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Home My WebLink About1200DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.62 -1 -79 BOX 12 ��y'L . rv., . sl ;, 1 is , v 6 'm 4 No T mi I■ i 1, L- L hill 01200 05/21/01 12:49 PW SCOTT 4 19142787921 A BRUCE'R. FOLLY . . _._... �.._._. _.. Awie Health Director DEPARTMENT OF HEALTH 1 Geneva 'Road Brewster, New York I0509 is 5 •. r5 LORETTA MOLINARI RN., M.S.N. Arroeiare Public /Maki Director Dirmor of Patient Striker ATTENTION: o ,ADAM STIEBELING ' 90GENE, REED All information below mus t be fylt completed prior to any scheduling. DATE:—jA--�_U[ ENGINEER OR FIRM: _9 u.7. S6a�= e-- J4 14 ?VZC-A PHONE #: 8'Y�E - c'7 (r; d-1( L7 REASON: / DEEPS: V PERCS: h1` PU?O TEST: ❑ ROAUSTREET: �_ CAN–r" TOWN: Ps "l`1�'�( i.9sV TAX MAP #: 2 [s 2 z I " 7-1 SUBDIVISION: .ROT r„ ; LOT #: ,(�,,,__ OWNER: CA– �}c�tn.ic�-Z'�ETatt -aS YES NO ❑ Proposed& M within the dminage'basin of West Branch or Boyds Corner Reservoirs. ❑ gel Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. ❑ _ Pro _g3nd- $STS.wttlnn 200 feet of a- watercocarse or a DEC *06and. Q O� Proposed SSTS design flow mreater than 1000 gallons /day or SPDES Permit required. o t� Proposed S STS for a Commerical Project It is the responsibility of th a 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 answere 1;= to any of the questions, NYCDEP must witness the sot? 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 detv mined to be Delegated based on the above response and then subsequent information indicates NYC DEP is required to witness the soil testing, it will be the sole responsibility of the design professional ti i schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY r DATE � a°� rtatE 7 l0 R /: o cZMEN -rs; (FMLDTEST) on/21/01 1�: 4V FlW SCOTT 19142787921 0 e. R ..a: t�+ tM1r. :aj •P � � � i -' ' �a Nqs it gig N\ Z7- A. cl Ntt . . .............. eip cat2"ca.—M I— .- —.. .—. .. 2- ri -3. Ay% '' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner �-rtc'PkENs 'Address cRN'T`oM `/- Located at (Street) LAkC- r?o stT f Tax Map g<, 62.Block �_ Lot (indicate nearest cross.street). Municipality �t,4TTE72 s c�N Watershed EAST 3pdVc t't SOIL PERCOLATION TEST DATA Date -of Pre - soaking v - Date of Percolation Test I o 0 ---------------- 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 J 3 4 i8 -- �y a3 76 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 Indicate level at which groundwater is encountered cate-level-at-whi-ch--mottling is observed .. Indicate level to which water level rises after being encountered Deep hole observations made by: Date 4L7 Design Professional. Name: Address: Signature:. ➢esip Professional's Sell - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF EI�tV R0- NMENTT -. ]EREA:LT-H-SER'6 E _._. __ . INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project !. !apmw:s lfT )IYi'F��TT� SoN County j yiN/17N1 } Site Location _ r N RX rte. - l 7 9 Building construction begun ,rV o Extent Is property within NYC Watershed? ................. dyes F__J No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) I. a Hilly Q Rolling F_� Steep slope . Gentle slope. Flat 2. Evidence of wetlands F_� Low area subject to flooding Bodies of water ` F� Drainage ditches = F� Rock outcrops sv .gc Bow D�7t S 3. Property lines or comers evident..... ............................ ' ........: Yes dNo 4. Do water courses exist on or adjoin the property? ............................ a Yes dNo. 5. Will these affect the design of the sewage system facilities ?............ F__J Yes E��No 6. Do watershed regulations apply in this development ? ....................... d Yes F No 7 Will extensive grading be necessary? .................. Yes No ...8. , Will extensive fill be necessary " for SS' 1' S? :.:..... ..............................� Yes F No 9. Do filled areas exist within the SSTS area?: ...................... ............ F__J Yes No If yes, what is the condition of the fill? SECTION C. SOIL OBSER ATIONS - -" 10. Appearance of soil: Sand F__J Gravel . Loam ❑ Clay . 0 Hardpan a Mixture 11. Observed from: Borings a Bank cut a Backhoe excavations 12. Soil borings /excavations observed by _ , 7C-SD on 13. Depth to groundwater IVO/JF on 14. Depth to mottling IV P N A:: on 15. Are test holes representative of primary & reserve areas ...:.. ............................... Ye Q No 16. Soil percolation tests made by X o S o on 17. Soil percolation tests witnessed by G', ]K E ETA P,_ G D, J, . on - . SECTION D (on back) -Form ST -1 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes F_71 N 19. Will groundwater or surface drainage require. special consideration? ..................... Yes Zo 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... F-1 Yes SECTION L. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... F__J YesNo Inspection data 22. Do adjacent wells and/or sewage systems exist ?........ . ................. Yes 23. Additional comments 24. Site observer /inspector and title, 25. Date(s) of observation(s)inspection(s) z /ice o / ®� TEST PIT PROFILES Hole # Lot # Hole ,# Lot # - -Hole # Lot # Depth to water Depth to water Depth -to water .. _ _._ Depth to_ ottling_ .._. -_ _ - _:.:. - Depth-to -nottlirtg - -- a.._. Depth to mott ling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L.- ._ _ _ G.L. a . 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 i 01711+ 0.6-+