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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -4 -7.3 BOX 14 01515 ,. 9 Lo'' ' I r :��L'' �� F T. ■ It ' IN . 2 r- . �; . 01515 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION -OF ENVIRONMENTAILHEALTHSERVICES- __ 4 CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at Vy-1 )C 5 F® HP }�-�NP Town or Village Owner /Applicant Name 1 Tax Map `t' o Block Lot Formerly "' Subdivision Name�'%� Subd. Lot # Mailing Address �-� TC� � 1 41L1.!�(a iJr peTie�L600 ., Zip Date Construction Permit Issued by PCHD Separate Sewerage S,, stem built by j�'NWAI � � ���1 7, Address Consisting of pd© Gallon Septic Tank and 1 FZI'4 W Other Requirements: 1) i•'�' Water Supply: Public Supply From Address or: Private Supply Drilled by W! Address Building Type 1`{ 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 with the issued PCHD Construction Permit and approved plans and the standards, rules and regulation of the Putnam County Dee t o ealth. Date: 04 , � �� Certified by ? P.E. R.A. (D si n Profe ssion! ) Address U51D iii `' l )3 " !44 113'500\ License# 15 (r 1 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, modifica ' n or change is necessary. By: Title: Date 6 -W -OL White copy - HD File, a ow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 3 PUTNAM COUNTY (DEPARTMENT, OF HEALTH (DIVISION OF ENVIRONMENTAL, HEALTH SERVICES ......WELL. COMPLETION. REPORT -- _ _ _ - Well Location Street � Address: v'�c�' / / ' /G� Town/Village. r G��w Tax Grid # Map /�,+. Block 4 Lot(s)j, Well Owner: Name: A dress: Use of Well: 1- primary 2- secondary ><' Residential Public Supply Air con heat ump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion =X 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 footlb /ft. Materials: Steel _Plastic _ Other Joints: _ Welded %e' Threaded _ Other Seal: ' Cement grout _ Bentonite Other Drive shoe: e Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped K Compressed Air Hours Yield 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 s- lev,'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 Capacity -7- 't, Depth '�.�p Model 3_9A67 IJL Voltage -?_-j FW Tank Type t)2 Volume Ve Date Well Complete Putnam County Certification No. Date ofsport i W /el /l�P r /ills (signature) NOTE: Exact location of well with distances to at least two permanent lanamarxs to be provt. Ton a separate sneeuptan. Well Driller's N e Address:c�' %L�� Signature: Date: White copy: Hrile; ow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Page 1 of 1 ���Environmental Services, Inca � � 41 Kenosia Avenue WATER, SOIL AND AIA ANALYSIS Danbury. Connecticut 06810 1 Telephone 203 -798 -2229 H2O Services Mailing Information: Collector's Information: JMS ID: 009926 Name: H2O Services Name: Shaun Boyd Address: 13 Caldwell Road Address of site: Tom Williams Ice Pond Road City: Patterson City: Brewster State: NY Zip: 12563 State: NY Zip: Phone: ' (845) 279 -4420 Fax: Phone: Sample's Information: Site: Kitchen Tap Date Collected: 1/13/2006 Date Received:. .1/13/2006 Preservative: HNO' Time Collected: 11:30:00 AM Time Received: 11:50:00 AM Temperature: <4 Lab No.: J0600206 Matrix: Water Date Analyzed Test Name Result MCL Method 01/16/06 Color 8 Units 15 Units SMWW 2120 B 01/16/06 Hardness 60 mg /L . N/A SMWW.2340 C 01/16/06 Iron 0.07 ppm 0.3 ppm SMWW 31116 MCL = Maximum Contaminant Level mg /L = milligrams per Liter N/A = Not Applicable ppm = parts per million Units = Units Signature: j� %�RGi- Reviewed By: _ . • _ T _ ........_Michael .Lapman _ . ._,_ _ ::Sharon Houlahan, Director..... President State #: PH -0218 ELAP #: 11715 CONNECTICUT. NEW YORK AND NELAC CERTIFIED Toll Free 866- JMS -5097 I Corporate Fax 203- 798 -2408 1 Lab Fax 203 -798 -2107 1 www.jmsenvironment3l.ccm r April 19, 2006 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Michael J. Budzinski, P.E. Barry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22' Brewster, NY 10509 Tel .0845) Fax: (845)279 4567 Email: hnengineer @aol.com RE: Individual SSTS Compliance — Williams 221 Ice Pond Road Patterson, NY T.M. # 34.4-7.3 Dear Mr. Budzinski: Enclosed are the following: 1. . Five (5) prints of Drawing S -3 "As -Built SSTS ", dated 04/05/06. 2. "Certificate of Construction Compliance for Sewage Treatment System" -dated 04/19/06. - 3. u Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 04/19/06. 4. Laboratory Reports, dated 10/14/05 & 01/16/06. 5. "Well Completion Report", dated 01/16/06. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated 01/03/02. If there are any questions concerning the enclosed, please call.. Very truly yours, Ha /ry W. Nichol r., P.E. HWN:gav 01- 030.00 �FQLBY aARm MOLtNARI `RN., �. f Public'. Health Dineta Asradats Ptt w -Health Dinaa Dinator Q/ Ptukw Spvica - DLPARTMENT OF HEAL'T'H_....... . .1 Geneva . Road., Browster, -New Ygtf ,h10509 BovinoouoW Health (914) 278 • t 179•.41F."14.271.7921 Monist "ca (914) 278.65 {8 WIC (91'4)278-6678 :?&x(P14) 271.6015 Larly'Iotorreti W'(914) Vf- 6014 �Fraehool (91,4) 218604 Fax 0i4j!*'- 66/i - E911 ADDRESS VERIFICATION FORM OWNERS NAMEt W6 t:rbH TAX:.MAP N UMBER: r14 N. — 4..7 1 . - - _ E911 ADDRESS: DP d TOW N:a�?�' j AUTHORUED TOWN OFFICUL; - -- (Signature) DATE: The Putnam County. Department of Health will not issue .a Certificate of Construction Compliance unless the 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 Certificate of Construction Compliance. (1;911 VFRFW PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF- ENVIRONMENTAL HEAL'I H' SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by V.A 169' Q Q n : �-G -- Location - Street Building Type. � 4 t 4- a0t Tax Map Block Lot TownfVillage Subdivision Name 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 parr -of said *S -Ystem constructed by r me which fails'to operate fora 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 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 building utilizing the system. _ ..- .. . • _ _ .._�r �z� :, � /J�, _�i c 157 Dated: Month Day Year LAC, Signature: Title: General Contractor' Owner) - Signature- . Corporation Name (if corporation) Address: IA-D iPU%660 �tl tkn�i God WIWPO State oy Zip 06 Corporation Name (if corporation) Address: IV State Zi IO�Q� Form GS -97 ,........ ; Page 1 of 1 ��ysEnvironmental Services, Inc.) � 41 Kenosia Avenue V ✓ATEA. SOIL AND Alp ANALYSIS l Danbury, Connecticut 06810 1 Telephone 203- 798 -2229 H2O Services Mailing Information: Name: H2O Services Address: 13 Caldwell Road City: Patterson State: NY Zip: 12563 Phone: (845) 279 -4420 Fax: Collector's Information: JMS ID: 007099 Name: Shaun Boyd Address of site: Ice Pond Road City: Brewster State: NY Zip: Phone: Sample's Information: Color 10/12/05 Turbidity Site: Tank Tee Date Collected: 10/11/2005 Date Received: 10/12/2005 Preservative: HNO3 Time Collected: 11:10:00 AM Time Received: 12:30:00 PM Temperature: <4 Iron Lab No.: J0510732 Matrix: Water pH 10/14/05 Nitrate Date Analyzed Test Name Result MCL Method 10/14/05 Alkalinity 28 mg /L N/A SMWW 2320 B 10/14/05 Lead (first draw) <1 ug /L 15 ug /L SMWW 3113 B 10/12/05 Color 10/12/05 Turbidity 10/14/05 Hardness 10/12/05 Odor 10/14/05 Manganese 10/14/05 Sodium 10/14/05 Iron w 10/14/05 Chloride 10/12/05 pH 10/14/05 Nitrate 10/14/05 Nitrite 10/14/05 Sulfate Oil 2i05--------- Chlorinne Free Residual 10/12/05 4:00 PM Total Coliform *16 Units 15 Units SMWW 2120 B 2.3 ntu 5 ntu SMWW 2130 B 64 mg /L N/A SMWW 2340 C 1 mg /L N/A SMWW 2340 C 0.114 mg /L 0.3 mg /L SMWW 3111 B (NY) 13.4 mg /L N/A SMWW 3111 B (NY) *0.339 ppm 0.3 ppm SMWW 31118 -7,57 mg /L . _ 250 mg /L SMWW 4500 Cl C _ * *5.6 S.U. 6.5 -8.5 S.U. SMWW 4500 H B -NY 0.4 mg /L 10 mg /L SMWW 4500 NO3E <0.1 mg /L 1 mg /L SMWW 4500 NO3E 19.8 mg /L 250 mg /L SMWW 4500 SO4F <0.1 mg /L N/A SMWW 4500CIG Absent Absent SMWW 9222B Comments: *ABOVE MCL * *BELOW MCL At the time of the analysis the sample was Acceptable for Total Coliform CFU = Coliform Forming Units MCL = Maximum Contaminant Level mg /L = milligrams per Liter N/A = Not Applicable ntu = Nephelopmetric Turbidity Unit ppm = parts per million S.U. = Standard Unit ug /L = micrograms per liter Units = Units Signature: Reviewed By: �+s� I Michael Lapman Sharon Houlahan, Director President State #: PH -0218 ELAP #: 11715 CONNECTICUT, NEW YORK AND NELAC CERTIFIED Toll Free 886- JMS -5097 I Corporate Fax 203 -798 -2408 1 Lab Fax 203 - 798 -2107 1 www.jrnsenvironmental.00m TAX MAP: 3 4-.- 4 - 7 ommommummmm PAW-- KSA.E-RIESt 2.2 to. ICE PO )YA OF PAT r. M.A 22,CTATTERS01 .p -1 .A TTEIRS6N Hair DPAINSION CHART (i. ,i feet) Number (_ 55 55 2 69 44 5 GI G6 6 64 �) 7 6 7 -15 g 70 Sa g �4 64 10 12a 65 II I19 59 12 tI8 53 13 I I7 41 14 I L5 41 5 114 3.5 N-56011'13" w 23.61 ?N. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - a ",- FINAL SITE INSPECTION � Date: lvl -71e, 5 Inspected by: • t Street Location Owner Town Permit # 3, TM # 3 y, — # ^ 7.3 Subdivision Lot # 3 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 .............................. IL Sewage Svstem a. Septic tank siz - 1,00 .......... 1,250 ......... other ........ b. ' S eptic tank i ' st a 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 & trenc e. Junction Box properly set ... ............................... 6. Trenches 1. Length required 7? Length installed 3 2. Distance to watercourse measured + I o o Ft......... 3. Installed according to plan ... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot....... 5. 10 ft. from property he - 20 fb. 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 ....... :...... ends capped ................ ............................... Pm Dose - Svstems - ize 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.... III. House/Building a. house located per approved plans .......................:.. b. Number of bedrooms .........................5 ..:(3.. IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured ZD® * - ft ... 7 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. Backfll material contains stones <4" diameter........ e. Curtain drain & standpipes installed according to p f. Curtain drain outfall protected & dir.to exist water g. Footing drains discharge away from STS area......., h. Surface water protection adequate ........:................. i. Erosion control provided ........ ............................... Rev. 12/02 r � SITE INSPECTION FOR FILL PAD v Deep r,-,4-., Date: ` o Inspected by: 'C' Fill pad located per the approved plan Fill Pad Length ��� Pla.y _ Required Length Fill Pad Width P" P) Required Width Xwee rS 6 ks.r4 Fill Pad Depth Require Depth Run -of -Bank Fill Quality Slope from Top to Toe /t/p 5 061 e- Impervious Layer Installed�S Erosion Control Installed V/ e 5 Sieve Test Results (if applicable) A/ I� Additional Comments: Reserved for Field Sketch if Applicable folic / 4v111, �,_p4 ®� �%� auk .r•� �g k��e 4 4 `� Pl ofVt '0-9 4 G` ®�� OCT -05 -2004 09:29 AM HARRY W NICHOLS 914 279 4567 P.01 oa PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES =IMST XOR, FINAL INSERML For:. Fill L� Date: 1 -5- - 9' Trenches PCHD Construction Permit Located:., (T) L amv e� 5 1 Owner /Applicant Name: M2-,i TM 3. Block Lot i,7, Formerly: " _ _ Subdivision Name; _ Subdivision Lot Ts'systeu •.M[ completed? Date: I's system complete? Ale � Date: Is system constructed as per plans? )) Is well drilled? Date: -- .Is well located as per•plans? Are erosion control measures in'placel I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and -verified. their completion. in •accordance with the issued PCHD Construction permit and. approved ,plans and the Standards, Rules and Regulations of the Putnam County Department of Health. ' Date: ! y -� _ (.ertilied Gy:, -V PE RA - -- DwW professional Address:..Y Lic. # Comments: i FOR: ❑ ADAM ' Form FIR -99 OCT -5 -2004 TUE 09:47 TEL:845- 278 -7921 NAME: PUTNAM COUNTY DEPARTMENT OF P. 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 Harry Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: October 13, 2004 Re: Williams Ice Pond Road, Lot #3 (T) Patterson, TM# 34. -4 -7.3 ROBERT J. BONDI County Executive An inspection of the fill pad at the above referenced project has been completed. Comments are offered as follows: 1. It appears portions of the fill pad do not meet the required depth. An appointment must be made with this Department to dig deep holes in order to prove out existing depth. Please note that field measurements by this Department in no way suggest that exact size, depth - — - -- --and-location -of -the fill pad. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:km SENDING COMMON DATE : OCT-13-2004 WED 15:57 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845-278-7921 PHONE : 92794567 PAGES : 1/1 START TIME : OCT-13 15:56 ELAPSED TIME : 00'41" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT PRANSMITTED... LOUTTA NIOLINAX ROBERT 3. BONDI P—Wk 111n - Comfy DEPARTMENT 0,!. iHI?AURI I Geneva Road, Ttrcwsl, N - York 113509 F.'Ira.-W Haub W5)278 6131.1 F—fV451V8 ."01 (8AS)178-6558 WIC (84',17+!'.:JM F-W, (145)278 - 0035 rjrIy hit—tion frmchaaI,-'845);*.'A V Himy Nichols, P.E. Pattern-on Park, Ste. 106 2050 Route 22 Drcwstcr,NY.10509. p1j f,*o;j,l. Ln. 4.3 7.3 Dear Mt- Nichols: An innycationofthe fill pad at the above reft-.,_.o co,nplotcd. Comments are 00cmd As follows: 1. it appears portions of the rill pod do net me,11 depth. An Appointment must be made with this Department to dig d&•r h! '- to order to prove out existing depth. INcanc note that field measurements by this in i.o -iv !.i ggest that exnct size, depth And location orthe nu paid. Ify(Iii have any 11arther qiiestinim please cont-Wt yol'e: r.4'; 31). ovi. 2261. .4a iette U. Recd Fii-j'ronmenuil Health Engineering Aide GDR:kni OCT -06-2005 09:00 AM HARRY W NICHOLS 914 279 4567 P.01 ®! -Cj '3'!!� PUTNAM COUNTY DEPARTMENT OF REALTD DIWSIION OF ENMONMENTAL EMALTR SERVICES BEQ,IMST �'�'ION For; Fill Date: Trenches lie PCHD Construction Pirmit # Located: .x,.,... w�/ (T) (V) Owner /Applicant Name: n 0.1 TM �... Block �,_ _ Lot Formerly: Subdivision Name: 1_9 1 wgwi j Subdivision Lot # Is system fill completed? A-4�` Date: Is system complete ? Date: Is system constructed as per plans? Yra Is well drilled? W, Date: Is well located as per plans? y Are erosion control measures in place? I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: Certified'b E._ — RA rrmcfessiotw Address- �' U Lie. # Comments: FOR: ❑ ADAM 0 /GENE ❑ (NAME) Form FIR -99 -- SHERLI -TA AML-ER, AVID, MS,. FAA—R. , Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health October 12, 2005 Harry Nichols P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Field Inspection — Williams Ice Pond Road, (T) Patterson Lot #3, T.M. 34. -4 -7.3 ROBERT J:. BONDI _.. . County Executive The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: 1. A pump test needs to be witnessed by this Department once the electrical - -- - ---•° ___--inspection _--inspection •has °been completed and notification-of suclrhas been-submitted to this Department. 2. A bedroom count needs to be performed by this Department. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR: cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL IIEATLI1 SERVICES FIELD ACTIVITY REPORT ADDRESS: Am 4d 1W, Ln f S 1/C � Street Town State PERSON IN CHARGE / ,� , , i _ / _ •- I� PUMP TEST': DOSE TEST . -, Signature and Title : ••: i acknowledge receipt of •• If a— 3 Zip REQUIRED GALLONS 7 - ig 7, V E3 EL. START STOP 02/96 Title: R av o v .. ® Ci O O O Signature and Title : ••: i acknowledge receipt of •• If a— 3 Zip REQUIRED GALLONS 7 - ig 7, V E3 EL. START STOP 02/96 Title: R av a; A Signature and Title : ••: i acknowledge receipt of •• If a— 3 Zip REQUIRED GALLONS 7 - ig 7, V E3 EL. START STOP 02/96 Title: R av APR -19 -2006 09_53 f-M HARRY W NICHOLS 914 279 4567 P.01 Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 RLQUEST F R FIELD 'TESTING __. ROBERT L BONDI All information below must be fully completed prior to any scheduling. DATE: Oki III* ENGINEERING FIRM. �t�'Y'1 w � 5.1�(J�tpt,S . �. i� PHONE #: PER80N ,ro CONTACT: JkNEW CONSTRUCTION ❑ REPAIR PROGRAM ❑ ADDITION PROGRAM REASON:. TaEEPS: ❑ PERCS: ❑ PUMP TEST: ROADISTR.IEET:ZI TOWN: o� Pr�s�' Tex MAP #: t4 SUBDIVISION: LOT #: OWNER: Tram -Y NYCDEP CRITERIA FOR JOINT REVIEW AND WITNESSING OF SOIL 'TtSTING YES NO Proposed SSTS wi6fii-the drainage -basin iof.W. ,estBranch.or VoydkQorner_& Croton Palls Reservoirs.. D Proposed SSTS within 400 feet of a reservoir, reservoir stem or control lake. ❑ ; Proposed SSTS within 200 feet of a watercourse or a DEC wetland. o Proposed SSTS design flow greater than 1000 galloss/day or SPDES Permit required. a Proposed SSTS for a Commercial.Project. It is the responsibility of the design professional to provide the above information prior to soil testing. Tlie bepartment will determine the NYCDEP. project status (Joint or Delegated) based on the response. If you answered ves to any of the questions, NYCDEP must witness the soil tests. This Department will coordinate a mutually suitable time for Meld testing 'With the Design Professional and NYDCEP. if a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP b required to witness the soil tests, It will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE:::. COMMkNTS: r� //: 0 0 RCS. POP P[BI A 70.tttWeIALV % EnArcoinentai iiealtb (845)218-613d Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 22S -5418 Norsitig Services (845) 278 -6558 Fax (943)27&W26 WiC (845) 278 -6678 Nursing Home Care Fax (845)278 -6085 Early Intervenden/PreseboO (845) 278.60.14 Fax (845) 279.6648 APR -19- 2006,09:54 AN HARRY W NICHOLS 914 279 4567 P.02 .- ._. _ ......_ ... :. °3Y Ti- I CERTIFICATE OF :CObAP6�.IAliICE.::T°�Itm.:.. NEW. YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET w NEW YORK, NY 10038 CERTIFIES THAT Upon the appleatian of upon premises owned by [NDEPEND.ENT ELEC�'RiC CORP. THOMAS MARY WILLIAMS 221 ICE FOND ROAD 221 ICE, POND ROAD BRFMISTER, NY 16549 PATTERSON, NY 125x3 Located at 221 ICE POND ROAD PATTERSON, NY 12583 Application Number: 2028930 Certitfica4e iduttglier: 2028930 Section: 34 Block: 4 Lot: 7.3 Building Permit:3878 SDC: W104 Described as a: Residential 3000 -4000 square ft. occupancy, wherein the premises electrical system consisting of electrical devices�and wiring, described below, located inton the premises at: Sasarnerit; Outside, A visual inspection of the premises electrical system, limited' o, electrical devices and..wiring to the extent detailed herein, was conducted, in accordance with the requirements of the applicable code andlor standard promulgated by the State of New York, Department of State Code. Enforcement and Administration, or other Sauthority having jurisdiction, and found to be in compliance therewith on the 11th Day of April,2006. . . A�z Switch 50 0 Gemara[ Purpose Receptacle S 0 GIFCI Fixture 60 0 Incandescent. ReA.ept$cie. 1 0 30a Dryer Paddle.Fati .: .1 0 switch 1 0 well Motor Control Switch 1 0 septic. Motor Control Disconnect 1 0 30K Air Conditioner 4 0 CATV 4 0 Telephone Arc Fault Circuit Interrupter 3 0 15A Service 1 Phase 3W Service Rating 200 Amperes Service Disconnect: 1 200 mcb Meters: 1 seal 2 of 2 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 1, Fn iia :..I TFI : A4.9-P72 -7921 NAME: PUTNAM COUNTY DEPARTMENT OF P. 2 APR -19 -2006 09:54 AM HARRY W NICHOLS 914 279 4567 P.03 - SY ' --THIS - CERTIF DATE -.•OF.- COMPLIANCE THE NEW YORK BaARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FVLTON .STREET — NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by INDEPENDENT ELECTRIC CORP. THOMAS &MAMI►Y WILLIAMS 22A. ICE POND ROAD 221 ICE POND RD . 6REWSTER, NY 10509, BREWSTER, NY 10509 l ocaied at 1 ICE.POND RGBEtEWSTER: NY 10509 - .Application Number: 2094945 Certificate Number, 2094945. "Section:. 34 Block: 4 Lot: 7.3 Building Permit:426 -08 BDC: W10.44 . 'Described .as a'. Residential 0.599 square ft. occupancy, wherein the premises electrical system consisting of .electrical' devices and wiring; described below, located in /on the premises at: a A visual inspection of the premises electrical system, limited to' electrical devices and .wiring t the extent detailed herein., was condpcted in accordance. with the requirements of the applicable code and/or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or:' other " authority' Baying jurisdiction, and found to.be in compliance therewith on the 12th Day of April, 2006. ra - - QTy ....K�fi _R„ k ;trc Tine -- _..'. _ : Alarm and; EmergenO.Equipment Signaling .Device 1 0 Alarm. A,pp#wKes and Ae msories Turnp., 900 ' 1 0 .75 H.P. Wiring ao.d Devices Receptaclo 1 0 20A Special TF1 : R4S -P7R -7921 NAME: PUTNAM COUNTY DEPARTMPNT nF P _R 4 APR -19 -2006 09:55.AM HARRY W'NICHOLS 914 279 4567 P.04 - - BY THI$`" CERTIKICATE' OtF' OWPLIAN E- THE--a! NEi V YORK BOARD OF FIRE U-N DERW.RITERS BUREAU OF ELECTRICITY 40 FULTON STREET — NEW YORK, NY 10038 CERTIFIES THAT ,,; Upon the appUcation of upon premises owned by INDEPENDENT ELECTRIC CORP. THOMAS + MARY WILLIAMS 221 ICE POND ROAD. 221 IGE POND ROAD BREWSTER, NY 10509, PATTER'SON, NY 12583 Located at 221 ICE POND ROAD PATTERSON, NY 12563 ' Application Number: 2026930 Certfticate Number: 2028930 Section: 34 Block: 4 Lot: 7.3 Building Permit:3878 BDC: W104 Desenbed•as a Residential 3000.4090 square ft. occupancy, wherein the premises electrical system consisting of electrical cievices,and wiring, described below,, located in /on the premises at: Aasetnmm, 0u�ide, ' A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed herein, was conducted in accordance with the requirements of the applicable code. and /or standard promulgated by the State of New York, Department of State Code Enforcement and Administration, or other authotity- having jurisdiction, and found to be in compliance therewith on the., 11t Day of April, 20o6. Nai 2Ti Ratine r .. .. TYM Alarm and Einergency Equipment Sensor 1 11 Carbon Monoxide 5bnsor 6 0 Smoke Appliances and Aeaewories Hydeo Massage;Tt b (Thorapoutio) 1 0 20 Amps Ovcn 2 0 4 KW Exhaust Fan 2 .0 F.Fi P: Eleetrie Heater Unit. , 1 0 .1.5 KW Dish Washer 1 0 F.H.P, Motors 2 0 .. .75 .Air Conditioner 1 :0.. 30 Amps Furnace 1 0 boiler Oil Motors 1 0 flu F.H.P. Air Handler 1 0 F.H.P. Panets 1 60 12 Wiring and. Devices seal Receptacle 54 0 General Purpose Continued on Ncxt Page 1 of 2 . This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location lndi+rated. APR -1 q- PAAf:- IxIFf 1 L.jq. TFl :1 45- R7A -7gP1 NAME: PHTNAM rni INTY nPPAPTMPNT nF P 4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE 9� PERMIT Located at TCV, Town or V,jlKge zZTe, V 8 c� Subdivision name a.&v /k ri c. Subd. Lot # j Tax Map 3-f ; Block — Lot Date Subdivision Approved Renewal Revision Owner /Applicant Name TL 11�,;L{ X41 a `It ex, tst Date of Previous Approval - -7 -O Mailing Address z AIrl -race-, V l f *_zj (_1' )�g l Tevs -c� Zip 1,2_�Ce_3 Amount of Fee Enclosed `- Building Type /L is t J Lot Area 4, 1 S' No. of Bedrooms 3 Design Flow GPD 666 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1600 gallon septic tank and 3 3 3 ?,fir Other Requirements: V To be constructed by TA D' Address Water Supply: Public Supply From Address r or: Pivate- Supply. Drilled 1� - - _ ._ ppY by Address _ . - - I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 9 - / S -O �� License # 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 wh co idered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm A roved discharge of domestic sanitary sewage only. By: Title: Date: f� �b 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 Routc 22 ^Brg�rstg, NY I.OSQ9 .; .� Tclephone (845) 279003 . Fax (845) 279 -4567 f� Sent Via: �ur Messenger Blueprinter First Class Mail Special Delivery Your Messenger Hand Delivery Copy to Very t ly yours Harry WUN ols Jr., F-1. - Date. To: Job No.: Project UYo,00o ,J JAS 1'5 Ice-- R-1i v / i G.� Attention: v : Gentlemen: We enclose (� copies of �B(W Prints Reproducibles Reports Tracings Specifications Memorandum Copy of letter Description: RevisionlDate No. c„ F, `c e_- � �j-..� rG, f� Sent Via: �ur Messenger Blueprinter First Class Mail Special Delivery Your Messenger Hand Delivery Copy to Very t ly yours Harry WUN ols Jr., F-1. - PUTNAM COUNTY DE "RTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE t�r " CONS'I'tRUCT101 P19 T. F6k'SF'WXGE TREATMENT SYSTEM— PERMIT # V. .c Located at 7c e_ 10c, ,� �c C� Town or V.UKge �2 V C Subdivision name �.�1� 5 Ale, � rrSubd, Lot # .,: Tax Map Block Lot '715 Date Subdivision Approved / J Renewal Revision Owner /Applicant Name Date of Previous Approval - 7 '© Mailing Address " c l C P s, �ev 5 Zip 12-S Amount of Fee Enclosed Building Type I?u Lot Area -1, d �' .1o..of Bedrooms 3 Design Flow GPD 666 Fill Section Only Dieth Volume PCHD NOTIFICATION IS RE .IIIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of � 6 C /p. gallon septic tank and Other Requirements: y ,0' .. . To be constructed by T / � D � � ' Address Water Sunal4: Public Supply From Address .s or: Private Supply Drilled by _.�'�` ^ _ _ Address f I represent that I am wholly and completely responsible ,.ior:lhe design and location of the proposed system(s) and that the separate sewage treatment s, sv 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" satisfactpry 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 approvZI of the Certificate of Construction Compliance of the original system or any re airs thereto. r Signed: P.E. Address 9-o 5d A R.A. Date License APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatmen system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh �dcotisiidered ecessary by the Public 14ealth`I7itector. Any revision or alteration of the approved plan requires a new perm A • roved discharge of domestic sanitary sewage only. r � By: Title: Date: L b White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 Harry W: Nichols Jr:, P.E. Patt mn Park, Suito 106 2050 Route 22 : - Brcwz;ter, I Y 10509 _ Telephone (845) 27915003 Fax- (1;45) 279-4567_ Date.- To: Job No.: Project o o ' J. ! S _ 1z), tf' Ice_ Attention: AO rvi � C %C� �s �� Gentlemen: We enclose (� j copies of ,--/131W Prints Reproducibles Reports Tracings Specifications Memorandum Copy:ofletter Description: Revision/Date No. F R t cw rr, F, Sent Via: Our Messenger Nueprinter First Gass Iviail Special Delivery Your Messenger Hand Delivery Copy to Very t 1y yours Harr , W'.LiN ols Jr., F.E. - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE`S APPLICATION TO CONSTRUCT A WATER WELL � Ne please print or type PCHD Permit # P- 32 . A 1 ~ Well Location: Street Address: Town/Village Tax Grid # t CE P06+1�- Q oA*P PA-m-1Z scN Map 34. Block 4 Lot(s) 7.3 Well Owner: Name: Address: 22 c.. 4Amozso4 J,LLA;z c-r. ' 40HAS W,LL1AK5 . P,.Miz6ov, Aiul oa.tc 12563 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 5"* gpm # People Served 3- S Est. of Daily Usage boo gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling �/ New Supply (new dwelling) Deepen Existing Well Detailed Reason N�� Rtsl�ruats for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes 1/ No Name of subdivision NAOkS AE-9-1E 50"t%)IS1os1 Lot No. 3 Water Well Contractor: TbD 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 to be provided on separat she Date: to -ot -o4 Applicant Signature: //I- plan. - v PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health. Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue o'► /07 /04 Date of Expiration y J lo? lob Permit is Non - Transferrable Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 f.J To: PG /+ r) vows i � � • �,�—. Attention: A.0 ✓r Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 Date: 6 -1�. -U`t Job No.: 0) -036 Project Pvaa 2©s Toe- , of gar Gentlemen: We enclose( .)copies of 3/W Prints Reproducibles Reports .Tracings Specifications Memorandum Copy of letter Description: Revision/Date No Scent Via: Our Messenger Your Messenger Copy to Blueprinter First Class Mail Hand Delivery Very trul yours r' Harry Y's''. ichoo Special Delivery PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYS PERMIT # ?_Z2-01 n � 16I04 U Located at 1 zi Poy1 ftAb Town or Village asno Subdivision name l;Ab1KS Agetr Subd. Lot #'_ Tax Map 3+ Block 4 Lot 7.3 Date Subdivision Approved Renewal �_ Revision Owner /Applicant Name /�F40 M AS bJ t L1a A".S Date of Previous Approval Mailing Address 22o J.LLArf GT. F rncaspo A y Zip 1256 Amount of Fee Enclosed Building Type 916ibR011AL Lot Area4AS Ac..No. of Bedrooms 3 Design Flow GPD 600 Fill Section Only X Depth V Volume V00 PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of pM gallon septic tank and Z33 kr AC35 'Msc►acH Other Requirements: 3' R.O. G. F, 1.L To be constructed by -M*> Address Water Supply: _ Public. Supply From. _ . _Address or: o/ Private Supply Drilled by TBI> 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 treatments 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. A Signed: Address R.A. Date 05104101 License # 56124 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme stem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh condidered n ssary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm' . owed f charge of mestic sanitary sewage only. By: Title: Date: O 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 ......_t.. .. .c. ..,_ —.. _. .._ -'.AP— PL$.CA,A 1G.�— T-0. VOKS :RUCTA� ; ,1!,CkT.til.( -W �S'w TIT, please print or type PCHD Permit # �� Well Location: Street Address: Town/Village Tax Grid # t es QOiJ� e0A-b 1PAWq&:50 6-i Map 3-* Block Lot(s) -1.3 Well Owner: Name: Address: 2z c. fAmizsoa J%11AgZ G'r: `AO'AA5 W A-LIAMg Pa Y 12563 Use of Well: V 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 3-5 Est. of Daily Usage 5 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ✓ New Supply (new dwelling) Deepen Existing Well Detailed Reaso® for Drilling Well Type ✓ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yeses_ No Name of subdivision "A,4" AlAtf Lot No. 3 Water Well Contractor: -$*S> Address: �--� Is Public Water Supply available to site? .................................. .............. .I................ Yes No ✓ Name of Public Water Supply: Town/Village -- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separa a sh t/ Ian. Date: .. . Applicant SagnararE :' V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water wler certified by Putnam County. Date of Issue' Permit Issuing 2�� // ri, Date of Expiration o Title: Permit is Non- Transfeirable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 T-1 Harry W. Nichols Jr., P.E. Patterson Paris, Suite 106 2050 Route 22 -Brewsar, -1 X, N - -M9X Telephone (845) 2794003 Fax (945) 2794567 To: P G 14 D c4A -e V C-I PI-o Attention: 'R4 Ac) r c� JE Gentlem*en: We enclose (73co' pies of- V-1,B/W Prints Reproducibles Specifications Memorandum Description: -15F-3 Date: 6? - -30 - 60-1 - Job No.: 0 -'$ J —0'3 5 .Project -*3 bLa 4vk A e ✓ 1/ 101, llri, '-,4), 101�-e�OLII IVY Reports Tracings Copy of letter . Revision/Date No. . Sent Via: //Our Messenger Blueprinter Your Messenger Hand Delivery Copy to First Class Mail Special Deli-very Ve ry, .1y yours Harry YWC Nils Jr., R.E. Q9 AWQ AWKW 1 7n," S� �z monsoon 1 na 7. W QW-Mr, Sheet 93" n A all 4.010"n 0" C01 HEALTH -' PUTNAW UNTYDEPARTMENTT OF, l vv� 'I u S. WS MW Streets Ty. of, 0z" wAue Q Z <p �QZ "Lot... C - - - - - - - - - - - Town State= jp,� -ST All. A . . . . . . . . . . . . . Name and 4 ANT Poo, TYPE 1z offs,'� MONO, 777 not Wr Of "now- 0. TARS MN "to SsQ 4410 B. OEM, K.;," "Q_ 9�1 5- 'y tn� So loci' lilt, Q 4- am J-00 v 1�` A� � - i:111, s. -7, ONE WY -v koQ Pik 10 WAS Monty NOW 1 j Whals, Ty WhAvy �A Z. Cr VIM— -�,w A Y" Z P. 001 02 lain 7FfQQ 64 wn Qf �400, ne. A WESS AM act", nowsi MA A MAR -W OWN& tt_ . . . . . . ..... owls, A 'Room- ��.7 N; 7". not Vol 00 1`4 POW, into 001 kill Go, A KAW-, W" along acknowledge -,receipt ,'-'df 7ihii f,'00 Ap QQ ns,L;p 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) 279 - 6648 May 25, 2004 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed Renewal: Williams Ice Pond Road, Lot 3 (T) Patterson, TM #34 -4 -7.3 Dear Mr. Nichols: ROBERT J. BONDI County Executive Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: A 'field inspection was conducted on May 18 ' 2004. It appears that the driveway has been cut and the fill has been placed in the SSTS area. Any plans submitted must reflect current field conditions. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly yours, t�4,b Robert Morris, P.E. Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF .HEALTH D-1 VISION OF ENVIRONMENTAL HEALTH •SERVICES.; LETTER -OF AUTHORIZATION >'� 1 RE: Property of -54061AS VJ tLL%AK.S - - - - -- .1 . Located at ► cs Aa : . _.. st'oesD Ro � ..�.. T-N QAMeso* Tax Map # 34 Block A _Lot 7.3 -:- Subdivision of HAW IBS AaF-I5 Subdivision'Lot # Filed Map # Date Filed.-.-. iled_ �5) 5 Gentlemen: This letter is to authorize a duly licensed Professional Engineer or Registered Architect to—p21-y for the• required wastewater treatment and/or water supply permit(s) to serve the above- noted•propertyn :a�cordarice,.. 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 pro, isions. of Article 145 and/or. 147 of the Education.Law, -the Public.Healtly ` Law,`and the Putnam Qoiirity Sanitary Code. -Countersigne P.E., R.A., # Mailing Address State .13,LkS yo2V_ Zip.__ I. O.S01 Telephone; fjsj5 --2'1 cl =4003 'ery truly yours, (Owner of Property) - Mailing Address: 2t0 •••QAWft2wy J%Llh6r• cs" State oil.), 102- V- . Zip ...1.. Telephone:. - , Form LA -97 May 7, 2004 Robert Morris, P.E. Putnam County Health Department 4 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 - Renewal Williams - Hawks Aerie Subdivision - Lot #3 122 Ice Pond Road Patterson, NY T.M. #34.4 -7.3 Dear Robert: Enclosed are the following: 1. Two (2) prints of Drawing SS -3, "Proposed SSTS ", dated 05/03/04. 2. Four (4) prints of Drawing SF -3, "Preliminary Design for Fill Placement Only", dated 05/03/04. 3. "Construction Permit for Sewage Disposal, Sys id405/03.0.4. n', 4. "Application to Construct a Water Well ", dated 05/03/04. 5. "Letter of Authorization". 6. Two (2) copies'of residence floor Plan(s), f� bedroom count only. 7. Review Fee in the amount of $400.00; If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN:gav 01- 030.00 ox PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT E TREATMENT SYSTEM PERMIT # 3 a ° 0) Located at � CE P o N D 20 AD Town or Village Subdivision name �A 4\0 Y j NSERW- Subd. Lot # Tax Map _SA Block 4 Lot -1 Z Date Subdivision Approved i K13f Renewal Revision Owner /Applicant Name .T ��� M P S W \L l�� A l Date of Previous Approval Mailing Address 22 Q, P N CLSO N V \L L C-, Q-� I P / TTC -_RS O Zip � 2S 63 Amount of Fee Enclosed Building Type \ �l Lot Area �L� A No of Bedrooms Design Flow GPD 6 Q Q Fill Section Only X_ Depth 3 Volume 8 0 0 PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of `� �\ l gallon septic tank and 333 L-F• AQS 'SCzE 1U C1� Other Requirements: � � P", 0 To be constructed by I Q Q Address Water S 1 : Public Supply From Address ®r .... Private Supply Drilled hy"�9. Address �= ��_ a.: ., /terarate present that I am wholly and completely responsible for the design and location of the proposed system(s) and that the wa n 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: _m Address P.E. \oSo� R.A. License # Date 1;024 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 ghe o sidered n essary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe t.� A roved f scharge of domestic sanitary sewage only. f � By: * Title: Date: 1 A .. G White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL y�? please print 6 type' PCHD Permit Well Location:. Street Address: Town/Village Tax Grid # I G� Q N b MN'�3 FAT A_E(Z_SQN Map S 4, Block 4 Lot(s) ,3 Well Owner: Name: Address: 22 C. PATTEC-SON v1L4AGC CTi TIAOMNS \J\Q,, NMS I PATS�-_C—SON/ Ny 4663 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 �5 �' gpm # People Served 3 - q- Est. of Daily Usage q O gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling -\Z- New Supply (new dwelling) Deepen Existing Well Detailed Reason N GF- for Drilling Well Type JDrilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes -- No Name of subdivision \A 1\W Y S S U 9b \ \ \ S \OIL Lot No. 3 Water Well Contractor: Tab 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 contaminatio to be provided on separate sh et/plan. Dite: '24--0 1 Applicant Signature: y PERMIT TO CONSTRUCT A WATER WELL Tiis permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Artnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided tlat within thirty (30) days of the completion of water well construction, the applicant or their designated rpresentative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the rquirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form povided by the Putnam County Health Department. During all well drilling operations, the applicant and/or vwll driller shall take appropriate action to assure that any and all water and waste products from such vwll drilling operations be contained on this property and in such a manner as not to degrade or otherwise cntaminate surface or groundwater. APPROVED_ FOR CONSTRUCTION: This approval expires two years from the date issued unless enstruction of the well has been completed and inspected by the PCHD and is revocable for cause or may be mended or modified when considered necessary by the Public Health Director. y revision or alteration tithe approved plan requires a new permit. Well to be constructed by a water-wel driller certified by Putnam Ounty. E3te of Issue : J Z c Permit Issu} g fficial: Lte of Expiration ,; . Title: t Frmit is Non- Transfe rab Xsite copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 P�Z.;c�sly CD Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 ...._ 2050 Route 22 Brewster, NY 10509 y r Telephone (845) 2794003 Fax (845) 2794567 October 4, 2001 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 RE: Individual SSTS - REVISION Williams - Hawks Aerie Subdivision, Lot #3 Ice Pond Road Patterson, NY T.M. # 34.4 -7 -3 Dear Robert: The Applicant recently received a Permit ( #P- 32 -01) dated 8 -28 -01 for a 4- bedroom SSTS system. The Applicant now wishes to reduce the design to a 3- bedroom system. In this regard, enclosed are the following: 1. Two (2) prints of Drawing SS -3, "Proposed SSTS," revised 9- 18 -01. 2. Four (4) prints of Drawing SF -3, "Preliminary Design for Fill Placement Only, revised 9- 18 -01. 3. "Application for Approval of Plans for a Wastewater Disposal System. 4. "Construction Permit for Sewage Disposal System." 5. "Application to Construct a Water Well," dated 8- 24 -01. 6. "Design Data Sheet." 7. Short E.A.F., dated 8- 24 -01. 8. Two (2) copies of residence floor Plan(s), for bedroom count only. 9. Review Fee in the amount of $150.00. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN: his 01- 030.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DRgSION,DEENYIRONMENTAL HEALTH•SERVICES APPLICATION FOR APPROVAL OF PLANS °FOR .......... ._ .,�... • ._ M.. _..__ - A WASTEWATERTRSATMgNT- SYSTEM_ 1. Name and address-of applicant: 2, Name of project• PCLCJPO 'S'� S5 LS 3. Location TN: 4. Design Professional: N �� \' Xo A. Address: 209`3 Cz� 2Z REV S W l 6. Drainage Basin:' C� \� 7. T ; Private%Residential Food Service _ Commercial Apartments., , _ Institutional Mobile Home Park Office Buildin g : Reaity Subdivision Other (1pecify) 8. Is this project subject t4 State�Environmsntal Quallty Review (SEQR) ?. Type Status (check oAe),,... .. ................ ..........:.........,.:.:.....; ,Type..I Exempt - ,.Typell Unlisted 9. Is a Drag Environmental Impact Statement (DEIS) required? ......................... 10, Has DEIS been completed and found acceptable by Lead Agency? ............... 11 Name of Lead. Agency N /A _.: - .12... Is.this project in an arts under lthe control of local planning, zoning, or other, offctafs.., ordinanc ......... ......... ...................... ............................... M ID 13. If so, have plans been submitted to'such. authorities? ::..:.:: ..::.........::................ N 14. Has preliminary pprovil bcen'gianted,by, sue*. authorities?. N D Date granted: N�Fl . ti 15. Type of Sewage Treatment System Discharge:.......::.`..::: surface water groundwater 16. If surface water discharge, what is.thc:stream -class designation? ..................: %u /A 17. Waters index number ( surface).: :.......:..:........:.:..........:......... ..................:.......:.... Nl 18. Is project located near a public water supply system? ....... ......:............ .......... .. N O 19. If yes, name ofwater supply: ` ` N/A Distance .to water supply 20. I s p rod ect s ite near' a public sewage, collection or treatment system? ..:.....::.::..: N 0 21 Name of sewage system lU/ Distance to sewage system NA 22. Date test holes observed 1 0 \ 23, Name of Health Inspector G N 24. Project design flow•(gallons per day) ........................... ..... ............................ .:... (�GG 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... NO 26. Has SPDES'Application been submitted to'local DEC office? ...... ............ ..... NO __ h �, 27• 28• 29, 30. 31. r Is any portion o;this projectaocated within a designated Town or State.wetland? t ` Wetlands ID Number .............i.!. 0,..7.....:: 0,..,,.99 .:V..,.......... goo .Y.,.....:. go too I ego 09,10.4 ... N// 1 Is Wetlands Permit reg**c'd? .:...... �..... , ::..:.: ...............::::..:. ...sett::::.. ::.:..::.......... Has application been made to Town or Local DEC off ce? ...............:........:..... No Does proJect..require ya4DEC Stream Disturbance Permit? .. .....:. ...............I........ IV O -11 Is or was project site used for agricultural activity involving application of pesticides to orchards :oi other crops, solid or hazardous waste disposal, -- landfilling, sludge application or industrial activity? ............................ Yes/No 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 O DESCRIBE: 33. Is there a local master plan on f le:with the 'town or Village? .............. :...:.:::.. 34. Are community, _ . ty. water and /or sewer'facilities:planned to be developed within. • � • 15 years aii or.,a�jacent to project si' te? ................................ ............................... I eD 35. Are any sewage treatment areas in excess of 15% slope? .... ........ ...........:.......�... NO 36. Tax Map ID Number ...::::::..:,.:,.::::.:.: : :....................to...I.... Map Block Lot��3 37. Approved plans are to be returned to : : :.. Applicant Desi ._.� . PP .� . gn Professional , ...1LOTE:.A11' applications- forreviewand 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..platis.or the creation of impervious surfaces, and thc;p{ojectapplicant should obtain the appcopriate�forms for such'activities- from DEP and submit those forms to DEP for rev! wand approval. „ :f... f the application is signed by a person other than the applicant shown in Item .1 .,the "application must' • )e accompanied by-a Letter of Authorization (Form LA -97). Failure to comply with'this provision nay be grounds for tie rejection-of any submIssion.. I hereby affirm, underpena' lty of' that! Information provided on this form -is.trde to the best of-Ty .Anowledgrarid belief. False statements made herein are p unlshable as -- a Class A misdemeanor pursuagn ,,Io, Sectlon; 210.45 of the Penal Law. 'IGNATURES &.VnitaiR3. 9M. 1,J Tailing Addresf - ....... 20 1�O fzOU� E .2'2.. _.. - 14.16.4 (9155)—TOA 12 PROJECT I.D. NUMBER >; 6M20 SEQR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM _ For UNUSTEO ACTIONS Only PART I— PROJECT INFORMATION (robe completed by Applioant or Project sponsor) 1. APPLICANT ISPONSOR ��.►��s v����1A 2. PROJECT NAME P2oPoSED SSS J. PROJECT LOCATION:. ('� n Munklpallty \ (� �2SO County � 0 N A 4. PRECISE LOCATION (Street Wdresa and road Intaraeotlons, prominent lanaawta, *to, a provide map) \CE POW .6 R-UNn 5. IS PROPOSED ACTI01M . QrNew O bpanalon O ModiflatlWalteratlon 6. DESCRIBE PROJECT BRIEFLY: P CZoP o SEA sB�"� 7. AMOUNT OF 0 AFFECTED: p ,L `'y Initially som Ulunwtsly . +At,- aora 8. V44 PROPOSED ACTION COMPLY WITH OUSTING ZONING OR•OTHER DUSTING LAND USE RESTRICTIONS? Y" ON* If No. deaw be Wetly 9. WK y 1$ PRESENT LAND USE IN VICINITY OF PROJECT? . Resldentlal O Industrial - O ComnWoW , ❑ Agr1cultun _v �.QuJIIForeatl0pen.apace -- -. -O Other- - - �.-. - 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE R LOCAQ? STATE O No If M Qat agwwAQ and perrWI/appmuls 11. DOES ANY 3NWOF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yaa< o .. a ysk Ilat &cow game and pwmll/Wwal 12. AS A RESULT PRONGED ACTION WILL DUSTING PERMIT/APPROVAL REQWRE MODIFICATION? OYes .9No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applkantlsponaor nam« I V v ; (� 1c C�, oat« ' S19natur« If the action Is .In the .Coastal Area, and you are a state agency, complete the . Coastal Assessment Form before proceeding with'this assessment QVER . �wwurus n►_ �... wlslna ha AnunrtVl y .. rot rii vinw mw,@ I^r r %,v -- _♦. --- - -„ A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN b NYCRR, PART 617.4?' If yea, coordinate• the review process and use the FULL EAF. Q Yes ❑ No 8. 1N�ll ACTION RECEIVE COOAtXNAYED Rl VI" AS PROVIDED FOR UNLISTED ACTIONS'IN a NYCRR, PART 617.6? - II No, a.negatNt declaration may be superseded by another. involved agtincyA t,. C3 Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, 11 legible) Cl. Existing air quality, surface or groundwater quality or quantity, noloo lovela, existing tralllo patterns, solid Waal$ production or disposal, potential for erosion, drainage or tlooding.pioblema? Explain briefly, C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant hobltats, or threatened or endangered species? Explain briefly: C4. A community's existing plans 0(9 . oall u officially adopted, or a chango in use or Intensity of use of land or other natural resources ?,Explain briefly CS. Growth, subsequent dtvelopment, or related activities I"ly to be Induced by the proposed action? Explain briefly. CS. Long term, short term, cumulative, or other effect& not Identified In 01-05? Explain briefly. C7. Other Impacts (Including changes In use of either quantity or typo VI ©nargy)? Explain briefly, , C'-) -:., CSl 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTA8LISHMENT OF A CEA? ❑ Yes ❑ No rt L IS THERE, OR Is THERE LIKELY TO 6E, CONTROVERSY RELATE TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, oxplaln briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It is substantial, large, Important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occ4rring; (c) duration; (d) irreversiblllty;'(e) geographic loops; and (f) magnitude. if necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant tadvsrse Impacts have been Identified and adequately addressed. If question D of Part II was checked yes, the determination and signlfIdainco must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. C3 Check this box If you'have.determined, 0ased on the Information and analysis .above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name R ItesponAle Of ficer In Laaa acy Title of Responsible Officer Ivuture of es y' Slaouturg 91 Preparer different from respwsibio o Icer Cato n PUTNAIII `CO�JNTX �EPAT'MENT OF �iEALTH »• . _.. _ -_ D IVIS —INN �* XNVI-RONMENTAL HEALTH-- SER`VI GE.S - • DESIGN 'DATA''SHEET'= "SUBSURFACE SEWAGE TREATMENT SYSTEM . • **22- C ; V -�, -7 —u-s SN ... V 1 LL.A 6F C T Owner T OM WiLU&bfda , Address �AcSEP��oN� N`I. :1:2 Loa Located . Tax Maps Block Lot .mLm cipaliry V Watershed..L A.S'T �CZANG�� _ ..... ...� ........:....._.........::. ._ SOwpERCOLATION TEST DATA Date of Pre - soaking 1_ 1 / O 1 _..Date of PercolatlonJest'-. b'/ . .- ° <��;: ''� u � �`�,���• ' ma '.� - e, 't6�• of 1 Oia•Q 0 � :� Xt ' <� � .z�::: ; :. ; . �POCCDIAQOA sole .No. ` rjR]!.0 "� l .) ,n� 4 tQ � `' y >.MialIacb �. • 2 10 _._ ......... . 1 V_ 1 • 3 oo _ .. _...._.. 4 _ 5 , NOTES; 1. Teat P rl a-t ItAmw A,..,►6 11 ., ►u • - - - - rr•�•••,••�•�� v,��o+ }�wo�iv� R�C3 are Mapned at each percolation test hole. (Le, s 1 'min for 1.30 min/inch, s 2 min for 31.60 rn't %inch) All data to be submitted for review, Denth m�scnromp -nt, t*% to maAm �dicate level at which groundwatc is cncountercd NQNE idicate level at which mottling is observed I\!�N' tidicate level to which, water leve1 . rises after being cncountercd eep hole observations made by; . � FF N CZ�Gb .Date III 10 _. 1 'Sign Professional Name; _NAc �, N tclaots JR, P,F, _2©_� 166 nature; Jj Deslgu Professloual's.Seal 0. - TEST PIT DATA DESCRIPTIOMOF'$01148 ENCOIINT4RED IN- TEST HOLES +.. DEPTH HOLE NO, l i 2 °'. _H -N ..._ is . �°� _ HOLE .NO-.a.;. �.... G.L. C b�s�1 �F PAWN . �E� 8�ow � .�— �,CLQwN . . ?.0' �1IV�SANO`I �1NE SAI�V Fl(�E" N4�J F1 F_(S 1MD`J " ".. ',S LoAm Y.0 FINESR�I�j., C?�Ay,151� 9!1?C 6Ay1S�1C�m2�c� 6�P� 1SN . C�i�+1Pi�C� s' : ���lv� =:: :: � .�:j��� •sa�� ,. F�NF,SAN��t�aV�l,� � 1 N E .SAN Giza EL 5.01 . _ : w1MCCLO' &:pEL wJso czoc 6.5' _... ,. �dicate level at which groundwatc is cncountercd NQNE idicate level at which mottling is observed I\!�N' tidicate level to which, water leve1 . rises after being cncountercd eep hole observations made by; . � FF N CZ�Gb .Date III 10 _. 1 'Sign Professional Name; _NAc �, N tclaots JR, P,F, _2©_� 166 nature; Jj Deslgu Professloual's.Seal 0. _ __ .. _. - - - - -- - f �� Ira { ``. COUNTY DEPARTMENT O HEALTH DIVISION OF ENWRONMENTAL HEAL'TH SERVICES t ONSTRLJ (bTI614 P'�IT'i6R SEWAGt $TREATISE -N"" ' §VS'TEl!'I —y_ __ ... =.r * _ ,_ .... PERMIT # P -- 3-,) -0 / Located at I GF— po 'H V - P-0 Subdivision name '°��L '" A`F- HG Subd. Lot # Date Subdivision Approved 41�5I�1 Town or Village Tax Map Block 4 Lot Renewal Revision Owner /Applicant Name !MOO 6 -�- �\ 6* Date of Previous Approval Mailing Address VL & ? NTTO '6' H Zip � l' Amount of Fee Enclosed riQo Building Type Pf�p i 1-)i� 61B Lot Area 4 4 No. of Bedrooms 1 Design Flow GPD bQ Fill Section Only X Depth '9--)j Volume 91QZUY PCH D NOTIFICATION IS RE IJIRELD WHEN FILL, IS COMPLETED Sebarate Sewerage System to consist of 19—iso gallon septic tank and 444- LIF k�b Other Requirements: To be constructed by Tbp Address Water Supply: Public Supply From Address or: -Private Supply Drilled -by 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 tern 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: � L4OP.E. Address �'`� `t 1 o <� (DO\ R.A. Date License # 150 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage trea system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified en c sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew perm' . prove discharge of domestic sanitary sew a only. djp"�,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 APPLICATION TO CONSTRUCT A WATER WELL piin- t— .tYPe' -- Well Location: Street Address: Town/Village Tax Grid # Map Block A Lot(sfl ,,� Well Owner: Name: Address: V NI10 ;Oo14 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 G;,+' gpm # People Served A -rya Est. of Daily Usage �,c_o 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 No Name of subdivision }-fir+ `� '�– ? /�.L F-1� Lot No. lb Water Well Contractor: 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 to be provided on s7 et/plan. Date: l� � Applicant Signature: } V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. y revision or alteration of the approved plan requires a new permit. Well to be constructed by a water a driller certified by Putnam County. /1 Date of Issue(/° Permit Issui 'al: Date of Expiration Title: VA Permit is Non- Transfe ab White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 BRUCE Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 _ - ..._-_ - , ........_ . . L61;tk _ k:- -MOLINARI R.W. M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 August 6, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: William Ice Pond Road, Lot #3. (T) Patterson, TM# 34 -4 -7.3 Reservoir Basin Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on July 23, 2001 is complete. The - -- • -Department-will notify you by August -23, 2001 of its deterininatiori: ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a proj ect, such as stormwater plans s -o Letter to: Harry Nichols, P.E. - August 6, 2001 -2- or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of . Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. RM:tn V ry rruly you G� Robert Morris, PE Senior Public Health Engineer BRUCE• - -R:.. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 A LOREIVA " 7MOL.INAld-1 N., _M-.S.N. '"� Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678, Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Williams Ice Pond Road, Lot #3 (T) Patterson, TM# 34 -4 -7.3 Dear Mr. Nichols: August 6, 2001 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. The spot elevation of the knoll or depression is to be provided. 2. Driveway grading has not been shown. 3. The minimum of 3 feet of fill is to be provided for the entire SSTS. 4. SCS soil boundaries has not been shown. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly yours Robert Morris, P.E. Senior Public Health Engineer RM:tn PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT - NAME OF OWNER: STREET LOCATION: ;V1ENVED BY: RM, GR, AS, SRDATE: TAX NLAP =: (CONFIRMED) DOCUMENTS Y N (REQUIRED DETAILS ON PLANS CONT'Dl RMIT APPLICATION C_)r HOUSE SE«'ER -' /." FT. 4 "0'; TYPE PIPE CAST IRON LL PERMIT OR PWS LETTER uNO BENDS; MAX BENDS 450 W /CLEANOUT LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION HORT EAF LANS -THREE SETS C! )L_)HOUSE PLANS - TWO SETS L_)L_)VARLANCE REQUEST *LEGAL SUBDIVISTON SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE S w — CJC_)FILL REQUIRED DEPTH L_(JCURTAIV DRAIN R QUIRED f GENERAL ( �! )LOCATED IN NYC WATERSHED ( 1Y )PLANS SUBMITTED TO DEP EGATED TO PCHD APPROVAL, IF REQ'D P TEST-HOLES OBSERVED CS TO BE WITNESSED - APPROVAL SSDS ADJ, LOTS ;TLANDS (TOWN/DEC PERMIT REQ'D ?) TA ON DDS PLANS & PERIMI T SAME E 1969 NEIGHBORNOTIFICATION ,ETTER BI/ZBA 00 YR: FLOOD ELEVATION W/I 200' ,OIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS ( SEWAGE SYSTEM PLAN- (NORTH ARROW) SSDS HYDRAULIC PROFILE dGRAVITY FLOW CONSTRUCTION NOTES 1 -15 �U DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT _,)(-)FOOTING /GUTTER/CURTAIN DRAINS _ (_JUSDA SOIL TYPE BOUNDARIES U )TITLE BLOCK; OWNERS NAME ADDRESS TNL;, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVISION (DATUM REFERENCE U LOCATION OF WATERCOURSES, PONDS / LAKES,WETLANDS WITHIN 200' OF Y.L. (�V)PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS PWELLS & SSDS'S WMI 200' OF SSTS L—)PROPERTY METES & BOUNDS (__)(__)EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE CON YIENTS: (REVSIiEET)09 /01/00 RENEWALS U SITE NOTE (NO CHANGE) FILL SYSTEMS 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS' FILL NOTES 1 -5 FILL PROFILE & DIMENSIONS U FILL L\ EXPANSION AREA FILL GREATER 7W.4 N 2 FEET CLAY BARRIER (_j , FILL CERTIFICATION NOTE DEPTH GAUGES (__)/r—)VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & I1NIPERVIOJS (� SEPAR-ATION DISTANCE FROM TOE OF SLOPE TRENCH EN CH (� LF TRENCH PROVIDED LOFT MAX. PARALLEL TO CONTOURS T 100% EXPANSION PROVIDED DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL EOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS (__)( O10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL U 20' TO FOULNtATION WALLS X100' TO WELL, 200' IN DLOD, ISO- TO PITS 0( ,100' TO STREA,N1, WATERCOURSE, LAKE (inc. expan) (� / 50' TO CATCH BASIN, 35' STOR_NIDRAIN, PIPED WATER �10' TO WATER LINE (pits - 20') �50' P;TERIMITTENT DRAINAGE COURSE (� 100'iHO' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS _)10' -,HN TO LEDGE OUTCROP ff SEPTIC TANK Lj(__ )10' FROiv1 FOUNDATION; 50' TO WELL WELL C�,)6DI.NLENSIONS TO PROPERTY LINES Lj JLOCATION OF SERVICE CONNECTION C__) MLN 15' TO PROPERTY LINE SLOPE JSLOPE IN SSTS AREA (520 %) e U.�j REGRADED TO 15 %, IF REQUIRED �!� DOSE/PUNIP SYSTEMS UMP NOTES U( OSE 75% OF PIPE VOLUINIE/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) (� IT AND D -BOX SHOWN & DETAILED (j 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN C_j STANDPIPES, 5' BOTH SIDES, DETAIL U 15' MIN to CDS = >5 %, 20'4 %, 25' -3 %, 35' -1 %,100 % -<1% C___) 20' DIIN to CD DISCHARGE /100' with 182 cons day discharge (__)( 10' b1LN to NON - PERFORATED PIPE Harry W Nichols Jr., P.E. Patterson Park, Suite 106 205.0 Route 22 Telephone (845) 279 -4003 July 17, 2001 Fax (845) 279 -4567 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS Williams - Hawks Aerie Subdivision, Lot #3 Ice Pond Road Patterson, NY T.M. #34.4 -7.3 Dear Robert: Enclosed are the following: 1. Two (2) prints of Drawing SS -3, "Proposed SSTS," dated 7- 19 -01. 2. Four (4) prints of Drawing SF -3, "Preliminary Design for Fill Placement Only, dated 7- 19 -01. 3. "Application for Approval of Plans for a Wastewater Disposal System, dated 7- 19 -01. 4. "Construction Permit for Sewage Disposal System," dated 7- 19 -01. 5. "Application to Construct a Water Well," dated 7- 19 -01. 6. "Design Data Sheet." 7. _ "Letter- of Authorization." ... , ., ., .... 8. Short E.A.F. .. � . .,...... .. .. - - ._ - ..... _ . ._. .... 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 enclosed, please call. Very truly yours, Harry W. Nic s Jr., P.E. HWN:his 01- 030.00 14-161 (41113) —Text 12 PROJECT I.D. NUMBER SEQR -Appendix 'State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNUSTED ACTIONS Only PART I— PROJECT INFORMATION fro be completed by Applicant or Project sponsoo 1. APPLICANT ISPONSOR 'T'40 1v6 + HAP V4 2. PROJECT NAME t J. PROJECT LOCATIOlt � i ►TTt: ��7 ®1� v T�JAH Munblpallty t minty 4. PRECISE LOCATION (Street addrm and road Inleraaotlons, prominent landmarks. etc, or provide map) l�E •�v i-a� � �. D S. 13 PROPOSED ACT101k ; X..7•New ❑ Expansion ❑ Modlllcatlonlalteratlon 6. DESCRIBE PROJECT BRIEFLY. 7. AMOUNT OF LAND AFFECTED: 4 � i `x ` � � Initially aces UltlMO* , eons 6. WILL PROPOSED ACTION COMPLY WITH W=NG ZONING OR • OTHEA. EX=NG LAND USE RESTRICTIONS? 0 Yu ❑ No It No. desorlbe briefly ~ ` 4. WHAT IS FREW UWD,VSE IN VICINITY OF PROJECT? ,�t bL . IRealdentW Indwtrlal Cortuneralal ❑ Agriculture [3.PIForaUOpen space Other - - - �ii�G� 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)?�f 11 Yes 5A No It yet, Iltt apww*) and WmItlappmWo It. DOE8 ANY ASPECT OF TH9 ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Y- . U yell. Wt aGW.O,y ums and wrmltlapprovsl - 12. AS A RESULT OF.PROP0SED ACTION WILL EXISTING PERMITIAPPROVAL REQWRE MODIPICATIM O Yes No 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE 19 TRUE TO THE BEST OF MY KNOWLEDGE E -7/ Appikantlsponsor name _j Da t« / Signature If the action Is In the.Coastai Area, and you are a state agency, complete the . Coastal Assessment Form before proceeding with this assessment 9VER PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 811.47' It yea, coordlnate'the review process and use the FULL EAF. ❑ Yea ❑ No -S. Will ACTION RECEIVE COORI?INATEO REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 11117.0 If No, a neg&ItV@L declaration may be superseded by another. Involved agencyx ❑Yes ❑No :t . C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: Wawa($ may be handwrllten,.11 legible) Cl. Existing air Quality, surface or groundwagr . quality or Quantity, nolae levels, existing traffic patterns, solid waste production w disposal, potential for erosion, drainage or hooding problems? ExpI&W briefly, C2. AesthelIC, agricultural, archacologlcal, historic, or other natural or cultural resources; or.:community or neighborhood character? Explain briefly: CJ. Vegetation or fauna, fish, shellfish or wildlife species, significant hobitata, or threatened or endangered species? Explain briefly: C4. A community's existing plans w goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. C6. Long term, short term, cumtelaUve, or other effects not Identified in C1-057 Explain briefly. C7. Other Impacts (Including changes in use of elther quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ NO . . I- IS THERE, OR iS THERE LIKELY TO BE, CONTROVERSY RELATElb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly — PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, Important or otherwise significant. Each effect should be assessed In connection with Its (a) setting p.e. urban or, rural); (b) probability of occurring; (c) duration; (d) irreversiblllty; (e) geographic scope; and (t) magnitude. If necessary; add attachments or reference supporting materials. Ensure that explanation# contain sufficient detail to show that all relevant adverse, impacts have been identified and adequately addressed. It question D of Part 11 was checked yea, the determination and significance must evaluate the potential Impact of the proposed action on the environmental charactedstica of the CEA. ❑ Check this box If you have Identified one or more po4entlally large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box. if you •have, determined, used on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Nan* of Load Agency Print or Type Nafne of er. a ncy Tide of r Signature Of es , y tuff W Mparer erect from responsible o icer al0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,,QF,1. : O�NTAL HEALTH. SERVICES _..;APPLICATION APPROVAL-OF- FLANS;FOR - - :..: . A WASTEWATER .TREATMENT SYSTEM 1: Name and address of applicant: +° 0R`? M/''_ 2. Name of project: 1 `''�� 3. Location T/V:'iT. ?J . 4. Design Professional: tkW �'-_ `HkAIN-�?1✓ 5. Address: 6. Drainage Basin: 7. Typc of PrQiec ; . Pnvate/Residential Food Service Commercial Apartments. Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State.Enyir9nment4l Quality Review (SEQR)?, - Type Status (check one)...... f.......; ......... . ... ..................:........ iType.-I Exempt Type iI Unlisted x 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... N 10. Has DEIS been •complete'd and found acceptable by Lead Agency? ................ �} 11. Name of Lead Agency {� _..._12_ .Is this. project in an area under"the control of local planning zoning,-or other officials, ordinances? .::::::.:::...:...:....:..........................:........ ......::.,..................... ; c 13. If so, have plan's been submitted to `such authorities? ............. ::...... :.::.,............ %v . 14'. ,. Has preliminary pp otval been granted .4 such. authorities ?. NO Date granted -. - kA - 15. Type of Sewage Treatment System Discharge :......::...:.::. surface water X .. 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 4o, water supply N 20. Is project site near'a ublic sews e,collection or treatment system? ........::.:... ` 21. Name of sewage system Distance to sewage system N► r- 22... Date test holes observed 6) t 1 ° + 23. Name of Health Inspector EHE¢-aEV 24. Project design fl6w•(8allons per day) ....................................................... .... ... . 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?...�9 26: _._ . .. Has�PDES'Applicatian been submitted to local DEC office? .:.:......... :......:. 27. Is any portion of this project located within a designated Town or State wetland? ' - O _2$..—.WetlandsJD. Numb er:.:. oo ..:: :::::::...:.:- .:::.:- .- ::::.:. s. .�.:o.....oawe.save ;...;....... 29. Is Wetlands Permit required? ....:.::...........::..:...................... ............................... 30 31 Has application been made to Town or Local DEC office? �' .... ............................... Does project require a DEC Stream Disturbance Permit? .. ............................... 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 0. 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No ' DESCRIBE: 33. Is there a local master plan on�file with the Town or Village? ......................... E� 34. Are community water and/or sewer facilities planned to be developed within. _ . 15 years in or adjacent to project site? ............................................................... _ 'N5 35. Are any sewage treatment areas in excess of 15% slope? .................. Nti4 36. Tax Map ID Number .......................... ............................... Map '�A, Block 4 Lot '1 37. _Approved plans._are to be returned to ..... Applicant _ Design Profess' ional 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 DEP and submit those forms to DEP for review and approval. ... .f the application is signed by aperson other than the applicant shown in Item .l.,the application must )e accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision nay be grounds for the rejection of any submission.. I hereby affirm, under penalty of per/ury, that Information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.0 of the Penal kaw, 'I GNA T URES & OFFICIAL TITLES: Tailing AddressJC� Z�- PUTNAM COUNTY DE.PA.RTMENT OF HEALTH I PU I.O NViR� EN SERVICES.— f... _ .. NM . '�'A� HEALTH,. DESIGN' DATA - SHEET= L'SUBSURFACE:SEWAGE TREATMENT SYSTEM _ ... __ .�. _.....� .... ,.._ .. ......:.....:_._.._..... 2 P/�Ti�P�SoN yiU- A�G�i; C,f PP�ft�P`.�� Owner T'f-f o ��� tl!}P —`s� W 11�t --1� M 5 Address % :T 1,4173 ID Loc.aced ac.(Street), 1C. ibHD .p-g f.;; czoi ..!}j1.! . -Tax Map Block Lot _ street Muni Municipat - ivy P All- PaR-/�0H .Watershed...... .,A..,_. ...... ...'- ~ Saa:PERCOLAtm TEST DATA Date of Pre - soaking '5 )',�t I o i ......Date of Percolation - Test - o l Fota•�m a• `<,• Y.e P.ercDtxtio.a "•rR. 1,A.)::;� , toP;:.•.' } c. �p �:<�:Sta � �"� •�•... es; •p, >'Mltillcc>x • 4 :3... �..• 1�• ✓ �o I� i 4 .......:a ...:,:.I . ,: >:... .. _2... ., ... _ 4 NOTES: 1, Testa'to bo repeated at samo depth until approximately equal percolation rates arc obtained at each percolation test hole. (Le, s 1 ;min for 1 -30 min inch, s 2 min for 31 -60 m''Rinch) All data to be submitted for review, ;.- 2. Depth measurements to be made from toti of hole. TEST PIT DATA ` DIESCR11>T10N,0F'S.0ILS ENCOUNTERED IN-TEST HOLES L� NO - - xoLE- No . .. _ . oLl✓ o __ 0.5` V5 1.0' . r%1 V, P� ! ndicate level at which groundwater is encountered Mop. indicate level at which mottling is observed M*6 Indicate level to which water level rises after being eneountere r . Deep hole observations made by: O#V4 vl`9i;l1%5 3�- C?Vt�E �E .. 'Date G) ( A,? & PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Z_ DESIGN DATA SHEET -.SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address Located at (Street) 'J'-? Tax Map 321 -Block Lot (indicate nearest cross street) Municipality P,4 ''T' Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking 0 Date of Percolation Test Depth rnn NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 ........... ... 101 2 3,7 10;25 — /0; 37 /'cz 6 3 jf 4' 3 1409, 3 — /v ;W W /0 4 5 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 Indicate level at which groundwater is encountered -- - rr,,U- - - - -- - -- - ---- ----- -- -- - - - - -- - - -- Indicate -level at which mottling - Indicate level to which water level rises after being encountered - -- - - - - Deep hole observations made by: (?, ���� �, �, Date._zo I. . Design Professional Name: Address: Signature:' Design Professional's Seal i TEST PIT DATA 2 ¢ DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES x DEPTH HOLE NO. HOLE NO. HOLE NO. G.L. 0.5' �„ T S• ��� TS. G�• t 1.0' vt eoe. S 1A - firl , e- 5, u slay s.►� -�� 2.0' L 2.5' 3.0' _ J 4.0' , a 4.5 -rem o,c — - - - - - - -- - - - -- 5.0'::. 5 r f' 5ti 5.5' e l we- 6.0 me -raek5 —rack 7Z., 6.5' ly 7.51. 8.0' .._.. .8.5'-- -- -' - -- - -- ....- --- --------------- - - - - -' -' -- - - - -- - - - - -- - -'- - - -- -- _... - -- - -- - - -- ..- '- - - 9.5' 10.0' _ Indicate level at which groundwater is encountered -- - rr,,U- - - - -- - -- - ---- ----- -- -- - - - - -- - - -- Indicate -level at which mottling - Indicate level to which water level rises after being encountered - -- - - - - Deep hole observations made by: (?, ���� �, �, Date._zo I. . Design Professional Name: Address: Signature:' Design Professional's Seal d i - d 30; d� PUTNAM COUNTY DEPARTMENT OF HEALTH - : - , D:I'YNIONzOF EN 'VTRONMENTAL- -HEkLTH,SSERVIC ES, - : LETTER OF AUTHORIZATION RE: Property of G i� � . - (`�' 1kR-`� W1 '-w -'0 5 Located at 1 D HD F�-o AD T/V PI iT -�a�H Tax Map # u'' , Block Lot -7 Subdivision of Subdivision Lot # '� Filed Map #1661- Date Filed 5 �L Gentlemen: This letter is to authorize VP`Pl-�4' V4, ` � i Gjl.s�� + j �p- ' 0 —t-� a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatment and/or water supply permits) to serve the above-noted property in accordance - with the standards, rules or regulations as promulgated by the Public Health D rectbr of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this �._... _ --- maaer- and- to4upervi -se- the - construction -of said wastewater -tretment- and/or-water•supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. ((f NEB/yd� N'cHO�s'fi Very truly yours, Countersigned: � i �� p °� Signed P. E., R. A., # ` (Owner df?r-o'j�ny) No. 56124 Mailing Address j�-� �Ab E S51 Mailing Address: A" State Zip �' d Telephone: L'6 4 r�l � -.4 () C) Telephone: 25 -/ . 14-uvri-I f- Nu00 e CS a " SUct�_of_ /_ a . PUTNAM COUNTY- DEPARTIVIENT'OF HEALT)FI- - DIVISION OF ENVIRON- MENTAL - HEATI,H SERVICES - _N YO�� FIED:,ACTIVITY REPORT ~ _ F Y w _ ADT)RF'44 . :.. Street °.'Town - State = Zip PERSON IN CHARGE .fir - AX&4 S Na- and Title TYPE_ OF FACILITY . .' j TS _ FINDINGS�— - �c R • z .. - y i , Y 3 .. i r y _ •• 4 Y ' - TrfenF - / _ .T�21 Signature-and Title; ,• 3 • R° PC1RT RFC'F °T�TFn RV. - L acknowledge" receipt of this report. ,;.n. SIGNATURE; _ 02:/96 1- Title, PrU 1 NAM COUNTY DEPARTMENT OF HEALTH.-.,,,..-.,,-. ° DIVISION OP-ENVIAONMEiv'f HEALTH SERVICES INITIAL INDIVIDUAL/COMMERCIAL. SITE INSPECTION FORM SECTION A. ,,GENERAL INFORMATION Name of Project County 7 ,zr.-y Site Location _ 1 GL poA/Z2 72e6 Building construction begun Extent Is progerty within NYC Watershed ? ................. yYes ❑ No SECTIO B. TOPOGRAPHY (Please check all appropriate boxes) 1. Hilly.. Rolling _ _.. - Steep slope.. - .... .. __. Gentle slope — - - -Flat - -- - - 2. ❑ Evidence of wetlands Low area subject to flooding F_� Bodies of water ❑ Drainage-ditches Rock outcrops 3. Property lines or corners evident ....................... ............................... ❑ Yes No 4. —Do water courses exist on or adjoin a properly? Noti „ Fov -- ........�:......nd.:.... � Yes / - N 5. Will these affect .the design of the sewage system facilities ?............ 6. Do watershed regulations apply m this T -Will- extensive grading --be necessary? t .......................... .,.......:Y ..: 8. Will extensive fill be necessary for SSTS? ........... ..............................? F7 Yes Yes -Yes ❑ Yes No LEDCr ❑. - -N.o- NO -� ❑ ��ass 9. Do filled areas exist within the SSTS area? ........ ............................... ❑ Yes No what. is_the condition of the fill? - SECTION C. SOIL OBS `VATIONS - -10:- Appearance of soil: Sand ❑Gravel , Loam ❑Clay -_ ❑Hardpan ❑Mixture = 11. Observed from ❑ Borings ❑ Barik cut ❑ Backhoe excavations 12. Soil boringslexcavations observed by 'XFr;� 7. H on 4 13. Depth to groundwater 1/o ni o on 14. Depth to mottling uolvc on 15: Are test holes representative of primary & reserve areas ...... ............................... 16. Soil percolation tests made by 8/,,c/, on 17. Soil percolation tests witnessed by 4-C -R 0- etj . on SECTION D (on back) 0 Form ST -1 M 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? � Yes !o 19. Will groundwater or surface P drainage require special consideration? ......:........ 7 El Yes N 4 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... F-1 Yes No SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... Q Yes No Inbection data 22. Do adjacent wells and/or sewage systems exist?.-... ::...::: s . . . No 23. Additional comments gopa5 g n - uJ,LIuS 24. Site observer /inspector and title ��r�E 7�, T���y __.._�,A- , ._7'_,�, -- IDS- kf -,-- -� - -- - -. 25: Dates) of obse ry ation(s)inspection(s) %! %/ - - -- - - - -- -- -- -- TEST PIT PROFILES Hole # Lot # - - Mole # _.. - - -- - .. -- -Lot # ... _. - -- Hole # .- -- :........ -Lot # - Depth to water p -- .Depth to water Depth to water _ - -- .. -Depth to mottling Depth to rock/imp: - - Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. 0.5 - - 0.5 1.0 1.0 1.0 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 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 MAY -04 -2001 03:33 PM HARRY W NICHOLS BRUCE . R FOLEY. DEPARTMENT 1 Geneva Brewster, New 914 279 4567 P.01 d 3o od OF HEALTH Road York 10504 LORETTA MOLINAJU. _IM, M.S,.N. Dtrcetor gf.Pottent Scrvlca ATTENTION: o ADAM STIEDELI G M GENE REED All information below must be LtI11C completed prior to any scheduling. DATE: ENGINEER OR FIRM: 'Vfe�ek , PHONE 0: — 7 - tit? `; REASON: DEEPS: D� PERCS. -,g(/ PUMP TEST: o ROAD/STREET: TOWN l�ct'��s, -,foti � TAX MAP #: --4 —7,3 SUBDIVISION: _ 4 i" % -C I %e. _ OWNER: 149tt$ r 1AJ- � t Lift, &-. r YES NO a � a !d a.___.. Proposed SSTS within the drainage basin of West Branch or B.oyds Corner Reservoirs. Proposed SSTS within $00 feet of a reservoir, reservoir stem or control lake. Proposed SSTS within 200 feet of a watercourse or a DEC wetland. PrQpQs.ed SST& design.06w greater than 100.0- galloas/day. or_SPDES.Permit required. Proposed SSTS for a Commerical Project. It is the responsibility of the design prol=essional 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 j= 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. DATE: � i ea-) #-,ego LQ1I�tP.N7s: (FIMLDTM) FOR COUNTY USE ONLY TIME: AL . ,• I5 - 64.98 AC. AC. CAL. ` _ i' �i 26 • /lN Y 6CA , a - - - _ 70.06 Ir CA: JL\ •� -•� 62 .47 %. As C3 i �� �•�.J �• � s s. 3402 oP Jti'• 2560 AC.. 954• \ 497.07 t? 119.7 164.80 ti i 12 • ua/p 25 ° 71.91 AC. 96.55 e 40.73 AC. � , 14 74.41 AC. -- - -- - - -.... 75.97 AC. - o POND - . �.. 392.Sq y JL 14 4' Q 1 JL Ex7 10.09 ;C. CAL•. 39 a 4.49 AC.° s y t; ToINN OF • t3as' ,u„ 10 a 9 \ ��+ ss►as 15 `�4 \ 28 /86.83 36 li s �• a �• a 3.09 AC. 3 , 8 �,r� r 3.T9 At. s > y • • \ s ., y,cp = i _ c, 43.46 AC. v 1 4.45 AC. 7.76 AC. `b ° 16 � 19 / 9.39 AC. 6 J< o ..- _.._.- . 45sp0 ` X2.87 a� 17 17.11 22.26 AC. CAL Cal. J 2f a� � a 2.87AC. ieq Ac.�`�6 IJL 35 \� \ p 7 2 18 a AL e p4• AL SW 51asI tia 415 AG - . ,Mre I i 34 TO1vNt ° J fi 20� c ° PATTERSON - -24- 551 w h o 2 _._:_ .p 1 71 A 7 5.89Ar- Y0 t q + 22.27 10. 49.0 - - -- a ,.v CAL. 93.50 AC. 5.38AC. �r , r d: // 22.26 33 v vJ d to 402 ° , . a•d' a J. � e0s.es 22.25 1/ • 1 2.28 e t 3.09AC. 4 • ^ap i - .28AC. as 30- s °o 22.24 h 23 21, 30 ° \ +" $01.03 8.24 AC. sRi" 3 22.29 $ 2.42AC. 29 • r� o3.29AC. 22.23 a'+ ` 23 • °'.b 12.63 AC. CAL. =I 7.65 AC. 457.052 �, Q a 2.4ac. >i ° >; 20.87 AC. d t t a No i08 A e a 22.22 455,68 i 2tiL1 � 2.54AG • 509.15 8 Llf AL ' 1.85A • o w V aS iwNEFAM 22 • ;LIIE AICT L. 1 iICT LIN PREL.I M I NA TOWN OF PATTERS( PUTNAM COUNTY, NEW YOf 1 wEnARDS uRE AND s7Lea �•_� DEVELOPERS LOT MAW. J Dom° °"'M'°" '°°`DI SCALED OIAERSION 100( s) CAMILARD AREA 234 AC. CAL VIVA II711ROID � � PlRC31 AA":BER T2 LEGEND 22 • 23 24 yg� o $ PREL.I M I NA TOWN OF PATTERS( PUTNAM COUNTY, NEW YOf ...WE COfflw1 m O'A7ER911P �.� pmv. Dlsavrco AREAS ............... "aD A SiR1M/MA1Efill� r• SPECIAL DISTRICT LINE -i 9o*k DISTRICT LINE . - -s PORT O< PARCEL Ba90AAT � - wEnARDS uRE AND s7Lea �•_� DEVELOPERS LOT MAW. J Dom° °"'M'°" '°°`DI SCALED OIAERSION 100( s) CAMILARD AREA 234 AC. CAL VIVA II711ROID � � PlRC31 AA":BER T2 33 35 44. 45. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT We1Fl;ocahon" -" ._ _,� Sfreet Address:' Town Nillage "Tax Grid # Map/J4-Block 4 Lot(s)j, Well Owner: Name: Aldress: Use of Well: 1- primary 2- secondary X Residential Public Supply Air con eat ump 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 16: in. Weight per foot lb /ft. Materials: Steel Plastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: V 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 Pumped K Compressed Air HoursYield gpm Depth Data Measure from land surface- static (specify ft) / � , During yield test(ft) _kX) 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 V� t =i `' - C'D C) If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type / Capacity Depth Model 2 E Av'7 1)� Voltage 2 HP '3 * Tank Type � 02_ Volume _ �, ,y Date Well Complete Putnam County Certification No. Date of eport Well 2011 (signature) iNqj i r:: txact iocation of weu witn aistances to at least two permanent ianamarm to be provit on a separate sheevplan. Well Driller's Name Address: Signature: White copy Date: ile; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97