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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
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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
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. .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"
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G3
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: 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"
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: G3
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: 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
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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
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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
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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
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e M 179.11
ro
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to
11;1_5 - 12
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2-
3
12,11\41 i
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1-7
2.,
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3
4
0
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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,
_'�,�'=
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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
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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.
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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