...
..............................
14. Has preliminary approval been granted by such authorities? Date granted:
15. Type; of Sewage Treatment System Discharge ................. surface water '' !/groundwater
—
16. If surface water discharge, what is the stream class. designation? ....................
17. Waters index number (surface) ........................... ....................................
I& Is project located near public water supply system? ........ ................. ; ........... AV)
19. If yes, name .of water.. supply Distance to water. supply
20. Is project site near a public sewage collection or treatment system? ................
21. Name of sewage system Distance to sewage system
22. Date test holes observed '7 .23.. Name of Health Inspector.
24. Project design flow (gallons per day) ................................................................ 6e_00 -
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?... ./Vc)
26. Has SPDES Application been submitted to local DEC office? ..........................
Torm PC-97
2
-27. Is any portion of this project located Within a desigh'ated Town or State wetland?_ _J)d
28. Wetlands ID Number............: ....... e ............................................................
29. Is Wetlands Permit required? ..............................................................................
NOTE:All -applications _for review And rovalpf-o'.new-SSTS-tobeloca.f-A-",.�-.,� e atershe&sh,,ell
Vp
be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval. by the Department. Projects within -the watershed may also
require DEP review and approval of other,aspects of . a proje6t, such as stormwater plans or the creation of
impervious, surfaces, and the project applicant should obtain the appropriate forms for such activities from
DEP and submit those forms to DEP for review and approval.
If the Application is signed by a person -other than the applicant shown in Item I.,the appli
cation must
be accompanied by a Letter of Authorization (Form LA-97). Failure to 'omplyWith this provision
may be grounds for the rejection of any submission.
I hereby affirm., under penalty ofperjury, 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 t6' Section 2 0.45 of th e. Penal Law.
SIGNATURES& OFFICIAL TITLES.-
Mailing Address: ......................................
Has application been made to Town or Local DEC office? ................................ .
1CR AFL.
36.
Does project require a DEC Stream Disturbance Permit? ..................................
31.
Is or -was project site used for agricultural activity involving application of
rt
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfillingi sludge application or industrial activity? ............................. Yes/N 0
.
32.
Is project located within 1,000 feet of existing or abandoned landfill,
Co.
salt stockpile, landfill,
hazardous waste site ill, sludge disposal site or any
other potentially known source of contamina tion? ............................... Yds/No
'DESCRIBE:
33.
Is there a local master plan. on file with the Town orVillagc?..'.. ................... I.
34.
Are community water and/or sewer facilities planned to be developed within
15 .years in or adjacent to project site? ................................................................
35.
Are any sewage treatment area's in excess-6f 15% slope? ................................... ..
hi
36.
'52
Tax Map ID Number ............................................... ........... Map _�Ijs /-Block__L_ Lot
37.
Approved plans are to be.returnedto Applicant L-`besign'Pro'fessional
NOTE:All -applications _for review And rovalpf-o'.new-SSTS-tobeloca.f-A-",.�-.,� e atershe&sh,,ell
Vp
be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval. by the Department. Projects within -the watershed may also
require DEP review and approval of other,aspects of . a proje6t, such as stormwater plans or the creation of
impervious, surfaces, and the project applicant should obtain the appropriate forms for such activities from
DEP and submit those forms to DEP for review and approval.
If the Application is signed by a person -other than the applicant shown in Item I.,the appli
cation must
be accompanied by a Letter of Authorization (Form LA-97). Failure to 'omplyWith this provision
may be grounds for the rejection of any submission.
I hereby affirm., under penalty ofperjury, 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 t6' Section 2 0.45 of th e. Penal Law.
SIGNATURES& OFFICIAL TITLES.-
Mailing Address: ......................................
14164 (9/95) —Text 12
PROJECT I.D. NUMBER
617.20
Appendix C
- -- State- Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART 1— PROJECT INFORMATION (To be completed by Applicant or Protect sponsor)
SEOR
1. APPLICANT 1SPON OR p _T
2. PROJECT NAME
�m ss TS
r�
3. PROJECT LOCATION:
Pa *.Pjy Pd �k
Municlpallty v County w
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map)
Z�r
5. IS PROP99ED ACTION:
ew ❑ Expansion ❑ Modificationlalteration
6. DESCRIBE PROJECT BRIEFLY:
Ty
7. AMOUNT OF LAND AFFECTED:
�� �4 r, �%�
Initially acres Ultimately acres
6. WILL P
,SO POSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS?
es []No If No, describe briefly
9. WHAT PRESENT LAND USE IN VICINITY OF PROJECT?
Residential 0 Industrial ❑ Commercial ❑ Agriculture Park/Forest/Open space
❑ Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE 0 LOCAL)?
Yes ❑ No If yes, list agency(s) and permitlapprovals
14. DOES ANY ASPE F THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑Yes No If yes, list agency name and permit/approval
12. AS A RESULT OF PR OSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes o.
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Appilcant/sponsor a e: �/ Date:
v
Signature: O.L. J.-
(/ "
If the action is in the Coastal Area, and you are a. state agency, complete the .
Coastal Assessment Form before proceeding with this assessment
OVER
1
PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate'the review process and use the FULL EAF.
❑ Yes ❑ No
B. WILL ACTION RECEIVE - COORDINATED REVIEW AS PROVIDED -FOR UNLISTED ACTIONS IN -6 NYCRR, PART 617.6? — If No;`a' nega`ti`ve declaration
may be superseded by another involved agency.
❑ Yes ❑ No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
•.,
rn
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? kot 'briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain brie ly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain brr fly.
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly.
C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly.
D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA?
❑ Yes ❑ No `
.E-.IS..THEBE,.O.R.IS_T. HERE.. LIKELY.. TO_ BE — CONTROVERSY _RE)eATED_TO_QOTENTJAL _ADVERSE- EN\IlliO.NMENTAL IMP .AGI$.______ —_
❑ Yes ❑ No If Yes, explain briefly
PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant.
Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring,. (c) duration; (d)
irreversibility; (e) geographic scope; and (f) magnitude: If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If
question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action
on the environmental characteristics of the CEA.
❑ 'Check this box if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration.
❑ Check this. box if you have determined,. based on the information and analysis above and any supporting
documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts
AND provide on attachments as necessary, the, reasons supporting this determination:
Print or Type Name of Responsible 'Officer in Lea Agency
Signature of Responsible Officer in Lead Agency
2
Title of Responsible Officer
Signature of Preparer (If dif erent from responsible officer)
_ SHERLITA AMLER,MD,.MS, FAAP.__
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Harry Nichols, P.E.
Patterson Park, Ste 106
2050 Route 22
Brewster, NY 10509
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
September 29, 2005
Re: Proposed SSTS: Gagliardo
Homer Drive Lane, Lot X
(T) Patterson, TM # 25.32 -1 -5 & 6
_ROBERT..J.- BONDI.
County Executive
Dear Mr. Nichols:
.Review of plans and other supporting documents submitted at this time relative to the above regarded
project has been completed. Comments are offered as follows:
1. Neighbor notification is required. Current codes require a site ma showing all lots, names and
g q q p
tax map 'numbers.
2. All existing and proposed wells and SSTS's within 200 feet of the property line are to be shown. /
3. The system must be equal distribution or a drop box system "splitting" the system into four is not ,t/
permissible, unless the effluent is pumped or dosed.
4. Two feet of solid trench is to be provided prior to the perforated pipe.
5. The D -Box must be -a minimum of 20 feet from the dwell' g: -
-- - .__ - _- _..._.— _ "e - --- - ,--- -- ,-- ._ - -__ .-__
6. All drop boxes must be 20 feet from the dwelling.
7. All trench lengths, including expansion, are to be noted and the two foot solid pipe is to be
shown.
8. Footing/gutter drains — How will the footing drain discharge to daylight at the approximate
elevation of 601? Footing drain evaluation is to be noted.
9. All lot line setbacks are to be shown.
10. Minimum distance from the proposed well to the property line is 15 feet.
11. House, well and SSTS are to be staked by a licensed surveyor prior to construction. This is to be
noted on the plan.
12. Erosion control should never be installed perpendicular to the contours. Revise as warranted.
The construction of this sewage disposal system may be subject to local wetlands regulations. You
should contact local wetlands officials in this regard.
Upon receipt of a submission, revised to reflect the above comments, this application will be considered
further.
Ve ly yours,
,�IA.//�` gqW
Robert \{ii %%Morris, P.E.
Senior Public Health Engineer
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
RM'kly Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION-PERMIT'------
NAME OF OWNER: STREET LOCATION:
REVIEWED BY: RM, OP, AS, SRDATE:
Y .'.. Jq DOCUMENTS
(f )PERMIT APPLICATION
/L
WELL PERMIT OR PWS LETTER
C_f_)UPC-97
LETTER OF AUTHORIZATION
(_)(_)DESIGN DATA SHEET (DDS)
CORPORATE RESOLUTION
( _)SHORT EAF
7 � PLANS -THREE SETS
HOUSE PLANS - TWO SETS
(__)VARIANCE REQUEST
SUBDIVISION
GAL SUBDIVISION'
( /}SUBDIVISION APPROVAL CHECKED
C RATE
, REQUIRED DEPTH
.TAIN DRAIN REQUIRED
GENERAL
ATED IN NYC WATERSHED
NS SUBMITTED TO DEP
EGATED TO PCHD
APPROVAL, IF REQ'D
P TEST HOLES OBSERVED
CS TO BE WITNESSED
APPROVAL SSDS ADJ, LOTS
'LANDS (TOWN/DEC PERMIT REQ'D ?)
�D' 5 &PERMIT SAME
1969 NEIGHBOR OTIFICATION
)100 x.R. FLOOD ELEVATION W /1200' _-
)SOIL TESTING LOTS >10 YEARS OLD
REQUIRED DETAILS ON PLANS
)jS WAGE SYSTEM PLAN - (NORTH ARROW)
SDS HYDRAULIC PROFILE
)GRAVITY FLOW
:CONSTRUCTION NOTES 1 -15
)DESIGN DATA: PERC & DEEP RESULTS
);'CONTOURS EXLSTING & PROPOSED
DRVWAY UOPES, AIN
DRAINS OOTING /G&ER/CUR
)USDA SOIL TYPE BOUNDARIES
)TITLE BLOCK; OWNERS NAME ADDRESS
_TM #, PE/RA; NAME, ADDRESS, PHONE#
)DATE OF DRAWING/REVISION .
)DATUM REFERENCE
)``LOCATION OF WATERCOURSES, PONDS
LAKES,WETLANDS WiI'ffiN 200' OF P.L.
PROPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS
)WELLS & SSDS'S W/IN 200' OF SSTS
)PROPERTY METES & BOUNDS
)EROSION CONTROL FOR HOUSE, WELL &
SSTS, EROSION CONTROL NOTE
COMMENTS:
(REVSHEET)09 /01 /00
MAP #: (CONFIRMED)
Y--N (REQUIRED DETAILS ON PLANS CONT'D)
(_) HOUSE SEWER - %" FT. 4 "0'; TYPE PIPE CAST IRON
NO BENDS; MAX BENDS 450 W /CLEANOUT
RENEWALS
ZL—)SITE NOTE (NO CHANGE)
FILL SYSTEMS -
10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
FILL SPECS/ FILL NOTES 1 -S
FILL PROFILE & DIMENSIONS
�) FILL IN EXPANSION AREA
FILL GREATER THAN 2 FEET
CLAY BARRIER
FILL CERTIFICATION NOTE
(_) DEPTH GAUGES
�) VOL. ON PLAN FOR R. O.B., UNCLASSIFIED & IMPERVIOUS
SEPARATION DISTANCE FROM TOE OF SLOPE
E C
L� "LF TRENCH PROVIDED 60FT MAX.
0( () PARALLEL TO CONTOURS
� 100% EXPANSION PROVIDED
( �t .)DETAIL/DUST FREE CRUSHED STONE OR WAND GRAVEL
(_)(�GEOTEXTILE COVER
SEPARATION DISTANCES ON PLAN - FROM SSTS
U 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL .
20' TO FOUNDATION WALLS
100' TO WELL, 200' IN DLOD,150' TO PITS
100' TO STREAM, WATERCOURSE, LAKE (inc. eapan)
(�50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
10' TO WATER LINE (pits - 201)
�
% INTERMITTENT DRAINAGE COURSE
200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS
10' MIN TO LEDGE OUTCROP
SEPTIC TANK
UNDATION; 50' TO WELL
WELL
TO PROPERTY LINES
ON OF SERVICE CONNECTION
15' TO PROPERTY LINE
SLOPE
LOPE IN SSTS AREA 520 %)
RE
GRADED TO 15 %, IF REQUIRED
TACT MTTT O%TCTT AMA
PUMP NOTES
DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED
NUDETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
PIT AND D -BOX SHOWN & DETAILED
L_)1 DAY STORAGE ABOVE ALARM
CURTAIN DRAIN
IPES, 5BOT o CDS = >5 %, -1 %, 100 % - <1%
(to CD DISCHARGE /100' with 182 cons day discharge
to NON - PERF ORATED PIPE
September 8, 2005
Putnam County Health Department
1 -Geneva Road
Brewster, New York 10509
ATT: Robert Morris, P.E.
RE: Individual SSTS - Gagliardo
Homer Drive
Patterson, NY
T.M. # 25.32 -1 -5 &6
Dear Mr. Morris:
Enclosed are the following:
Harry W. Nichols Jr., P.E.
Patterson Park - Suite 106
2050 Route 22
Brewster, NY 10509
Tel: (845) 2794003
Fax: (845) 2794567
Email: hnengineer@aol.com
1. Five (5) prints of SS -1, "Proposed SSTS ", dated 09/06/05.
2. "Short EAF ", dated 09/08/05.
3. "Application for Approval of Plans for a Wastewater Disposal System ".
4. "Construction Permit for Sewage Disposal System, ", dated 09/08/05.
5. "Application to Construct a Water Well ", dated 09/08/05.
6. "Design Data Sheet ".
7. "Letter of Authorization ".
8. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ".
9. Review Fee in the amount of $400.00.
We would appreciate your review, approval and issuance of the Construction
Permit at your earliest convenience.
Very truly yours,
#4 VLIV�
Harry W. Nic ols Jr., P.E.
HWN:gav
04- 054.00
a.
October 4, 2005
Putnam County Health Department
1 Geneva Road
Brewster, New York 10509
ATT: Robert Morris, P.E.
RE: Proposed SSTS - Gagliardo
Homer Drive
Patterson, NY
T.M. # 25.32 -1 -5 &6
Dear Mr. Morris:
Harry W. Nichols Jr., P.E.
Patterson Park - Suite 106
2050 Route 22
Brewster, NY 10509
Tel: (845) 2794003
Fax: (845) 279 -4567
Email: hnengineer@aol.com
In response to your September 29, 2005 review letter, we note the following:
1. Enclosed are proof of certified mailing receipts with list of lots, names of
current. owners and Tax. Map - Numbers.
2. All existing and proposed wells within 200' of property are shown on plan.
3. SSTS revised to drop box system.
4. Two (2) feet of solid PVC provided on each lateral.
5. D -Box deleted.
6. All drop boxes minimum 20' from building.
7. All trench lengths and 2' of solid noted on plan.
8. Footing drain will discharge at elevation 593.5
9. LA IA WilcWigl% backs added to plan.
10. .t' �ted i /t -,from property line.
�: ° {�d
3
11. Required note regarding staking by surveyor added to plan.
12. Silt Fence locations revised.
Reflecting the above, we are enclosing five (5) prints of Dwg. SS -1 "Proposed
SSTS ", rev. 10/04/05.
Kindly continue with your review and issuance of the Construction Permit.
Very truly yours,
C-I
Harry W. Nirois , P.E.
HWN:gav
04- 054.00
c
LIST OF ABUTTING PROPERTY OWNERS
PETER GAGLIARDO (04- 054.00)
Homer Drive
■ uaaa.■ aav■ ■, ■� ■
T.M. # 25.32 -1 -5 &6
25.32 -1 -3 &4 . - Reynolds, Sandra
50 Homer Drive
Patterson, NY 12563
25.32 -1 -7 - Triscari, Joseph
48 Allen Drive
Patterson, NY 12563
25.32 -1 -8 - Ross Alan, Inc.
56 Allen Drive
Patterson, NY 12563
25. -1 -59 - Mednick, Allan
449 Haviland Drive
Patterson, NY 12563
25. -1 -61 - Gagliardo, Peter
61 Allen Drive
Patterson, NY 12563
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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1 ;tWell� %mti�# � _•
WELL COMPLETION REPORT
Well Location
Street Address:
II
� 3 �o ►� cr �da d
Town &A agge:
�[
�a�,ey�'D� �` (�
Tax Map #
7 T, 3 Z
Map Block Lot(s)
GPS:.,,:; w';. s:
Well Owner:
Name: Address: /�
I,O SS >•`I' GY `,` Ce �p BJ Lb ►-d
Use of Well:
1- Primary
2- Secondary
X Residential _Public Supply Air cond /heat pump _Irrigation
Business Farm Test/monitoring —Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary _Cable percussion kcompressed air percussion Other(specify)
Well Type
_Screened _Open end casing Open hole in bedrock _Other
Casing Details
Total Length 5ft.
Length below grade t 8 Z
Diameter _j�? in.
Weight per foot lb/ft
Materials: =&=Steel Plastic Other
Joints: Welded Threaded Other
Seal: Xcement grout Bentonite Other
Drive shoe: X Yes ' No
Liner: _Yes No
Screen Details
Diameter (in)
Slot Size
Length ft
Dept to Screen (ft)
Develo ed?
First
I
I 1—Yes
_No
Second
I
I lHours
Well Yield Test
_Bailed _Pumped Compressed Air
Hours (al
Yield /5 gpm
Depth Date
Measure from land surface static (specify ft)
Z. O
During yield test
2-0 s
Depth o compete well in ft.
20 s-
Well Log
If more detailed
information --
Depth From Surface
Water Bearing
Well Diameter
in
Formation Description
ft.
ft.
Land Surface
--- -
- - -
- p - .- ` .. - - -
descriptions Or
sieve analyses
are available,
please attach.
2Q -
If yield was tested Feet
at different depths
during drilling
list:
Gallons Per Minute Pump /Storage Tank Information
Pump Type Capacity 10
Depth P+S Model Oi JO" jZ
Voltage 23 a HP Z
Tank Type X-T►v I Volume %e-
NOTE: Exact Location of well with distances to at least two permanent landmarks to be provided on - an,
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
�j Rev. 3106