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HomeMy WebLinkAbout1485DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34.-3-23.12 BOX 14 6 .. ��.. q�6m :r ,� �r i , , , , 3 , 01485 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIY1SION-OF- -Eli -N'IRONMENI- AL- HEALTI �E-R -V-IC CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE REATMENT SYSTEM ." ... `- ». -.,.I t; Lit PCHD CONSTRUCTION PERMIT '` = "" Located at 41 CA(40 t,-{ ) to i,r! Town or 1 age Owner /Applicant Name �fw `I STIc'6eU-J C- Tax Map '34- Block 3 Lot -23 • iol_ Formerly Subdivision Name !-L -m is- Subd. Lot # 1 PJ Mailing Address 241 gdL)L_La- k-WI-j5 9jiyko GA ti "1-- '1 Zip w5 i Z- Date Construction Permit Issued by PCHD 3 111,,D l 0� Separate Sewerage System built by CX211 C 4 G". 1 �'L- Address 4--1 AL L i 0 _ &2LWJibP,. Consisting of ► Zjc�,0 Gallon Septic Tank and 4-Go ue o F 'V 4&;c L -T 1y'- =' 1V o4C-4t 460 -r tzafS Other Requirements: Water Sunaly: Public Supply From. Address or: Private Supply Drilled by Act. -T ti . N yAm! k- QoA5 Address Building Type j►'l Has erosion control been completed?' Number of Bedrooms Has garbage grinder been installed? 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 wi LissueAPCHD Construction Permit and approved plans and the s dards, rules and re Partment of Health. Date: `ot d Certified by , P.E. R.A. (Design rofessional) Address P ^ayi Ev'-16 a- i61:a2.uJ f5 0LAz, L License # 0(o-14" 4 GW 9411111: C t (sa -c-->i iTt2 " 1050q 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 Public Health Director, such revoca 'on, modificati or change is necessary. By: , Title: Lq, Date: ?,-33 White copy - HD 4e; ii copy - Building Inspector; Pink copy - Owne ,, Oran opy - Design Professional Form CC -97 BRUCE R. FOLLY Public Health .Otrectcr LORETTA MOLD AR1 RN., NUN. . - 44ssociais PYolic Health Diractcr Director of Pettont Servicts DEPARTIMENT OF HEALTH i Geneva Road Brewster, Now York 10509 Taviroamental Health (914)279-6130 Fwt (914) 278 - 7921 tutslnt; Sorvlees (9141 273 .6559 WIC (914; 279 - 6679 FU (914) 278 - 6083 Early Iaterreatiam (914)2,3 -6014 'Preschool (914) 278 -6082 Fix (914) 278-- 6648 M111 "MAE91991411tAN OWNERS NAME: TAY 4APiNI;I'IBER: /Z E911 ADDRESS: TOW N: /� i�iil ;c -c1 AUTHORIZED TOWN OFFICIAL: (Signature) DATE: /,- -/ The Putnam. County Department of health will not issue a Certificate of Construction Compliance unless fhe above form is completed, i.e,, a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E91, I ERFi"M4 ) UTVAM Engineers and Architects SEPTIC SUBMISSION FORM TO: IVIICL- L'U^��iC -1 DATE:s 92 1 PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: otp�p 1 S - 'J 1 3 - 3 - V . k2. --T ENCLOSED, PLEASE FIND: "I� COPIES OF THE SSDS "AS- BUILT" PLAN CONSTRUCTION COMPLIANCE CERTIFICATE WELL LOG HEALTH DEPARTMENT FEE ($r?B9 d0 ) ' WATER ANALYSIS GUARANTEE FORMS - 3 ORIGINALS E 911 ADDRESS FORM ❑ LETTER OF EXPLANATION REMARKS: COPIES TO: SIGNED: . , 4 OLD RouTE 6, BREWSTER, NEW YORK 10509 • (945) 279 -6789 • FAX (845) 279 -6769 • EMAIL: puteng @bestweb.net PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT elIT`ocatlon Street Address: ' Town/Village: r 0 n Tax Grid # Map ,34' Block Lot(s)Z. Well Owner: Name: Address: Ct r . Use of Well: 1- primary 2- secondary Drilling Equipment sidential blic Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Casing Details Screen Details Well Field Test Total length ft. Length below grade 2SL—ft. Diameter _ 7 in. Weight per foot 17 lb /ft. me er Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _ Cement grout Bentonite Other Drive shoe: Yes No Liner _ Yes No th to Screen eloped? First _ Yes No Hours Hours Yield —0— gpm Second _ Bailed _Pumped X Compressed Air Depth Data Measure from land surface- static (specify ft).. During yield test(ft) �6YOOL Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type > iyCapacity 441 Depth g kJ t Model �7 6s , Voltage36 HP z! Tank Type / Volume t? Date Well Completed 7 �/mo Putnam County Certification No. 007 Date of Report 71�MO,3 Well Driller (signature) A&>� -1) Igm NOT : Exa t location of well with distances to at least two permane lan arks to be provided on a separ s eet/p an. Well Driller's Name o �01�$ ��C • Address: s0� 7/ii pa Oh /V �* Signature: A&Z Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 NORTHEAST LABORATORIES, INC. 129 MILL STREET - BERLIN, CT 06037 -9990 NORTHEAST LABORATORY OF DANBURY ��o `N A I 00A ,�parslwry anad?le Dry Off Site:; 100 Mild Plain Road, Suite 342,- Dar,•P y,,.GT]•,_ TELEPHONE: Toll Free (in CT) 800 - 826 -0105 (Outside CT) 800 - 654 -1230 £ Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 Q x FAX: (860) 829 -1050 REPORT TO: E -Mail: NELABSCT@AOL.COM www.NortheastLaboratories.com ADAM STIEBELING 34 CAROLYN WAY PATTERSON, NY12563 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: • Total Coliform (Bacteria) • E. Coli (Bacteria) PHYSICALS: • Color (Apparent) • Odor • pH • Turbidity CHEMISTRY: DATE SAMPLE COLLECTED: 1/7/2004 TIME COLLECTED: 10:30AM COLLECTED BY: HENRY STIEBELING DATE RECEIVED @ LAB: 1/7/2004 TESTED BY: LAB #11471 DATE TESTED: 1/7/2004- 1/9/2004 LAB I.D. # D0402809 REPORT DATE: 1/15/2004 41 CAROLYN WAY, PATTERSON, NY BATH FAUCET WELL WATER NONE MAXIMUM CONTANIINANT DATE TESTED & LEVEL (MCL) OR TIME WHERE RESULTS METHOD # STANDARD APPLICABLE Absent per 100 ml SM 9222B 0 per 100 ml(ABSENT) 1/712004 Negative per 100 ml SM 9222B Negative 1/7/2004 5 mg/L EPA 110.2 15 1/8/2004 @ 9:15am ND mg/L SM 2150 Not to exceed value of 2 on 1/712004 @ 3:25pm EPA 353.3 • Hardness 112 scale of 0 -5 EPA 130.2 7.62 mg/L ASTM- D1293- 6.4 to 10 Range 1/8/2004 @ 9:15am <0.03 mg/L 99 • Manganese <0.01 0.49 NTUs EPA 180.1 5 NTUs 1/8/2004 @ 9:15am • Alkalinity 112 mg/L SM 2320B • Chlorine Residual <0.05 mg/L 4500CIG • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 • Nitrate Nitrogen <0.05 mg/L as N EPA 353.3 • Hardness 112 mg/L EPA 130.2 • Lead 0.003 mg/L EPA 239.2 • Iron <0.03 mg/L EPA 236.1 • Manganese <0.01 mg/L EPA 243.1 • Sodium 4.5 mg/L EPA 273.1 1.0 mg/L 10 mg/L Combined limit for Nitrite plus Nitrate= l Omg(L as N 150 mg/L ** 0.015 mg/L* 0.30 mg/L* 0.50 mg/L * ** 28.0 mg/L ** 1/8/2004 1/7/2004 @ 3:25pm 1/9/2004 @ 9:15am 1/9/2004 @ 10:05am 1/13/2004 1/9/2004 1/9/2004 1/9/2004 ml= milliliter mg/L--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level ** *Action Level <Q= Analyte detected below quantitation limits. Data deemed estimated 3=Water containing more th 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or 01NOTPOTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) R 1 Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 129 MILL STREET - BERLIN, CT 06037 -9990 �N A FO [Dan6uiy R raTiOlRe 13 p LABORATORY o dDANBURDznbury CT] - TELEPHONE: Toll Free (in CT) 800 - 826 -0105 (Outside CT) 800 - 654 -1230 �. Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 ` - FAX: (860)829 -1050 REPORT TO: E -Mail: NELABSCT @AOL.COM www.NorthdastLaboratories.com DATE SAMPLE COLLECTED: 1/7/2004 ADAM STIEBELING TIME COLLECTED: 10:30AM 34 CAROLYN WAY COLLECTED BY: HENRY STIEBELING PATTERSON, NY12563 DATE RECEIVED @ LAB: 1/7/2004 TESTED BY: LAB #11471 DATE TESTED: 1/7/2004- 1/9/2004 LAB LD. # D0402809 REPORT DATE: 1/15/2004 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED 41 CAROLYN WAY, PATTERSON, NY BATH FAUCET WELL WATER NONE MAXIMUM CONTAMINANT LEVEL (MCQ OR STANDARD 0 per 100 ml(ABSENT) Negative 15 Not to exceed value of 2 on scale of 0 -5 6.4 to 10 Range 5 NTUs 1.0 mg/L 10 mg/L Combined limit for Nitrite plus Nitrate = I Omg/L as N 150 mg/L ** 0.015 mg/L* 0.30 mg/L* 0.50 mg/L * ** 28.0 mg/L ** DATE TESTED & TIME WHERE APPLICABLE in/2o04 1/7/2004 1/8/2004 @ 9:15am 1/712004 @ 3:25pm 1/8/2004 @ 9:15am 1/8/2004 @ 9:15am 1/8/2004 1/712004 @ 3:25pm 1/9/2004 @ 9:15am 1/9/2004 @ 10:05am 1/13/2004 1/9/2004 1/9/2004 1/9/2004 mi= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level ** *Action Level <Q= Analyte detected below quantitation limits. Data deemed estimated 3 =Water containing more th 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding" times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or aOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTAB LE WATER) Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 RESULTS METHOD # BACTERLAL: • Total Colifonn Absent per 100 ml SM 9222B (Bacteria) • E. Coli (Bacteria) Negative per 100 nd SM 9222B PHYSICALS: • Color (Apparent) 5 mg/L EPA 110.2 • Odor ND mg/L SM 2150 • pH 7.62. mg/L ASTM- D1293- 99 • Turbidity 0.49 NTUs EPA 180.1 CHEMISTRY: ® Alkalinity 112 - ..mg%L......._._ SM2320B • Chlorine Residual <0.05 mg/L 4500CIG • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 • Nitrate Nitrogen <0.05 mg/L as N EPA 353.3 • Hardness 112 mg/L EPA 130.2 • Lead 0.003 mg/L EPA 239.2 • Iron <0.03 mg/L EPA 236.1 • Manganese <0.01 mg/L EPA 243.1 • Sodium 4.5 mg/L EPA 273.1 MAXIMUM CONTAMINANT LEVEL (MCQ OR STANDARD 0 per 100 ml(ABSENT) Negative 15 Not to exceed value of 2 on scale of 0 -5 6.4 to 10 Range 5 NTUs 1.0 mg/L 10 mg/L Combined limit for Nitrite plus Nitrate = I Omg/L as N 150 mg/L ** 0.015 mg/L* 0.30 mg/L* 0.50 mg/L * ** 28.0 mg/L ** DATE TESTED & TIME WHERE APPLICABLE in/2o04 1/7/2004 1/8/2004 @ 9:15am 1/712004 @ 3:25pm 1/8/2004 @ 9:15am 1/8/2004 @ 9:15am 1/8/2004 1/712004 @ 3:25pm 1/9/2004 @ 9:15am 1/9/2004 @ 10:05am 1/13/2004 1/9/2004 1/9/2004 1/9/2004 mi= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level ** *Action Level <Q= Analyte detected below quantitation limits. Data deemed estimated 3 =Water containing more th 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines. -All holding" times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or aOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTAB LE WATER) Laboratory Director CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Pur haser of Building �Ap_m�,�4 ebe, L t2cL_ Building Constructed by Location - Street S,n a Building T e 3y 3 �)3..10-L Tax Ma Block Lot 6 N lU TownNillage ' I� f✓lt Subdivision 14ame 1 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 .system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County. Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month Day Year General Contractor (Ow r) - Signature ,1� Corporation N me (if corporation) Address:dHi State Zip Signature: Title: Corporation Name (if corporation) Address: State /V- Y Zip Ac o Form GS -97 : PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION . Date: ?-(0-03 Inspected by: _.. � y4 , O:S *a:eet.:L t -ocatronY Town — Y t A-f ?6R� Permit # 'P-6- ) TM # 34 - 3— Z S. 1 Subdivision Lot # I T --_1 > 1. Sewaze Svstem 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 , ' - ......... 1250 .........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 & trenches e. Junction Box - properly set ......... ............................... 6. T renc i— es _ 1. Length required _ Length installed�q 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 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 .......:........... 10. Pipe ends ca ed ............... ...... ............................... g�- wnp or Dose ystems / A 1. Size of pump chamber.......... ...... ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ............ ........................................ 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... ffi. House/Building a. House located per approved plans ........................... b. Number of bedrooms ................. ..................................... IV.. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured 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.. U f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 07.1'08/2003 TUE 13:32 FAX 1 845 279 6769 PUTN.AM ENGINEERING Z001/001 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTIEI SERVICES A'ITE TTON 11 ADAM XGENE r� For Fill All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit # _ _ .P Located: C ARO LW WAT M K /.�M!3ef o JJ - — Owner /Applicant Name: • Sr j gj a1'36 Tom 7 4 ^ Block 3 Lot 7-3.1 Formerly: __ . Subdivision Name: -34!�uzY A. S-ns3 gut Subdivision Lot # ; Is system fill completed? G - 1 Date: 7 4 rzifl Is system complete? ES Date: Z kzky Is system constructed as per plans? L'"f Is well drilled? No Date: Is well located as per plans? Are erosion control measures in place? I cer* that the system(s), as listed, at the above premises bas been constructed and I have inspected and verified their completion in WAwdanoe with the issued PC) D Construction Permit and approved plans and the Standards, Mies and Regulations of the Putnam County Deparimeat of _ Health. Date: a Certified by: RA • Design Professional Address: tic. # 6-9/w - Comments: ° -cw,.p �,vuxc f�1 G 'n [ 5-1 -fGsa - I" _'lk�� ' N Form FIR 99 51 OYtA- rte. JUL -8 -2003 TUE 12:28 TEL:845 -278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 T= Michael J. Budzinski, PE Fr=m Adam B. Stiebeling 5/21/2003 Ree Alternative Water Well Location Referenced project: Henry A. Stiebeling, 41 Carolyn Way, Patterson IVY - TM # 34.- 3-23.1 As discussed, we wish to move the proposed well location shown on the approved plan prepared by Putnam Engineering, Rev. Dated 02- 18-02; approved 03- 20-03; to the altemative well site located on attached copy of plan(s). As discovered upon site development, proposed well location will demonstrate a problem to drill. Please advise as to method of "aRemative "approval. Thank you for your consideration 2-19 /0 7 � /0 ca4-c-� '45; 0 e- 6, \ \ - 36g!. � \ �\ "1.• � :� ti � �: �,�� . mo �. PRO LE OPOSED 'DRAlE1tA�E all .00.0 ON Aft N. VN \► \� ' w #$: ; y 9. s ,t _ �. / i -- WAU _ 61_ / ' �� .� .y I'` Y' �ISPFfiitA��': `• a%�Si��� is ; T T 7 T T T T T PUTNAM ,COUNTY HEALTH DEPT. 02-4524 1 Geneva Road (848)278 -6130 Brewster,. NY 10509 fat � 'aQ� 3. �3 IJ/ Received of The Sum Of. Dollars For r a" 1s THA _ K YOU! ❑Cash E:] Check WO. ❑ Credit Card By q�p•�ia.�;rL ►r , jig 01 91114 CONSTRUCTION PERMIT FOR SEWAGE TREAT. ��_ SYSTEM Located at Town or Village TA-wsa5ot--� 1-1�u tts/ /�nz><wi Subdivision name C�.EU 06 Subd. Lot # 1 to Tax Map 3LA Block 3 Lot "..d Date Subdivision Approved Z I -Z-t, j (->:3 Owner /Applicant Name ileaM X. �� G Mailing Address n L-L -r`e-1— Amount of Fee Enclosed Building Type --Si i�J4CC Lot Area Fill Section Only Renewal Revision Date of Previous Approval Zip l 0i l z—. No. of Bedrooms � Design Flow GPD. Depth Volume Separate Sewerage U s� tem to consist of 1,7"50 gallon septic tank and M629 C'-ri Od 1-MC- M LA Other Requirements: � ' ©1� V � u. --, cr-'% b 4 To be constructed by .ro 36gr ►t�� =� Address Water Sun ..Public Supply From _ _.. _ Address. on Private Supply Drilled by :V2 -6,e j2;i -r 9 -K I M g10 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 s sY tem 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 the Signed: P.E. R.A. Date 6 Address 9,,-.t4A.4,x C w(.a+:�eo., ioi - 'L c D R4 ° La License # 19t.- Li q to .57"- "-c zF— KP-i % l 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 hen considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new it. prove or discharge of domestic sanitary sewaA only. / 03 gy; Title: Date: White copy - HD File Yell w c py - Building Inspector; Pink copy - V er; Oxmfge copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL Q ,� 2 _ . please print or type r — � ~ IPCHD Permit # / —S `�LJ. Well Location: Street Address: cam' illage Tax Grid # C_A Map -'3._J Block Lot(s) Z3 .t Well Owner: Name: Address: yy�� Use of Well: Residbntial 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 _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reasons L �q for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes__5�',No Name of subdivision 1-�- rvy A,�_\ Sr 1 c-��L l,� cr Lot No. 1 T�> Water Well Contractor: -T-6 11F, Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: A- L Proposed well location & sources of contamination to ed on se sheet/plan. Date: 7 riol Applicant Signature \,, 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. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a w ter well driller certified by Putnam County. Date of Issue &/10A Permit Is ling Offioa Date of Expiration; N 7U /O S Title: Permit is Non- Tran+sferrhble I 1� 0 ( U White copy - HD file; Yellow copy - Building Inspector; Pink copy -Owner; Orange copy - Well driller Form WP -97 UT4N.� M I\ EINEEF170NE- PLLC. Englneers and Architects SEPTIC SUBMISSION FORM TO: PUTNAM C UNTY OfALTH DEPARTMENT PROJECT: r720 �i/- 3 -.!�g, o DATE: '-51 A ?' "3 ENCLOSED, PLEASE FIND: {7 COPIES OF THE SSDS PLAN ® COPIES OF THE HOUSE PLANS ® CONSTRUCTION PERMIT APPLICATION ® WELL PERMIT APPLICATION ® HEALTH DEPARTMENT FEE ($300.00) ® SHORT EAF ® DESIGN DATA FORM ® LETTER OF AUTHORIZATION ® APPLICATION FOR WASTEWATER TREATMENT (PC -97) ® LETTER OF EXPLANATION REMARKS: O✓&V Arm 5&Vp1As'1 Al Or L,g-,&/ - o P7 -6 4z'� la• lb -9Od,a ; r Apps 01,4r7/�i0EisA -4e;'U(/a11311sTlN -rf/� CPR ?1-1 r1 CallAIAM ?cS. COPIES TO: SIGNED: 4 OLD ROUTE 6, BREWSTER, NEW YORK 10509 • (845) 279 -6789 45) 279 -6769 • E Al . puteng @bestweb.net LORETTA MOLINARI R.N., M.S.N. _ - ........ Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Mr. Gary Tretsch Putnam Engineering 4 Old Route 6 Brewster, NY 10509 Dear Mr. Tretsch: Jlvti ROBERT J. BONDI County Executive March 10, 2003 Re: Steibeling SSTS — Lot 1B Carolyn Way (T) Patterson This Department has received and reviewed the engineering report and plans for the above referenced project and the following comments are offered for your consideration. 1. The road name should be provided on,the SSTS plan. 2. The finished grade contours should be labeled. 3. The first floor elevation of the proposed house is to be specified on the plan. 4. The, proposed drainage--systems cortipoiients,- located in the drive, are to be ,identified. 5. The septic tank inlet and outlet inverts are to be specified on the SSTS profile. 6. The slope of the septic tank effluent pipe is to be specified on the SSTS profile. 7. The proposed footing and leader drains from the dwelling are to be shown on the plan. 8. Erosion control measures are to be provided for the proposed well. 9. The septic tank volume and dimensions are to be specified on the septic tank detail. . Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. Respectfully, ILA 4, Michael J. B dz1 ki, E. Director of gineering MJB /jp UTNAM NEiINEERINE. PLLE. Englneers and Arch/tects SEPTIC SUBMISSION FORM TO: 1� 03z- i)\)su I P, I . DATE: PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: 'ko +-U A' SM tF-(S au �.J 4 ENCLOSED, PLEASE FIND: ® COPIES OF THE SSDS PLAN ® COPIES OF THE HOUSE PLANS C NSTRUCTION PERMIT APPLICATION LL PERMIT APPLICATION HE TH DEPARTMENT FEE ($300.00) SHORT EAF DESIGN DATA FORM ETTER OF AUTHORIZATION APPLICATION FOR WASTEWATER TREATMENT (PC -97) ® LETTER OF EXPLANATION REMARKS: COPIES TO: SIGNED:'1 J" A 19&v 4 Oro ROUTE 6, BREwsTER, New YORK 10509 - (845) 279 -6789 o Fax (845) 279 -6769 a EMAIL: puteng @bestweb.net PUTNA-Al.,COUXTY. PZP , NT.t HEALTH DIVISION OF ENVIR'ON'MENTAL HEALT SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner _ N r ;v �4 - t rt"� �►� �� �; Address 9,111W Lis Lgto c4�� �k Located at (Street)._ (;VV_0LQ L,. +L1 Tax Map .�A Block 3 Lot 23, (indicate nearest cross street) Municipality 1� r<cr�sa P tY ��., Drainage Basin SOIL PERCOLATION TEST DATA Date of Pre- soaking Date of Percolation Test 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 revierv. 2. -Depth measurements to be made from top of hole. Hole No. Run No. Time Start - Stop Ela se Time (pMin.) De th to Water From Ground Surface (Inches) Start Stop Water Level Dro In Tnc�es Percolation Rate Min/Iuch I 2 U5 PATA Fkfo 3 4 5 l 99 -A 2 .. 3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repented at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for revierv. 2. -Depth measurements to be made from top of hole. 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' — 9.5' 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 N° - Deep hole observations made by: ktika, e, url4,Hi�Zr Date Ze' J� Design Professional a. Address: 4. r&C Cv Signature: 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: k Date 1l /-74 10 Design Professional Name: J? t� IM, L`t Address: j�r2 Ls�ti Signature: Design Professional's Seal TEST PTT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES �.. - I-I- DEPT - - T -- - , 7 HOLE NO G.L. 0.5' T S. 1.0' (' 14 13 0 2.0' Lela Low,. 2.5' 3.5' (,at v Lilt, keg Gemp 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' / 7.5' 8.0' 8.5' 9.5' t0.01 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: k Date 1l /-74 10 Design Professional Name: J? t� IM, L`t Address: j�r2 Ls�ti Signature: Design Professional's Seal P TN M O r N T D p M s B HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES MAN RE: Property of I4om au A U Located at Uri j�'ti V-4 Al VV &�cc25c >��, Tax Map # �_ dock 3 Lot Z ; Subdivision of �`T� STIT3�LI l�f� Subdivision Lot # t 7_�> Gentlemen: This letter is to authorize pQ )r&'1A f-' R- L--c -- a duly licensed Professional Engineer -- 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- G®unty Health Department, and to -sign .all necessary papers on half in connection with this matter and to supervise the construction of s ' L reatment and /or water supply systems in conformity with the provisi S. nd /or 147 of the Education Law, the Public Health Law, and the . . tX a itary Code. Very trul ours, Countersigned: Signed: P•E•, R•A., # 6944(e (Owner of Property) Mailing Address: ��c_� �,�t Mailing Address: MEMO= C State: Y_ Zip: 1 tl_3'05 OR Telephone: TB .- G' "I 9A 5UL,L-�-C- Atue— PLP, iuur�C� State: u` Zip: I a I L- Telephone: PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR .. . A °WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: .14C-Al " 2. Name of project: ai� Locatio�. 4. Design Professional: (',;; t, ,AN, IoLruiA% 5. Address: 6. Drainage Basin: T— j_ tLw 7. Tvne of 'ect: Private/Resid intial 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 EIS required? PD 10. Has DEIS been completed and found acceptable by Lead "Agency? ................ 11. Name of Lead Agency %A 12. Is this project in an area under the control of local planning, zoning,- or other. officialsa ordinances? -_ _ _ 13. If so, have plans been submitted-to such authorities? L 14. Has preluninary approval been granted by such authorities? ti Date granted: bO9 VY7 s 3 -f-- 6 15. Type of Sewage Treatment System Discharge................. surface water _groundwater 16. If surface water discharge, what is the stream class designation? .................... 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? ................ � 2.1. Name of sewage-system Distance. to sewage system 22. Date test holes .observed l l V� v ( 23.. Name of Health Inspector Vet �L gvj7 u S4--1 24. Project design flow (gallons. per day) ..................... ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... G 26. Has SPDES Application been submitted to local DEC office? ......................... /✓7-� Form PC -97 2 -27. Is any portion of this project located within a designated Town or State wetland? J✓y w._ ... . - 28 Wetlands.ID;.Number .. w .. ;. ...... ......:.... -. 29. Is Wetlands Permit required? ............................................... ...........................:..: � Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? ... ............................... 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. 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.? 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... K-1 35. Are any sewage treatment areas in excess of 15 % slope? ....... :............................ 36. Tax Map ID Number .......................... ............................... Map Block 3 Lot Z 3, 37. Approved plans are to be returned to ..... Applicant �� Design'Professional - NOTE:A11 applications for review and"approval ofd new SSTS to be located withiniheNYC 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 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 better of Authorization (Form LA 97). Failure to comply with this provision may be grounds for the rejection of any submission. -- T hereby affirm, under penalty of perjury, that information provided on this fora: __rue . to the best of nay knowledge and belief.. False statements made herein are punishable as: a Class A misdemeanor pursuant to Section 2 -af en SIGNATURES & OFFICIAL T'IT'LES. Mailing Address: .... ............................... tip. y 16 �6 .14-164 (9195) —Text 12 PROJECT I.D. NUMBER 617.20 S EO R Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT' FORM For UNLISTED ACTIONS. Only PART I— PROJECT INFORMATION (To be completed by Applicant or Proiect sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME 'VAg� 94 S' re t`.i L p� Et�1C11 T112 ' 4l �L 3. PROJE& LOCATION: Municipality County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: ONew 0 Expansion 0 Modifleatlonlalteratlon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially 3 %•1t S acres Ultimately Z i 5 acres 8. WILLpROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes 0 No If No, describe briefly i 9. WHAT,4 PRESENT LAND USE IN VICINITY OF PROJECT? ntial 0 Industrial ❑ Commercial ❑ Agriculture 0 Park/Forest/Open space ❑ other Describe: L3� nLrls(r 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes If yes, list agency(s) and permlUapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE.A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes A410 If list agency name and yes, permlUapproval 12. AS A RESULT OF ROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION? 0 Yes No 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AppllcanUsponsor name: �Date. I Signature: 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLIETION 'REPORT Well Location Street Address: CaM/Up �lt Town/Village: r,,- 0A Tax Grid # M Block Lot(s),Z3, j Well Owner: Name: V V Address: - A� clye,6 ►� BJLt e Use of Well: 1- primary 2- secondary sidential blic Supply Air cond/heat pump 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 ft. Length below grade _ ft. Diameter _�in. Weight per foot %7 lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout jt Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details me er th to Screen ft eloped? First _ Yes—No Hour Second Well Yield Test _ Bailed_ Pumped XCompressed Air Hours Yield -9— gpm Depth Data Measure from land surface - static (specify ft)- During ,yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions..or..... -: sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameteron) Formation Description ft. ft. Land Surface Jill If yield was tested at different depths during drilling, list: Date Well Completed 7/ 6.� Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ev ^ Capacity 2 Depth g a t Model 6S0 Voltage 7 3o HP J /iv Tank Type Volume Putnam County Certification No. DatZwoe Well Driller (signature) 00? -IWAI - nvym rxaet location or wets wim atstances to at least two permane�t lana�+larxs to be proviaecl on a separa sheevplan. QQ� Well Drillees Name ec-, �O�ls C • Address: 60' r 7/9 Oh R. Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller I V 4158., 5, r CW "10 t�� ' s L 4158., 5, A5 -BUILT MEASUREMENTS ( I 4P� REVISIONS f TNAM .. N0. DATE DESCRIPTION . NGINEERING" Puc • ENCGINEERS ARCHITECTS 4 OLD: R6M- 6, BREWSTER, NEW YORK 10509 - (845):279-6'1$9 'FAX (845) 279-6769 B161t�z1'tYZ.PLLG n :fir. A _ �° ...,. ..''� *.d x. .. ..� . 4 .. ... :�. .. •��._ ... � ?. �.. ...`` .._ x' .e ti'•�. ..., _ e .. .. � _ .> � .._� �. ',� I 2 3 4 5 6 7 8 Cl 10 II 12 .13 14 BU -U" 7(0` 74'0" %2 -(0'' 7/ =0° 112 =d" J�;q=�` 135 d' rd!` �" 118` o" 1r8' �' / /i =�" rvQ "" 98' �" 9/= �" 77 -0" e3' o "o'o' �7-�" D 2� 4P� REVISIONS f TNAM .. N0. DATE DESCRIPTION . NGINEERING" Puc • ENCGINEERS ARCHITECTS 4 OLD: R6M- 6, BREWSTER, NEW YORK 10509 - (845):279-6'1$9 'FAX (845) 279-6769 B161t�z1'tYZ.PLLG n :fir. A _ �° ...,. ..''� *.d x. .. ..� . 4 .. ... :�. .. •��._ ... � ?. �.. ...`` .._ x' .e ti'•�. ..., _ e .. .. � _ .> � .._� �. ',� WELL 4P� REVISIONS f TNAM .. N0. DATE DESCRIPTION . NGINEERING" Puc • ENCGINEERS ARCHITECTS 4 OLD: R6M- 6, BREWSTER, NEW YORK 10509 - (845):279-6'1$9 'FAX (845) 279-6769 B161t�z1'tYZ.PLLG n :fir. A _ �° ...,. ..''� *.d x. .. ..� . 4 .. ... :�. .. •��._ ... � ?. �.. ...`` .._ x' .e ti'•�. ..., _ e .. .. � _ .> � .._� �. ',�