Loading...
HomeMy WebLinkAbout1197DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.62 -1 -75 & 25.62 -1 -77 BOX 12 O , Iy a IN i 9 J �16 ' I I IN IN a � 6 IN ` 111111 01197 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health_ _ . LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 March 3, 2006 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Re: Proposed SSTS for Gagliardo Newburgh Road, (T) Patterson This Department has received and reviewed the submitted application and plans for the above referenced project and the application has been determined to be unapprovable for the following reasons: 1. The proposed force main is shown off of the property line. The Town of Patterson Town Board requested a legal opinion from their attorney, and legal counsel for the Town recommended that the Town not approve the construction of a private sewer line Within the town road right -of -way. 2. The proposed force main is less than 50 feet from the adjacent existing well. The following additional comments are offered for your consideration. 1. The percolation and deep test holes are to be numbered on the plan. 2. The location of the existing SSTS to the south of tax parcel 25.62 -1 -75 is to be shown on the plan. 3. The pump pit gate valve is to be operable without having to enter the pump pit. 4. Please refer to Section 4.A.7.r of the PCHD Bulletin ST -19 for the correct pump pit notes. Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. MJB:cj Respectfully, 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 SHERLITA AMLER, MD, MS, FAAP .. Cornnussioner of Health - -.. •, - - - - - - - LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive February 23, 2006 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Gagliardo SSTS Newburgh Road, (T) Patterson TM# 25.62 -1 -75 & 77 East Branch Reservoir Basin Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on January 20, 2006 is complete. The Department will notify you by March 15, 2006 of its determination. ❑x The project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you tiled the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the New York City Department of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed approved, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the New York City Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2148. Respectfully, Michael J. B inski, E MJB:cj Director ofE ineeri I 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 02/gi8/2006 22:50 18452796725 O FAX COVER SHEET Total pages including ,cover: 3 /// send to: Attention: p /1,D) -14s Offiee Location: F'ax No.: Comments: -Sc..P,, -V/ j 0`2 i EAST HUDSON UROLOGY: From:+i...rCf�C'� Date: Office Location: 4Fax No.: &V4 -d tg 79 -1no7� PAGE 01 02/08/2006 22:50 TIMOTHY J. CUIMMS WILLIAM A, 9141"ING. JR. ir"NIFER M. NCRODCS ANITMONIY "..MCLf 18452796725 EAST HUDSON UROLOGY: C&S. %W 80 CHURCH STREET CARMCL. Ntw vomit IopiR Februa 6,2M MIA, )F'AX NO AM M 875.4 379 Charles W -Iftla us, liighwa) Superintendent Town of Pathnon ffighwa:. Department 1142 Route 311 P.Q. Box 470 Patterson, NY 12563 Re: 8 Newbm%h Road, Patterson, New York Talc Map No. 25.62-1 -75 Dear Mr. Williaans: PAGE 02 AF CA CODC 040 VIA. =2C•51100 rfjc! 2 29.5046 VINCENT L. LCIMLL. in OF COUMEL k RE Il/ T.O.P. FEB - 7 2006 OFFICE OF SUPERVISOR T6 .It 41116 rbs6atly come to the Torun Board's aI W n that these is a residence proposed to be constructed on the above -re Fwd property. in w lab, the pfd emn to propose a sewer lime that would be piked in the -f wburO Road n& -of -war and 0 cl the lot known as 14 -Neufinjr3 . gead-name~ by Ib mricia P :ddc&. Tlx nwo Him wavy iw W the Town night -of -way from the raitlnm to be ioo� cstnrcted at 8 Newbu�t 1RoW slog Nowb o Read crossing on the easterly side of the Paddocl. property them ant *aftlY ela" import Drive on the northerly boat Avy of the P Wdock property stud outing's a abart!>aee sewage treatmeat system constructed on the Pr'o'perty located. at 26 Iroquois il*4 Tax Map W. 25.62 -1 -77, This proposal is shown on a plan d" 7a -teary l7, 2006 piepsrald by Hwy W. Nichols, Jr., P.B, erAjtled "Proposed SSTS Newburgl: Road prepared for James ( aShardo." The Town Board re► guested del oar office =ab ntt to you our legal opinion as to the sewer line b4ing constructed with o the Town roald ,ftU -of -way. It is our recommendation that the Town'r+at appsov+e the conW=tion of a private m war lint within tire. Town dgbt -f -way as such would rami Maras kimwty Issues with respect to the sWo sewer Base. 1t woul,l cct be in the Town's bat nuttiest br liabr'lity purposes to percnit installatioia' of a privak sb% ar line'withio the ?owe 601 of -wry, Obviously, if the sewer: ine FEB -9 -2006 THU 10:41 TEL:845- 278 -7J21 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 02/08/2006 22:50 18452796725 EAST HUDSON UROLOGY: PAGE 03 February 6, 2006 Pap 2 were to rupture is the Tovn, right -of -way and caut lcdmp and spillagc imo the Town road, the Town may incur liability. ' his is not a risk that the Town should incur. If you wish to discu s this matter further, please do not be iwe to contact our offtc very Vim. -r a" AxAmy R. Mo* AMU cc: Mi N01 , 3u NIM'sor Mem the Toum Board FEB -9 -2006 THU 10:41 TEL:845 -278 -7921 :PUTNAM COUNTY DEPARTMENT OF P. 3 BRUCE "K., - OLEO - - - LORETTA MOLINARI R.N:, M.S.N. Public Health Director �� Y O4� Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 St ,SSY pc dSSr�` TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGA TED PROJECT: 6�,A6,u 09A7 JS �� r' ��(a C TOWN. :.__ -.0 .S.E. F..�_._.P�,.. _. - - •i�ATE'�L °i� i� � NOTICE OF COMPLETE APPLICATION DATE. Z 3 I__.... . -- - -- -.. . .. - --° -- -- - .- - . - - - - . - - - - - -.....- -- -. - - -...- . .. - i New York, February 4, 2006 Dear Mr. Morris, Recently we've received a neighbor notification letter along with 'a site plan for a new house to be built on the lot next to ours. Tax Map 25- 62- 1 -75 &77 On this site plan, we've noticed that the proposed well is rather close to our septic fields and could represent a problem in the future if we decided or had to repair our existing septic, especially due to the fact that our house is an old construction. We've already called the Health Department and they suggested us to contact you. Therefore, we would appreciate if you could call us at 845- 278 -8142 or 845 -612 -9478 as soon as possible to clarify our concerns. Mr. Peter Kuehl Mrs. Renata Kuehl APPENDIX FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTER RE: Department of Health Review of Proposed SewageTreatment System for Property ... .. ..... . ... -Tlo`�NML fi'm J �p- -e-4f O\A Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. 'Attached please find a copy of the latest site plan. , If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may Call the Health Department at 278-6130. Very truly yours, Y. T* e- Received By: Address: Tax Map 9: August 1997 2-1 r 0 c( Dennis J. Sant Putnam County Clerk _ Puublic lnformation Officer Application for Public Access to Records ITo: Records Access Officer Name of Agency Address Check one: ❑ I will hand deliver myself ❑ Please submit to the specified department for me licant Signature I HEREBY APPLY O INSPECT THE FOLLOWING RECORD: Pt -0 DOS ea S ST.S CLIENT- V a) a 6 (� - Q a� Applicant Signature M71eiCIX Applicant Name (PRINT CLEARLY) Se /Je7 R re enting e Ail &o&, -,*W ed- , -S09, �/ Mailing AddreSdIPhone Number APPROVED DENIED veze- FOR OFFICIAL USE ONLY: Date: DENNIS J. SANT Public Information Officer 510 -9 Record of which this Agency is Legal Custodian cannot be found. i BLS', fr Recor is of mai ned by this Agency. J/ ot- G y Y 1 3 Signature Title Date NOTICE: YOU HAVE A RIGHT TO APPEAL A DENIAL OF THIS APPLICATION TO THE PUTNAM COUNTY EXECUTIVE. Name Business Address WHO MUST FULLY EXPLAIN HIS REASONS FOR SUCH DENIAL IN WRITING SEVENS DAYS OF RECEIPT OF AN APPEAL. I HEREBY APPEAL: Signature Date AM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SER - CONSTRUCTION PERMIT FOR SEi�VAGE TREATMAENS T-SYST PERMIT # Located at iNRW &�-&A jLo Ap Subdivision name PiiblW, (,W Subd. Lot # l am Date Subdivision Approved `�'' jA° Owner /Applicant Name -,Dc G WIA A M Town or Village i ATT-eT- -5oH Tax Map X19," Block i Lot 16+11 Renewal Revision Date of Previous Approval Mailing Address _'S� '�PA V5 P(V PrWIA Zip 11-6( . Amount of Fee Enclosed GQ cc Building Type FV) Lot Area 0,6M No. of Bedrooms Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and AM Lf, , PM Other Requirements: Q V mi to ' a n To be constructed by X(t\CF6 644AP(Wr-) t=k LID, Address '1I WE iWAAA kl ' DSCA Water Supply: Public Supply From Address or: Private Supply_Drilled byt '1-_ _. Address 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 `'ice a-0 P.E. jer R.A. Dater �� G O� License # 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 when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM cCOUIY'll'Y DEPARTMENT ®IF HEALTH IlDIIVffSffC N OF IENWIB®IMIENTAIL HEALTH SIERW CIES . . nl WELL—— �__-. __._...._. - _ -. -_ -: �0-PLIC A- ION- TO-CONSIRUCT A WAT4A :..._._ ._ please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # KVJN N,u NQ 0 Map2,' V� Block Lot(sil;' 1 Well Owner: Name: TC� Ukb[*J�o Address: V G91f FOfk Use of Well: �_ Residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- seconds ry Industrial Institutional Standby Amount of Use Yield Sought 6+ gpm # People Served Est. of Daily Usage D gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type �_ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No _ tl Is well located in a realty subdivision? ...................................... ............................... Yeses No Name of subdivision Mom 5 Lot NAM— k 11 Water Well Contractor: TU Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: '- Proposed well location & sources of contamination to be provided on separate heet,/plan. t- �..�.� t._ - _...Applicant Signature.. _.. :.- ......_. - P ERhUT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED ]FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue Date of Expiration Permit is Non-T ransffe>r>rabRe Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR : - - - A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: J Pk M 15,6 - 6 , (0 L, l 0 2. Name of project: 1N1)1�1i�tl4�j G�J 4. Design Professional: 6. Drainage Basin: 3. Location T./V: 5. Address:. 2-050 7. Type of Project: jl 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 -(SEQR)? . Type tatus (check check one ....... ............................... Type I Exempt ) ................ YP Type.II Unlisted X. 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... �0 10. Has'DEIS been completed and found acceptable by Lead'A gency? ............... 11. Name of Lead Agency 0 0 12. Is this project in. an area under the control of local planning, zoning; or other. officials, ordinances? .......................................... .................... :....: a,:.:.,.....::..:.....: , ....(,.... _..... 1.3.. If so, have plans been submitted-to such authorities? ... :................ :....... ......... ..... (�0 14. Has preliminary approval been granted by such authorities? t4 Date granted: llj ;� 15. Type of Sewage Treatment System Discharge ................. surface water _�I_groundwater 16. If surface water discharge, what is the stream class designation? .................... tJ A 17. Waters index number (surface) :................................. :.................................. :........ 18. Is project located near a public water supply system? ........ :................. :............ 19. If yes, name .of water. supply '�J Distance to water supply 20. -Is project -site-near a public sewage collection or treatment system? ...... ...:....... 21. Name of sewage-system (U Distance to sewage system 22. Date test holes observed 23.. Name of Health Inspector 6EHE PLt-'p 24. Project design flow (gallons per day) ........................................... I...................... C) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... J�Q 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 2 -27. Is any portion of this project located within a designated Town or State wetland? N� 28. Wetlands ID Number............: .............................................. ............................... �A 29. Is Wetlands Permit required? .....: ........................................ ....... ......................... Has application been made to Town or Local DEC office? . ............................... 30. Does project require a DEC Stream Disturbance Permit? .......................... �4 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling; sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet :of existing or abandoned landfill, hazardous waste .site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ................ ................ Yes/No DESCRIBE: 33. Is.there a local master plan.on file with the Town or Village? ........................... Yes 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 areas in.excess of 15% slope? ......... :..�i 36. Tax Map ID Number ...................:...... ............................... Map�S•b -Block , Lot 1-S+ 1 37. Approved plans are to be. returned to ..... Applicant Y Design*Professional NOTE:.AU apphcatioris. for review and approval of a new, SSTS to. be located within the NYC'.NMitershed shall 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 project, such as stormwater plans or the creation of impervious surfaces; and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item L the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply •with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on thisf form is Prue to the best of f my knowledge and belief. (False statements made herein are punishable as a Class A misdemeanor pursuant to Section 1®a4S of She -Penal lLa . n ,SIGIVAT ►S & OFFICIAL TITLES Mailing Address: ..................................... Q PUTNAWC Y P4 4 DIVISION OOF ENVIRPNMENTAL HEALTH 'SERVICES DESIGN DATA SHEET- -:SIMS 'ACE SEWAGE. TREATMENT SYSTEM Owner'- JAvtfS &AALIAQI�Z2-1- Addf6ss ' u�M Lodt'iEm' Located at (Street] Tax Map, zsl, 4 .816ck .(indicate neartst•c*ro*ss street) Municipality- t-&§�7V- L3r- -7 Watershed SOIL-PZCOLATION TEST DATA' Datea Pre-soaldng.- it- Is - 0 S Date of-Percol-aiion'Test - -S 2,• I=L3 w. ve mpuaFq At 5dTv urpul Until uppru imamy cquw peirpoiation rates are obtained at each. pere-o -h.test hole. miO.fbr*l­jQimiirin,6hi,:5- Zm4foria-1-4.6 'inj ld b-cr e,-xq�h) AlLdffil submitted forieview.'. Depth m ments i0_p'Oi4dp-.ft-o M top . I -. p Form DD-97 ON m INNER T M*. to ;�§wNrgtj��, S%, : t"•X VAG 0: Ov - (0.! 20 V.- .23 .3 .1 Ot 20 .. 23 5 Ito, 214- 1,1 p -2- 2 2.. 2.3 20 It- os -'it .,3%, 23- 4 io 2,• I=L3 w. ve mpuaFq At 5dTv urpul Until uppru imamy cquw peirpoiation rates are obtained at each. pere-o -h.test hole. miO.fbr*l­jQimiirin,6hi,:5- Zm4foria-1-4.6 'inj ld b-cr e,-xq�h) AlLdffil submitted forieview.'. Depth m ments i0_p'Oi4dp-.ft-o M top . I -. p Form DD-97 TEST. PIT DATA - 2 DESCRIPTION OV SOILS EIVCOUNTERED.IN TEST HOLES. TJnT V VC) HOLE NO. Design-ProfessionaflNam �4* OWEV' Av RR Address:..5 Signatures 14rj .l�esip Fr., ss o: -,aVS Seal. t V FW Yp ~` Npiz4.. 1 , 14.16.4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 Appendix C _ -_ -.• _ St. to Enviro mantat Quality Retiiew SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant or Project sponsor) SEOR 1. APPLICANT /SPONSOR 2. PROJECT NAME 1 NQ►v1 D��. �h i � 3. PROJECT LOCATION: � �i � Ll •alit Municl County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: XNow ❑ Expansion ❑ Modlflcation/alteratlon 6. DESCRIBE PROJECT BRIEFLY: IND,11. WPA, 0P44C 61- I k47Ioar(/1, -0P� 7. AMOUNT OF LAND AFFECTED: / Q Q! �g� Q Initially acres Ultimately v D� acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? 4Yes ❑ No If No, describe briefly 9. WkT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ 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 OR LOCAL)I ? icr4� ❑ Yes No If yes, list agency(s) and permitlapprovals 11. DOES ANY ArSSDECT OF THE ACTION HAVE A CURRENTLY. VALID PERMIT OR APPROVAL? ❑ Yes o If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes No, I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ' Ei � ' 01A1)*__ AppllcanUsponsor n me: `' Date: Signatures 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 i i i 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, coordinate1he review process and use the FULL EAF. ❑ Yes ❑ No -B. VvItL ACTION RECEIVE COORDINATELTREViEW'AS PROViDcU FO,R UNLISTED ACTIONS7iN'6 NYCRR, %PART 617.67 - ff Nof a negatiQe- dacctaration 7 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: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: 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 resotiices? Explain briefly. 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 THERE. OR IS THERE :LIKELY TO .BE. CONTROVERSY RELATED TO POTENTIAL ADVERSE. ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART 111— 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: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsi le Office r in Lead Agency Signature of Preparer (If different from responsible officer) 2 PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of JR (�E� V h b !A A�, 00 Located at Nv AJW "aD T/V iPKrf> F-60i -i Tax Map # Block Lot 5111 Subdivision of 2\11 O N�\ L-RV . Subdivision Lot #A 11 %. h li5% Filed Map # 144 - 6 Date Filed Gentlemen: This letter is to authorize ii 1kP* 0, , 'P-- FE a duly licensed Professional Engineer ',*.4_ or Registered Architect 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 io 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 Law; and -the Putnam- Co Sanitary Code: - - . .. _ _.__.._..._._ _....___ _.... _ ......_.. _. .Y Countersigned; P.E., R.A., # Mailing Address ssl M, b �.-E 0 ��/ �. P-1 State Zip. I� So Telephone: � � 21 4 d0 Very truly yours, Signed:_ i 9 caner of Property) `r Mailing Address: lyll 6ME Km POND FA w i--i [a State W V-W �'*� Zip l 66 4- Telephone: (114) 40 � i of 1 Form LA -97 ���� ��` Icy i t1.�� ���� i��� �� --.. �., �... 4 =7 " P and THF Models { "B" Models t r F i ps Harry'.W. Nichols Jr., P.E. JOB No. - -- i s 4�T —,4T1 G -Patterson Park, Suite 106 SHEET No. l -'OF 2050 Route 22 Brewster, NY 10509 COMPUTED B Y _DATE __ (b45) 279 =4003, Fa)c 279-11.55-67 - H� �. CONSULTING. SITE ENGINEERS CHECKED.BY DATE ...__._ ............ -- - ........-' - ._... - ....---- ._.......- -'- - '- °-'-- ._._.._....... Tp 14, -_3 v ?evL--- w�?o3� LE GT f -- - -- i s 4�T —,4T1 G E o T-To ... -- - - � �►u+��t Pates of P►P� - -- ------- - - - - -- _ -ms s`' 60 .u1>lA4�P NT : p _ T t . i - - - - - -- �. Ed E, �— — ...__._ ............ -- - ........-' - ._... - ....---- ._.......- -'- - '- °-'-- ._._.._....... Tp 14, -_3 v ?evL--- w�?o3� Harry W. Nichols Jr., P.E. =Patterson.Park;'Suite 106. 2050 ,.Route 22 -... Brewst0r, NY 10509 (.8416) 279=4003, fax 279 -4567 CONSULTING SITE ENGINEERS JO, B No..4�i - °lb4 SHEET No. COMPUTED BY CHECKED BY ;,' 2 jr� OF DATE 1I ob DATE 3. bQS In, hV OL I�� F � ' C7s" /o d !✓ s'�s i`C:1� UoLV�nFI T ` � _ d►2-� -j LF • sa ; ._���o * �•��f� Jam'__ lz ��,�'� ±�t 7,�f! ���; � X U:"7 S — I ° CAL,' b 65 - - ­77-T � 41" AC S -- - - d N E 6-rO PAC, 1 = ZIXIN - - -- - r 1 CH 0EDFiOO11 3 BEDR0011 2 1` X i6'- G` --ti —• Imo' -S'X !0` -G` :• \J Firs z F llbor oll ;2 • i I "' \ 0I.YIKG ROOM! KITCHEN G' X. LS' - G` 1•!.'.S TER BEOROOK ��I ~� LIVING ROOM 14' -1` X 13' -G` U P t r r I I I i GEDFiOO14 3 14,- 1, X 16' - G' LN I I ........... OEDROOK 2 I,-' -5,X 16' -G' i .- �; 16 .I Firs z F:c•or C C.C: _ IC L14'- ER BEDROOK � �- LIVI G ROON X 13' -G' j'� I<'- G'X13' -O• u P r r t-2 t= 5 I r- January 17, 2006 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Mr. Robert Morris, P.E. Senior Public Health Engineer RE: Individual SSTS (Gagliardo) Newburgh Road Town of Patterson T.M. # 25.62 -1 -75 & 77 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) 2793567 Email: hnengineer®aol.com 1. Five (5) prints of Drawing SS -1, "Proposed SSTS ", dated 01/17/06. 2 Short.EAF, dated 01/17/06.. . 3. "Application for Approval of Plans for a Wastewater Disposal System ", dated 01/17/06. 4. "Construction Permit for Sewage Disposal System ", dated 01/17/06. 5. "Application to Construct a Water Well ", dated 01/17/06. 6. "Design Data sheet ". 7. Two (2) copies of residence floor Plan(s), for bedroom count only. 8. Pump Calculations, dated 01/17/06. 9. Neighbor Notification Paperwork. 10. Review Fee in the amount of $500.00. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. ichols Jr., P.E. HWN:gav 05- 034.00 I i t d �l _ I 9L - I _ ESL._ - -I-�_- -- - -- S 8 = I _- -'C.�: •=yG- - - -- - - - -- I I 9 �rn I • I f r I I I i. I i _elf � - - - - -- - r- : i i ADJACENT NEIGHBOR UST... _:_.___. _.... ._._ _ ..._..._.... ...... 05- 034.00 25.62 -1 -22 Hart, Margaret M. 31-4986 th Street Jackson Heights, NY 11369 25.62 -1 -27 Horrace, Norma 25 Iriquois Road Patterson, NY 12563 25.62 -1 -28 Cilenti, Mathew & Angela 19 Iriquois Road Patterson, NY 12563 25.62 -1 -64 Trongone, Robert & Paddock„ Patricia 7 Newburgh Road Patterson, NY 12563 25.62 -1 -65 Gallagher, Carol 2 Washington Road Patterson, NY 12563 25.62 -1 -72 Connolly, Arthur & Alice 17 Newburgh Road Patterson, NY 12563 —2-5-620=74— _.:.. Kuehl, Peter &.R?nata 2 Newburgh Road Patterson, NY 12563 25.62 -1 -76 Paddock, John & Patricia 14 Newburgh Road Patterson, NY 12563 25.62 -1 -78 Opromolla, Daniel & B. 25 Canton Road Patterson, NY 12563 25.62 -1 -79 LoBraico, Maureen 3022 Old Covington Road Conyers, Georgia 30013 25.62 -1 -85 Eiseman, William & Donna 31 Barnard Road Patterson, NY 12563 APPENDIKE FORMAT CONSTRUCTION PERMIT NEIGHBOR NOTIFICATION LETTE PO& RE: Department of Health Review of Proposed SewageTreatment System for Property —Name-:-- -T ?_4;;99Vd K­ Please be advised that an application for a Construction Permit relative to the construction of a sewage system and/or well proposed for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's. review of this application, you may Call the Health Department at 278-6130. Very truly yours, 4q, Received By: Address: Tax Map August 1997 ru S:b �`��t. ;':'�,-:r`3�:e'� ° Po'stal Service M�.: � $t � }y � t't* 1 •. se'''y'..i,yr'kiSA'F ( 'U S Postai Service�M.} ���^ �.� " aECE`RTIFIED MAsIL M R "ECEIPT` °- E s -. R t n 14.. 1 '.l IiV J'!' ru _r �J CERLr >ryIFI;ED M1tAIL h,,, CEIPT .. •�%e� +- 1'1"^` S „y >.7t T i #t;, C3 L 1 l J. _+,. ` DoS _ mestic Mar! Onl No Insurance Covera erProvtded , 3(Domestrc Marl Oniy�,•No Insurance {Coverage °Ptorrded)_r��,� Restricted Delivery Fee Clem:: Q7FSk0 (Endorsement Required) `k Total Connolly, Aimur &OMZ46 For deliVgry�i reformation wstt ou site atwww cbm» �;a o o Foradehvery informahoniyisit our webs�te at www uses comf.; per -asps o � ° • • ° - • • 'PS Form 3800°'June•2002 �'# + 3Jr � See Reverse for�MSt�ucbons° jPSiF _ .., — . - ,..... _ s. a tstiucf�oris�, 'Ys s t S• U S Postal Ser'vlceTM _ ��. � cr � x'{ j� � t�.�< ?j w �,t,t �CERTIFfED�MgILTM RECEIPT ' k CERTIFIED MAl�Try; RECEIPT S � �` .� (Do!neshc Marl Only, No }Insurance ` ' (Domestic Marl Only;,No Insurance Coverage Provrded) �� � Coverage Prov►ded)', : For - �' delrvery;iniormatron For tfelrvery mtormation;vrsit visit our` websrte:at w wuvusps comp Cc } } ourswebs�te:at �1L'iY • t '�. �_.1 { 0. :PS:F,orm uner2002' _ f n- � . ?..tu�SeeAeverse,torinstrucUons PS;F.orint „ ru ° r Er- ru •. C3 IWAAL USE ru _r Postage $ 0.87 UNIT ID: 0012 C3 CertfOed Fee 2.40 postmark O C3 Return Reciept Fee 1.85 Here (Endorsement Required) O rzi Restricted Delivery Fee Clem:: Q7FSk0 (Endorsement Required) 05- 03'9' r Total Connolly, Aimur &OMZ46 17 Newburgh Road o o FeW Patterson, NY 12563 M — - - - °- Er, W (pallnbay;uawaslopu3) MSIAO : is }i0 tti �D eaj IGan,lea p@loutsay etS �f� Postage (pennbey 3uewasIopu3) 00- Idleoey wnmeb O .... `uos to £95Z I• AN filed 18OdJo , 13 0 ...... - peon sionbu.1 9Z _. Sod pe114180 W 0 ZTOO :91 lINA _ i 0j. Was euaaoN `aoeJ�oH n -i V Here 90M /To (IT'S d ISM 0 M — - - - °- Er, W (pallnbay;uawaslopu3) MSIAO : is }i0 tti �D eaj IGan,lea p@loutsay SIGH Postage (pennbey 3uewasIopu3) 00- Idleoey wnmeb O NJVWIsod O 0 , 13 0 C3 Certified Fee Sod pe114180 W G8'O $ ZTOO :91 lINA GOM"d - •-j Certified Fee 40 4 ° n -i V Here O Q-' Clerk: Cl7Far 0 Postmark ru M — - - - °- Er, 0 z tti F"diW f- Postage $ 0.87 UNIT ID: 0012 M 2.40 13 0 C3 Certified Fee 1.85 0 Ir 0^ Receipt Fee 0 Return Receipt ::::l Certified Fee 40 4 ° . (Endorsement Required) 1.8 5 Here C3 Restricted Delivery Fee E" (Endorsement Required) M Clerk: Cl7Far 0 Postmark 0 Ln T, Cilenti, Mathews An �l 7i�� 0 Se. 19 Iriquois Road or. p,_w; ., �.., o nnp���nn b T ' el o r- ro ru a- M.. U 'E 0 T Y F"diW f- Postage $ 0.87 M M Certified Fee 2.40 13 0 Return Fee (Endorsement Req 1 re d) 1.85 0 Ir Restricted Delivery Fee (Endorsement Required) ::::l r- ro ru a- Total Postage 'ji 01/17/06 OLn Sent o Hart, Margyaret M. 31-49 86t Street or PO rrO P Box No. . Jackson Heights, IVY 11369 Clry State, ZIF ,�suol�5n13 �l Io; aslanaa aag�n�,�s���" ��w = *- .�sti�t' � ZOOZ a�i,�0885u1�a�°�t�Sd •. C99ZL AN - . . peo piewee Le OL - wes :euu�qLy/fy8lll! (A 1 BWGISI - :C GISH - - ® - '© •4 $uwo�sdsn nmm�n to a ;tsgaao its n not ewlo w IUanr a Jo .,(p'a� sadsa�a�o��a�ue�nsu/ oN ,(/up /leyy s/ ;sawop) ., �- Wiaainaas let o� •S•� U S Postal'ServiceTM CERTI!EFE MAILTrn RECEIPT (Domestrc�Maiht2nly; Nq Insurance C- ,O,V,ege Provided) M.. U 'E O T Y F"diW P FSC1i47 Y 184'3 Postage $ 0.87 UNIT ID: 0012 M M 0 Certified Fee Certified Fee 40 4 ° Here 0 Return Receipt Fee 1.85 Postmark Here Postmark M Return Receipt Fee (Endorsement Required) Clerk.: tl "rFSRO 1.85 Here 117 Restricted Delivery Fee ° Clerk: 97FSRO (Endorsement Required) M Total Postage 'ji 01/17/06 OLn Sent o Hart, Margyaret M. 31-49 86t Street or PO rrO P Box No. . Jackson Heights, IVY 11369 Clry State, ZIF ,�suol�5n13 �l Io; aslanaa aag�n�,�s���" ��w = *- .�sti�t' � ZOOZ a�i,�0885u1�a�°�t�Sd •. C99ZL AN - . . peo piewee Le OL - wes :euu�qLy/fy8lll! (A 1 BWGISI - :C GISH - - ® - '© •4 $uwo�sdsn nmm�n to a ;tsgaao its n not ewlo w IUanr a Jo .,(p'a� sadsa�a�o��a�ue�nsu/ oN ,(/up /leyy s/ ;sawop) ., �- Wiaainaas let o� •S•� U S Postal'ServiceTM CERTI!EFE MAILTrn RECEIPT (Domestrc�Maiht2nly; Nq Insurance C- ,O,V,ege Provided) - Total I M.. I 1 1 A L - o P FSC1i47 Y 184'3 U }SIT ID: 0012 ` Postage $ 0.87 Ut1IT ID: 0012 M Postmark 0 O Certified Fee 40 4 ° Here 0 Return Receipt Fee 1.85 Postmark Here (Endorsement Required) Clerk.: tl "rFSRO fr IT' Restricted Delivery Fee Clerk:: 97FSRO - Total I ,_ •_ Kuehl, .. Ln -.. '... - Patterson, NY 12563 FSent P$�F,'o n 3800�Ju• nej2002?*��Fu�?�. �� "-��'° " ��%See Reve'rse,for Instructions;: M (Endorsement Required) C3 Tots Trongone, Rob MdNk„ Ln 0 Patricia Sent: 7 Newburgh Road .- ,- •_ -_._- orPC Patterson, NY 12563 city PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 6_,46Zz,4727_-.)e,> Address 1jFz,18L)-z6 jy 7o,4 D g Located at (Street) Tax MapxF, 6;LBlock j Lot 75-- 72 (indicate nearest cross street) Municipality &Lr_Z__ZS OA) Watershed —e-H-57- SOIL PERCOLATION TEST DATA Date of Pre-soaking zz Zz� ZoS Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I 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 ........ ..... . . . ........ . rom. Ground Level Percolatton . loo . ..... Time Surface AI OF !. `Stop: r In in Rate Hole ................ ............ . .......... ........... . ................. ......................... . ............... Stop,.: ................................. .... ... ........... ................ . ....... ...... ....... . . . ail X c es,.�.. ......... . .. . . .:...:: Mm/Inch ... ......... ... 0o - 2- -3 2 3 #; vg ra z6 3 4 5 /0'0 3 '3 p 1`4 2 1 2_3 3 11,o i5 - Hl ;Z3 C> 4 5 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 I 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 —VEP i H-- G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' TEST PIS' DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES - -HOLE NO. } MOLE NO. 2 - - I€OLE %O. Indicate level at which groundwater is encountered AJ"942 Indicate level at which mottling is observed yA J a s 16 Indicate level to which water level rises after being encountered Deep hole observations made by: �,, , ' --p, Date ,[t7`_lela Design Professional Name: Address: Signature: Design PiroffessionnaVs Seal 2 i 1 PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVISION OF ENVIR:ONMENfAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIA.L SITE INSPECTION FORM .SECTION A. GENERAL INFORMATION Name of Project _ �!44Z�U D O ) Y`TEiZ So�J County `/emu T?1J,i�N1 Site Location' AL94yEu2 -Kad 242 2 ��', _ / — -7 5 7 �7 B uilding' construction begun Extent' Is property within NYC Watershed ? ................. Yes a No SECTION B. TOPOGRAPHY (Please check all appropri a boxes) 1. F7 'Hilly' 'F7 Rolling 0 Steep slope Gentle.slope Flat 2. a Evidence of wetlands Low area subject to flooding F7 Bodies of water 7.. Drainage ditches 0 Rock outcrops 3. Property lines or corners evident ......:.......:. `3�'�5...........:.. des No ........ ... .e .... 4. Do water courses exist on or adjoin the property? ............................ 0 Yes F7 No 5. Will these affect the design of the sewage system facilities ?............ F7 Yes �i'lo 6. Do watershed regulations apply in this development ?....................... Yes - F7- No 7 Will .extensive grading be necessary? ...:.............. .......:..:.................... F7 Yes F,761,io 8. 9. Do filled areas exist within the SSTS area?...... .. ............................... 0 Yes No. If yes, what is the condition of the fill? SECTION C: ' SOIL O7Sand ATIONS 10. Appearance of soil: F_� Gravel �Loam Clay F7 Hardpan � Mixture . 11. Observed from: a Borings F7 Bank cut PBackhoe excavations 12. Soil borings /excavations observed by on 13. Depth to groundwater Aj,y f j 6 on 14. Depth to mottling ;�1 ��g ,� on 15. Are test holes representative of primary & reserve areas ...... ................:.............. s No 16. Soil percolation tests made by on 17. Soil percolation tests witnessed by on SECTION D (on back) Form ST -1 SECTI ®N D. DRAINAGE : 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? a Yes- No 19. Will groundwater or surface drainage require special consideration? ........::........... .Y. es No. 20.. Will gullies, ditches, etc,, be filled'and watercourses be relocated ? .......................... F7 Yes o SECTI ®N E. REMARKS. 21. If a common water supply is proposed; has an inspection been made of the g P P ? ............. source and facilities? ................... ............................... Yes No existing or ro osed Inspection data 22. Do adjacent wells and/or sewage systems exist ? .......................................................... 11 Yes F-] No 23. Additional comments 24. Site observer /inspector and title 25. Date(s)- of observation(s)inspection(s) TEST PIT PROFILES Hole # Lot # Hole # Lot # Hole # Lot # Depth to water 2 Depth to water Depth to mottling _._ _ _.... -� _ n.._. , Depth to mottling Depth tc rr�rttlig SECTI ®N D. DRAINAGE : 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? a Yes- No 19. Will groundwater or surface drainage require special consideration? ........::........... .Y. es No. 20.. Will gullies, ditches, etc,, be filled'and watercourses be relocated ? .......................... F7 Yes o SECTI ®N E. REMARKS. 21. If a common water supply is proposed; has an inspection been made of the g P P ? ............. source and facilities? ................... ............................... Yes No existing or ro osed Inspection data 22. Do adjacent wells and/or sewage systems exist ? .......................................................... 11 Yes F-] No 23. Additional comments 24. Site observer /inspector and title 25. Date(s)- of observation(s)inspection(s) TEST PIT PROFILES Hole # Lot # Hole # Lot # Hole # Lot # Depth to water Depth to water Depth to water Depth to mottling _._ _ _.... -� _ n.._. , Depth to mottling Depth tc rr�rttlig Depth to rock/imp. Depth to rock/imp.. Depth to iock/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 8.0 8.0 9.0 9:0 10.0 10.0 .BRUCE R_ FOLEY Public Health... Director - DEPARTMENT OF HEALTH 1 Geneva' Road Brewster, New York 10509 ATTENTION: - o ADAM STIEBELI G fil GENE REED LORETTA MOLINAIU R.N., M.S.N. Associate Public Health Director _ _ Director of .Patient 'Services All information below'must be f�X completed prior to any scheduling. DATE: o9• ol- OS EiNGINEER OR FIRh1: 14AR- -Y W. AJ Ir.MOLS Tae. P.E. PHONE #: ZM -4003 REASON: - DEEPS: K ' . PERCS: 19 PUIYIP TEST: ❑ ROAD /STREET: _OE01b6a e.R koAp . TOWN: TAX "M: 2S.62 -1- 15.17 SUBDIVISION: LOT #: OWNER: :VAhES GA�Ltw�bo NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OE SOIL TESTING YES NO o 0- Proposed SSTS•within the drainage basin of West Branch or B.oyds Corner Reservoirs. . o.._ _:: : - - propose&SST$ within X00 feet of u watercourse tsor a�I)EC wetland.' control lai e,'_; _ ....,_.... ,..,_..:._._.._ P o CR Proposed SSTS design, flow greater than 1.000 gallons /day-or SPDES Permit required. o Proposed SSTS fora Commerical Project. It is the responsibility of the design professional to provide the above inform' ation prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered= 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. COMME.STS: .. - (MLDTEST) as no-da /4&rpy • t j �_i, % �Fl:fI5ME0 GRACE %.- '" too .` 1 SEE PL:.11 Fj(pe.� �. is i•!_ryl .�i 11..� I Cg` - PROFILE `" W I_" 014 (EL.991 STORAGE,) - —� - r„ PUb:P C:f : (EL.99l. rf) 1i� ?� I C s k � Ext *T SS TS a ( i Ii.,NoTES: TENON EXIST. i _ �u MP. IHbTPLLFT WM 9)F�I,L fA 11t Uf W1TN Tim TYp \� +� , - ,`�I WELL ELEVATION COM- `` \ . — - ALL PU! ? N40-- -M41)- n - ^L W10 -I14a PUMP CHAMBER DIP -EafU% 1C TAC I.HZI. WISVI'cN(. R}✓ ur:,lu� hPL1�Ffr. *_ - NOT TO SCALE - tFE. P� „f G91+iQpL' P0440l; -' I ° PUMP GAL-: 42:P k 0 05-7 i-4$ x o.'15• ZIO &At- in Lsox `wti p r Ala a_ vin 40° m \ f +l SHED - Z�Y ENCE COBBLGS'fN O E Os °J rlot,w 1 `�,,�WIf16 F 200.001 m® �® ®o i 'CIO P� R NCf (R EM41N5_F —• C /JOS. 'S$ 10° (A/ ` 10 Ff 0 -001.. •``11 ' 1000 CAI. 57bCKADE Fk NCE .4 "4 'lip �2' /•MR1. SEPf GT/1N E A� PUMP Ct'.AMBGR / ,\ 900 402.331+ ' f'� sTrLa� Pdc soa•33� ! /� \__ •9pp'QO I `` \�_ >c 7ER W``3 v1c 4l� `Pk'QVOSE*�.'I 3 BR. y�eu` -� RESfDEWCrC p•F`412.00' 1 GAP-AGE '- -- - - -_ 8,F.409.00' VNDER HAX.4 RFT. W4'. 1 +1 +410. . - Lu 408 IA \\ _ ♦` \ WELL - 2 1/, ------ _ I `11 ♦ ZPm sr-F4 8o PUMP LINE ~�