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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -53 BOX 13 IN No 4 ON .bj. Loa Is NN ML Isms , 1%, L. - - il -; 01463 PUTNAM COUNTY DEPARTMENT OF HEALTH `DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 3 / Ti/POr6 jam' / Town/Village: (';S0 1A Tax Map # Map34' Blocko2 Lot(s)S3 Well Owner: Name: Address: Y o M't 116m e6 A5 G 7T ~"gym* c Pri 59;v i /77.r A1,J Use of Well: 1- Primary 2- Secondary _Residential a _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment _Rotary _Cable percussion XCompressed air percussion Other(specify) Well Type Screened _Open end casing X Open hole in bedrock Other Casing Details Total Length Uft. Length below grad46t. Diameter Lin. Weight per foot nib /ft Materials: Y Steel Plastic Other Joints: Welded Threaded Other Seal: Cement grout Bentonite Other Drive shoe: Yes _ No Liner: _Yes _No Screen Details Diameter in Slot Size Length (ft) Dept to Screen ft Develo ed? First I _Yes No Hours Second I I I Well Yield Test Bailed _Pumped X Compressed Air Hours 6 Yield gpm Depth Date Measure from land surface - static (specify ft) During yield test (ft) -7A A Depth of compete well in Well Log If more detailed information desciipiions'or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Eliameter in Formation Description ft. ft. Land Surface q Sad JZ I - - 405L If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacit Depth— M o d p I Voltage a 36 HP �- Tank Type Ytro I Volume Date°Well Go pleted { Well Driller P-C Certificate #�� NY State # ®� �� zw , Installer Date o Report We Drill r Name "8� Atltlress F a ' k i ell rillert(si naty e)xk i:i,:x Pump installer ;Ni'' address , a 1 ` } T 11 1 t iYx rt. F4 '' }' ] t Pump Installerz( ture) 1 ftF I l li d nu i t: txact Location OT Nell wan aistances to at least two permanent landmarks to be provided on a separate sheet/n. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 . PUTNAM COUNTY DEPARTMENT OF HEAL DIVISION OF ENVIRONMENTAL HEALTH S.ER CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATN PCHD CONSTRUCTION PERMIT # P- ©/ — /O Located at / 7A eeGryye 0;41.1 Town or Village '6&enraw Owner /Applicant NameA% p6% 0j4en& &2Tgr Tax Map �7 4- Block Lot k5- i Formerly. Subdivision Name ,5'NC7 - 6M"070" r ra�G> Subd. Lot # 8 Mailing Address %�� /0�,��jg���S ', Yan-4n-," h� ,y, , AZ Zip jacs"7.0` Date Construction Permit Issued by PCHD Selsarate Sewerage System built by-- rack h a'" e CO�tS' �; Address /Qi>yrq %�; �1,�f /OJ'O® Consisting of S'4 Gallon Septic Tank and .5771 / , ,of, zVSr���f Other Requirements: Qr„ ;0-fo J- a5,1 �,7 9r Water Saaia>p9v: Public Supply From. Address ®>r: Private Supply Drilled by /644# 0'e- c fay,. S' Address A %/ �ecf en , A1Jq Building Type Has erosion control been completed? 4!fG.7 Number of Bedrooms Has garbage grinder been installed? Lj I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: 7— ,g8—/O Certified by P.E. ✓ R.A. Y (Design Professional) License # 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 are subject to modification or change when, in the judgment of the Director /Commissioner, such modificatii White copy - HD change its necessary. 0-" e Title: Date: opy - Building Inspector; Pink copy - O ner; range copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: t3 Tife o�� Tom' -/ Town/Village: A& I^;S01A Tax Map # MapJr+ BlockA Lot(s)J7 GPS Well Owner: Name: Address: o Af 67a-~1 6ft4OP (Fr �%iklowln ffj Use of Well: 1- Primary 2- Secondary Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion lCompressed air percussion _Other(specify) Well Type Screened _Open end casing X Open hole in bedrock _Other Casing Details Total Length Uf t. Length below gradet. Diameter '7 in. Weight per foot nib /ft Materials: Y Steel Plastic Other Joints: Welded XThreaded Other Seal: Cement grout XBento nite Other Drive shoe: X Yes _ No Liner: _Yes No Screen Details Diameter in Slot Size Length ft Dept to Screen ft Developed? First _Yes _No Hours Second Well Yield Test _:. Bailed _Pumped Compressed Air Hours 6 Yield gpm Depth Date e_asure from land surface - static (specs L During yield test Depth of Comp ete d well in ft. ZIAZ- _ Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing We-11 Diameter (in) Formation Description ft. ft. LandSurface If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths 7 Pump Type Capacit , during drilling '1 DepthaUU Mol� list: Voltage } HPI _ Tank Tvoe X'if vl Volume *q)' NOTE: Exact Location ofi II with distances to at least two permanent landmarks to be provided on a separate shee n. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 i BRUCE R. FOLEY, Public Pleoldh Director 2000 LORETTA MOLINARI R.N., M.S -N_ 'associate Public Health Director Director of Patient Services DEPARTMENT 'aF aA LTH 1 Geneva Road' Brewster, New • York 10509 rw4founientai ilcalt 1 (914)378.6130 Fax (914) 278 - 7921. Nursing Services (914)276,6$53 lYtC (914)272-6678 Fax (914) 278.6085 Early Iatervcn(ion (914).278-6014 Preschool (914) 278.6082 Fax (914) 278 - 6648 I 3T@ 0-9-111191tall) 00-N O��1VEItS Nr ItiIE: �.iofLTA Gaupi-ry 'Act-Ac- 5, it►JG. TAX LNI.A P NUNMER: 511 Z 53 � Lsr �� CLDC sysplvl tared E911 ADDRESS. 3 /`i�v da•Q� '`/PAS G TONYN: 42 AUTRO =ED TOWN OT.FZCUL: (Signature) DATE: �13 0 . / c� The Putnam County Department of Health, will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal r"911 address is assigned by an authorized town official, This form is to be submitted with the application for a Certificate of Construction Compliance. 0'•.911 VEItI.12Ni) alm SILHIOOSSB OSSIS AUG. RECEIVED 2 - zoro OT99 LLZ M 1211 MOT 311E OT /LZ/LO PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM _ L�LUCf� COU�ify �y�lBS, l•-!c 3 df_ oZ ,i3 Owner or Purchaser o ;Building Tax Map Block Lot Building Constructed ty TownNillage 7W6 e5�c 's.�G7`7�,.� 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 operate properly is caused by the willful or negligent act of the occupant of the building utilizing the 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 ql! the byilding utilizing the system. (� Date Month Day ,28 Year 1010 f General Contractor (Owner) - Signature Corporation Name (if corporation) Address: State Zip 5 Signature: Title: NF;f Corporation Name (if corporation) Address: State Zip Form GS -97 Jul 27 2010 16:28 HP LnSERJET FAX P.1 YML ENVIRONMENTAL SERVICES 321 Kear Street yorktown- Heiahts. N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB 1.003085 ... CLIENT_#-.__647.11 ------ -------- NON - STAT - PROC ---- PAGE: - I - of-1 -- NORTH COUNTY HOMES DATE/TIME TAKEN: 07/26/10 02:00 156 TOMAHAWK ST DATE/TIME RECD: 07/26/10 03:00 YORKTOWN HGTS, NY 10598 REPORT DATE: 07/27/10 PHONE; (914)-447-8780 SAMPLING 'SITE: 8 THEODORE TRAIL, PATTERSON, NY SAMPLE TYPE..; POTABLE PRESERVATIVES: NONE 4C BY: JOE NoTIES. - - COLIFORM METH:.-MF ------ :.L ------------------------------ ----------------------------- ~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 07/26/10 MF T. COLIFORM ABSENT /100 ML ABSENT SM 18-20 9222E COMMENTS: MFTC Coliform = This result indicates that the water (was), (was not) of a satisfactory sanitary quality according to * 1, 2e w York State and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE NLY T CIE E S RECEIVED BY THE LAB SUBMITTED BY: P — Albert HI -P-a& ?van tr M.T. (ASCP) Direct?), ELAP# 10323 RECEIVED AUG 2 2010 07/27/10 TUE 14:12 (TX/RX NO 5894) Q 001 Jul 27 2010 16:28 HP LASERJET FAX P -2 YML ENVIRONMENTAL SERVICES 321 Kear Street YorktQwp Heiaht� N yY. 1:0.598 (914).' 24.5-:'2800 Albert H. Padovani, Director LAB #: 1.002784 CLIENT #- 6471 NON STAT PROC PAGE: 1 Of 2 NORTH COUNTY HOMES DATE /TIME TAKEN: 07/08/10 10:00 156 TOMAHAWK ST DATE /TIME RECD: 07/08/10 11:55 YORKTOWN HGTS, NY 10598 REPORT DATE: 07/27/10 PHONE: (914)- 447 -8780 SAMPLING SITE: 8 THEODORE TRAIL,.PATTERSON, NY SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COLD BY: JOE FESTO TEMPERATURE..: < 4C. NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 07/13/10 LEAD (IMS) 07/15/10 NITRATE NITROG 07/09/10 NITRITE NITROG 07/15/10 IRON (Fe) 07/13/10 MANGANESE (Mn) 07/13/10 SODIUM (Na) 07/08/10 pH 07/09/10 HARDNESS,TOTAL 07/09/10 ALKALINITY (AS 07/09/10 TURBIDITY (TUR RESULT <1 ppb 3.79 MG /L 0.013 MG /L <0.060 MG /L 0.035 MG /L 66.8 MG /L 7,0 UNITS 264 MG /L 156 MG /L 0.9 NTU NORMAL - RANGE 0 -15 ppb 0 - 10 1.0 MG /L 0 -0.3 mg /1 0 -0.3 mg /1 N/A 6.5 -8.5 N/A N/A 0 -5 NTU CUN1MEIv'`1'S Fe /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. METHOD SM 18 -19 3113B SM18- 20450ONO3 SM18- 20450ONO2 SM 18 -20 3111B SM 18 -20 31118 SM 18 -20 3111B SM18 -20 4500HB SM 18 -20 23400 SM 18 -20 2320B SM 18 (2130B) 9a No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium is suggested. ?H pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RA14GE OF pH IS 6,5 TO 8.5. -id TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0- 70.MG /L VERY HARD WATER: ABOVE 300 MG /L RECEIVE* 0 AUG 2 - 21fj 07/27/10 TUE 14:12 [TX /RX NO 58941 0 002 Jul 27 2010 16:28 HP LnSERJET FR}{ P•3 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Haigr*a,�_N_v,. 10598— .._._ .._. .. (914) 245 -2800 Albert H. Padovani, Director LAB ##: 1.002784 CLIENT #: 6471JV - -__ ___��. .NON- STATMPROCr��yPAGE: 2�of -2 NORTH COUNTY HOMES DATE /TIME TAKEN: 07/08/10 10:00 156 TOMAHAWK ST DATE /TIME RECD: 07/08/10 11:55 YORKTOWN HGTS, NY 10598 REPORT DATE: 07/27/10 PHONE: (914) -447 -8780 SAMPLING SITE: 8 THEODORE TRAIL, PATTERSON, NY SAMPLE TYPE..: POTABLE WELL TANK PRESERVATIVES: NONE COLD BY: JOE FESTO TEMPERATURE..: c 4C NOTESry� ------ -- _------ --- --- -- - -- - -- ------------- _- _COLTFORM- METH- MF .. _ -..��� DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD MODERATELY HARD WATER: 70 -140 MG /L MG /L = MILLIGRAM PER LITER HARD WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG /L) THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELATE ONLY AO TIASE SAMPLES RECEIVED BY THE LAB SUBMITTED BY: nA;wa/1V �p Albert Paaovani, .T.(ASCP) Direct r FLAP# 10323 07/27/10 TUE 14:12 [TX /RX NO 589i] Q003 5 �.j �' a `�S.0 • ^.+ .0 u. �i ..:i. tii .1 _iF �i-tfr?e• 2.4 ,:+}'' .:1..._ 'r�r q.s,tiAx�4'L3F �� +7' {�y1? ; -: {evGi r -, �2 .7_Y�i �' -tlr'1t ,, v.��f �f.`�iK P.`i�� .!n 's � �� ,.,i.; '•. r,, _.,� To: �- e DATE: 7- d 1477h Ali *c WE ARE SENDING YOU (i.1) ATTACHED ( ) UNDER SEPARATE COVER THE FOLLOWING ITEMS VIA # COPIES DESCRIPTION L� LCe eor oti Gr% Xr J n (!�,- t4Ce5i4 175 / �r� � � cg7L�h �vti,► e, TriESE ARE TRANSMITTED AS CHECKED BELOW: ( FOR YOUR APPROVAL ( } AS REQUESTED ( ) FOR YOUR USE ( ) FOR REVIEW AND COMMENT REMARKS: SIGNED: COPY TO: 293 ROUTE 100 — SUITE 203 SOMERS, NY 10589 (914) 277 -5805 — (914) 277 -8210 FAX — bibbc @optcnline.net IF EiVCLOSURES ARE NOT AS NOTED, IQNDL Y NOTIFY US AT ONCEAT (914) 277 -5805 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION --� ., Date: ns I - �� L�A Street Lo '��,VU2.J Owner Town Permit # ~- TM # — Subdivision of # 1. Sewaze System Area a. STS area located as,per approved plans .................... :....... b.. Fill section - date of placement 3:1 barrier Lgth.. Width . Avg.Dpth c. Natural soil not stripped ..:......... .............................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/ wetlands ............ ...................... :. II. Sewage System a. Septic tank size - 1,000 ...: ..... 1, 250 ..... .... other ................ b. ' Septic tank installed level ................. ............................... c. 10' minimum from foundation .... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. . 2. Protected below frost ....:............. ............................... 3. Minimum 2 ft. Original soil between box & trenches1� e. Junction Bog -properly set ....................:: .... N 6. Trenches 1 1. Length required Length installed f 2. Distance to watercourse measured Ft.....:...dCc 3. Installed according to plan ......... : ...................... . 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line 20 ft:- foundations.......... . 6. Depth of trench <30 inches from surface ................:. 7. Room allowed for expansion, 100 % ......................:.. 8. Size of gravel 3/4 - 11/2" diameter clean ..................:: 9. Depth of gravel in trench 12" minimum ....... >........... -- -. - -0: - �'ipc;uds..cap ed: _.._.. -" g. Pump or Dosed Systems 1. Size of pump chamber .............................. -j 2. Overflow tank ......................... ............................... N� 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade .................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... M. House/Buildihe a. house located per approved plans ........................:.. . b: Number of bedrooms ............ ............................... ...... IV. Well Well located as per approved plans ............... ..:...... !...... b. Distance from STS area measured 716 ft........... C. Casing 18" above grade ....................:.... . ...:......:.......... d. Surface drainage around well acceptable ....................... V. Overall Workmanship,. a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled .................................. ......... c. All pipes flush with inside of box ............. :..................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist waterco se g. ,Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ....... . ......... ............................... Rev.' 12/02 DMSIO• OF FNVIRONMENTAL REALTH SERVICES ATTENTION 0 JOSEPH C1 GENE 14 K4-0- NSPEC-TION For: Fill — All information must be filly completed prior to any Trenches X inspections being made. bo -s "44! Tevr PCHD Construction Permit Located: S I I Motw lel— Tey-N11- M Owner/Applicant Name: t-b'Lzlv Co�Ww AmNS-S,102(- Block Z Lot Foxmerly: Subdivision Name: - ar-AaA6MAtJ .cht—) Subdivision Lot # 'XI Is system fjR. completed? Is system complete? `e f- 5 Is system constructed as per plans? -fe 5- Is well drilled? It well located as per plans? YES Are. erosion control measures in place? Ya5 Date: Date: Date: I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion. in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health- PE Date: X RA Certified by. - Letl2r�—pE= —0, 6esign. Professfonal MWASSOMMUP Address: 43 %Xft 10D - &ft M Lic.. Kf TM Comments: *X"c,,M e, �� t� ^-e Form FIR -99 aulij <-+-+- All RRIVIDOSSY OqqIq OTZ9 LLZ VT6 lal 6C:LO IUJ OT/TT/90 9 A PUTNAM COUNTY DEPARTMENT OF HEAL DIVISION OF ENVIRONMENTAL HEALTH SERVI CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # �j?— O` — I Located at Town or Village 1�?%1G0'c'ovl Subdivision namek f ` Z5 carq Subd. Lot # 8 Tax Map Of- Block 2- Lot Sri Date Subdivision Approved Renewal Revision Owner /Applicant Name Cgiwor �fOl•� e . , Date of Previous Approval -- " —�ic. Mailing Address /S'� � cr�,� S � ..... a�✓� his /OS l� Zip Amount of Fee Enclosed v�OO °' Building Type Lot Area/,,.; 7 No. of Bedrooms Design Flow GPD---0E--2:P Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 119716�1 gallon septic tank and 7 -ew44 —7 Other Requirements: To be constructed by Address Water Supply: Public Supply From Address Private Supply Drilled by - _ f; f%; - 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 treatmentsystem 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 Director /Commissioner will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date a—f /O License # O�'v�li2 g APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered pecessary by the Director /Commissioner. Any revision or alteration of the approved plan requires a new p it. Approved r discharge of domestic sanitary sew ge only. B Title: Date: —Z� i�7 Y White copy - HD Fi ; Y llo copy - Building Inspector; Pink copy - Own O n copy - Design Professional Form CP -97 � w PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES T APPLICATION TO CONSTRUCT A WATER WELL please print or type Well Location Street Address: Town/Village: Tax Map # 31 Themalaree Tom, -1 Map 3+ Block Lot(s) .J,5 Well Owner: Name: Address: ��-6 TD��djq�� �pj'; Phone #: /�- NDo'1�JI fY®/+cif IVY 10S 7,f Use of Well: X 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��gpm # People Served Est. of Daily usage 00 gal. Replace Existing Supply Test/Observation Additional Supply Reason for DrillingNew Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes — No it Is well located in a realty subdivision? ........................................... ............................... Yes Ar No Name of subdivision (2/' .1Arca1g -rX 0- SW6; /�s'SoGS� Lot No. 49 Water Well Contractor: %';,Z ,0 Address: Is Public Water Supply available on site? ....................................... ............................... Yes _ No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. :_- Applicant- Si(inature: � ___� ��t �. ®r�/n�%�, . PERMIT TO CONSTRUC I A WA I tK WtLL 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. 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 Commissioner of Health. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam Cpunty. A rVI Date of Issue ���� Permit I �— Title Date of Expiration Permit is Non- Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - V� Orange copy - Well driller Form WP -97 Rev. 3106 Bibbo Associates, L.L.P. Mill Pond Offices 293 Route 100, Suite 203 Somers.'.. New Ycrk-,105-89 9 14.277 -5805 914.277.8210 fax TO WE ARE SENDING YOU ❑ ATTACHED ❑ Under separate cover vla ❑ Shop drawings ❑ Prints ❑ Copy of letter ❑ Change order LETTER OF TRANSMITTAL DATE _ O JOB NO. ATTENTION - RE ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted the following items: ❑ Plans ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ef"A's requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment 21-11e-91- C"ur e �7`G'r a f /tee 6 , f 020/0 ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US THESE ARE TRANSMITTED as checked below: ff For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ef"A's requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment 21-11e-91- C"ur e �7`G'r a f /tee 6 , f 020/0 ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US 20010 Amvlcen legs[Nek Inc. SHERLITA AMLER, MD, MS, FAAP Commissioner, o Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Joseph Buschynski, PE Bibbo Associates Mill Pond Offices 293 Route 100, Suite 203 Somers, NY 10589 Dear Mr. Buschynski: DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 ROBERT J. BONDI .County Executive ROBERT MORRIS, PE Director of Environmental Health February 19, 2010 Re: Proposed SSTS for North County Homes SMG & Gramatan RS, Lot # 8 (T) Patterson, TM # 34. -2 -53 This Department has received and reviewed the application and plans for the above referenced project and the following comments are offered for your consideration. 1 The construction permit and design data on the plan specifies 571 LF of absorption trenches � although only 492 LF are shown on the plan. V/2. The dosing chamber detail is to be revised to provide for an access to grade manhole frame and cover. The septic tank detail is to be revised to specify a maximum cover depth of 12 inches over the top of the tank. If greater than 12 inches of cover is over the tank than access to grade manhole frame and cover are to be provided. The distribution box detail is to be revised to specify a minimum of two feet of solid pipe prior to the start of the perforated pipe. The distribution box detail is to specify a maximum cover depth of 12 inches. A minimum separation distance of 10 feet is to be specified between the footing and leader drains to the absorption trenches. Should you have any comments concerning this matter, please contact this office. MJB:kly Respectfull, Michael J. I Director of Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI,`RN, MSN Associate Commissioner of Health Joseph Buschynski, PE Bibbo Associates Mill Pond Offices 293 Route 100, Suite 203 Somers, NY 10589 Dear Mr. Buschynski: ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health DEPARTMENT OF HEALTH February 16, 2010 1 Geneva Road. Brewster, New York 10509 Re: North County Homes, Inc. 31 Theodore Trail (T) Patterson, TM # 34. -2 -53 Middle Branch Reservoir Basin The Putnam (- county Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on February 11, 2010 is complete. The Department will notify you by March 8, 2010 of its determination. 0 The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision 1. .......: _ ._ + n .1 n i _n _ i . .. r ,. a r� r .. is ov'u'�i�l'i'i:i'�1CGJi �l'ai�Gc vviti�'JG'� UVtI i0-GJ `U) t6� UL Me 1V' i C Dept. Of Envtroitl7ieTital Pi6[eCClotl Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed approved, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the 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 Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 43148. MJB:kly espectfu Michael J Director c Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 Public Health Director LOPE -1 r:,—MOI T.: Lit R.N., Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085' Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 TO: DEPARTMENT -OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED -7'1kj -2 o &� -A2+ L PROJECT: NOTICE OF COMPLETE APPLICATION DATE: _T r1T�T\T� _.' ivwiv. ... /"�. _['�T._ C a,s. �i .. r_..r�' _ . -...- .TT, nT _ )T1_ T1T _ T 7 A T-. - D'A1r aJb LrAr'rRGvru. NOTICE OF COMPLETE APPLICATION DATE: y . i yam' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET — SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: b�aev a C"NiY t�o S ., Inc . Address: yorffTdWH h17`s -, NY Located at (street): TNI # Section" Block ?- Lot ;_�; QS , g Municipality: ?A'CTCe_5o,J Watershed: /es��J /G�aG�j/pP�S . SOIL PERCOLATION TEST DATA Witnessed by: M%LaycC_L_ %y'D�%r.jXA Date of Pre-soaking: Z Z Zoo . Date of Percolation Test: Z 1 3 (Zo 10 Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to Water from ground surface (inches) Start . Stop Water level drop in inches Percolation Rate min /inch Zo - Z3 3 5. " Z to.3 - t0'.ti°I t`d Zo - 23 3 bo 7. 4 5 I 1 - z► 3 q 33 Q-" 2 ►o.'i5- t'.t5 30 l$ - 20•S Z. 12 mo 3 t'.v. 'y6 3o ►sd - zo. z S tz.00 4 5 �s I 10'• 1°l - to•.-16 Z 4-u 2 0' - '.1 Irt - 21 3 10.00 3 11•'1 0 Vt - 21 3 1p. o0 4 5 _ 1 Io'.2z- t 1 11- 2`l 3 3,6 02 �,!�rl'l iti It),3y- lo'. 1 zi 2`A.Z< 3.ZS .Z 3 - 1 o 1 Io 2 \- Yo s �- Arp 1 �ST�sts to''�, ated at same depth until approximately equal percolation rates are �411,bbtaine��ach percolation test hole. (i.e., < i min for 1 -30 min/inch, < 2 min for 31 -60 min/inch). — ta to be submitted for review. 2. Depth measurements to be made from top of hole. TEST PIT DATA - -- - - _.•nESCRiPTTO,N Q.F- SOILS.EaN_C.O.UNTER,ED IN.TFST_ffnOIF,S -...- - ...._ .... _.� .. DEPTH HOLE # HOLE # HOLE # HOLE # HOLE # 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' 777\777- 9.5' 10 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Design Professional Name: o e�l�,% ediyasl.' dal a{ hoes �A, a E'S LLP Address: w I -�{�iG. IIy r* o" i ,.ej. Signature: Design Professional = Seal Date N PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �w...._.._e`.. _ _. .. �_...� .... -...p __ ._. .. _. ... - •.... a `APPLICATION'FOR APPROVAL `OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: /(%Prf1j ��,� �fp�-'sr 2. Name of project: ,[offg 3.. Location TN: 4. Design Professional: 4153a s. GG/O 5. Address: 6. Drainage Basin: 7. Type of Project: �r 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 H Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... /Vv 10. Has DEIS been completed and found acceptable by Lead Agency? ..........:.... iV 11. Name of Lead Agency 12. Is this project in an area under the control of f ca n i g r_ - o l.plannk zan._n ,_or -or officials, ordinances? ......................................................: ..:..........................:. S' 13.. If so, have plans been submitted to such authorities? ........ ............................... s 14. Has preliminary approval been granted by such a uthorities'?9e.s Date granted;All4v 15. Type of Sewage Treatment System Discharge.................. surface water k groundwater 16. If surface water discharge, what is the stream-class designation? .................... ICJ 17. Waters index number (surface) ......... ......................... 18. Is project located near a public water supply system? 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? :............... 21. Name of sewage system Distance to sewage system 22. Date test holes observed /% / 9 - 98 23. Name of Health Inspector 24. Project design flow (gallons per day) 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... %y 26. Has SPDES Application been submitted to local DEC office? .. .....:.................. . 2 , 27. Is any. portion of this project located within a designated Town or State wetland ? /(%p .:.:...:....::.:.:..:.:.: ................. ............................... ....... 29. -Is Wetlands Permit required? ..... ..................... ..... ........ ...:......................... Has application been made to Town or Local DEC office?. ............................... 30. Does project require a DEC Stream Disturbance. Permit? ::.:.......... /(lp 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 Ne 32. Is project located within 1,000. feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or.any other potentially known source of contamination.? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... e es 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ............ : ......... .......................................... 35. Are any** sewage treatment areas in excess of 15 %o slope? 36. Tax Map ID Number—, ......... ......................... * .................... Map Block_,,2 _Lot S3 37. Approved plans are to be returned to :..:.: Applicant Al Design Professional NOTE: All a hcations for review and a royal of a never SSTS to 6e`_1 ocated within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as storniwate 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. Ifthe application is signed by a person other than the applicant shown in Item l .;the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision . may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury; that information provided on 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 Law. SIGNATURES & "OFFICIAL TITLES. 91990 ASSOMM UP Mailing Address: ..................................... 293 Route 100 - Suitg 2 3 Somers, -NY 10589 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVS. LETTER OF AUTHORIZATION RE: Property of Located at T/V /"� f ferSoh Tax Map # L3-f- Block oZ- Lot s,3 Subdivision of �5W45� n A5- L5SOGS. Subdivision Lot # eol Filed Map # Date Filed o/ Gentlemen: This letter is to authorize a duly licensed Professional Engmeer X or registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of_ Article -1 -45 and/or 147 of the Education I.aw; .the_P_t?h1:ir.HeTlth.- . -. Law, and the Putnam County Sanitary Code. Very truly yours, Countersigned: Signed: P.E., R.A., # Mailing Address BIBBO ASSOCIATES LL 29$ ROUte p CC - Suite 203 State (914) 277 -58C%p Telephone: State i(, y Zip /OS98 Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH ...-....-...D I I 1 : ® :. 'N LRONME11' AL HEALTITSE�2�IIC AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: � (7 re c//A" 110co -l-vo, that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: Having offices at: I S Whose Officers Are: President - Name: VrU Address: Vice President - Name: Address: (s G Secretary -Name: Address: Treasurer - Name: Address: U C �0s5� 'h. I4v_.1 es-i and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Signed: Title: Sworn to before me this It day of (mont ZLO,!v (year) Notary Pub c DENIS J. TIMONE NOTARY No 60 Stet of Never York Corporate Seal Qualified In Westchester County Commission Expires April 30, eW 41 Form CA -97 ,SSOCIATES, L.L.P. Engineers - Planners February 8, 2010 Putnam County Dept. of Health 1 Geneva Rd Brewster, NY 10509 -2339 Attn: Mr. Michael Budzinski P.E., Director of Engineering RE: Lot #8 GDC Subdivision North County Homes, Inc. (T) Patterson, TM 34 -2 -53 Dear Mr. Budzinski: -- - -- Enclosed irrthe above-matter- are- the-following- items.- - --- - -- - - -- 1) Construction Permit and Well Application 2) Design Data Sheets 3) Letter of Authorization, Affidavit form, EAF, PC -97 4) $ 500 Application Fee 5) 4 prints — SSTS Site Plan 6) 2 copies — House Plans Joseph J. Buschynski, P.E. Timothy S. Allen. P.E. -Sabri Barisser. „P.E:.,_ John P. McNamara, P.E. Robert A. B. Howe, B.S., Phys. The regulations of your Department required the re- testing of soil percolation rates in the approved SSTS on Lot #8 due to the amount of time since the original testing (10+ years). The re- testing was conducted on February 2 & 3, 2010 under your observation. The enclosed data sheets contain the original and new percolation test results. The original tests produced rates of 40 and 60 min. /in. while the new tests ranged from 5.3 to 12.0 min. /in. When comparing the two test sessions the original tests were conducted at 38" which is substantially deeper than percolation test depth standard of 24 to 30 inches. As noted on the deep test description, the soil substratum at the 38" level is moderately compact which is often typical in till soil and likely attributable to the slower,perc grate. We do not recall the reason for testing at ,.4a es the deeper depth. The slowest rate arTi&g the' new tests was 12 min. /in. at standard test depths. It would seem reasonable then to place the design percolation rate for this system Planning . Site Design . Environmental Mill Pond Offices 293 Route 100. Suite 203 • Somers. NY 10589 Phone: 914 - 277 -5805 Fax: 914 - 277 -8210 - E -Mail: bibboQoptonline.net 4 PCDH — M. Budzinski, P.E. Lot # 8 - GDC Subdivision February 8, 2010 _ .Rap 2.nf.z .._ . area in a lower category than 60 min. /in. as originally assigned. Placing the design rate in the next higher category of 15 -20 min. /in. would provide a reasonable factor of safety. We have therefore prepared the SSTS site plan showing 571 l.f. of fields for the proposed' 4 bedroom home and respectfully request your approval for the adjusted rate. Very truly yours, Joseph J. Buschynski, P.E. JJB /Mme Enclosures cc: 01/26/10 TtiE 11:25 TEL 914 277 8210 ;, ...guFRrt .r�r s 4 MLPR_M}v1, MS. ,FAAP Commissioner ofleahh LORFTICA MOLINARL RNI MSN Associate Commissioner of Health BIBBO ASSOCIATES LLP 444 PCHD ROBERT J. BONDI [a 001 -DEPARTMENT OF HEALTH Call ns 4 1 Geneva Road, Brcwster, New York 10509 I' REQUEST FOR FIELD TESTING �1 � '77 � All information below must be f. ully completed prior to any schedu " g. DATE_ :1 ENGINEERING FIRM' ' u�QG , GT L 1� PHONE #: PERSON TO CONTACT: 0y,9-c & . ,X NEW CONSTRUCTION ❑ REPAIR PROGRAV ❑ ADDITION PROGRAM REASON; DEEPS: 11 M PERCS: 9 PUP TEST: 11 ROAD /STREET:or�+r� TOWN: 4 Br-j'¢ TAX MAP SUI3AXVISI.ON: ? ii/�"t�eP6A .4Asy„�,s� LOT.#':_ OWNER_ � G' - NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL TESTING ,�( Proposed SSTS within the drainage basin of West Branch or Royds Corner & Croton Falls Reservoirg. ❑ '� . Proposed SSTS within 500 feet of a (reservoir, reservoir stem or control lake. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetland• ❑ proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ r Proposed.SSTS -for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered ves to any of the questions, NYCDEP must witness the soil tests. This Department Will coordinate a mutually suitable time for field testing with the Design Professional and NYDCEP. 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 tests, it will be the sole responsibility of. the design professional to schedule re-wituessing of the soil testing with NYCDEP. FOR COUINTY USE ONLY DATE: MICE' CpMMENTS- pA, n1LV J2S. WKLY Environmental Health (845) 278 -6130 .Fax(845)278-7921 Water Supply Section (845) 225 -5186 Fax (845) 225.5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278-6678 Nursing Home Care Fax (8445) 218.6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -WS .1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: /�/'��l WGIr� /�i�l�S yl C - Address:G`kw.+ Located at (street): 31 7h- X&& ne- Ma,- TM # SectionZ� Block Lot Municipality: �T� /P�So� Watershed: SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: -10�2-/ -4� Date of Percolation Test: Hole No. Run No. Time Start - Stop Elapse Time (min.) Depth to water from Found surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch Ya % I; O .� 3fO - --- -- 4 5 O 1 =9G- 9'i6 30 3 3 3 3 2 7- :.r7 JO p % 4a 3 2r7la,' O Q 4a 4 5 1 2 3 4 5 1 No es, ° ; J�ie"� -., J} 4,, jests to�+ted at same depth until approximately equal percolation rates are percolation test hole. (i.e., < 1 min for 1 -30 min/inch, <2 min for 31 -60 min/inch). 1:.data�to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97, pa I of'_ TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #__j!j HOLE # HOLE # HOLE # HOLE G.L. i. 1.0, 1.5- 2.0' 3.0' 657/5� 4oww_ 3.5' JWYaDe - 4.0' 7�7z?cel 5.5' 7 01- W1, 6.01 6.5' 7.0'.L__ 7.5' 8.00 8.15' 9.51 10.0' ','-Indicate level at which'groundw . ater . is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: �Ta5-&coqh Address: IBBO A8800MVES LLP - :ate -u,- W440689 2-/7.5W.,5 Signature: Design Professional = Seal 617.20 Appendix C State Environmental Quality Review �....- : SHORT EN1lIRONMENTAII ASSESSMENT FORM..., For UNLISTED ACTIONS Only PART I - PROJECT INFORMATION (To be completed by Applicant or Proiect Suonsorl 1. APPLICANT /SPONSOR �o'h Co�.�7` ffo•��s� l„C . 2. PROJECT NAME Lodes' G�CS�h� 3. PROJECT LOCATION: 0/ Municipality eo c°rs"O County 4. PRECISE LOCATIO (Street address and road intersections, prominent landmarks, etc., or provide map) 5. PROPOSED ACTION IS: New ❑ Expansion Modification/alteration 6. DESCRIBE PROJECT BRIEFLY: ,De ,Sjs pe4-, 7. Initially �t �D� AFFECTED: Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ® Yes No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? ® Residential F-1 Industrial Commercial Agriculture Park/Forest/Open Space Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? 0, Yes ❑ No If Yes, list agency(s) name and permit/approvals: 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes No If Yes, list agency(s) name and permittapprovals: /�G� � — /Qea► /�y s�r� ��Q�fror/a 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Yes No I CERTIFY THAT THE INFORMATION PROVI ED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor me: �J��``j Ccf, h C Date: Signature: h U, 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 PART II - IMPACT ASSESSMENT To be COMIDIeted bv Lead A enc A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. Yes Ej No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic pattern, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats; or threatened or endangered species?. Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly: C5. Growth, subsequent development,. or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENTAL AREA (CEA)? 11 Yes 0 No If Yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes ❑ No If Yes, explain briefly: PART III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (Le. urban or rural);, (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail . to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly.to the FL EAF and /or prepare a positive declaration. Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WI NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting this determinati Name of Lead Agency Date Print or Type Name of esponsible Officer in Lead Agency, Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) t! Zco It 0 1.4( i 1110 Z 71 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA S EET - //SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Address: Located at (street): TM # Section: _ Block _. Lot Municipality: Plat Watershed• SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: _ % —--�L)_ Date of Percolation Test: — Hole No. Run No. Time Start — Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch 3 4 5 19 'L 2 L 3 'i' i; t.Z C;;� f 4 5 . 1' iulq °0 I ZI f 2 d4- 4 /cam 3 ? r y+ 4 5 1 10142, F 2 10 - c; ' 11 3 4 5 Notes: P-mc;- vaia-1 `---- it -30 30 3/ 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation. test hole. (i.e., < 1 min for 1 -30 min /inch, < 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, pg i of 2 TEST PIT DATA ES _ , F.�SOI)<,S ENCOUNTERED IN TEST DEPTH HOLE # HOLE # HOLE # HOLE # HOLE # G.L. 0.5' 1.0' 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'' 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level.rises after being encountered Deep hole observations made by: Date Design Professional Name: Address: Signature: Design ]Professional = Seal 0 40000 0. Trans. ®DMH )?-50 00 ' L--8. THEODORE TRAIL ce Pavement 1 CB _ 146.66' Ele. Box J Tel, Ped. FLOATING OUTLET DOSING CHAMBER Lot. 9 1250 GAL P/C CONC SEPTIC TANK ,O I j I V1 0 \ 1 v \ 1 \ \ 1 >V PLAN GRAPHIC SCALE YZ \ 1 (IN S) ! q I aBOX \ 1 \ Yp\ 1 \ \ 4" 8DR-M \ 1 I \ 1 1 \ \ 1\ 1 1 1\ 1 4 ", GOP—M 2 42. Story Frome We #h79 er const) i i 0. H. d Well Lot 8 Area= 1.2774 Acres 758.00 to N 0 IM4'17'53 "A' Lot i2 PLAN GRAPHIC SCALE M 0 10 .70 ._ .!0 110 (IN S) ! I inch - So M moraNeao onuAp01an� n 17� or TW NEW town 37ATE t p�R� Opp �0,r�dUd W 758.00 Macadam Curb -Ot % cc w J OFFSET DIMENSIONS # ITEM "A" loge 1 ST-IN 27.5' 49.5' 2 STOUT 28' 58.6 3 DC 33.5' 82.5' 4 DB-IN 44' 551. 5 DB-OUT 50' 51' 6 TE 54.5' 53.5' 7 TE 59' 50' 8 TE 83.5' 46.5' 9 TE 68.5' 44' 10 TE 73.5' 41.5' 11 TE 78' 40.5' 12 TE 83.5' 39.5' 13 TE 124' 117.5' 14 TE 123' 120' 15 TE 122' 1220' 16 TE 120' 17 TE 119' 127' 18 TE 119' 130' NEAP 4i SEf"ffimw. c6j Tj ®SPARSE 0 p1V S 0 Of ENVIRONMom QED fQF� £DNFOR4NS Q�HE ApPR��ABLE RULES AND RF., ARiMENZ HOUSE LOCATION AND PROPERTY BC FROM SURVEY PREPARED BY: DONNE SURVEYING, P.0 , YORKTOWN HEIGHT SHEET: 34 BLOCK:2 . LOT: 53 1 FIELD REQUIRED: 571 FT. 24 IN. WIDE FIELD INSTALLED: 574 FT 241N. WIDE THIS IS TO CERTIFY THAT THE SEWAGE TREAT CONSTRUCTED AS INDICATED ON THIS PLAN i WAS INSPECTED BY BIBBO ASSOCIATES,LLP. COVERED OVER. THE SYSTEM WAS CONSTRU WITH ALL STANDARDS RULES AND REGULATI( COUNTY DEPARTMENT OF HEALTH AND THE t DEPARTMENT OF HEALTH.