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01217
AM COUNTY DEPARTMENT OF HEALTH
IVISION -OF E- NVIRONMENTAL-HEALT l-= SERVICES=
FICATE OF CONSTRUCTION COMPLIANCE
PCHD CONSTRUCTION PERMIT #
FOR SEWAGE TREATMENT SYSTEM
Located at 40 LAW OAT VP-NI5 Town or Village ATTF -4 D N
Owner /Applicant Name Faw'*oO 6401A Tax Map 25.0 Block Lot
Formerly Subdivision Name P UTKAA -Lr
Subd. Lot # A+5,, A40
Mailing Address 40 LAf-G7 f o t -l- D !ZI ug� PA'Tr&-F'6 0 A r NY Zip 12�i 6
Date Construction Permit Issued by PCHD
Separate Sewerage System built by Or C:AVA1'lo ^' Address 24 mccv�w y povoL f t.4Wj
l Zti Z
Consisting of 0 Gallon Septic Tank and Wo L-F
Other Requirements:
Water Sunoly: Public Supply From Address
or: Private Supply Drilled by Address p�T��� P � � x-o0
-Buidiri i
g yp e "' " .� � �� "'� � 'Has erosion control- lfee`ri "c6mpl'efed7
Number of Bedrooms f�) Has garbage grinder been installed? 00
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 regulatiops of the Putnam County
Date: 01) ®11 rj
Certified by
of Health.
(De i n Professional) /
Address l�sO �`L g A1, Y 1 Il License #
P.E. X R.A.
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 ar ubject to modification or change when, in the judgment of the Public Health Director, such
revocatio ,, m 04fica tio change is necessary.
By: Title: �� Date: 3 ��
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
v
- r
WE L Le.COMrLETj.UDlr%zrUA1
��..�
� .DEPARTMENT OF HEALTH
,r
Q�o- Of P Env{ rnnment:al Healt`Iq Services
PUTNAM COUNTY DEPARTMENT „OF'.HEALTH, .
Office; Use Only
WELL�LOCATION
STREET AOORESS ; . W. ,t TAX GR!O NUMBER:
: ��� R -. �®$�rSf_o VOrk '
WELL OWNER
ADDRESS BIVATE
' .' ku I7g0 Der :DId10 ` Ors. f +d York O PUBLIC
USE OF WELL
1= primary
2 - secondary
RESIDENTIAL O PUBLIC SUPPLY_ 0 .AIR /COND, /HEAT PUMP. 0 ABANDONED.
O BUSINESS O.fARM_ _ O TEST /OBSERVATION O OTHER .(specify)
O INDUSTRIAL O INSTITUTIONAL' O STAND-BY.' 0,
`o
MOUNT OF USE
YIELD SOUGHT 5 gpm. /N0. PEOPLE SERVED -2 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
[]REPLACE EXISTING SUPPLY NEST /OBSERVATION ADDITIONAL SUPPLY
N..SUPPLY' (NEW DWELLING) DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 2� ft.
STAT16WATER LEVEL 20 ft:
DATE MEASURED 0/�
DRILLING
EQUIPMENT
O ROTARY:,. COMPRESSED AIR'. PERCUSSION .. ' O DUG
O WELL POINT 0 CABLE PERCUSSION. O OTHER (specify):
WELL TYPE
y
TI SCREENED O OPEN END CASING OPEN HOLE IN BEDROCK O OTHER.*
CASING
,.DETAILS----
TOTAL LENGTH .
MATERIALS:. ,_STEEL” : 0 PLASTIC' O OTHER
LENGTH..BELOW. GAADE ` ft.
JOINTS: .....:0 WELDED :.(THREADED 0 OTHER
DIAMETER' - in.
SEAL CEMENT.GROUT-. 0 BENTONITE.:OOTHER
WEIGHT PER FOOT Ib. /ft.
DRIVE SHOE:UYES 0 NO ..
LINER: OYES. 0 NO
SCREEN
DETAILS
DIAMETER (in)
'SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN VQ
DEVELOPED?
FIRST
OYES ONO
HOURS
SECOND :;
GRAVEL PACK.
❑YES
D No
cRAVEL:: . .. . . . . .. ... .
SIZE
DIAMETER
OF PACK In:
TOP
DEPTH fL
BOTTOM
OEM tt.
WELL YIELD TEST If detailed pumping
METHOD: O PUMPED i tests were done is in-
w ^MPnESSED A!R i formation attached?
O SAILED O OTHER o:0 YES ., .0 NO
if more detailed formation descriptions or, sieve analyses.
WELL .LOG are available; please attach.
DEPTH FROM "
SURFACE
Water Well
gear- 013-
ing meter.
In
.: FOR!,tATIOM DESCR!?f!OH
ON
t.
1t.
WELL•DEPTH
IL
DURATION'"
hr. min.
DRAWOOWN
ft.
YIELD
9Cm
Surface
o grime o
d5
I
y
Soft we® Ie e
220
2 30
.220
3
HOPE g 0
285
G
o
260
20
723
285.
,
H®M grey white grit teo
WATER .. X(CLEAR :
QUALITY O CLOUDY -,.,HARDNESS
O COLORER. ? yMyES ONO
ATTACHD
STORAGE TANALYSIS
CAPACITY, GA I0
PUMP II�FORPdATIOtI
TYPE ubmrsible CAPACITY I.
FAKER DEPTH
MODEL 12, VOLTAGEM.HP
WEu DRILLER NMI,_ MILL -DRILLING' INC o oa
ADDRESS :' pllenl.� _ slGia,
Br te6 NY r$ Mo M1110 President.
3/69
Jan 07 05 01:,09p TOWN OF PRTTERGO 845-878-2019 P•1
JAM-07-2005 12:10 PM HARRY id NICHOLS' 914 279 4567 P.02
BRUCE L FOLEY
PiA11C mow vk*10; 4 upwa....
OF BEAM—
I Optys-Road.—
1sftwstG4 New Yo;x '10509
Nwgb&IkM4w (flQUI-SUS .-VIC JNQ-171-M F11Vt4)174-6*17
Tmshosipi4pyijan F4x(pw)t7r-6641
7211 ADDRPSSY&RIETCAnON FORM
TAX'w nmuc- M2. 4Co
Ae L. AV-CPDK P P.- N
AMP?
=1) Tow-AMCLAU
77 -7 75
7
Thf, Put== County Depament of Health will not L�ue
ConstructiouCo=p9anceunliss the above P0rM-L--C:0mp1cttd,'1.e., a legal y,911
j4 a3ithosind tows o
MtIBI-' ThislOmis to be submitted'-
vii � ih;'application for it CertMcatc of Contraction Cataphum
January 7, 2005
Putnam County Health Department
One Geneva Road
Brewster, NY 10509
Aft: Robert Morris, P.E.
Harry W. Nichols Jr., P.E.
Patterson Park - Suite 106
2050 Route 22
Brewster, NY 10509
Tel: (833) 2794003
Fax: (845) 2794567
Email: hnengineer@aol.com
Re: Individual SSTS Compliance - Edward Gracia
40 Lakeport Drive
Patterson, NY 12563
Permit # P -13 -91
Dear Mr. Morris:
Enclosed are the following:
1. Five (5) prints of Drawing S -1, "As Built SSTS," dated 01/04/05.
2. "Certificate of Construction Compliance for Sewage Treatment System, ".
dated 01/07/05.
3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment
System," dated 6/15/93.
4. Laboratory Report, dated 06/09/93.
5. "d1/ell Completion Repo lt" dated-06 /415;93.
6. Application Fee in the amount of $300.00 payable to Putnam County
Health Department.
7. "E -911 Address Verification Form," dated 01/07/05.
If there are any questions concerning the enclosed, please call.
Very truly yours,
H ry W. Ni hols Jr., P.E.
HWN:jmm
04- 014.00
,�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SU13SURFACE SEWAGE TREATMENT SYSTEM .
Owner or Purchaser of Building Tax Map Block Lot
Building Constructed by y TownNillage
Location - Street Subdivision Name
p—E`) t Df5t-t c,v�
Building Type
A464
Subdivision Lot #
I represent that I am wholly" and completely responsible for the location, workmanship, material,
. ' ..
construction and"drainage of the sewageireatment system serving the'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`.gt�arantee to the owner; his successors, heirs or assigns, to place in.good op.e.rattng.condition
any parr =-of said `9ystetn constructed by me which fails vto operate for. a period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, 'or. any repairs made by me to such system,..except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing,the
system. _...... _.._.._..
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 .0 b Day � Year Signature: _
Title:
�2
General Contractor (Owner) :Signature
cv�a,r 6N.
Address:;...G�c.
corpoiation)' :> `Corpo ` to ame (if'� corporate ri)
r pD::.:. ::p�1 ~ o►d y' };Address�:�q hd UST...
-
State Zi �G State ,Q L1� lNs Zip
1' �� �
Form GS -97
Northeast
n29, 6AIlIl Street
06037-9990'
RAW
REPORT 'TO:
Mill Drilling Inc.
Putnam Avenue
Brewster, NY 10509
C'T.Destitflcmtionn: PHA -0606
EPA Certification: CT -024
USDA Certilficai>tion"i' '0976
LABORATORY REPORT -- WATER SNIPPILY TIESTIIZG
-- Sr't&IPLE SITE.t-
Edward Garcia
Adrian Road
Patterson, NY. 10509
SOURCE:
New Drilled Well
DATE SAMPLE COLLECTED:
TIME COLLECTED:
COLLECTED BY:
DATE RECEIVED @ LAB:
DATE(S) TESTED:
TESTED BY:
PURCHASE ORDER NO.:
REPORT DATE:
6/2/93
5:00 p.m.
Mill Drilling Inc.
6/3/93
6/4/93
M.L.
N/A
6/09/93
SAMPLING POINT
Not Given
TREATMENT:
None
TEST PERFORMED RESULT: RECOMMENDED LIMIT
BACTERIAL: Mg/L = Milligrams per liter.
Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml
ICHEMISTRY:
Chlorine Residual 0.00 m /L - - - --
._....:..RESzUL 51A5ED,ON - -SAIi PL)ES- S'U-BPATTT 7-ID /DOLI.IjuC'TLD: - • 6/3/93 - ..3... ...._.....� ._._.. _.... .._..._ _ _
SAMPLE, LIE, AS TESTED ABOVE: E POTABLE or ONOT POTABLE
,PER STATE OF CONNECTICUT DEPT. OF HEATH SERVICES STANDARDS FOR POTABLE WATER)
co AAO�n,�
Director
CT: (203) 828 -9787 o>r -800 -825 -0105 / OUTSIDE CT: 1 -800 -554 -1230
I/
DIVISION OF,ENVIRONIVIENTAL HEALTH SERVICES
COUNTY OF PUTNAM -STATE OF NEW YORK
IN TIM MAT ) R OFT COMPLAINT AGAINST
�G1
RESPONDENT(s),
P t Jul �2
Arising ut of the Alleged Violai ions of the Public
g g
Health Law of the State of New York, the Sanitary . Code
of the State of New York, the Sanitary Code of the County
of Putnam, and Administrative Rules Regulations and
Standards Promulgated Pursuant Thereto
STIPULATION
OF DISCONTINUANCE
CASE NO.
Facility No.
&,e4
IT IS HEREBY STIPULATED AND AGREED by and between the respective parties hereto that the
within matter is hereby terminated upon the following terms and conditions.
1. The Respondent(s) admit the truth of the allegations set forth in-the Statement of Charges....
2. ThatXespondent(s) represent:
it is in compliance-with the Code(s).
it will be in compliance with the Code(s) by
90
El
That Respondent(s) understand an appropriate civil penalty may be • posed b , e
Eby Order which amount will be determined at the discretion o ti u lic eat � r..
That in mitigation Respondent(s) Asserts: 6)4"
LA
DATE: a
Brewster, New York 10509
• i s0-
STIPULDISCONTAFFDV
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B.^• ' ^ A•! • ta...b . ^ qn t ,.v! M' � r I .nn "4 Du b •M tit ?oar , �Yi•� ! 1 � •n � M t
N9 d. -..ry r • ®� '4 h'N` m w ii�W U' :Y t♦ n "AMP, r.ry�..y. 1 .gal a
m r 4w~«�►s. a ".a � ti•!. r a t r to ut h ., ^
PAUL P. PIAZZA
Building Inspector
TOWN OF PATTERSON
CODE _ENFORCEMEI\NT_.,,4>�FJ�E.. .....�_--- .._:........_.._ _.......,._... _... _
_._ _.. PUTNAM COUNTY
P.O. Box 470
Patterson, New York 12563
December 9, 2003
Mr. & Mrs. Edward Gracia
40 Lakeport Road
Patterson, New York 12563
RE: TM — 25.63 -1 -46 ,
Building Permit # 1905
Dear Mr. & Mrs. Gracia,
Telephone
(845) 878 - 6319
Fax
(845) 878 - 2019
Thank you for meeting with me on December 1, 2003. As I explained to you, the
reason for my request was to see for myself the status of the open building permit,
number 1905. This permit was issued in 1993 and to this date, remains open. The permit
was issued for a single family, three - bedroom home with an attached two -car garage.
During my inspection, the following items were observed and need to be corrected. This
inspection is not to be considered a final inspection and there may be other items that
need to be addressed.
._.. _. _.._ __ . ..... 1. The fourth bedroom in tliebasenient is to lie iemoved.
2.
The furnace room door hinges need to be adjusted .so that the door is self -
closing.
3.
The furnace room ceiling needs to be fire rated with a one -hour rating.
4.
Handrails need to be installed on all stairs, both interior and exterior.
5.
Smoke alarms are to be installed in all three bedrooms and in the common
hallway on the second floor.
6.
Smoke alarms are to be installed in the first floor and basement ceilings.
7.
The door from the mudroom to the garage needs to be self- closing, self -
latching.
8.
The handrail on the rear deck is leaning and needs to be re- secured.
9.
The Putnam County Health Department permit has not been signed off.
Due to the fact that you are living in the residence, it is imperative that this be
accomplished as soon as possible. Please be advised that at this time you are in violation
of not only the Town of Patterson Town Code, the State of New York Building Code but
also the Putnam County Health Department rules and regulations.
Until such time that the Health Department_issues..are resolved, your,- building - permit is - :- being-placed on hold. Please contact this office when the matter is resolved. If I do not
hear from you within 60 days, I will be forced to issue a Court Appearance Ticket.
If I can be of fiuther assistance, please contact my office at 845- 878 -6319.
Thank you.
PPP /cs
Sincerely,
Paul P. Piazza,
Building Inspector
cc:. Robert Morris, Putnam County Health Department
�.
_ -.._ .. LORET"T -A. - MOVINF.RI.•:'.V:; �4.S:N, - - - . - .
Acting Public Health Director
Director of Patient Services
_..... _ .. _ _ _ ...� .._ .. - �•-" �OBERT� J: ' BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 ; 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (84)) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
OFFICE USE ONLY
/if0
Re:
Dear
Letter of Continuance
Case#
This letter is to inform you that Eric S. Zaidins, Esq., an Administrative Law Judge, has
order that the informal Hearing of
Id—
J 1/ Case # will be
�1 t
continued on , at A.- M..,at the, Putnam, County .
Department of Health, 1 Geneva Road, Brewster, NY 10509.
Should you have any question relative to this matter, do not hesitate to contact me at this
office.
Sincerely,
Rick Carano
Supervisor, Public Health Protection
RPC:tn
(CONT'D LTR OFFICE USE – RC)
LORETTA MOLINARI
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental health (845) 278 - 6130, Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
CERTIFIED RETURN EIlD RECEIPT REQUESTED
Mr & Mrs. Edward Garcia
40 Lakeport Road
Patterson, NY 12563
Re: Case No. 117 -04 -19
Facility No. P -13 -91
40 Lakeport Road
Dear Mr. & Mrs. Garcia:
ROBERT J. BONDI
County Executive
September 1, 2004
The Hearing scheduled for September 1, 2004 has been rescheduled for October 6, 2004
at 9:30 A.M. in the Hearing Room, at the Putnam County Department of Health, 1
Geneva Road, Brewster, New York 10509.
Sincerely,
Rick Carano
Supervisor, Public Health Protection
RC:tn
cc: R. Morris
G. Reed
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OF PUTNAM -STATE OF NEW YORK
_. _._._....._ _.___.__ ..-- - ,.
_.�.____ . .� ._._. __._.,.._ - _- ..- ......- - - - - .. -.
-_.
IN THE MATTER OF THE COMPLAINT AGAINST i
Mr. & Mrs. Edward Gracia .
RESPOND- ENT(s), :
Arising out of the Alleged Violations of the Public NOTICE OF HEARING
Health Law of the State of New York, the Sanitary Code CASE NO. 117 -04 -19
of the State of New York, the Sanitary Code of the County Facility No. P -13 -91
of Putnam, and Administrative Rules Regulations and
Standards Promulgated Pursuant Thereto
TO: Mr. & Mrs. Edward Gracia PREMISES: 40 Lakeport Road
40 Lakeport Road (T) Patterson
Patterson, NY 12563 TM# 25.63 -1 -45 & 46
Permit #P -13 -91
PLEASE TAKE NOTICE THAT CHARGES have been preferred against you to the effect that you
have violated the health laws as more fully set forth on the reverse side of this notice:
YOU ARE. HEREBY SUMMONED TO APPEAR at a hearing to be held under the provisions of the
Putnam County Sanitary Code and Public Health Law of the State of New York before Eric S. Zaidins,
Esq., an Administrative Law Judge of the Department of Health of the County of Putnam on the 1 s`
day of September 2004 at 9:30 A.M., in the Hearing Room, located at Route 312, 1 Geneva Road,'
Terravest Corporate Park, Brewster, New York, at which time the charges will be informally discussed,
and such adjourned dates as may be designated.
AT ALL TIMES YOU WILL HAVE THE RIGHT to be represented by counsel and the right to deny
the charges, in whole or in part, following which the matter *wff be 'rescheduled io a'date certain 'and a
Formal Hearing will be conducted thereon, and a record of all the proceedings will be made, witnesses
will be sworn and examined and cross examined, and documentary evidence maybe offered and received,
and you may produce witnesses and evidence in your behalf;
AT THE HEARING; IN THE EVENT YOU WISH TO ADMIT TO THE CHARGES, the Hearing
may be terminated by written stipulation of discontinuance provided the violations have been corrected;
UPON YOUR FAILURE TO APPEAR, a warrant compelling your appearance may be issued or an
Inquest Hearing conducted and a determination made;
CIVIL PENALTIES up to $1,000 for a single violation, per day, may be assessed against you,'and such
further orders may be made herein. as the circumstances may warrant; THE BOARD OF HEALTH may
issue a warrant to any Peace Officer of the County, pursuant to Section 309 of the Public Health Law, to
bring to its aid the power of the County whenever it shall be necessary to do so, with the same force and
effect as if such warrant had been issued out of a court of record.
PUTNAM COUWY BOARD OF HEALTH
DATED: August 13, 2004 BY:
Brewster, NY 10509
Public Health Director
STATEMENT OF CHANCE
1f 1S HEREB e ALLEGED THAT -THE P EI`'O°NS-HEREIN -BEFOR NAN/iC�.i� D RESJF�DI�YD EKTS
are charged with violations of the Health Laws of the State of New York and the County of Putnam as
follows:
PUBLIC HEALTH LACY OF THE STATE OF NEW YORK
Violations of any and all provisions of the Public Health Law of the State of New York and the State and
County Codes and Administrative Rules and Regulations promulgated pursuant thereto — which shall be
found to be found to constitute a NUISANCE, particularly, and not limited to the provisions of Article 13
of the Public Health Law.
SANITARY CODE OF THE STATE OF NEW YORK
PUTNAM COUNTY SANITARY CODE
Article III, Section 2e - August 11, 2004 site visit shows evidence of Sanitary Sewage Treatment
System being utilize without a Certificate of Construction Compliance.
ADJOURNMENTS: Public Health Law violations are serious. They affect or may affect the.
health, safety and welfare of the community. They cannot be permitted to go on indefinitely.
Casual adjournments or hearings will be granted. Applications for adjournments must be made in
person or by counsel to the Hearing Administrative Law Judge at the time set for hearings, except
for legal excuses. Persons operating an establishment, business or facility without a permit, for
which a permit is required - will not be granted an adjournment. Health matters are involved
and the Public Safety is a paramount consideration.
I,M: t11
cc: L. Molinari 0
R. Carano
R. Morris
File ❑
i
HEARINGS JANUARY 5,
2005
1/3/20U5
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:.:.w«�:,m.�ta.z .R:me..,n ,t ,.� x.n:.'ean=
.r
JOANIE'S OLD SPRUCE HELL INN
162 -04 -02
39 -AA78- B.S.
09:30 A.M.
12/24/04
WATER CONDOMINUM W.S.
169 -04-01
A.B.
09:30 A.M.
12/13/04
,
COUNTRY HILL ESTATES W.S.
170 -04-01
A.B.
09:30 A.M.
12/10/04
t
NEMAREST CLUB W.S.
171 -04 -01
A.B.
09:30 A.M.
12/17/04
ARCHER ROAD W.S.
172 -04 -01
A.B.
09:30 A.M.
12/10/04
ALPINE ACRES W.S.
173 -04-01
A.B.
09:30 A.M.
11/9/04
t
GRACIA (40_�LA_I£EP_ORT ROA)�
M `
0930.A.M
8 MILLER AVENUE APARTMENTS
163 -04-01
A.B.
10:00 A.M.
12/10/04
,
12 CROTON FALLS ROAD APART.
164 -04-01
A.B.
10:00 A.M.
12/10/04
ENERGY BUILDING CORPORATION
165 -04 -01
A.B.
10:00 A.M.
12/10/04
i
R & J's EAST END DELI
144- 04 -34A
39 -AT37
MAB
10:00 A.M.
GARRISON LANDING W.S.
059 -03 -01
A.B.
10:00 A.M.
RAINBOW W.S.
176 -04-01
A.B.
10:30 A.M..
12 /10/04
SIGORJONSON /SAMANTHA LANE
147 -04-19
B.H.
10:30 A.M.
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Page 1
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LORETTA
Acting Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
O FIFRC E USE ONLY
lie. �PP S. 9 po,TiF�njl V. � t;7_5_0
C) �I�KWOAr
Re: Letter of Continuance
..Case # W -0 f ./7
Dear
ROBERT J. BONDI
County Executive
This letter is to inform you that Eric S. Zaidins, Esq., an Administrative Law Judge, has.
/
order that the informal Hearin Si MOCase'# of �l ~� will be
_.coi1tirilzed'_ .on. .. )
- !� -at ..9 ,13 A. Ni: -at the Putnam County-...
Department of Health, 1 Geneva Road, Brewster, NY 10509.
Should you have any question relative to this matter, do not hesitate to contact me at this
office.
Sincerel
Rick Carano
Supervisor, Public Health Protection
(CONT'D LTR OFFICE USE — RC)
f _.-._ _...�
LORETTA MOLINARI R.N.,
Acting Public Health Director
Director of Patient Services
a
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 27,8 - 6014 Fax (845) 278 - 6648
OFFICE USE ONLY
Re: Letter of Continuance
Case # W -a
ROBERT J. BONDI
County Executive
Dear
This letter is to inform you that Eric S. Zaidins, Esq., an Administrative Law Judge, has,
order that the informal Hearin of S'i . QM Case # l -0~ will be
-.
ccL�tinue�i. orC..L 1. �at A: M: at "�h Fuui�u3r Cuirr�ty
k
Department of Health, 1 Geneva Road, Brewster, NY 10509. ,
Should you have any question relative to this matter, do not hesitate to contact me at this
office.
(CONT'D LTR OFFICE USE - RC)
Sincerel ,
Rick Carano
Supervisor, Public Health Protection
�.526 170 670 P—
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Division
110 OLD ROUTE SIX CENTER, CA
APPLICATION TO C
.7
T. •OF'..RE
RMEL, N:Y
h Sv •
225 =0310
E'
ITER WELL
PCHD PERMIT,#
WELL LOCATION
trees Address
T Village Cis ;Tax', Grid Numb r
WELL OWNER
Name Mailing? A/d ss $' Wrivate
�. O Public'
E OF WELL
RESIDENT
C PUBLIC SUPPLY Q AIR /COND /HEAT PUMP`;, O;ABANDONED
primary
0 BUSINESS
0 FARM 0 TEST` /OBSERVATION ,0 OTHER (specify
2 - secondary
0 INDUSTRIAL
CIINSTITUTIONAL 0 STAND-BY
AMOUNT OF USE
- YIELD SOUGHT
5 7°
gpm /Il PEOPLE SERVED �r' /EST. OF DAILY�USAGE- gal
13 REPLACE EXISTING SUPPLY 0 TEST/OBSERVATIOON
M ADDITI,ONAL SUPPLY
REASON 'FOR
DRILLING
NEW UPPLY
EW DWELLING) 0 DEEPEN EXISTING WELL
DETAILED
Y7-, � J
REASON FOR,.
DRILLING
WELL TYPE
MDRILLED
® DRIVEN ®D UGC - ^Q
GRAVEL.:'--;
OTHER
+'Q
IS WELL SITE SUBJECT TO FLOODING? YES 3_ L NO�
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: "g
Lot
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE:
YES
NAME OF PUBLIC WATER SUPPLY: /t) TOWN /VIL /CITY
_.- .DISTfiPTC--iO-- FRCyi'EItY- FROM NEAREST WATER' "MAI'N:' ` '-/��� .;.- __...,_......_.._..,...�.. ,
-
LOCATION SKETCH & SOURCES OF CONTAMINATION PROV
�ON SEPARATE SHEET
(date) signature
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirti� (30) days of the co0 mmpletion of water well construction, the applicant shall:
1. Pump the well'until the water is clear.
2. Disinfect the'well in accordance withrthe requirements of the Putnam County Health
Department attached to this permit.
0
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such �a manner as not to degrade or loth wi e contami ate surface or groundwater.
Date of Issue: _19 Z/ ��✓
Date of Expiration V 19 q 3 Fe it Issuing Official
Permit is Non_ Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
J
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225-0310
October 9, 1991
Randolph Laurent
73 Fairfield Road
Patterson, MY 12563
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Re: Proposed SSDS: Gracia
Adrian Road
(T) Patterson TH 025.63 -1 -45,46
Dear qtr. Laurent:
Revien of plans and other supporting documents submitted at this time relative to
the above- captioned project has been completed. Comments are offered as follons:
1. Lot area, design plan, subdivision name and subdivision lot numbers have not
been noted on construction permit.
2. Deep test hole data notes ledge at 6 feet in test hole 1. This nould require
1 foot of R.O.B. fill. Revise plan accordingly and note volume and fill
specifications. A /
3. 'Lab_?- •propcood -and existing veils on- pla;ae t L�!
4. Pump pit dimensions, elevations for alaro, on, off, etc., dose volume has not
been noted on plan. O �i
5. Actual SSDS hydraulic profile has not been shorn on plan.
6. Equal distribution system is to be utilized nhen a pump system is proposed.
Lateral to be dosed are to be of equal length. Distribution boas detail is to
be shorn on plan.
7. Neighbor notification is required as per outlined in the Putnam County
Program Revien and Policies.
Upon Receipt of a submission, revised to reflect the above comments, this
application hill be considered further.
der ;;-; ours ,
9MW
Robert Norris
Assistant Public Health Engineer
RH /jp
`
. T
Pur, ; .CO(.JNTX.br'l'� Or, fiEALTd': .
DIVISION OF FNVIl2CPI2�rAL' "'F�ALTfi _= S�TZVTCFS
1
'
DESIGN DATA SHEET- SUBSUFACE vSEKPGi DZSA'KAL. cvcTlu tii�E 'i�TJ.
-
Owner 6109 42 1,4 _ Ac dress
Located at (Street)'. D%z //T7o %7417 ° ` . ,. +See_- �� Block Lot �(o
( indicate nearest cross strut)
..
�s ` {
municipality .. �7� 3 ' Watershed
GQB 771
SOIL' PE20QLATION TEST nATP, RDC)CllII.M TO BE ..SUBMI -= WITH APPLICATICNS
Date of Pre- Soaking 1 Date of Percolation Test
HOLE
NUMBER CLOCK TIME PrRa1=CN '
PERaOIA'I`ION
Run Elapse Depth to Water From Water Level-
NO. Time Ground Surface In Inches
" Soil Rate
Start -Stop Min. Start Stop Drop In
. Min/In Drop
G ° T # Z Inches Indies Inches
'f 1l 2
o - /o.d4-
ZZ"
s'
4
1 101,05-119.-Z-6 : ZI Zd"
4
3"
3�
2-311
�. 7
�7
7 o.
210 2-6 -'10 Y9 L� �o�_.. _ _._Z3''. 3' To
3 /o; 4.8 -
'lo 27- Zolt Z3 3•.
7.3
4
5
1
'
2
3
4
S
NOTES: 1. Tests. to be repeated' at same depth until apprcxiaately equal soil rates
are'obtained at each. percolation test hole. All data to' be suimdtt0d
for review.
2. Depth measurements to be made fron top of hole.
rev. 9/85.
i,
INDICATE 1= AT. WHICH GROUNDWATER IS EN
INDICATE L=mmmai WATER LEVEL RIM AFTER G EMOUNMERED • DEEP BOLE OBSERVATIONS MADE BY: i 7-c 9c _DATE: _4LO/z/
DESIGN
Soil Rate Used 6,1 0 min/I" Drop.- , 0.90 S.D. Usable Area provided
No. of Bedrooms Septic Tar-j-, Car-le-city s- C!
Absorption Area Provided By 6 a & L.F. x 240 width trench
I Other
0A),L,:
LAUReAtT F_A1GiA1oEiA1G
Name 43_$0C1ATES.1 P•c.- Signa
Address. 73 rAiRFIEzo QgovE SEAL
V.
TTERSoAl A1,6V__Y_0R1-z 1z
THIS SPACE MR USE BY HEALTH DEPARM4ENr ONLY:
3oi1 Rate Approved ...; sq-ft/gal. Checked by Date
c ti 71", yl 3 3
PUTNAM COUNTY DEPAFtTMENTYi OF HEALTH
APPLICATION FOR APPROVALS OF PLANS =FOR A``WASTEWATER'DISPOSAL SYSTEM fl ,
1. Name and. Address of Applicant. F Vl
6,
2. Name of Project: fROPO S &`� SS DS 3. _. Location T/V /C: ��!'T�`?2SOP3 .'
4. Project. Engineer: Kiq DOL1014 l,1)•)- %10E7AJT 5. Address: 75 F/1 //?F/EZZTPDIE'
License Number: Phone
6. Tvoe of Pro ect: ;
l� Private /Residential Food .Service ...Commercial
Apartments, Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject to State Environmental Quality Review (SEQR)?
Tvpe,Status (Check One) Type I.. Exempt
Type II. Unlisted _—
8. Is a Draft Environmental Impact Statement (DEIS) required? ............. /yy
9. Has DEIS been completed and found acceptable by Lead Agency? ........... /J /A
4 _
10. Name of Lead Agency A2 II �
11. Is this project _ .__lc�cai . n.lAnni.ng., .zoning,
�or other officials aordinances ?r. the. contr_, o l._nf•..••........••......•..•: A9 0
12. If so, have plans been submitted to such authorities? 4
ties? ..................
13. Has preliminary approval been granted by such authorities? ��fi- Date Granted:
14. Type of Sewage Disposal_ System Discharge...... Surface Water-2( _Ground Waters
15. If surface water discharge, what is the stream class designation ?........
16. Waters index number (surface) ........• ... ............................... 41�
17. Is project located near a public water supply system? ..... .............. A)
18. If yes, name of water supply :)o Distance to water supply
19. Is project site near a public sewage collection or disposal system ?..... NO
10. Name of sewage system x)14 Distance to sewage system
A. Date observed: 23. Name of'Health Inspector: . (794,1012
4. Project design flow (gallons per day) ...... ............................... ��
25 Is:,State Pollutant Discharge-Elimination System (SPDES)�- P.ermi,t required ?.. A7D
26 Has SPDES•Applicat`ionbeen` submitted to local DEC Offi e? ..............
'2 Is any portion of this project located, within a desi :gnated Town or State
° land ? ............... ¢. ................... wet . . .....
l�28. _Wetland ID Number ...................... ......°o e .....: >............
.
29..J s Wetland Permit• required? ............o . ..................o............
Has application been made to Town or Local DEC Office?
..................
/om
p� 0
No
30." Does project require a DEC Stream Disturbance Permit? ....o ..............
;:,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 or NO
32. Is project located within 1,000 feet of existence of abandoned landfill,
hazardous waste site,* salt stockpile, landfill, sludge disposal site or l) 0 .
any other potential known source of contamination? ........... _YES or NO
DESCRIBE:
33. Is there a local master plan or file with the Town or Village? ...........
34. Are community water, sewer facilities' planned to be� developed within 15 years?
35. Are any sewage disposal areas in excess of 15% slope? ........................ A C�
36. Tax Map ID Number ........... >.. .................. .......... ...... .....a f.�
37. Approved Plans are to bes returned to: .................. Applicant iC Engineer
Yf the application is signed by a person other than the applicant shown in Item 1; the
application must be accompanied by a Letter- of Authorization. Failure to comply with this
provision may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information prodided on this
form is true to the best of my &nov7edge and belief. False statements made
herein are punishable as a Class A aisdemeanor pursuant to Section 290.45 of
the Penal Law.
0
SIGNATURES & OFFICIAL TITLES
MAILING ADDRESS:
t � .
PUTNAM COUNTY'
DIVISION OF ENVII
Re'' of
ITT ♦TT1lT1TT ATE >•iT }y y.i �'�, .�
ERVICES
F a
Located at
(T) r T rz�g ection o2!5`.;,&'?j ..,"Block ;`` /' Lot
Subdivision of
Subdv. Lot # Filed
Gentlemen:
p # Date
This letter is to authorize k,,4 7- d��f/
a duly licensed professional engineer X or registered architect
(Indicate
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my'�behalf,in�
connection with this matter and to supervise the construction of'said
zcnformity ,with the -provisions. of A t-_:-cle. 111-5 or.
147, Education Law, the Public Health,Law, and the Putnam County Sani-
tary Code. ; OF NEW N C
r �P� «uAM
06 4
J Ti uJ
Countersig o 1 �g�
0 45 ,/
R.A. , ��(DP-E. '.' ; P
Address
Telephone
/t ^l
Very truly yours,
i
gned`�... FA2�6
::Z - a,
Owner of Property
Address _
Town
Telephone
LAURENT ENGINEERING
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
?ATTERSON, NEW YORK 125133
(914) 278.6108 -(FAX) 278.2658
HARROY W. CHO S JR.,, PE. CONSULTING SITE ENGINEERS
October 18, 1991
Putnam County Health Department
110 Old Route Six Center
Carmel, NY 10512
Atta Robert Morris
RE: Proposed S5DS
Adrian Road
Patterson, N.Y.
Dear Bobo
In response to your review letter of October 9, 1991, we offer
the following:
le Lot area and design flow have been added to the
construction permit. Subdivision name and subdivision
lot numbers do not apply. Please destroy the old
construction permit and replace, it with the enclosed
one.
20 One foot of R.O.B. fill had been indicated on the plan
and volume and fill specifications are now shown.
3.
Existing and proposed wells and SSDS °s have been
4e Equal distribution and laterals of equal length have
been provid.edo Distribution box detail has been shown
on the plan.
Enclo "sed are four (4) prints of the following:
SS -1' "Proposed SSDS' °, revised 10 -13 -910
And one (1) copy of the following:
"Construction Permit for Sewage Disposal System",
dated
9 -25 -910
Kindly review the enclosed items and contact us with your
comments and /or approvals.
Very truly yours,
LAURENT ENGINEERIN ASSOCIATES, P.C.
Randolph W. L urent, P.E. `"�'`�'''•�-- •° �..''�a
RWL :bd Nv
i'f.l.l,_,
91030
encs o
cc: E. Gracia
JOHN N. CALBO
Building Inspector
i
/ V
TOWN OF PATTERSON
PUTNAM COUNTY BBB —ssis
PATTERSON. NEW YORK 12563
Laurent Engineering
Associates, P.C.
73 Fairfield Drive
Patterson, New York 12563
RE: Edward Gracia
Slater Road
Patterson, New York
October 21, 1991
Dear Mr. Laurent,
As per our conversation relating to the above mentioned
property, according to Patterson Town Code, Mr. Gracia's
property is considered to be a buildable lot with the stipulation
that it receive Department of Health approval.
-•- If I.may be of further assistance, please do not
Hesitate to contact my ofgice:
Sincerely,
J N. albo
lding Inspector
JNC /cs
.......... ....
. .
L. AUR .EN,T- .ENG1- N- EER- I- NG.._....
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
PATTERSON. NEW YORK 12563
914.278.6108 .
?�
\
CONSULTING SITE ENGINEERS
Date: 10 -21 -91
To: Putnam County Health Dept. Job No.: 91030
Project:
110 Old Route Six Center Proposed SSDS
Carmel, NY 10512 Adrian Road
Attention: �--
p�TO Patterson, NY
Gentlemen: We enclose ( copies of:
O B/W Prints O Reproducibles O Reports O Tracings
O Specifications O Memorandum 0 Copy of Letter ❑
Description: Revision/Dote No.
Letter from Patterson Building Inspector 10 -21 -91
Per your request.
Sent Via:
KI Our Messenger
O Your Messenger
Copy to:
• Blueprinter
• Nand Delivery
O First Class Moil O Special Delivery
0
Very truly yours.
LAUR ENGINEERING ASSOCIATES, P.C.
Per:
Randolph W. aurent, P.E.
LAURENT ENGINEERING
ASSOCIATES, PC.
73 , FAIBEIE1_D DRIVE
- ' PATTERSON, NEW YORK 12563
RANDOLPH W. LAURENT, PE.
(914)278-6108-(FAX) 278.2658
HARRYW.NICHOLS,JR.,•PE. CONSULTING SITE ENGINEERS
I
LIST OF PROPERTY OWNERS
ADJACENT TO
EDWARD; GRACIA
ADRIAN ROAD
PATTERSOH, NEW YORK
59 -1 -4
Alex & Wanda Chewuk
45 Lakeport Drive
Patterson, New York
2563
59 -2 -7'
S. Imbimbo
59 -2 -8
40 Park Avenue, 11E
New York, New York
10016
59 -6 -2
Hazel Martinez
59-6 -3
10 Slater Road
59 -6 -4
Patterson, New York
12563
- 59 -6 -15
James V. & Bonnie S.
Daleo
57 Allen Road
Brewster, New York
10509
59 -7-2
Fernanda Lorenzo
RD3 Highland Drive
Peekskill, New York
10566
59 -7 -3
G. Paul Habersang
626 Riverside Drive
New York, New York
10031
59 -2 -4.4
Paul O. Habersang
626 Riverside Drive,
Apt. L15
New York, New York
10031
V 429
56
58 /, 58
- --- --------
0, ------- I
%
-- -- -----
- - - ---
46
fill
---- — ----- -
-
-------- - --
--------- --- --------
7
------- 45
------------
60
- ------------
---- -- jo I
3,
------------ ---------
- - - --------
VII
- -------------
----------
44
- --- -i
429 :1 44 --- o . I
FOR TUX PURPOSES ONLY REVISIONS sFm-L osmx-r mFoZ—To N—o`--r—'
LEGEND
kz
. . . . . . . . . .
PRELIMINARY
TOWN OF PATTERSON
coumry. N.Y.
A T X 3
S !C'
---NT C� CF
cr -N:
SZS7-E�!S
D7S
20 N1 & SU---CU--IFA -
A D
on
c a-T-e-ENIS
EYS
10
I
PC - t
j
I'
eS
Pre-1969
N--j�bor norifica-LIO-11
Li tre.-)ch orovided
60 f:
rc-) n.
A6 X
10 Lam.
I
sill rot=s
s
100 vr. _lord elev.
200 ft. resen,702.ri, etc. L_j
150
D C CL 2
-7
plans Three sats
_mac; thcrizat c�
I (D SU.-=7�:7. S TCN
CJ s•; i —
Coll c pes "t-s (1) Fi
a=rc F01-2 ce Oth ca
jo,asd pip-is
Two se -s
wall 1=- =r
NTariaLpce Re=.L:e
A-T
Subdivis --oa
Azorovai checkai
1 SsD.s Adi. Lotts Checked
x-aporc,va
w,atland (T-�,m/DEC P= R & D)
Data On DDS PlaIs • Same
� - u —I � �, D E 7� =I- -S 0 -N P! : --N' S
Sawac:a S-11 -11 a1l, arrcw)
-Lil- & D —47,-.=ns- 7
D or i Bck; Tr=---C�-!1Ga11 =rY; =-'g P'
D Serv4ce 17 comer
-Ine
N 1=
0-*
;.Gr
&
&
& Daeo =S
nd e.,czar z: c:1
=vity zlvw,S-az�. C".Ze
tz
Ha.:'.se - INZo. Of- B--3-r,-cr-Ls
Is & ss-LsIS -,;/in 200 0;: p- :JCS c,;
&
(Ti-q-11t.- lot)
pe P-1 7
Fo-.-,se Sawer Ty, :-B -
No 3ar-3s; Max. Ber-s .15" w/cleanou-,
N" DT S:, ON P—T-.N
F-i=—' ds j
10, -t-o P.L. Drivel a\7, jarq-a 'Imes, T:;: O-L ---
20, to Fouma-a-tion wahs
100, to Well; 2001 in D.L.O.D, 130'
100, to st-'rea-m, Waterco,--=
Lake Unc. ex a,
15, F--\o----
n, pc
10 to Wat -r Line
50,
SeStic
101, fr= tO Wall
i.:,), well t. pr- 9
PUTNAM COUNTY (DEPARTMENT OF HEALTH
(DIVISION OF ENVIRONMENTAL HEALTH SERVICES /
FINAL SnT INSPECTION
a' Date: �6 0
Inspected by:
Owner_ _ .
.. - GI 4 .-
Town �,�1rT� �Sonl Permit #
TM # 2- -, 6 ; 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., greater than 15 from STS area....
e. 1 00' from water course / wetlands ............................:.
II. Sewage System
a. Septic tank size - 1,000 ...:....1,250 .. ....other.........
b. ' Septic tank installed level .......... ...............................
c. 10' minimum from foundation .... ............... .................
d. (Distribution Box
1. All outlets at same elevation -water tested...........
2. Protected below frost ........... ...............................
.3... Nfmimurn 2 ft. Original soil between box & trenc]
e. Junction Box properly set .... ...............................
6. Trenches
1. Length required 3 6 Length installed 3j
2. Distance to watercourse measured ..�- (o c-> 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 - 1'/2" diameter clean ...............
9. Depth of gravel in trench 12" minimum .......:.......
�Fi e ends capped ................. ...............................
6 - Pum -o: IDose�� steans _ ... .
. ize of pump chamber ......... ...............................
2. Ovedlow tank .......:............. ...............................
3. Alarm, visual/audio ........:.... ...........:...................
4. Pump easily accessible, manhole to grade...........
5. First box baffled .................. ...............................
6. Cycle witnessed by H.D.estimated flow /cycle.....
IM 16louse/Buildlifig
a. house located er approved plans ........... ... .........
b. Number of bedrooms ....................... ��...: -.....
IV. Well
Well located as per approved plans . ......:........................
b. Distance from STS area measured -'/ o° 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. Backfill material contains stones <4" diameter..........
e. Curtain drain & standpipes installed according to pl
f. Curtain drain outfall protected & dir.to exist waterc
g. Footing drains discharge away from STS area.........
h. Surface water protection adequate ........:..................
i. Erosion control provided ......... ...............................
Rev. E/002
vi
f► co
Sheet.
of�_
�t PUTNAM.:COUNTY DEPARTMENT OF HEALTH:
DIVI$JON.OF,ENVJRONMFNTAX iIEATt NvcFRVICES
.... ;
�,.. , a...
.
FIELD ACTIVITY REPORT
N AMF :i =� -7`- TPI-
An )RF.CC: /�
7
Street Town- State
y
Zip
�� ``�.y•
PERSON IN CHARGE _
(1R TNT_FRVTF?WFn : l'7 4✓.f C
Name and Title
TYPE OF FACILITY:
FINDINGS:Og�1� ..��1/St'��G7'J�iIJ' �.v+`r'i
��&A=T?—X
,1 e2'D ,r2 �22
_ - A5— R73ZV
h;—)F L Y
A 5"
.Signature and Title
RFPORT RFrF-TVFT) RV:
I acknowledge receipt of thi's report: SIGNATURE:
-
0.2/96
Rev. fi
G35
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