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HomeMy WebLinkAbout1399DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 33. -2 -19 BOX 13 �� ,r �,, kv ti . - i` . yf L9 i 01399 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Weil tc cation Street Address: "" " " Town/Village. "" " "- Tax Grid Map Block Lot(s) J 9 Well Owner: Name: Address: i7C� //o L i Use of Well: 1- primary 2- secondary Residential 13u,blic Supply Air cond/heat purdp Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _>( Open hole in bedrock Other Casing Details Total length __CV ft. Length below grade f�D ft. Diameter IO in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other —S—ea-l-.7 Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) Q / During yield test(ft) Depth of completed well in feet ✓77 _J�;7!!5 Well Log If more detailed information descriptions or sieve_ analvses..._.._.. are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 7 / 3 C �- If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 5AL& Capacity 12-1 1,y'lj Depth 320 Model � *i( Voltage 2Z,0 HP Tank Type 60live Volume Ak, AP Date Well Completed Putnam County Certification No. QV Date of R port �' /�' D Well Drille (signature) NOTE: Exact location of well with distances to at least two permanent land -marks to be provi on a separatte sheeVplan. .� ®yam �����. Z��- / 5zl AZ- sa Well Driller's Name :.1 Address: Signature: Date: 42 L White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH O. NVIRONMENTAL -:SEAL TH SIERVIr C.ES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT - SYSTEM - Owner or Purchaser of Building Tax Map Block Lot C6LM �OM I�EALITITI PATT'iF_�2-60 Building Constructed by TownNillage Location - Street Subdivision Name . Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material; construction and drainage of the sewage treatment 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 guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period. of two years immediately following the 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 operare_proI—. is . SPd b; :l:e Mllfi;; or negligent act ofthe 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..b ' g utilizing the system. Date : th m "J Day it— Year � CCQ- .. Signature; Title; ?re General Contractor (Owner) - ature Corporation Name (if corporation) Address: p ' `gyp . �l� LAP- (�`Q�tl�� State Zip Z060rj Wkul-Y Corporation Name (if corporation) Address: �� 60Y, �Ao 6w\1A State N'� Zip K e� Form GS -97 NE NORTHEAST LABORATORY OF DANBURY S�0 �N ACCOg0 0 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 ' ert203) 7 471 cc I.ASiS www.NORTHEAST LABORATORIES.com LABORATORY REPORT REPORT TO: MCGLASSON REALTY INC DATE SAMPLE COLLECTED: 04 /24/02 P.O. BOX 610 TIME COLLECTED: 10:30 AM CARMEL, NY 10512 COLLECTED BY: TM DATE RECEIVED @ LAB: 04/24/02 TESTED BY: LAB #PH11471 LAB I.D. # NY18 REPORT DATE: 05/08/02 SAMPLE SITE: 653 FAIR STREET, RIDGEFIELD, CT SAMPLE POINT: WATER TANK SOURCE: - • - WELL . TREATMENT: NOT STATED MAXIMUM CONTAMINANT TEST PERFORMED RESULTS METHOD # LEVEL (MCL) OR STANDARD BACTERIAL • Total Coliform (Bacteria) Absent per 100 m1 SM 9222B 0 per 100 ml PHYSICALS: • Color (Apparent) 0 - EPA 110.2 15s • Odor ND - - Not to exceed value of 2 on scale of 0 -5* • pH... 6'54..., = ....`...' ::. EPA 150.1. 6.4 to 10 Range* • Turbidity 0.23 NTUs EPA 180.1 5 NTUs* CHEMISTRY: • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 1.0 mg/L • Nitrate Nitrogen 2.8 mg/L as N SM 450ONO3D 10 mg/L Combined limit for Nitrite plus Nitrate • Alkalinity 192 mg/L SM 2320B No defined limits • Hardness <5 mg/L EPA 130.2 200 mg/L • Iron <0.03 mg/L EPA 236.1 0.30 mg/L • Manganese 0.01 mg/L EPA 243.1 0.50 mg/L • Sodium 20.5 mg/L EPA 273.1 28.0 mg/L • Lead <0.001 mg/L EPA 239.2 0.015 mg/L * ** ml--milliliter mg/I--milligrams per Liter ND=none detected MCL--Maximum Contaminant Level TNTC =Too Numerous To Count *No State of Connecticut MCL established. * Levels noted are United States Public Health Service (USPH) recommendations. "•Notification Level ** *Action Level COMMENTS: -All holding times (were) met. SAMPLE, AS TESTED ABOVE: UOTABLE or �OTPOTABLE RESULTS BASED ON SAMPLES SUBMITTED: 04/24/02 i LJa,Q,>�c1- 4�s��trn�u�i Laboratory Director -NORTHEAST LABORATORY, 129 HELL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105.OUTSIDE CT: 800 -654 -1230 C k b� PUTNAM COUNTY DEPARTMENT OF HEALTH L DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIAN E TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT #� ' a Located at 66b r-AA- I C496T Town or Village r ATTEF-60H Owner /Applicant Name he- bLA 6 `504 P-EAIJ, Tax Map d Block 2— Lot Formerly Mailing Address Date Construction Permit Issued by PCHD Subdivision Name Subd. Lot # '51mi3'l Zip i oj J'L Separate Sewerage S,sy tembuiltby 0L6�4,AJ KAL11" Address �060y- CID (APML OK(2- Consisting of 100() Gallon Septic Tank and � 00 4 At),50f, "G J H &RE� Other Requirements: Water Sup"I : Public Supply From Address or: Private Supply Drilled by b� P �E5i-A� �'5V— Addresslos%� Q1 6�_ cp*mo_rl' WVL i�� Building Type -�� Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed? 0 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 pl`nns and the standards, rules and regulations of the Putnam County ep ent of Health. 6 Date: 5 �� Certified by �t, P.E. R.A. e P ofe sional) License # Address 6 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 , o 'ficatio or change is necessary. By: Title: -� Date: Z- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 0 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 Im _.... 2050 Route 22 .......... Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 May 20, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Dear Robert Re: Individual SSTS - McGlasson 653 Fair Street Patterson, NY : Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "As Built SSTS," dated 5/17/02. 2. "Certificate of Construction Compliance for Sewage Treatment System," dated 5/16/02. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 5/16/02. 4. Laboratory Reports, dated 5/08/02. 5. "Well Completion Report," dated 5 /15/02. 6. Application Fee in the amount of $200.0vayable to Putnam County Health Depart ment. 7. "E -911 Address Verification Form," dated 5/20/02. If there are any questions concerning the enclosed, please call . Very truly ours, Harry W. Nichols Jr., P.E. HWN: JM: jmm 00- 161.00a Yurlroumc#W ilaltb (914)211.6130 Pa(914) 271.7921 Nur&Wl Scrvlca (914);7$-655$ WIC (914) 271.6671 F"(914) 278.6015 eulr•r9srv4d6o-(914) 111*- 6014 Presdool (9l4) 278-6012 _ Pa (914) 279% 6641 -• PUTNAM COUNTY DEPARTMENT OF HEALTH s. DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION_ q j< tdcr bT. j5, rgop Street Location -5-1,f Owner Town �,¢j-,7-,-7z:sovy Permit# 1°— a/ -,:P,( TM # Subdivision Lot # 1. Sewage Svstein Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 1% 3:1 barrier Lgth._Width Avg.Dpth c. Natural soil not stripped................... ............................... 15 STS, area.......... e. Stone, brush, etc., greater than e. 100' from water course/wetlands ..................................... 11. S ewag gq4vsten 7RP r tit -C, I -innET rz�,�_nrlh b-. Septic tank in!qlledel ............................................... c. 10' minimum from foundation ......................................... d. Distribution Box III out lets at same elevation-water tested ................. Protected below frost ................................................. 11. Minimum 2 ft.Original soil between box & trenches e. q.uncnon_b.gx_,-_ ppervy..set.. _,pr length rquired & ao _ten--jffi installed o 2. Distance to watercourse measured Ft .......... 3. Installed according to plan ........................................ 4. Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10 ft. from propdtty line - 20 ft, foundations ........... v,' 6-Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 - -1 %Z" diameter clean ...................... . . -9.-D, ep4tri-uigra-vel-irrtrench-1-2" minimurrf.-.-.. ....... ......... -.-, 10. Pipe ends capped ........................ ............................... .00 g Pump or Dosed Systems 1. Size ot pump chamber ............................................... 2. 'Overflow tank ............................................................ ____.3..Alarm,visuaVaudio ................................................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled ......................................... * ......... * ........ 6.- Cycle witnessed by H.D.estimated flow/cytle ............. III. House/Buildmig - a. house located per approved plans .................................... . .. b ?1u b rem of bedrooms- `r" - - - - - - - - - - - Q COMMENTS 'd -measure " Distance — -fflrf� ST 9- are a c. Casing 18" above grade ................................................. 76, d. Surface drainage around well acceptable ....................... V. Overall Workmanship A 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 plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ................ h. Surface water protection adequate. i. Erosion control vrovided ........... : .................................... - --------- ----- --- /8" NOV -26 -2001 06:36 PM HARRY W NICHOLS 914 279 4567 P.02 '.1 .. , _.r._. - .. --s ,.- -- � _ ,, 'yam . _' - ,. � .,_._•_- ,- - __,. .. -. - ,-_. _..ti. � Mai! W � '• Aczor D AD WarM"Embl"o-opm PCHP p 24 -0 4 v �.0 TrOC�iOd' `'I Tb( !r-7 �i- �� ty�trm eo�'tf0ad�w�K I � •19' -fJ/ Is wdt driU�� l _�.j�. • " ----. Dot" e. , u vr�Il140a11d.Y �o�t Ant�� ' I «wy �atLe �pr� a1bmfe1bo�sd `odoa P ad Mutt oa�platloo ud . and yatm r -. t o p um � Of - - Ho" _o -- - .. �plfteaL ..- •- -- __ - • - -- - - - -._ .. ... eud4Wbjr • • Addrox Prolbsriotu! 12-4 Fora FDt . ..... .,� .- .r�r7• nnne� 4 n. AO TCI . Q'dcz- :)7Q -7Q ?9 . .717.• NAMF:PUTNAM COUNTY DEPARTMENT OF P. 2 a BRUCE ' R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LOREITA MOL•INARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 November 29, 2001 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - McGlasson Realty Fair Street, (T) Patterson TM# 33 -2 -19 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: 1. Expose corners of septic tank and cast iron pipe. connection. 2. Rotate the-first junction :box so all inverts work proper v.. ...._.....- 3. A bedroom count needs to be performed by this Department upon the completion of the house. 4. The well was not found at the time of inspection. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide 'tl it SENDING CONFIRMATION DATE : NOV -29 -2001 THU 17:42 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845- 278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME NOV -29 17:41 ELAPSED TIME : 00'39" MODE G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED•.• a k BRUCE R. MEY LORSrTA MM MARL RN., M.S.N. P011- Heald Dfnemr AR0dWV AWk YeaM Deader DEPARTMENT OF HEALTH Oka d Fm7aa S '— 1 Geneve Rod Bmw4w. New York 10509 F.Mnasnitl Hea14 (Wn3A -6t3a Fe Mi)376.79r1 Na^b s"— (64s)37s -6766 wtC (bM276.667! ?a(643)273.6W " tahraed—(un 376.6614 Fn(146)276.66a P-30001(145)221-3912 61[(846)226.6112 November 29, 2001 Harry Nichols, PE . - Patterson Park, Suite lOG _.. -.. Brewster, New York 10509 Re: Field Inspection - MCGlasson Realty Fair Street. (1) Patterson TM# 33 -2.19 Dear Mr. Nichols: The above referenced separate sewage treatment system can be bacidtllad. The following comments must be eottected in the field t. Expose comers of septic tank and cast iron pipe connection. 2. Rotate the first junction box so all inverts work properly. 3. A bedroom count needs to be performed by this Department upon the completion of the house. 4. The well was not found at the time of inspection. If you have any further questions, please contact me at (945) 27 8-6130 ext. 2261. Very truly yours. Gene D. Reed GDR:cj Environmental Health Engineering Aide BRUCE k * FOLEY Public Health Director March 11, 2002 'LORETTA MOLINARI" -RN.-- M.S.N. Associate 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 (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - McGlasson Realty Fair Street, (T) Patterson TM# 33 -2 -19 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. No further comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide SENDING CONFIRMATION DATE : MAR -11 -2002 MON 22:10 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME : MAR -11 22:09 ELAPSED TIME : 00'39" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED.. BRUCE A. FOLEY 1.ORMTA MOLINARI RN., M.9N. Peblee rledU, Dearer AMet" Peblm Hrra1M Domes Dbww aJ Paluw .S.W- DEPARTMENT OF HEALTH 1 Gems Reed Brearter, New York 10509 ammheam..pl Bntlb iNSirn -6130 F..(945)272-MI , Ne W1%ftn1 Ms)77e -67fa WICW$)rn -N7e ib1(143)375-013 nary rw.r.ve a ("211-6014 va(UA2M.ag vrereaaal plA 771 •s9U ha(841)330-6113 March 11, 2002 Harry Nichols, PB 2050 Route 22 Brewster, New Yo* 10509 Re: Field Inspection - McOlasson Realty Fair Shoct, (r) Patterson TM# 33 -2 -19 Dear Mr. Nichols: The above referenced separate sawage treatment system can be backfilted. No &rtber oommaft if you have any further questions, plesse contact me at (845) 278 -6130 ext, 2261. very truly yours, 0, W-4t Oene D. Reed ODR:aj EmAromcutil Health Engineering Aide n Am la y WITH N/ r FAIIANn w`g N/ 1 \ \` FUH5r 2`� tow. 5TRWM -- '-- _ _ _ �_ � � _� -- --- —. �-�`- � _� � '� � -- —_ _— — __ --'_ __ —_ _-_ _� _ —_— - "-�D" •. ,/.-- 511.40' S4 "E 27'44'58 T (DUG WILL) \ \ A561d1 �1z6A01M_ Q9 T91? 310,OT \ - - — - -JrMAJ IC', AC 6-A TOLE WMN LM / F P05r < IZ�UINAM COUNTY 180UTE 60) wM.; M: ftMMiMtMitlA€ MhN/! �3MsMt�PFl lnyMeMfnJ liMell. nsiln, nP+. M- M:: 0.!; inl�tinrl; M5' AJ�: M7nAaM; M;! �n, M: n1� ?MeM:M:MSMtinJlNtinpMS�1!�;M:M M..A.n -M -.M M b n PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - ' - _-CONSTRUCTION PERMIT F®RSEW E TREATMENT SYSTEM PERMIT # 10-a? Located at FAR ST (SECT Town or Village Subdivision name je% i Subd. Lot # JV 1,P\ Tax Map Block Lot Date Subdivision Approved X11 Renewal J Revision Owner /Applicant Name G L I't SSO N K C.. E LT Y Date of Previous Approval Mailing Address V132 ROUTE io G 4 W!– L I N EW ORK Zip w0— �_ rep Amount of Fee Enclosed 300 Building Type A0 vs i Lot Area _(Lo �1 � 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 MOD gallon septic tank and Other Requirements: To be constructed by 71-B p Address 62-0a )c. r, i a6 u. Water Supply: Public Supply From Address Priv__ate Supply_Drilled by 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: R.A. Date 3 ° 1-f Address'-�U 1-1 rZ_ 19(,) V ATTIL.�SO fir; V A�K License # 12-4 205Q ROU T �-_- 22 N�.W joy Ir, \Ogol APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage trer en system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified h n nsiderednecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe, ppro f discharge of domestic sanitary sewage o ly. V o Title: Date: By. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCI ID'Permit # Well Location: Street Address: Town/Village Tax Grid # AI S ��ET PR11P_Qr,0N Map Block L Lots) Well Owner: Name: Address: 1-1'32 ? 0V'T 1= (o MC6LJ CScN REALTY CARMEL pJEvw 10kK 1CGCL Use of Well: _/Residential Public Supply Air /Cond/Heat Pump . Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought S gpm # People Served S Est. of Daily Usage dal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling L^ew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type 4.,6rilled Driven Gravel Other Is well site subject to flooding? ....... Yes No Is well located in a realty subdivision? ..................................... ............................... Yes No Name of subdivision Lot No. _ Water Well Contractor: 'T 13 D Address: _ Is Public Water Supply available to site? ................ .............. ............................... Yes No Name of Public Water Supply: f}— Town/Village Distance to property from nearest water main: N Proposed well location & sources of contamination to be provided on separate she plan. Date: Signature: V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water We 11 iller ce ified by Putnam County. 7R _ Date of Issue � Mlv Date of Expiration p Permit is Non -Trans a ab e Permit Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 14-164 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEAR Appendix C State Environmental 00el)ty Review - -SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Prolect sponsor) 1. APPLICANT /SPONSOR T 2. PROJECT NAME 3. PROJECT LOCATION: Municipality P Rfi^C �RSO/U County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) TAX MAP 3� 6LO Ck- 2 Lod 1� �A1P. S�P.EE� \N PR��EPoS0�1 5. IS PR POSED ACTION: ➢U Now ❑ Expansion ❑ Modl(Ioatiordalteratlon 6. DESCRIBE PROJECT BRIEFLY: PRDPOEn v��LL,S` >> SI ANA 7. AMOUNT OF LAND AFFECTED* �-7 `. �� tt ' .... Initially acres Ultimately — __ � acres IL B. W PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? NYes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? fM Resldentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/FoMt/Open apace 0 Other Dascrlbe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE R LOCAL)? t� _ Yes ❑ No If yes, list agency(s) and permll/approvals P C'" T O W N OG C'A�� ARSON i3�i L�� N 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes No if yes, list agency name and permittapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? d C1 Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Date: — Signature: V ' 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 �-- 4o• _ First Floor . '. . t• E -. .S_ •� •.1 •.....`'- - - DINING ROOK :. _ .......... t'X13' -O' ; 1 � ' • % .2 8 ti M • 1 1 1lAsreR 8EOROON LlVl.YC ROOM 14.1 X 13' . 0 • . 5—' *-J !4'- 0'X 13' • 0' \ PUT!"% 141 41�'U?y.a �I.. J��...^i�C�7wd il'- :Jl'l., ET, iiM •" ! 1. -• - \• • .. .. d'�A t - Il'VV.7l'�1M'+L J «., �%. .Tr•�T>Z. ��...�' ✓lrP..:'4 �. ULX �lll�n .:. .. ... � .. .... a �. p 4 PLANS I U BE TE S, TITLE Ail BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N.; M.S.N. Associate 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 (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 64$ 5, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: McGlasson Realty .. . Fair Street (T) Patterson, TM# 33 -2 -19 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: . 1) Neighbor Notification has not been submitted. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regards. Upon receipt of a submission, revised to reflect- the above comments, this application will be considered further. RM:tn Very -truly yours, Robert Morris, P.E. Senior Public Health Engineer %01 EE . Harav W. Nlchc�is Tr P,E. Patterson Park, suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 Date: 4--Z-2-01 To: Job No.: PC tt u 06— it't. v o Project re ►gas e-c{ S'571 Attention: �� �, d► �'rv�r �� h. „ Y/ 3 3` -Z - i `' Gentlemen: We enclose copies o— -�J� ' • B/W Prints O Reproducibles O Reports O Tracings • Specifications O Memorandum O Copy of letter O Description: ) �)L Revision/Date No. r' L 1q, e/ Sent Via: O Our Messenger O _Blueprinter 0 First Class Mail D Special Delivery D Your Messenger O Hand Delivery O ` Copy to Very truly yours, Harry W. Nichols Jr., P.E. ♦- D ear RE: Department of Health Review of Proposed SewageTreatment System for Property Name:;` Address:`�� Town: Tax Map ,c-I 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 ..yoli_.havP..any_ ,..Pst >o;,s,..concPrns. -or inforrat on.... which. .- ay bea: —:; Department's review of this application, you may call the Health Department at 278 -6130. Received By: - Address: Tax Map #: Very truly yours, By: U Title: August 1997 uT O Q 'Yru`�il� ;o I o-y-t - Postage $ 0.76 UNIT 1I1: 0012 CI M r- Certified Fee 1.90 Postmark rU Return Receipt Fee 1 . Here r� (Endorsement Reouired) O Restricted Delivery Fee'lerl'i' KT717H C3 (Endorsement Required) • �. C3Total Postage & Fees $ 4.16 4/26/01' S M i Al (lease Prinr Gear(yl (t4 b mp�rey bby, r) ............ . ............................ p p Stro-t. Apt. No.; or OU tNd � 1 L Ci 3 �If` 11 3 ..... C: die, LP -a - -.5. . m pl t iP ease r 'Ct a ly) r o -be t omple 'd by mai.'cr'- . jai` __ �.. Mss ..o�_1.C�--------------- - - - - -- S:r et. t. No or P Box No. (T Y .; 1 I C State. ZI^ -a o► n C`i 17— co l:r I to Postage 0 Certified Fee 1 a9 O N CO Lrl Postage $ CO 0i.le Sent To'. IT ID: 0012 O Pf�QWME ' Nf 0 CO s 0.76 UNIT ID: 0012 Postage C7 $ 0.76 m Cervfiec Fee h 1.40 Postmark ru Return Receipt Fee 1.50 Here rA ( Endorsemem Recuireoi I 1.90 Cleric: KT717H 0 Restricted Delivery Fee Return Receipt Fee (Endorsement Required) 1.50 O tEndorsement Reeuired) M O Restricted Delivery Fee (Endorsement Required) & Fees $ 4.16 ]04/.;601. Total Postage ° Jerk. KT717H M - -.5. . m pl t iP ease r 'Ct a ly) r o -be t omple 'd by mai.'cr'- . jai` __ �.. Mss ..o�_1.C�--------------- - - - - -- S:r et. t. No or P Box No. (T Y .; 1 I C State. ZI^ -a o► n C`i 17— co l:r I to Postage 0 Certified Fee 1 a9 O N CO Lrl Postage $ 0.76 IT ID: 0012 O CO 1 M I'- Certified Fee OPostage $ 0.76 UNIT II- 0011 M fl- Certified Fee Postmark M Return Receipt Fee (Endorsement Required) 1.90 1.50 Here Return Receipt Fee (Endorsement Required) 1.50 Postmark Here M O Restricted Delivery Fee (Endorsement Required) O Restricted Delivery Fee OO Total Postage & Fees $ ° Jerk. KT717H M (Endorsement Required) Nam_VPlease Print Cleart, to be compleled-b - 7 Total Postage & Fees $ 4.16 ! 26/01 M S Nppqq!�e (Please P (Clearly (to be comple by mq'ler) ...... t Str�et, AFL No.; o/ Po 8o ^--•---..\ - -....- ✓ Q ' M cir ,ware, zrP +e - Ids 1. PS . :,, M __O ' CO 1 .bD,V t d VP +j�� OPostage $ 0.76 UNIT II- 0011 M fl- Certified Fee 1.90 ru Return Receipt Fee (Endorsement Required) 1.50 Postmark Here M O Restricted Delivery Fee (Endorsement Required) lerk:: KT717H OO Total Postage & Fees $ 4.16 4/26!01 M Nam_VPlease Print Cleart, to be compleled-b - 7 y mat er) Street, ......... . _....-- O Apt. No.; or P ox o. Er :: 777 S f e'&-.A7 III: 0012 Postmark ru Return Receipt Fee r Here (Endorsement Required) 1.50 r-i O Restricted Delivery Fee Clerk: KT717H C3 (Endorsement Required) CI Total Postage & Fees $ 4.16 4/26/01 M Name (Please ' t Clearly) (to be com I t d by mailer) - - - - -- t .......�'5 ...... �^� ' an .............. p-- Stre t, A . No.; or P ox No. ctry C M � �s a BRUCE R. FOLEY T Public Health Director March 27, 2001 _ LORETTA_ .MOLIN_ ARM -RN.; M.S.N. _ _ Associate 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 (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 Harry. Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: Re: McGlasson Realty, TM# 33 -2 -19 Fair Street, Town of Patterson Reservoir Basin - Middle Branch The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 16, 2001 is complete. The Department will notify you by April 16, 2001 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. El 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 would 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 filed the application originally; and a- statement -that a- decisiorris -st�ugiitin'ateordance-wirth section 1'8= 23"(d)'-(6)'ofthd Ne "w 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 complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC 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 DEP review and approval is required. . If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2261. Very truly yours, 4 0, Gene D. Reed Environmental Health Engineering Aide GDR:cj PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SiiEET °FO &CONSTRUCTION PERMIT NAME OF OWNER: Pie, 6 LA55 -04 ffedkrV STREET LOCATION: fAhe 5rx6or- REVIEWED BY: RM,5 AS, SRDATE: �? /0! TAX MAP #: (CONFIRMED) jj. " 9 - / 9 Y N DaCUMENTS �4c—)NO (REQUIRED DETAILS ON PLANS CONT'1)) N'K PERMIT APPLICATION HOUSE SEWER -' /." FT. 4 "0'; TYPE PIPE CAST IRON WELL PERMIT OR PWS LETTER BENDS; MAX BENDS 450 W /CLEANOUT PC -97 RENEWALS LETTER OF AUTHORIZATION (lE,,j�DESSIIGN DATA SHEET (DDS) FILL SYSTEMS (� Z—)FILL RIZONTAL; PAST TRENC :1 TO GRADE SHORT EAF U PEC -5 PLANS-THREE SETS ✓ �) &DIME (-_)()MOUSE PLANS - TWO SETS 3 �� N EXPANSION AREA uTANrF .,,�. FILL GREATER TH.4 � 2 FEET SUBDIVISION UU�,�,Y BARRIER ( rll�i,EGAL SUBDIVISION . ��' , ,:: (_)(_)PERC L_ }(CURTAIN DRAIN REQUIRED \� GENERAL LOCATED IN NYC WATERSHED : /_)PLANS SUBMITTED TO DEP r- W LEGATED TO PCHD . EP APPROVAL, IF REQ'D EP TEST HOLES OBSERVED (� P RCS TO BE WITNESSED (j)( - APPROVAL SSDS ADJ, LOTS b�C:6WETLANDS (TOWN/DEC PERMIT REQ'D?) UDATA ON DDS PLANS & PERMIT SAME REQUIRED DETAILS ON PLANS LZJ�SEWAGE SYSTEM PLAN- (NORTH ARROW) (� SSDS HYDRAULIC PROFILE UGRAVTTY FLOW ( "CONSTRUCTION NOTES 1 -15 ,J )DESIGN DATA: PERC & DEEP RESULTS ( l I., T CONTOURS EXISTING & PROPOSED )DRIVEWAY & SLOPES, CUT ( V,/H_)TITLE FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVISION (� DATUM REFERENCE D(ZJLOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. UUPROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS CC��JWE_LLS-&ISSSDS�S V�/11�i 200' OF SSTS' UUPROPERTY METES & BOUNDS UUERO�� 3IONCONTOL FOR HOUSE; WEI:L & SSTS, EROSION CONTROL NOTE COMMENTS: (IIEVSIIEET)09 /01 /00 (_)(_)DEPTH GAUGES (_JUVOL_._ON FOR RO.B., UNCTA'SSILIFI) & I`IPERVIOUS U RATION DISTANCE FROM TOE OF SLOPE TRENCH LF TRENCH PROVIDED 4 00 LOFT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL (� )GEOTEXTILE COVER SEP_ARATION DISTANCES ON PLAN - FROM SSTS 10' TO P.L. DRIVEWAY, LARGE TREES, TOP_ OF FILL 20' TO FOUNDATION WALLS 100' TO WELL, 200' L I DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10!.TO WATER.LINE.(_w ., 2.(!1...__ .._ - -- _ ___ - ......_._.._.. _.._......._ -- _ >_.._... 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS "10' MIN TO LEDGE OUTCROP SEPTIC TANK ; • 10' FROM FOUNDATION; 50' TO WELL WELL ( )DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION (_MIN 15' TO PROPERTY LINE SLOPE (SLOPE IN SSTS AREA x(520 %) . L)UREGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS (�(�PU14tP A TES UUDOSE 759/6 O VOLUME/DOSE VOLUME NOTED UUDiAYSTOEAGE CE fYP ETC.) U(___)PTHOWN & DETAILED ABOVE ALARiti1 _ C URTAIN DRAIN C-7B__)20'MIN IPES, 5' BOTH SIDES, DETAIL (___) to C 0'.4 %, 25' -3 %, 35'-1% 100 % -<1% (_J to CD DISC 82 cons day discharge U - ERFORATED PIPE PUTNAM�CQUNTY DEPARTMENT OF HEALTH DIVISION. OF ENVIRONMENTAL.IHE.ALTH SERVICES DESIGN* DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM I Owner Address 1-732- Located at (Street) R ST RE_ _T Tax Map _5 Block'. 2— Lot (indicate nearest cross street), Municipality JP k.—\ -T N Watersfi6d FAST' BQNNCO SOIL PERCOLATION TEST DATA 'j Date of Pre-soaking.. lotm 06- Date of Percolation- Test 1111/00 H I ..e N: A 1 ffi.VX. N lb"t -.0t. q e e M 179.11 ro x a. M."16. Ch to 11;1_5 - 12 1) 2- 3 12,11\41 i �o ._ ��1� - Wi�� 4 D C) 2) 5/4 - 2A t f 2__ -3 /4 1-7 2., :5 22 3 4 0 2T4 P/ 20 2 3 4 NOTIES: I Tests to hP. rpno-atsbA at ee..a A +L �:l - -1 -_ _­ r v4ual prawiation rulc&= o0tained at each percolation test hole. (i.e. s I min fb;­1-"30 min/inch, :s 2 min for 31-60 m''iffi/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. DEPTH G.L. 0.5' 1.01 2.0' 2.5' 3.0' 3.5' 4.01 TEST PIT DATA DESCRIPTION OF'. SOILS ENCOUNTERED IN: TEST -HOLES HOLE N0. NO. HOLE'NO. 2 Indicate'level at which groundwater is encountered Indicate level at which mottling is observed. Indicate level towhich water level rises after being encountered Al Deep hole observations made 'by: Date I Design Professional Name: kApR\j\4, Address: 'SOa — I0, (o Signature Design Professional's Seal rr LAJ P OFESSOY� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES (47 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner /4-- Address Fes; f r Located at (Street) i-, a ; Tax Map 33 Block 52- Lot (indicate nearest cross street) Municipality '*A Watershed /yj, pp/ 4 r�rz �tcff SOIL PERCOLATION TEST DATA Date of Pre - soaking /o 7g o -> Date of Percolation Test /I NOTES: 1.' Tests to be reneated at same depth until annroximately eaual nercolation 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 -3 183�y 19�� I 3o 3 m00% , 3 3 ,f, 3 4 5 x - -- 2 lo�so /i; ao 4 5 1 2 3 4 5 NOTES: 1.' Tests to be reneated at same depth until annroximately eaual nercolation 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 DEPTH 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' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. 2 HOLE NO. 3 11 Indicate level at which groundwater is encountered /goiV Indicate level at which mottling is observed lVon , e Indicate level to which water level rises after being encountered Deep hole observations made by: g�' Date ii oa Design Professional Name: Address: Signature: Design Professional's Seal 2 PUTNAM COUNTY DEPARTMENT OF HEALTH _.....DMSION _OF Eli RONMENfAL HEr "SETH SERVICES gCEi = -a INITIAL INDIVEDUAL /CO1V MERCIAL SITE INSPECTION POIt1Vi SECTION A. GENERAL INFORMATION Name of Project L CjfQ t S o (T)(V) �'i9T i ��ls ®� County ''u i L,( r .Site Location Fib- / iL S 7 Building construction begun /o Extent Is property within NYC Watershed ? ................. El/ Yes No SECTION B. TOPOGRAPHY (Please ,check all appropriate boxes) 1• ❑ Hilly ❑ Rolling Steep slope ffGentle slope Flat 10 o'® A' -E N 2• ❑ Evidence of wetlands Low areasubject.to flooding - - ❑ Bodies of water ❑ Drainage ditches ❑ Rock outcrops A� 3. Property lines or corners evident ....................... ............................... 4. Do watercourses exist on or adjoin the property? ..Nkns�.., ejK.k— . - 5 31 Will these affect the design of the sewage system facilities ?........... Do t h d ❑ Yes dNo Yes - 0 No ❑ .Yes ENO' wa ers a regulations apply in this development ? ..................:.... Yes ❑ No 7 Will extensive grading be necessary? ............. . 8..- Will - extansiv,; ll-be necessary-for SS 9. Do filled areas exist within the SSTS area ?....... If yes, what is the condition of the fill? ❑ Yes No ........................... ❑ Yes No ........................... ❑ Yes No SECTION C. SOIL OB'9_kRVATIONS 10. Appearance of so' : [2:fSian ❑ an p ❑ Grav 1 Loam Clay Hard Mixture 11. Observed from: Borings ❑ Bank cut Backhoe excavations 12. Soil borings /excavations observed by 2C� � G 'p y� on o 13. Depth to groundwater on 14. Depth to mottling 165 on 15. Are test holes representative of primary & reserve areas ...... ............................... 16. Soil percolation tests made by �4 ;vc on 17. Soil percolation tests witnessed by 6 N �� r on SECTION D (on back) Form ST -1 2 SECTION A DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? F--] Yes, No 19. Will groundwater or surface drainage require special consideration? ..................... Yes b 20. Will gullies; ditches, etc., be filled and watercourses be relocated ? ..............:.......... Yes No SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities ? ...................... ......... 0 Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist? .......... ............................... Yes F--� No 23. Additional comments�;,� 24. Site observer /inspector and title 25. Dates of observation ins is ) ection s P �) 100 TEST PIT PROFILES Hole # Lot # Hole # Lot # Hole # - Lot # Depth to water Depth to water Depth to water Depth to mottlin g mottling..- _. _.. _ ....., . :.- D;yli to m�r�lt - Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L.-- G.L. 0.5 0.5 0.5 1.0 1.0 1.0.._ 2.0 _ 2.0- 2U - _ - - 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 K a ` Sheet of % PUTNAIVI COUNTY DEPARTMENT OF HEALTH DIVISION OF FN'�IPONMENTAT - HA'T_lN SERVICES- FIELD ACTIVITY REPQRT N<1MF '• /%IGr�SS�aia/ Tel: Al /� - Street - Town. State Zip PERSON IN CHARGE OR TNTFRUwWFTI: 11J14 Name and Title _ TYPE OF FACILITY FINDINGS., �rrira,R. �.c.�2.. ✓o % / /es, _'�,�'= Jt z K R D tf IT L , S L - L 5 _ TNCPFC"TnR+ - TFT •' ,. SigL a"ture and Title y _ I acknowledge receipt of this report: SIGNATURE; 02/96 Title; , Rev. OCT -12 -2000 02:30 PM HARRY W NICHOLS BRUCE R. FOLEY DEPART NT 1 Cinema BfGwster, New OF Road Fork 914 279 4567 P-02 00 — Jc:�1, ode Aaaoctere Pui tc 144114 D1r'W or ArNatev of Paere�v sa.vrcar HEALTH 10509 ATTENTION: o ADAM STIEBELING EiX REED All information below must be fWIX completed prior to any scheduling, DATEc p ENGINEER OR FIRM: —00 REASON: PHONE DEEPS: )� PERCS: §� PUMP TEST: 4 ROAD/STREET: TOrvIW - - �►� SUBD1V1SlON: OWNER: TAX KAPP: e� JV' L' 0. &1 S p l �Y•rL -� Yenn�C LOTM YES NO - - —� o Proposed SSTS within the drainage basin of Blest Branch or Boyds Corner Reservoirs. ° Proposed SSTS within 300 feet of a reservoir, reservoir stem or control lake. ° i Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ° � Proposed SSTS design _l lgw. gc�ater_than.ltl00- gallor•;,da7 vr�,ri�i�, �'i:rt�at re aired. — W-0posi-d SSTS for a Commerical Project. q ThpIt is the responsibility of the design professional to provide the above information prior to soil testing. _nse. 1 mcau will determine the N'YCDEP 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 MYCDEP. 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. 1:0a COU17Y USE (XNLY • (FIELDTEST) m E. N J m S � r a . N n o r N OJ! IJn r• ^;g: i Js W. 1 �� a C) •�'�j�9° e w k all 1 1132 I � - i i 1 i I 1 i (. 4 I i I j S .'t i '1 �4 I ; . 1 d j i 1 >1L I KENT 1 1 N k ' 339.06 � 206.05 _ �n J v tlt6t ri ,i0�{tn � —�ytb WW bt „t'4' bm o+ �� a vm CA IS = 1 r• 19'bib �� . � �� e 6 Y7 696'Ly ti •�•• k �1• — ' ;.1 . • �... �"' • • a' G 06'!La �i1 niJ9.03 ✓ cn 169.0 11.2 JENN I FER LANE I ^;g: i Js W. 1 �� a C) •�'�j�9° e w k all 1 1132 I � - i i (. 4 :i .'t E4 :1 I it '1 �4 jt �i �1 i r+ f >1L 'i 1 1 N k n N 0 O a to \ p r�Y d as bt „t'4' cu Ire i� ;.1 -DIMENSION-CHAR.-T.,(in feel) Number A loc 17 32 2 29 47 3 27 4 Z 4 26 39 5 26 33 6 28 29 7 31 26 8 34 24 9 39 24 10 44 25 I 1 54 29 1 z 99 97 13 ss 94 14 27 91 15 87 90 16- 87 88 7 88 96 Is 189 86 19 90 $5 20 92 85 1 914 86 ai C) C; te) loc E x p o A room Harry W. Nichols Jr., -P.E. Patterson Park, Suite 106 2050 Route 22 - Brewster, NY 10509 Y Telephone (845) 2794003 Fax (845) 2794567 March 14, 2001 Putnam County Health Department 2 Geneva Road Brewster, NY 10509 ATT: Robert Morris, P.E. RE: Individual SSTS Fair Street - McGiasson Town of Patterson Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSTS," dated 3 -1 -01. 2. "Short EAF," dated 3- 14 -01. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System." 5. "Application to Construct a Water Well," dated 3- 14 -01. 6. "Design Data Sheet. "_ 7. "Letter of Authorization," dated 3- 13 -01. 8. - Three (3) copies of Residence Floor Plan(s), for Bedroom Count Only. 9.- Review.fee m the amount of$3U0:0U: We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Nichols Jr., P.E. HWN:his 44,884.00 00.169.0® PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . LETTER OF AUTHORIZATION RE: Property of T E �J ' .�1 �.C� 1 _ A 5�Q.A Located at FL E, S T R E ET Tl GATT i�5 Q Tax Map # Block Lot Subdivision of Subdivision Lot # Filed Map # Gentlemen: This letter is to authorize ,'L Date Filed a duly licensed Professional-Engineer &�-Ibr 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 Directbr of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in �.�.._. _.. conformity.with.the:provisi.ons of.Artic!e 1.45_ancil_147.ofthe Edt!ction Law; the Public Health -- Law, and the Putnam County Sanitary Code.... Countersigned: P.E., R.A., # _ Mailing Address Very truly 01\0v (Owner of Property) Mailing Address: d , 60x ((/ coY�.�I State SW. '!Q R K Zip State Zip ( 6 ( Z Telephone: S A G— 21 M —4 0 b l Telephone: 2Q=�: — 7 9 8 8 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,.,OYENVIRONMENTAL HEALTH. SERVICES - = APPLICATION FOR APPROVAL- OF�PLANS FOR-­""" A WASTEWATER. TREATMENT SYSTEM 1. Name and address of apprWarX. NBC GMSSG N R .A. LVY 17 75Z R o u-T E (o CAR N\ C_ L J PJ Ew W)Mk 10512 2. Name of project: 0 d.S'J SS _r-3 3. Location T,� � � ,.s 1. > U �T F_ %0,, 2 V 1-s-C �Qso �1, 4. Design Professional: 5. Address: 24C� t�d� �E 22. 6. Drainage Basin: a c"�' �%�y -� f?�CZ�'�s� S (� �)U`f i�fl� 7. Type., of Project:. . k--'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 Status (check one) .. :............. .......................:....... :Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? .............. I.......... No 10. Has DEIS been completed and found acceptable by Lead Agency? 11. Name of Lead Agency ICI - 12-: - -is -dais projectvin'an--area uadec iuhe coricri�i`2�i iocal-plarining, zoning; or other _..._.__ _ ..._. officials, ordinances?'..; ............................................................. YES 1 ES 13. If so, have plans been submitted to such authorities? ........ ............................... IOJ 14. Has preliminary approval been granted by such authorities ?qL -Date granted: N 15. Type of Sewage Treatment System Discharge................. surface water groundwater 16. If surface water discharge, what is.the:stream-class designation? ...................: Nif ,�h 17. Waters index number (surface) ...................... ................ ............................... 18. Is project located near a public water supply system? ................... N 19. If yes, name of water supply I A Distance to water supply Lj ±- 20. Is project site near a public sewage. collection or treatment system? ........::.::. :' ` JAI 21. Name of sewage system N Distance to sewage system LL�\ 22. Date test holes observed 111 VbO 23. Name of Health Inspector 6 efne peQt 24. Project design flow'(gallons -per day) ................... , ............. . ........ ....................... (9 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... N b 26. Has SPDES Application been submitted to local DEC office? ..................... ...... N1 N z. 27. Is any portion of this project located within a'designated Town or State wetland? 28. Wetlands ID Number, ............................................. ........ .......................... _ N 2 Is Wetlan ds Permit required? N Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. ............................... N D 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. I's 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? ......................... I F S 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? .......... ............................... . ............... _ TJ 1;N 0v0J 35. Are any sewage treatment areas in excess of 15% slope? . .................:............. 36. Tax Map ID Number .......................... ............................... Map Block Lot 37. Approved plans are to be returned to ..... Applicant_ Design Professional NOTE: All a li - .._... - _.. PP.. _ cations :for:.eYiew._and.apQroval_c�f a -Pw. ScTS to be IQCWtd- vrithin -the IFC'vVarshec� shalt - 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 ihformation provided on this form -is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Lawvl SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... S Qr,n N P. _ 1 t: 2650 Po u� F 22. ,, a