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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -3 -43 BOX 14 01501 No. N n IN r ri Lo IN N! m I IN r 1: ' OL •l , 'r t IN 6m LNNN UL 15 JWJA IIN pqlk T 01501 1;& AM COUNTY DEPARTMENT OF HEAL N--OF- E- RONMENTAL--HEALTH SERYIC CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # F- '� I - ()2- Located at A W A Town or Village pflT r gF �-,60H Owner /Applicant Name JOEN FA-A F'5V0 61TD Tax Map Block', '�� Lot Formerly Subdivision Name Subd. Lot # � \Jq y 1 ci f 4 Mailing Address e L-0 ,J 14� ]Ja ��'%`�� ( kd" Zip l v S o Date Construction Permit Issued by PCHD I 'VO4 " Separate Sewerage System built by �+ ��yLa�� Address �� I�D��� °� Consisting of 11-60 Gallon Siptic Tank and a er ana ysis res uit-for- _^ Water containing more than .20 nxg/L of sodium should not be used for Other Requirements: 1j,f % rltL; should not be used by people on moderately Water Supply: Public Supply From Address or: k Private Sunnly Drilled by Q-F- 66411 t S401� / IQ(-' Address4 Vim A'YE Vew0i �-NYOOI . Building Type t ©MAC _ Number of Bedrooms A Has erosion coniiof been�compI ' ed? E� Has garbage grinder been installed? '40 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: 10 12 I DA- Certified by P.E. R.A. Address °-0'549 P-T- ZZ $ i� w l m SQ 9 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 ar bject to modification or change.;,when, in the judgment of the Public Health Director, such revocation, o ficatio r chan necessary. By: Title: Date: Iddo L/ White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 0 October 29, 2004 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY. -10509 - Tel: (845) 2794003 Fax: (845) 2794567 Email: hnengineer @aol.com RE: Individual SSTS Compliance - Esposito Burdick Glen Subdivision, Lot # 4 4 Michael Way Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S-4, "As -Built SSTS ", dated 10/18/04. - -2.- - --- --- "Certificate, of- Construction Compliance for Sewage Treatment System "; dated 10/29/04. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 10/29/04. 4. Laboratory Report, dated 10/14/04. 5. "Well Completion Report", dated 10/11/04. 6. Application Fee in the amount of $300,00 payable to Putnam County Health Department. 7. E911 Address Verification Form, dated 10/18/04. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic s Jr., P:E. . HWN:gav 02- 062.00 A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT 'Welil.Ldcation " SYreet�Address: _ - ... _ _ . 4 Michaels Way I'own7VilIage: - Patterson =Ma, # <.,_.... >,...._.. ,....... �: t ,... Block 3 Lot(s)4' ) Well Owner: Name: Address: R &R Development, C/0 Richard Rapp, Drewville Rd, Brewster, NY 10509 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _ Plastic _ Other Joints: —Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No _ Liner Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface- static (specify ft) 40' During yield test(ft) 420' Depth of completed well in feet 465' 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 10 DrillinE in over urden clay and boulders Hit roc at 10' -10 32 DrillinE in rock set..cas_i_ng, grouted_- 32 465 DrillinE in rock granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5 gpm Depth 440' Model 5GS10412 Voltage 230 HP I_ Tank TypeWX250 Volume 44 gall s Date Well Completed 6/25/04 Putnam County Certification No. 006 Date of Report 10/11/04 Well Driller gn re) ? ' Ad L . a NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's Name P. F. Beal 8 S s , Inc . Address: 4 Putnam Ave.. Brewster, NY 10509 Signature: % . I&I Date: 10/11/04 Adam L. Beal White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 4' Oct 18 04 10:07a -TOWN OF PRTTERSO 845 -878 -2019 P•3 OCT -18 -2004 10:26 AM HARRY W NICHOLS 914 279 4567 P•02 . MICE A FOLLY. � * LO=rTA �MOLIti/l U- 6. bl IN- rVatte NICIA of-got of- ,Aueetara P�blfe 111j�rolrl� i,7oaor DPvC1arrgf PeJHM Srrrkt� .• _• . - -- MA�tZZ+MT OF ' HEALTH .• �.. , . r , .. . _ ...._.... .. ..._• .. 1 Ogeave •Road .. _. .... , , Browater, New Yo* 10509 ' '•" •'L�tlnamiei�tNultlpl {1211.61)0 9a(91iyy11.79Z1 . tluaia =,84mun014) all -iSIB• w7c(911P711••6611 .F1*(Pt4)211.601J • Lar1y''ra�nii�a'plgZ1T.60td 9�uo!»I�911j47i�011 ts19N)i7C•ssaa - E211 ADUREM EE3FICATION FORM OWNERS NAME: J 0 *?A MA - ... .. '..y.;�'Y►LSi'. t�3'(JlYiZlE12;: _ . •�� � _ ':''� • i ; � :: .._r. .. . , . .,.'....... ... ,.... 1991 �►D� ss;... ... '4' ___I�►I >��1° wad. AZJ(tRiZp TO,.S�FSiCIJ6IIr:. (signature) The Putnam Catmi* Department of Health will pot Issue a "Certificate of Construeflom CompUsaee•aalcss the above f'arm fs.comptoted; i.e., a legal 19911 • address is a..;i fed B3! pn authorized town ofiicfal. Z'hIs form, is to be submitted.. _......, ...._.... tiYtth the'applieadots for a Cer•titicate of ConstrU.4012 Compiianee. .�.. ... ... . _ —� � _.• w_ .. r.•_•I lM'• • `ter •. .� �. • • _' . .. .N. • . _ .. � .." rn._ .s .PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SER.VICES.. , GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot - --Buil-dirig- Constructed-by TowrvVillage (L EA NAY Location - Street Subdivision Name Building Type.' Stibdiv -ision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, constructiors and'drainage of the sewagelreatment system serving the above- deschbed'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 Fart -of said.Yysterh constructed by'me which failsto 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 buildirig-utilizing.the.- system: The undersigned further agrees. to ac.cept 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 buildins utilizing th system` Dated: Month Day Year 2004 Signature: Title:�s� _ General Contractor '(Owner) :yAature . Caine Corporation Name (if corporation) Address: /"D �l0 State zip� Corporation Name (if corporation) Address: 10.q0 Deft StateI''UTV I- Zip 1� Form GS -97 r. r U b 1N AM %- V U A 1 x JL)JbrA1(11VIE14 1 V 1+' Jil•:AL'1'Ji DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION / Date: Inspected by: Z Street Location Owner Permit # P-31 - 007— TM # 3Y, - 3 _3 Subdivision of # 1. Sewage System Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... 11 Sewage System - a. Septic tank size - 1,000 ...:....1, 50.. ....other..........V b. Septiclank installed level .......-**,*.. ...... * * "*' ................ :... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost ...................... " * * * * * ............. ". I .. Minimum 2 ft. Original soil between box & trenches e. Junction Box - properly set ....... ............................... 6. Trenches — L. Length required QO Length installed p 2. Distance to watercourse measured- io 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 fed .. ......... 0� ,.. g.. _ -UM o os . , stems; - -- --- _ _ 1. Size�o apump-•ehamber= =.: _ ' _ "` - : 2. Overflow tank . ............................... ..W 3. Alarm, visual/audio. ..:...:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .....:.................... ............................... 6. C�yycle witnessed by H.D.estimated flow /cycle........... M. House/Buildirig a. House located per approved plans b. Number, ofbedrooms - 77 7.1 IV. W'e'll" Well located as per approved plans . ......:........................ b. Distance from STS area measured &0 ' . 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 watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :........................... i. Erosion control provided ................. ............................... Rev. 12102 Vie XA 1J GdN K'y °_'tz en D— 8oK w mK,e or/ e t/_$ e 5 a Form -3 131- YES N NO C COMMENTS 131- �P SITE -INS PE 1 F CTIO OR FILL PAA D -. ... n. , Date: Inspected by• Fill pad located per the approved plan Fill Pad Length 13 ;2- Required Length_ 3 2 Fill Pad Width ®� Required Width . �z Fill Pad Depth j , S Required Depth ?j , 5 .13 Z Run -of -Bank Fill Quality Slope from Top to Toe.. �OO Impervious Layer Installed S trosion Control Installed, u e 5 Sieve Test Results (if applicable) Al �. Additional Comments: Reserved for Field Sketch if Applicable r M . JUL -23 -2004 12:06 PM HARRY W NICHOLS 914 279 4567 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DM. SION.OF ENMONMENTAL HEALTH SERVICES ..,EiZL0g1 EQX FTA Y IN'S110-N For: bill +� Date: 0 2ZY_ Trenches ..... PCHD Construction Permit # F. 3t -ol: ]vacated: 4 NjQW&tia. I+�hY�r�, (T) ('V)�Si'ye�+toa3 Owner /Applicant Name: ' --ADA YUO—S►I'o TM—W. Block ,.&_ Lot ja_ . Formerly: Subdivision Name; &)Ab�w t Subdivision lot'# - -A Is systemf fill completed?-ye s + Date: ei r.... Is system complete? ; ,_._ , MIR Date: Is system constructed as per plans? 00 Is well drilled? , —_ �_012 Date: Is well located as per plans? Are erosion control measures i i plan? 41t.- I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verif ed 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. ji' Za,Zaq Certifieday. t 1 r s a 4 SENDING CONFIRMATION _.. DATE JUL -23 -2004 FRI 11:52 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845- 278 -7921 PHONE : 92794567 PAGES : 1�1 START TIME : JUL -23 11:50 ELAPSED TIME : 00'45" MODE : G3 RESULTS, : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... J"1- 23-3-J I-- PA MARRY M "iC1iOLG Yl•1 2— 4567 P.el FDTNAM'COUM DEPARTM&Nt OF HEALTH DIVISION.OF ENVIRONMENTAL HEALTH SERVICES Bfi jtST ROA bRItAT_ rNSPRr: OW For: Fill ✓ •• Date: Mr2a« e4 Trenches FCHD Comtrualioe Poimit al -cm Located: 4 .!t —oAll, 1"m (T) (v) y mesa Owlmv /ApplioatitName: .los�ss(Ri►Ce TM _2& Block _A — Lot __ I Formerly: Subdivhdon Name:. wall Goat .._.- . _....._.. - -- .._.__.__..- ... -._. ... . _ .. � _ ...-•� ,. ._.. _....._ _ > -. Svbdivis�ionLaf #,?� - - ---... .- - -- .._ .: � -.. �. ._........ -. ..... _.._.....-- - —._ I5'sysrrla'1111 compIC40- :yft Date: euair.et • i I s systempompletc? • bate: Is system constructed u per Viejo . Is well drillodl Date: . b wall loeeted as perphusrf An erosion control measures inplep0 1 mrd* that the spsleaKt), as Md. a the above premises has h'eev comucted and I have impected ' And verified their completion in eeeoidance with the Issued PC!M Conawdetion Permit and ' approved plans and the Standard; Rules and Regulations of the Putnam County Dopartmem of Health. . Da,Ie: Cetged by. a IA_ . lbsdonel . Address:"'is aWt sA. afJ �,y tobe4 Lis N.6 IZ4 •« Cotettecats:: .. FOR O ADAM F(O$1 - D� (NAM) Form M99 JLL -23 -2004 FRI 11:31 M:M- 278 -7421 ta- 'ME:Pl:MnM COLtM DEPRRrrt:if CF P. •••1 . u - LORETTA �MOLINARI Public Health Director July 29, 2004 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 Harry Nichols Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Esposito 4 Michael Way, Lot #4 (T) Patterson, TM# 34. -3 -43 An inspection of the fill pad at the above referenced project has been completed. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the separate sewage treatment system. Please note that -field measurements by this Department in no way suggest that exact size, _..�._____. - -• -and location of the -fill pad. _., ..., � .._., _ ... _ _ .. ........_ __._ If you have any further questions; please contact me at 845- 278 -6130, ext. 2261. Sincerely, ,0� 0, Gene D. Reed Environmental Health Engineering Aide GDR:km I SENDING CONFIRMATION DATE JUL -29 -2004 THU 15:37 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE 92794567 PAGES START TIME :'JUL -29 15:36 ELAPSED TIME : 00'40" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... O LORF3TA MOUNARI y ROBERT J. BONOI Po61'e 11ma6 D-- Cwmly frremhw DEPARTMENT OF HEALTH 1 Gene" Read Arrwster, New York 10509 xnA—. 0d K.Kh (845) 27A - 61)0 Fu(945)278-797.1 - "'nh18 servlm (845)278 -6558 %"C(945)279-6678 Fmr(845)27R -6085 Bartr raRrveatkNPr4 b-1 (845) 276 - 6014 );..(101278-6649 July 29, 2004 1" Nichols Patterson Park, Ste 106 2050 Route 22 — — - _ - - Brewster, NY 10509 • . Re: Esposito 4 Michael Way, Lot #4 (T) Pntt etson,'fM# 34. -3 -43 Dear Mr. Nichols: i An inspection of the fill pad at the above refercncM lirojevt has been completed. Trench plans must be submitted.to this Department for final approval of construction prior to the installation of the separate scaage tirotment system. i Please note that field measurements by this Department in no way suggest that exact sim, depth and location of the fill pad. If yon have any further questions, please contact rtic at 945- 2?9-6 130. ext. 2261. Sinocmly, _ 1 Gene D. Road Unvf onmental Health Enginmring Aide GDR:km SEP -27 -2004 01:5$ PM HARRY W NICHOLS 914 279 4567 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISXON,OF ENVIRONMENTAL HEALTH SERVICES gF0 E T FOR FINAL, TIJSPEGTIO9 For :. Fill Date: �:. — Trenches „ FCHD Construction Permit # P• 31.02 Located: 4 N let; , • „may (T) M AM 24a) Owner /Applicant Name: _ %'01[ 'lroSPO1:1TO TM 34. Block 3' Lot —43 . Formerly: Subdivision Name; BALatelt 4 L1L J Subdivision Lot # 4 Is 'system°fill completed? Bate: Is system complete? v,es Date; _*%Fr x� Is system constyucted' as per plans? 2195 Is well drilled? ,. Y 1 Date: SIG>p' '' 2'70 .Is well located as perplans? �Iss Are erosion control measures in pleso? �- I certify that the system(s), as listed, at the above premises, has been constructed and I have inspected and .verified their completion .in Accoida660 with the issued PCHD Construction Permit and approved plans and, the Standards, Rules and Regulations of the .Putnam County Department of Health. �� , 04 Certrfi ed by, DesigUrofessional, Address: 2 4o •Ra�y z2' bosiAgria 105QI Lit. # 56124 COLt meaty. _ 1 ' LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 October 5, 2004 Harry Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Re: Field Inspection — Esposito Michael Way, (T) Patterson TM # 34. -3 -43, Lot # 4 Dear Mr. Nichols: The following comments must be corrected in the field: 1. The cast iron pipe needs to be installed to septic tank. 2. All end caps need to be exposed for inspection. A-bedroom•eountneeds to- be-performed by-this- Department. 4. A dose test must be witnessed by this Department. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, 3-2� 4v A� Gene D. Reed Environmental Health Engineering Aide GDR:km ROBERT J. BONDI County Executive SENDING CONFIRMATION DATE OCT -5 -2004 TUE 11:18 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1�1 START TIME : OCT -05 11:17 ELAPSED TIME : 00'40" MODE : G3 RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... LORETTA MOLINARI - ROBERT J. BONDI hbllc HroIle n;rrele, yd'u, Y Cov9(v E—& DEPARTMENT Or HEALTH 1 Geneva R—d, Rra..xlrr; M:.. V1nk 10.509 GNr4neenb) RnIlh (R4512iR- Al:ilt Iu 1R4.t12'/R -:921 7tarrna8 8avkn (815)278.6558 WIC (805):78.6678 Fu(845)278 -6085 Wit, tel— tlmffl rh el (R45)27R. 6011 Nx(845)279 -VAR (lcloll�-1 5, 7004 Harry Nichols, P.E. Patterson Park, Ste 106 2050 Routc 22 .. . _ .. .._ 13) ewstel. A'Y• 10509 , Re: Field Inspectiou F5posin, Michael Way, (T) Patter um Dear Mr. Nichols: The following, comments must be corrected in thr field 1. The cast iron pipe needs to he installed to septic tanY. 2. All end caps need to be exposed for inspection. 3. A bedroom count needs to be performed by this Dcpartnlcm. 4. A rinse test mnsthe witnessed by this Dct•;nimad. . ifyou have any fbrther questions, please contort me at (K.95) 278.613U ext.'2261. Very truly your6, i(icnc D. Rccd Envirounienlal Hca!!h Fvgineering Aide i GDR:km DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION 7PPM1fFOR S EWAGE T MENT SYSTEM PERMIT # �� Located at 4 M i c N" ,&, i�: L_ W AY Subdivision name 6d 01U9, 6L'H Subd. Lot # 4 Date Subdivision Approved Town or Village PAT I-P5 P -60H Tax Map = Block '� Lot 4 � Renewal Revision Owner /Applicant Name JQ15 FFyPQ/? 1,f-Q Date of Previous Approval 02-11 e61 04 Mailing Address (6' ^,115 BVLEW 15-ri✓ p- N 1 Zip i c) L, D l Amount of Fee Enclosed Building Type 0a4CO Lot Area ° No. of Bedrooms 4 Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of J P_E��A CA Other Requirements: To be constructed by Water Supply: 1�_r) 0 "Ills, pm, D061�ji4 4_7,jFi40i4 Public Supply From gallon septic tank and C6 0() 1- P N Address Address °or: - X Private" -supply b rilled -by, _ ���P. .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 thereto. _ Signed: Address R.A. Date 0"1/ � o 14 License # 5 E i 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 w c nsidered nec ssary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe proved for charge ofd mestic sanitary sewage on By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner e�,-3r ©6 rn Address CD. GF "O MVO' Located at (Street) 4 tAkc4�W �iN,� f�011aMoLF-" +Tax Map 4 Block �S Lot (indicate nearest cross street) Municipality PATTa-�L.5 ®H Watershed EK &QA" SOIL PERCOLATION TEST DATA Date of Pre - soaking 01 H Date of Percolation Test 011-P) DI 2. percolation test hole. (i.e. s 1 min for 1 =30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. Depth measurements to be made from top of hole. Form DD -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktow�n Heights, N.Y. 40598 (914) 245-2800 Albert H. Padovani, Director LAB #: 93.402358 CLIENT #: 8481 STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ R & R DEVELOPMENT CORP 1040 DREWVILLE RD. ATTN: MICHAEL RAPP BREWSTER, NY 10509 SAMPLING SITE: 4 MICHAELS WAY : PATTERSON NY COL'D BY: MICHAEL H RAPP NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE DATE/TIME TAKEN: 10/09/04 09:00A DATE/TIME REC'D: 10/09/04 10:10A REPORT DATE: 10/L4/04 PHONE: (914)-279-4496 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD Na 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. PH 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 RANGE OF pH IS 6.5 TO 8.5. SUM�OFTHE_CA-.--'IUII &-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 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) SUBMITTED BY: n aL Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # �I a- Located w p Located at M �') �` �ry J on or Village FAT re P-'60H Subdivision name �VPICe— 6aH Subd. Lot # Tax Map Block ?� Lot -4 5 Date Subdivision Approved Renewal Revision Owner /Applicant Name j o � e 6 Fb 112 ri-® Date of Previous Approval Mailing Address F—"d —l�� �ti`d�� G�— N� Zip iI ©509 Amount of Fee Enclosed F 10 fk- 4I1alh✓ Building Type WAMHce I -' Design Flow GPD Lot Area e �%l No. of Bedrooms Fill Section Only X Depth tb,5 Volume 1G60 Cy PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: 4) 4 To be constructed by i'6o gallon septic tank and $oo L-f— M�6 . poilt-4 50400 Address _ Water Supply: = _ Public Supply From or: X Private Supply Drilled by T -rep Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date of / j1j ®y License # 561? -rj 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 whe sidered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permi A rove f ischarge of domestic sanitary sew ply. By; Title: Date: If White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22'=. . Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 January 23, 2004 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Re: Individual SSTS - Joe Esposito (Formerly James Roach) Burdick Glen Subdivision - Lot # 4 4 Michael Way Patterson, NY T. M. # 34. -3 -43 Dear Mr. Morris: 1. Five (5) prints of Drawing SF -4, "Preliminary Design for Fill Placement Only ", dated 01/23/04. 2. Two (2) prints of Drawing SS -4, "Proposed SSTS ", dated 01/23/04. 3. "Construction Permit for Sewage Disposal System ", dated 10/1 /02. -� 4." "Application to Construct a Water Well!% dated-10 /01/02. 5. "Letter of Authorization ". 6. Two (2) copies of residence floor Plan(s), for bedroom count only. Please note this is for Name Change Only. The permit expires 11/01/04. Also note that address is Michael Way, due to revised driveway location. If there are any questions concerning the enclosed, please call. Very truly yours, t Ha ry W. Nich Is Jr., P.E. HWN:gav 02- 062.00 . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # P Well Location: Street Address: TownlVillage Tax Grid # .' Mv,40L. W A� vPtii�" H Map % Block t Lot(s) Well Owner: Name: Address: 3b� � 15N2 i a ( BEN A-`4S f3F-EW'7�16F— Q e Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought !7 fi gpm # People Served 'J -S Est. of Daily Usage f(o,9 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Y, Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Y— Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision OU f%DiC+— Gi'6'f Lot No. 4 Water Well Contractor: Top Address: Is Public Water Supply available to site? .................................. ............................... Yes No X 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 she t/plan. Date: 01 11A 04 Applicant -Signature: 10-ri -- - Mw 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 water a iller ce ified by Putnam County. Date of Issue IJ F/9 � , in Permit Issu ial: Z Date of Expiratio d Title: Permit is Non- Transfe rab e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY D]EPARTIYIEN7C' OF HEA.LTH DIVISION OF ENVIRONMENTAL HEALTH •SERVICES. ra:: LETTER OF AUTHORIZATION RE: Property of Located at T/V PAMP -60H Tax Map # 1�4o Block _Lot Subdivision of Subdivision Lot # Filed Map # ` 1 Date Filed-.. Gentlemen: This letter is to authorize a duly licensed Professional Engineer 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 He' alth Director of:tl e.�Putiiam . County Health Department, and to sign all necessary papers on my behalf in connection :with -this matter and to supervise the construction of said wastewater tretment and/or water supply systems ml the provisious:.�f Article 145 and/0'r-. -147 -of the Education -Law; the Public-Health Law, and the Putnam County Sanitary Code. Countersigne P.E., R.A., # Mailing Addb State .���- YQ Zip Telephone: lo,io� Very truly yours, Signed: �• L (Owner f Property) Mailing Address: State f �1EW `i ��� Zip Telephone. .. __ .. Form* LA-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 4 Michaels Way Town/Village: Patterson Tax Grid # Mafi'q'° Block Lot(s)–T',' p Well Owner: Name: Address: R &R Development, C/0 Richard Rapp, Drewville Rd, Brewster, NY 10509 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot _1c�lb /ft. Materials: X Steel _ Plastic _ Other. Joints: _ Welded X Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed. X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface - static (specify ft) 40' During yield test(ft) 420' Depth of completed well in feet 465' Well Log If more detailed information descriptions or ey _arialys�s....._ .: _ ML are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 10 Drillind in overburden clay and boulders Hit rocl at 10' ___ - . 10_.. _--- -__32- 32 465 Drillin in rock granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5gpm Depth 440' Model 5GS10412 P Voltage 230 HP I Tank TypeWX250 Volume 44 is Date Well Completed 6/25/04 Putnam County Certification No. 006 Date of Report 10/11/04 Well Driller gn re) 4 Ada L. eal INOTE: Exact location of well with atstances to at least two permanent tanumarKs Lo oc pru—cu un a zovyaiam au-v li-1. Well Driller's Name P. E. Beal & Scis, Inc. Address: 4 Putnam Ave., Brewster, NY 10509 Signature: % . Date: 10/11/04 Adam L. Beal White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 N 75° 00`00." E `th 00 w ICE V i+M M 0 0 Z L= 39b1 \ R: 25.00 .n. 9A°54!2.1 4ox ; 51255P0 IGAALN. _T 6f K t � �S'tPHON. Gt�AM6ER Pfc 594-36 �. V 8 _ txt5T1N4 ¢ BEOROOM RESIDENCC N In N 100 j EXPAN910N 4aEA 1 J.Qox(TYP) 35' 30 :45 �F ABC, TaGNC V3 (TYP)tt z9 14 28 f -` t g 16 26 4 "fp SOLID, P, TyPj i'$ Z,5 tg 24 6 5 z3.1 zb w ICE V i+M M 0 0 Z L= 39b1 \ R: 25.00 .n. 9A°54!2.1 4ox ; 51255P0 IGAALN. _T 6f K t � �S'tPHON. Gt�AM6ER Pfc 594-36 �. V 8 _ txt5T1N4 ¢ BEOROOM RESIDENCC DIMENSI ®N CHART (in feet) Number ATT 15 20 2 27 30 3 37 G1 4 45 G7 5 51 73 6 5G T8 .7 6 Z 84 8 GS 89 9 74 95 10, 80. 100 I I 66 106 12 92 I IZ 13 101 106 14 101 100 I5 96 95 16 91 89 11 87 83 18 83 77 19 78 72 20 74 GG 21 70 60 22 59 100 23 63 103 24 68 107 26 77 115 27 83 120 28 88 124 29 94 129 30 99 134 YML ENVIRONMENTAL SERVICES 321Kear Street � - Yorktown Heights, N.Y. 1059`8 14) 845-280(7' Albert H. Padovani, Director LAB #: 93.402358 CLIENT #: 8481 STAT PROC ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ R & R DEVELOPMENT CORP 1040 DREWVILLE RD. ATTN: MICHAEL RAPP BREWSTER, NY 10509 DATE/TIME TAKEN: 10/09/04 09:00A DATE/TIME REC'D: 10/09/04 10:10A REPORT DATE: 10/14/04 PHONE: (914)-279-4496 SAMPLING SITE: 4 MICHAELS WAY SAMPLE TYPE..: POTABLE : PATTERSON NY PRESERVATIVES: NONE COL'D BY: MICHAEL H RAPP TEMPERATURE..: < 4C NOTES.I.: KITCHEN TAP COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY PROFILE- 10/09/04 MF T. COLIFORM ' 10/09/04 LEAD (IMS) 10/09/04 NITRATE NITROG 10/09/04 NITRITE NITROG 10/09/04 IRON (Fe) 10/09/04 MANGANESE (Mn) 10/09/04 SODIUM (Na) 10/09/04 pH 10/09/04 HARDNESS,TOTAL 10/09/04 ALKALINITY (AS -_ 10/09/04 TURBIDITY (TUR COMMENTS: FAX TO 845-279-3608 RESULT ABSENT /100 ML <1 ppb 0.81 MG/L <0.O1 MG /L <0.060 MG /I... 0.164 MG /L 56.7 MG /L 6.6 UNITS 70.0 M6 /L 194 MG /L N/A NORMAL - RANGE METHOD ABSENT 1008 0-15 ppb 9101 0 - 10 9139 N/A 9L46 0-0.3 mg/l 2037 0-0.3 mg/1 2037 N/A 6.5-8.5 9043 N/A N/A 0-5NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WAT AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCOR HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/CuLEAD limits for p/ EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. � �blic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L,-else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. ' `~ DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER — CARMEL, N.Y. 1.0512 (914) 225 -3641 APPLICATION TO CONSTRUCT.A WATER WELL PCHD PERMI.T # '� ._:' Street Address o Village /City Tax Grid Numbe WELL LOCATION {'_LJb''ui 1G �ltoM Lot No'. Af WATER WELL CONTRACTOR: Name �' l3 a i! Sol SWELL OWNER ✓Name Mailing Ad ress %3 r ate TOWN /VIL /CITY D /O Love- JaJS�^ %, O Public �� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION SE OF WELL O'RESIDENTIAL 0 PUBLIC. SUPPLY' ❑ AIR /COND /HEAT PUMP O ABANDONED - primary O BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER.(specify secondary 0 INDUSTRIAL_ b INSTITUTIONAL ❑ STAND -BY PERMIT TO CONSTRUCT A WATER WELL AMOUNT OF USE YIELD SOUGHT gpm /# - PEOPLE SERVED J' /EST. OF DAILY USAGE(,QOo gal ,REASON FOR EW SUPPLY OPROVIDE ADDITIONAL SUPPLY ®TEST /OBSERVATION DRILLING ❑REPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL 1FDETAILED the requirements of the Putnam a this permit. TREASON FOR form provi ed th utnam C ty, Health Depart ent. ` -, • : DRILLING m t I s s Official Date of Expiration: 19 WELL TYPE DRILLED DRIVEN DUG EIGRAVEL ®OTHER 2/87 Pink Copy: Owner Orange copy: Well Driller FmIS_WELL SITE SUBJECT TO FLOODING? YES ✓ NO �LSxIF WELLI-EjS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: {'_LJb''ui 1G �ltoM Lot No'. Af WATER WELL CONTRACTOR: Name �' l3 a Address: - PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 4 / NO NAME OF PUBLIC WATER SUPPLY: {��/� TOWN /VIL /CITY ,;� DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �� LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION N SE ARA SHEE ' <�:;( date) sigdature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant s.hal l : 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam ;... County Health Department attached to this permit. 3. Submit a Well Completion Repor a form provi ed th utnam C ty, Health Depart ent. ` Date of Issue: ?j r 19 m t I s s Official Date of Expiration: 19 White copy: H.D. File Permit is Non - Transferrable Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller 7 ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL= 'HEALTH SERVICES Date Re: Property of �AA .e �OCcG� Located. at �Jl,t.��P �- lkle koad (T) /�!I 7t1krSh w Section_! __Block 3 Lot_ Subdivision of A4 C /,P A Subdv._ Lot # ¢ Filed Map # J /// Date Gentlemen: This letter is to authorize L yru W "0 cdotS -3 r_ a duly licensed professional engineer / or.registered architect (Indicate) to apply for a Construction Permit for a separate sewage system, to serve the above noted - property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in .ma- t-ter. and- to- supervise -the-construction-of• -s•aid system or systems in conformity with the provisions of Article 145 or 147, Education.Law, the Public Health Law, and the Putnam County Sani- tary Code. uG Qtiv�„ Countersigned P.E. , R.A. , ?} 71 Emir ve_ Address 9'7d /Ina Telephone Very truly yours, Signed of Property COULIV 7 ess re" S� lk�"�. [ r" zro Gi Town z76- WV Telephone ("J, �; �-Ja I tiii 3'�as� M-T BY: d (Street Location) DOCUMENTS - Permit Application Corporate Resolution - Plans - Three sets s/E Engineers Authori`zation7 Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) Perc Hole Depth SUBDIVISION Perc Zf -- 3 a -. Fill cd House P]s - Two sets Well �� permit; FiVS letter Variance Request GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRM DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder rate) Design Data: Perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing - ter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity floa,suff. size If Plumped Pit.& D Box Shown & Detailed Haase - No. -of. -Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systans Property Metes & Bounds House Setback Necessary (Tight lot) House Suer - 1 /4 " /ft. 4 110; Type pipe No Bends; Max. Fiends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, large Trees,Top of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 351to catch basin, stormdrain, piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' from Foundation; 50' to well 15' Well to PL 9 -�Atx-lel-v PUMMM COURrY DEPAWMERr OF HEALTH ..DIVISION. OF ENVIPMMENZAL HEALTH--SERVICES DESIGN - DAM: SEi=-SU8SUFACE : SEKAGE DISPOSAL SYSTEM FILE .NO.. Owner :T4 M ¢ 5 �oa�A Address 1-1 PQc%w h ✓Oo i C i . ✓ ew J ���, N� Located at (Street) g �ly� ale kocw( sec. %3 Block 3 Lot (indicate nearest cross street) - Municipality Watershed . (fr 46o' SOIL PERCOLATION TEST DATA RDQUI1 70 BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking �� / Date of Percolation Test HOLE NEEBER C= TIME. PERCULATION PERCOLATION Run i Elapse Depth.to Water From Water Level No. Time Ground Surface in Inches Soil Rate - .. Stmt -Stop Min. Start Stop Drop In Min/In Drop Inches Inches Inches 2 U-441 3 2-44 4 .. 5 1 - 1 0 ! 46 -.1 V. 32 Z. 4 2 101.0-- It ',C1 32- .. , ..A z 4,... _ z•� r z 3 4 5 . l 2 3 4 ...... 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DAM M •• X11 TO BE SUM11TTED WITH APPLICATION DEPTH HOLE N0. . a. G.L. 2' PAP, 414 3 HOLE NO. HOLE NO. 4' 5' T gnpervvovs 4Y4- o'r l A+�G. -vfav� �4�tr► 6' 7' SF 'a P1�PtDvEt 1��•I? i i g.: s lit - 12! 13' - 14' fI; . INDICATE LEVEL AT WHICH GROUNDGv;TER IS ENOOUNTERP.D ` INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENO OUNTERED DEEP BOLE ,OBSERVATIONS MADE BY: SEf 4PPQ0 VeD 'PL ITT DATE. DESIGN Soil. Rate Used 31- 45 Min/1" Drop: S.D. Usable Area Provided Sfl°a No. of Bedrooms 4•- Septic Tank Capacity . t LS o gals.. Type Cohcv,,4e Absorption Area Provided By 00 L.F. x 24" width trench IF Other e�E Yn_ Name LCcw��n i' . F_ny ��,�er,'�G �sde��. Signature m Address 'i `S F4 ,e w P t SEAL :1 ,... nt ° -5s1z sac' .r - - :,,�UFrcSi.O: THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft/gal. Checked by Date v LAURENT ENGINEERING ASSOCIATES, PC. _ - 7 RIVE.: -- ,,.......w._ ..,.._. u.. .. _ ......_ .. _. _.. 3r.FAtRFLELD.;D .._.._.. _�._.�,..... >...,__.... .�..,...,_.._ - -_ .. . PATTERSON; -NEW YORK 12563 914.278.6108 RANDOLPH W. LAURENT, P.E.i HARRY W: NICHOLS JR.. PE. CONSULTING SITE ENGINEERS December,.. 3, 1987 Putnam County Department of Health 110.01d Route 6-Center Carmel, N.Y. 10512 At"t John Karell, Jr., P.E. Re: Proposed SSDS Bullet Hole Road Patterson, NY 12563 Dear Mr. Karell: Enclosed are the following: 1. Three (3) prints of Drawing SS -1 "Proposed SSDS" dated 12 -4 -87; 2. "Construction Permit for Sewage Disposal System ", dated 12 -3 -87; 3. "Application to Construct a Water Well ", dated 12 -3 -87; 4. "Design Data Sheet "; 5.: Letter of Authorization , dated _. -1'2 3 8.7- 6. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 7. Check in amount of $100.00 payable to The Putnam County Health Department. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. ichols, Jr., P.E. /map CC: James Roach w11 copy each enclosures: LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIV5:-' PATTERSON, NEW YORK 12563 - RANDOLPH W LAURENT, P.E. 914 278-6108 HARRY W. NICHOLS JR., RE, CONSULTING SITE ENGINEERS February 25, 1988 Putnam County Department of Health 110 Old Route 6 Center Carmel, NY 10512 `883 PER 29 P 2 :1 o Att: John Karell, Jr., P.E. RE: Proposed SSDS (Roach) Bullet Hole Road Patterson, NY Enclosed are four (4) prints of Drawing SS-1 "Proposed SSDS - Lot #4", Revised 1-19-88. We would appreciate your continued review, approval and issuance of the Construction Permit at your earliest convenience. -S-i-n-cerely-� LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr.,P.E. /map CC: Mr. J. Roach w/l print 48' 1 i 0 BATH `: y I i`•� O { a M. 0 TN 1 O BEORUOM. . ONe SS'NU { . • BEOROOM 7 f w4LK 1 W.LC. 17'0•'a • CLOS[T� MASTER BATH 28' W /GARDEN TLI y• - ` 1 -t tl MASTER BEDROOM BEDROOM] -• ••_ �. .. d OPEN1 I1'U. 16'B "� . ... 17' 0" a 1S'tl" i STUDY , SECOND FLOOR 4828 = 1344SF ". 48' IP I=- -� . f•I M1IIL:NLN P-�Y • DINING ROOM rll� MUii NINli IIUOM I, /'•a,;•„} nay >i f H+i -t �l F "-:) E r i I .III CD q n �. . DPEN C- a4 LIVING ROOM ! fAMILY ROOM . . 13 0— 16 '.0- FOYER . CD . 1]' 0 a 1) 0 ^ r ; H 1 rf`y't awJF/ La: 4. FIRST FLOOR 4828= 1344SF '`•: ALL FLOORTLANS AND ROOM SIZES ARE APPROXIMATE - .NORTH AMERICAN HOUSING (LORI ? / oi� box 145 (301) 694 -9100 m(301) 44214 0 ,j�JJ .PlatuE Pnca.Md Specifications Subject To Change Without Notice Copyright 1985 (See Revcrse.Sidc sm PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P- 3) - 0a-- Located at NLjEj- 4OLZ i" Subdivision name BUR "` wL-6�4 Subd. Lot # 4 Date Subdivision Approved Town or Village PATMR -150H Tax Map �` % Block f,6 Lot Renewal Revision Owner /Applicant Name .11WO P-o A&-4 Date of Previous Approval Mailing Address 1 ��� Lim 1 Zip _ Amount of Fee Enclosed Building Type P-e 6 1 00 Lot Area �' fa I No. of Bedrooms 4 Design Flow GPD . ®� Fill Section Only �_ Depth '3'L $5' Volume I (PSO Li PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of + ® gallon septic tank and Other Requirements: 'h% 'f0' 11-- o - b RLL) 0(30)'a 4L' 'r�' P MO H To be constructed by Y?)'p Address Water Supply: Public Supply From _ or: Private Supply Drilled by�a Address .. _ .. , ._ .... ..� . Address n 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 §y stem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: ALAt,4 P.E. R.A. Date Address ©S 0 License # 85 b l APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage trea t system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified en c nsidered ne essary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm' . proved f charge of domestic sanitary sewage only. By: Title: (f k,o-- Date: 2 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 BATH 0I x 12'-0- BEDROOM A BEDROOM 3. WALK ' IN 13'-0-x 10'-0** CLOSET f-4 Ito. PUTNAM COUNTY DEPART �f I T OF HIS tj r Y I E HOOUSE USE P PL LANS APPROVED FOP, P L`LR0i T r T, ONLY, f_qjF,•R.,q;1jj 2 OPEN 13, 0- x Is* -8— DITS TO THESE HOUSE ALI, su�-ISK*T-�-�,!:`T LAN i,7 1�1,, C "011 FOR APPROVAL MASTER BEDROOM 17•-0 it SECOND FLOOR DATE 4828 =.•1344SF 1.� KITCHEN r DINING ROOM MORNING AOOM 13'0"m 12'•0- LL4 OPEN ABOVE LIVING ROOM t.- FAWILY ROOM 13•.0• 13' 0- ■ 1 ]• 0- FOYER FIRST FLOOR 4228 = 1-lildqP PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO_ CONSTRUCT A WATER WELL j 2.._-7- _ please print or type PCHD Permit �1 0 Well Location: Street Address: Town/Village Tax Grid # N "K Q -/5 Map , Block Lot(s) Well Owner: Name: Address: 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 5+. gpm # People Served Est. of Daily Usage t� gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes--,K— No Name of subdivision �JHM- C*0-4 Lot No. Water Well Contractor: 'T60 Address: °- Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination o be provided on separate sh t/pl Date: �- " Oj `'Q� Applicant Signature:. 41 Al 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 water a ller certified by Putnam County. Date of Issue 1 16 11 Permit Isicial: Date of Expiration l 0 Title: Permit is Non - Transfer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 RE: Property of Located at J L "! Rts� P-4) T/V P �`' °'� Tax Map # Block Lot Subdivision of Subdivision Lot # Gentlemen: Filed Map # Date Filed.__ This letter is to authorize A`7 a duly licensed Professional Engineer .X or Registered Architect to_a^pply for the. required wastewater treatment and/or water supply permit(s) to serve the above- noted-property in accordai}ce, 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 tretment and/or water supply systems in conformity- with the proisi-ors-of Article -145-ard/or.147 =of tfie Education Law; the Public Heaith-`� - -' Law, and the Putnam C itary Code. Of NEW), 49 Countersigned: P.E., R.A., # Mailing Address f— F State Zip o5d� Tele P hone: ($ A-5) /1 � - Very truly yours, - Signed: (Own r of Property) Mailing Address: Telephone: - -- - Form LA -97 Hairy W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 27911567 October 2, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS - James Roach Burdick Glen Subdivision - Lot # 4 Bullet Hole Road Patterson, NY T.M. # 34.-343 Dear Robert: 1. 'Four (4) prints of Drawing SF-4, "Preliminary Design for Fill Placement Only," dated 10/1/02. 2. Two (2) prints of Drawing SS-4, "Proposed SSTS," dated 10/1/02. 3. Short EAF. 4. "Application for Approval of Plans for a Wastewater Disposal System," dated 10/1/02. "construction: Perrnit.for,Sewage.Disposal System; "dated .10/_1/02:.:,_ -,- 6. "Application to Construct a Water Well," dated 10/1/02. 7. "Design Data Sheet." 8. "Letter of Authorization." 9. Two (2) copies of residence floor Plan(s), for bedroom count only. 10. Review Fee in the amount of $300.00// If there are any questions concerning the een'closed, please call. Very truly yours, Harry W. Nic ols Jr., P.E. HWN:JM:jmm 02- 062.00 14-16 -4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 `SEQR Appendix C State Environmental Duality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR R�A6H 2. PROJECT NAME _ a r d7�ai"d7 3. PROJECT LOCATION: �Q�HQ `�'��'"'� M Municipality County A . PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) fug ► Gib A>;tyj � �� •� �� l�t,� �' i-� � AD 5. ISYpRR�OPOSED ACTION:. •. Id New ❑ Expansion .❑'Modlflcatlon /alleratlon - 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED :: . Initially ° 4 4 acres 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? N Residential ❑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)? ❑ Yes fgtlo If yes, list agency(3) and permiUapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes I No If yes;' list agency name and. permll/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Cl Yes ONO I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE !C�'T3 °' J �Q-- � r- A6 AW5Hr Data: Applicant/sponsor n4- Signatuee: 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 __.. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH' SERVICES" .. v.-.•... -.... ....�.....�. ._ _. ._._._ �. _ .. _..... -.. PLICATION FOR APPROVAL OF` PLANS FOR ` A WASTEWATER TREATMENT SYSTEM;. t .. Name and address of applicant: J AH 5 R� i f62 P-0 - UN A IAALI iIl�1) Nflw *9- L 2. Name of project: �� �' �° � 3. Location TN:,. 4. Design Professional: 5. Address: US-0 ._. 2.... . 6. Drainage Basin: 7. Type of Project:... K Private/Residential Food Service Commercial Apartments - Institutional Mobile Home Park -- Office Building Realty Subdivision .... Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR) ?' Type Status check.one Type I :.. : Exem t TYpe.II`..:...... Unlisted , X 9. Is a Draft Ei itoftmental, Impact Statement (DEIS) required? .... .................. N 10. Has DEIS been completed and found acceptable by Lead Agency. .........,,,:;,.- 11,., Name of Lead Agency 12. Is this :projeet.in an area under the control of local planning,�zoning, �. officials- ordinances? ....... ......... ... ..... ............. ............................... 'b✓� 13. If so, have plans' been submitted to such authorities? ............... .......... ...: N:�...:.. 14. Has preliminary approval been - granted by such authorities? Date' granted: N 15: Type of Sewage Treatment System Discharge ................. surface water . groundwater 1;6.. If surface water discharge, what is the stream class designation? ... ................ :, 17. Waters index number (surface) ............................ ............................... .... f f 18. ..Is project located near a public water supply system? ............................ .... ..... . �0 19. If yes, name of water supply Distance to water: supply; i.tj A� -20: Is project site near a public: sewage collection or treatment system? N Q" 21. Name of sewage system N Distance to sewage system '• --- 22. Date test holes'observed 23. Name of Health Inspector GEH5 R�E1 D 24. Project design flow (gallons per day) �T 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... 0 26. Has SPDES Application been submitted to local DEC office? ......................... t4 N Form PC -97 _..... PI/ _ 27.. Is any portion of this project located wiltitn, der;a�tedown or State wetland? 28. Wetlands ID Number ........:............. A 29. Is Wetlands Permit required? ........................`....:...... ............................... (�D Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit ?Q 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 withiri 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 No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? . ..........................._._S 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 to excess of 15% slope? . ............................... �4 Map ......... Map 3A0 Block �J Lot �j 36. Tax Ma ID Number ................. ............................... 37-: -Approve d--p ham -are tabe returned to ..... .._X"- Desigh Professinal` ` NOTE: All applications for review and approval of a new SSTS to be located 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 stormwater.plans_or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from m DEP and submit those fors to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97): Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, cinder penalty of perjury, that information provided on this form is trice 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,4aw. - SIGNATURES & OFFICIAL TITLES; k ,'W� AL*pTj Mailing Address :...... .............................(} PUTNAM COUNTY DEPARTMENT OF HEALTH.... .--.,...,..,.,,- __ .D1V1SIONOF ENVIRONMENTAL . HE ALTH.-SERVICES."_ . ..... DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner '.... . Address Located at (Street) Nujkti,e -Tax Map Block Lot (indicate nearest cross street) Municipality Watershed aA.,rjj", N��(Vb(A SOIL PERCOLATION TEST DATA Date of Pre-sQaking Date of Percolation Test Hole No... :.."R'' N .... .. ... . . ...... . .. ..... ..... . op El '84 Time RX n.) Dpll to ter From ground Surface (Incbei) Start Stop* wa or, Level eve :Drotin Inc es Percolation Rate Min/Inc V5 —2 -15 fj .3 4 5 . ...... 2 .9 t WIT 3 .06- 4 5. ----------------- 2 3 4 5 NOTES: L. 'Tests f6 be repeated . atsam . e depth until approximately equal percolation rates are obtained at each percolation -test -hole, -(i.e. s I min--for 1-30 min/inch, :5 2 min for 31-60 min/irich) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Design Professional's Seal h/1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET = SUBSURFACE SEWAGE TREATMENT SYSTEM �L? 14 Owner 7Eo Address Located at (Street) Tax Map 3 fl, Block _ Lot jf/ -' (indicate nearest cross street) Municipality �',�7- Watershedc,� SOIL PERCOLATION TEST DATA Date of Pre - soaking A W ZOle2 Date of Percolation Test :::....:...:........... :: . .............:.........:...........:....:.:.......:: . ..:::.:........................ :.:: :::.:.......:.:,: . ter..... J: . ..:., . <.:.. ::,:::: : ::.:.. «.:From:G ou :r.. :f o tart::::to .................. p ..;:.;;;:: ><::: » >: >:Starb::;<: >::;<:Sta ; >:: » >:: >:: Form DD -97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES - ° DEPTH HOLE G.L. 0.5' 1.5' A .. 2.0' 2.5'_a.wLe 3.0' 3.5 S r► 4.0'' r 4.5' 5.5' 6.0'�� 6.5' 7.0' 8.0' 8.5' 10.0' Indicate level at which groundwater is encountered Al / Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: �5 Date tl a 61- Design Professional Name: Address: Signature: Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH . SERVICES.,__.. _ ._... _ . INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project )1. _7 �Oe>V County T'C/L /✓3� Site Location Bu2—G,� 61 � L - RZ El e—:1EE 7 3 1; 4 , -' 3 e3 Building construction -begun Al-0 Extent Is property y witin NYC Watershed ? ................. E2-Yes a No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. 0 Hilly :a Rolling 0 Steep slope Gentle slope Flat 2. Evidence of wetlands Low area subject to flooding 0 Bodies of water Drainage ditches J/'Rock outcrops 3. Property lines or corners evident .......................................... Fo, Yes No 4. Do water courses exiA' on or adjoin the property. ... F Yes ffNo .......................... - -5. Will these affect the design of the sewage system facilities ?............ 0 Yes �No 6. Do watershed regulations apply in this development ? ....................... Ef Yes F__J No 7 Will extensive grading be necessary? ....:............ ............................:.. F Yes . E�rNo 8. Will extensive fill be necessary. far. SSTS2..............,��,....:.:. -�: - -: - - -Yes:,- . No- 9. Do filled areas exist within the SSTS area ? ............................ Yes No If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: and a Gravel 0 Loam Clay Q Hardpan F_� Mixture 11. Observed from: a Borings 0 Bank cut Backhoe excavations 12. Soil borings /excavations observed by 2� i7 fi�� G; , on f :2 l 13. Depth to groundwater 44 1.4 on 14. Depth to mottling Al- / on 15. Are test holes representative of primary & reserve areas ...... ............................... 16. Soil percolation tests. made by *,6,1Gt/�eh-gpL S P " on 17. Soil percolation tests witnessed by a, Z -E- D ,,� G f 4 JD on SECTION D (on back) C Form ST -1 2 : 4' SP TION,D.. DRAINAGE -,. 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? F] Yes N 19: Will groundwater or surface drainage require special consideration? ..................... F7* Yes No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... Yes No SECTION E. REMARKS 21. If a common water supply is proposed; has an inspection been made of the existing or proposed source and fac" ' ................................ ............................... F Yes o _---. Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................... ............................... es F No 23. Additional comments ybyy )2P(f74(r_V . -2 T c ; L � 4 24. Site observer /inspector and title 25. Dates) of observation(s)inspection(s) 0IA_ I /. e3► --a- TEST PIT PROFILES Hole # Lot # Hole # 'Lot # Hole # Lot #. Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock /imp: - . -- - --- D "epth to' rock/imp. Depth to rock/imp. G.L. G.L. G.L. 0.5 1.0 2.0 0.5 1.0 0.5 1.0 2.0. 2.0 3.0, 3.0 3.0 4.0 4.0 4.0 5.0 5.0 . 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 9.0 10.0 8.0 9.0 10.0 8.0 9.0 10.0 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION. OF, ENVIRONMENTAL -HEATLH SERVICES, FfEi:b XiHfN IT Y iiii—Oki NAM.: 1Z Tel: At)DRETS: -P-MU,67- 96t-F -IZdt 'ReTZ-L"P501V /w-/ Street Town State Zip PERSON IN CHARGE Name and TitIC TYPE OF FACILITY:- WABWK� FINDINGS: loop J. Signature and Title I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Rev. J"L -17 -2002 04:34 PM HARRY W NICHOLS 914 279 4567 P.02 46CE . R. FOLEY_- Public Neolth•.. Director -- LOIi.3MA MOLINARI .R.N.,. Araoclats Publk Health D/rector Dbvctw t1. Potlent Services DEPARTNZNT OF HEALTH I Geneva Road Brewster, Now York 10509 ,ATTENTION: o ADAri! STIEBELI G )(GENE REED 1 All information below must be L& completed prior to any scheduling. DATE: ENGINEER OR FIRM: w6 NIGM -6 0- PF PHONE #: p 7q.'fon -MAY REASON; ` DEEPS: PERCS: ( PUMP TEST: a ROAD/STREET: BQW r _ tiow . TOWN; f TAX MAP #: t' l 44) SUBDIVISION: LOTM 4" OWNER: AJ k�N ITS NO _Pro osed SSTS-within the drainage basin oU 4!Yest;Branch or.B.o- yds- Cother IUeserdoir,�. - = -� - -Q` posed SSTS within 500 feet of a reservoir, reservoir stem or control lake. a..... Proposed SSTS within 200 feet of a watercourse or a DEC wetland: , o Proposed SSTS design flow greater than 1000 gallons /day-or SPDES Permit required. Q Proposed SSTS for it Commerical Project, It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered jta to any of the questions, NYCDEP must witness the soil testing, This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP, FOR CO*ff Us$ ONLY — DATE- Ae. g 2 f 3 0 TUNIZ. 's 1_a�L& �p 0 0 (FLELDTEST) T111 -,7 -Mama 1. 117r) 1r- !47 TFI:A4S -278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 -OFAMINCJN SOJINI/10 41 -T 5 U '0 3T 39 ZIA. 48 pti K p 59 36 4.68 At 0 'ju "-, 47 2 2.03 A54yo C '&A 30-91 AC, 1 35 4 598.66 q2 A C• Las , &c. .0 31 C. 44 0 2.32 AC. 45 1.49 AC ED 97 21 .7 23 32 3 . 1 2.95 11 '1 G 38.70 AC. CAL.. I., At 3%4 A 1� Ar- 384.05 AL 24 34 33 1.74 51 At a - p 1.91 AG 0 1.* At. 4 jL Ar 59 t IA 36 22 38 44. W AC. 0 37 253T ;C. CAL. 15 AC. 2.45 AC. 4. 10 ACS 41 sc 57.9E AC. CAL. 114.6% iff, Los 2 4 1 170 9 Ar. ' 1627.32 1%94.43 20 1.00 A 4 3•, .0 &96 At ass 119 43 11.41 . 0 M JL Zl',W,v 94W *91.61 5.89 AC. AL '.A,t J, (N 761.99 U- I 5 -P 17 9 2.66 At 44 • 4 . 34.84 AC... 2.69 AC. 45 AL at? Ar NP 14 Z4 2.70 A . 46 • 7B1, ip 39 Ac- J. :9 O-A . 40 16 JY Sist 'k. �M 4 r�7t A49," 2.42, AC 24548 3.36 At At Ac /O I.N.1 A j 2 40 af� I+Y 14 a c -j 9 34.13 Q 6.81' ACI /11 0 75.97 AC. �Op ms 2.5 'AG 20 247 At AL SAC 5 At AL r m I N 13f At, 694.72 i d 111 329 AC. 697.5 A .92 4 54 10' 3.34 A 5.97 At JL 55 IL" 3.68 At 53.51 AC. CAL. X34.17 9.46AC. AL AL 1.4 �6 JL 21.95AC. 24.42 AC. 'ate 93.50 AC. 63 30.91 AC, CA . 0 iLla\ -16 ski .46 At. qr 15 CAL. 14 75.97 AC. • 270151 ilas4 10 3.09 C11% rn AP , 5 AL AL 14 75.97 AC. • 270151 ilas4 10 3.09 C11% rn AP