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01517
-i
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #fw 7
WELL LOCATION
Street Address Town/Village/City Tax Grid Number
_
WELL OWNER
Name Mailin Address
C/1/v F
BT, j � Oftivate
O Public
L7 !ATE'fZ /v.
USE OF WELL
1 - primary
2 - secondary
DIESIDENTIAL ® PUBLIC SUPPLY
® BUSINESS O FARM
® INDUSTRIAL U INSTITUTIONAL
O AIR /COND /HEAT PUMP O ABANDONED
O TEST /OBSERVATION O OTHER (specify,
O STAND -BY
AMOUNT OF USE
YIELD SOUGHT_�gpm /li PEOPLE SERVEDj_ /EST. OF DAILY USAGEgal
O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13. ADDITIONAL SUPPLY
WIfEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
BILLED
O
DRIVEN
®DUG ®GRAVEL
®
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name /Sff aZ'c- Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES T/ NO
NAME OF PUBLIC WATER
SUPPLY:
TOWN /VIL /CITY
DISTANCE TO PROPERTY
FROM NEAREST WATER MAIN:
A -;7/
LOCATION SKETCH 6 SOURCES OF CONTAMINATION
O ON SEPARATE SHEET
(date)
PROVIDED
Cp tl"
(si nature)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty: (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or 7!PC--)1WM,4j,-�j
se contaminate surface or groundwater.
Date of Issue• 1?- 19 4,0
Date of Expiration Z- _19 42— Permit 'Issuing Official
Permit is Non - Transferrable White copy: HD.File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
' PUTNAM COUNTY DEPARTMENT OF HEALTH
t Division of Environmental Bealth Services. Carmel, N.Y. 10512 Eoglueer to Provide Permit N
rJ on CERTIFICATE OF COMPLIANCE.
Permit N
CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM
lA�ti...
.. Located atL�2/''• f r<) !.a.... t,: t?.'c; �? owns or. Village - -
Subdivision Name Sabd. Lot N a-• Tax Map Block Lot
Renewal Revislon ❑
Owner /Applicant Name / ✓f[ /1 ��4Li �ia ' �_k' G:a; !,it i ,y
_ Date of Ptevlons Approval
Mailing Address /c'i � Town /_"'1,�,,,F_ "A "' ' ' A_ : (_7 Zip
/-,— r -�r
Ba11d1nQ Type Lot Area • Fill Section Od y
De th Volume
Number of Bedrooms — Design Flow G P D PCHD Notification Is Required When Fill Is completed
Separate Sewerage System to consist of &v it Gallon Septic Tank q
To be constructed by Address':''�MST^Y
Water SupPly: Pabllc Supply From Address
or: 4 Private Supply Drilled by r �x� Address
..., r
Other Ref #tllrements
1 represent that I am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules an regulations O • Putnam
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Healthwill
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 disposal system during the period of two (2) years Immediately following the date of the issu-
ance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto; 2) that the drilled well described above
will be located as shown on the approved plan and that said well will be installed in accordance with the standards, rules and requ a tons of the Putnam
I County Department of Health,
/ . jr� ✓ / • 's,
r
Date : � 7 Signed
�n - P.E.! R.A.
, —
Address license No-1-l" a,- 6,
f"'7
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction
requires a new permit,- Approved for disposal of domestic sanitary sewage, and /or•pr•ivate water supply only.
iC.
Rev. Date !. r BY_. • �._..- .r Title
1/87
��I.sa Pb
ai'
�� `*, •.
ARf CODPITY DERARTNEW OF IMALTH
DlvlaOon of &�vb oamen9ol Red& Services. Camel N M. 1051? Engineer 0 Pmvlde Permit N
_ , • _: ,. ,. LATE F
' ` Permit
CEH11F1 CO.
CON$*IICYION PEi<kiPr FOR §SWAGE DISPOSAti' SYSTEtI�
T
own or "_VlRsge
•� c� -' . a
Sabdlvlsbn Nails ', d:PQ : C�9� " / Subd., Lnf N 2° Tax )19rap� � Lot
♦__/UD lG�//��B�J� />% �/ Renewal_ E®vletoa ❑ i,
Namo
Owaor/ ikont � r
Date of Prevloue Approval ,
Addre a �% b �o .s Tows ° H%A/1 % � JV ,
l3allding �Pe - Lot Area Fill Section Oaly Depth -= Volume
Number of lledioame Destgtt Flow' G P D y 1?� Nofffieatloa Is;Reayalred When FIII Is completed
Separate Seweesge System to consist of GeDoa Septic Teo§ o".
64l1i�?�l '� W.
r�
• To be coneteuct®d by
1
Water S 1 Addrim
app) Pabllc Sapply From
•
iL f
ore Prlyate.Sdpply Dr1Ued by Added ®e•
Other ;itetlaireaieats
I represent that�l am wholly antl +completely responiiDlefor the desegnand location of.;the- proposed systems) 1) Ghat the separate sewage disposal system ^.±
above described will be constructed as shown on the approved bmendment there to and in accordance with' the standards, rules,a regu a ions o e Putnam
County :Department of YHeatthi,,and that on complet�on.tfieieof a Certif, cafe:. oP,Construction'COmpliance ". satisfaetory'tti tha Cori M1Woner.;of Hsalthwill_
_ .<
be submitted to the Department; sntl a.wntten guarantee -wnrhe furnished -,the owne►,;h�f fuccestors, helisor assigns °Dy.,the builder,,that,said_buitder will'
place in good operatengscondition any.,part of said sewage disposal- ayrtam <dunng ,the period, of tw,o.(2j years Irlirrled�atoly.followin thedste of the•issu-
ante .of the' approval of the C®rtificate ,ot Construction'sCO'mpliance of the;originaL:'systerh or :any repairs thereto; 2) thid the drlllod'well tlssiribed ,above
will be` looted -'ai shown on th ®'approved plan and that said well will bo inatslletl -- in accordance with the standards;'.. rules and' ±eg —ri%ns of aha Putnam
l
County. Department of Health ¢ xa;di
Date "s' Signetl x P ER A 1
Andress License No
APPROVED' FOR CONSTRUCTION This approvs( expires two years. from the ;date issued unless' construction of the bui iiing has been undsriaken, and is
revocable for cause or may -be- amended or moddioa,when considared.necessa by the . commissioner of - Health. Any change of alteration of _construction _
requites a' new perm' roved far disposal of domeslir`samtary sewo� and / pr' water ply only _
y. Date /6 Title 1
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION TO CONSTRUCT A WATER WELL QQ`�
PCHD PERMIT # )W- D
WELL LOCATION
Street Address 7 5 "'/�/ 'as7own Village City Tax Grid Number
c le 2.
WELL OWNER
Name
P.o
Mailing Address
5cp uT �1'?Z y f� . ��5�1'
Private
O Public
USE OF WELL
1 - primary
- secondary
RESIDENTIAL
O BUSINESS
O INDUSTRIAL
❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL Q STAND -BY
O ABANDONED
❑ OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE SERVED 6 /EST. OF DAILY USAGE .600 gal
REASON FOR
DRILLING
NVEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST OBSERVATION
OREPLACE EXISTING SUPPLY 13DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
LI DRILLED
DDRIVEN
ODUG
El
GRAVEL
El
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES k1 NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: /Cl4i940 IFIOIPAO
Lot No.
WATER WELL CONTRACTOR: Name ��� Address: �LF_.wI7% f2 -x�y /OS�DS'
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES I,,-NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON REAR OF THIS APPLICATION []ON SEPARATE SHEET
(date) ' (signature)
PERMIT
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days of the completion of water well construction,
the applicant shall:
1.
2.
3.
Pump the well until the water is clear.
Disinfect the well in accordance with the requirements
County Health Department attached to this permit.
Submit a Well Completion Report on a form provided by
Health Department.
hermit Issuing cia1 —%--
Date of Issue: 19��
Date of Expiration: 19�
Permit is Non - Transferrable
2/87
of the Putnam
the Putnam County
White copy: H.D. File
Yellow copy: Building Inspector
Pink Copy: Owner
Orange copy: Well Driller
iTTNAM COUNTY DEPARTMENT OF HEALTH.
tDIVISION OF ENVIRONMENTAL HEALTH SERVICES
TI Y °OFFICE BUILDING
N. Y. 10-c
A eta 7L� "g'
DESIGN A SHEET -SEPA E SEWAGE DISPOSAL YSTEM FILE NO.
icygCo
Owner �e•;r9R:h 1 �APp J Address 7 �e r�'/ =/R
/N7' Sic / o o F 74,.' .—
Located at (Street isa p °SJO n Sec. Block Lot .2
�indicate nearest cross street)
Municipality .10 �6 / 65 W. Watershed
T
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Ho 16
Number CLOCK TIME
PERCOLATION
Run Elapse
Depth
to Water
Water Level
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
1/a,9s 110.6 s' o
o"
-33
_3
7
2/4/0 1/, 3r s S
3:3 A
U"
3''
3//40 12,06 2.G
'39. &
3?
5
,
1
,
2�
7ioff ........ -.... �,. , .._ .. ........... _ ..,. _
5
1 „
2
3
5
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by.. Date _
TEST PIT DATA REQUIRED
TO BE SUBMITTED WITH.APPLICATI&V
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES e
DEPTH
HOLE NO. /
HOLE N0.
6"
►.
12"
18"
24"
oe
30��
eo
36"
ra
42"
�a
48!'
u o
6o"
s ...
66"
ro
8411
INDICATE
LEVEL AT WHICH GROUND WATER IS ENCOUNTERED off' C —Z0&N® 4eg Y, ec
INDICATE
LEVEL TO.WHICH WATER
RISES AFTER BEING ENCOUNTERED
TESTS MADE BY �Lyo�yL�G
/��S�oy Date
Soil Rate
Min/1 "Drop:
DESIGN
S.D. Usable Area Provided 02�c►
No. of Bedrooms Septic Tank Capacity /600 Gals.. .. Type
Absorption Area Prov ded By 3,?L,�L.F.x241' ��.� width Trench.
Other.
Name
< or i.. r,0"
igna ure
Address
1' 7X!E
SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by.. Date _
JTNAM COUNTY DEPARTMENT OF HEALTH
�;DYVISION OF ENVIRONMENTAL HEALTH SERVICES
COT.jNTY OFFICE BUILDING, CARMEL, .N. Y. 10512
DESIGN `A SHtET -SEPA E SEWAGE DISPOSAL SYSTEM FILE NO.
�Ci�9Co 1 2 4'pp Se c u 7 9,e'o f r
Owner �_ie�.�R./� 1 ,egpo J Address Y10,07, C
iNr S o .
Located at (Street ��� nO .* '" Sec. 7q Block Lot
�'Tndicate nearer cross free
Municipality ,row Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
noi.e
Number CLOCK TIME
PERCOLATION
PERCOLATION
Run Elapse
Depth
to Water
Wate r ve
No. Time
From Ground Surface
in Inches
Soil Rate
Start -Stop. Min.
Start
Stop
Drop in
Min. /in drop
Inches
Inches
Inches
1/0 e S �2 6
-76 '
-33
3
7
21 10 1/,35- :Z 5--
33 *
3C"
.3
`
31140 /2, e6 2. en .39—
3 9 ' �3
4
1
2 d Lzf' y
0
2
4
Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION,
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH HOLE NO.- HOLE NO. HOI S -NO .'
- - --
G. L.
6" o • ,
12"
18,E
24" ,-f
30" �!
361 o
42" le
48" o
5411
60"
66"
72 �.
78'1
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED C,e0VW,9
INDICATE LEVEL TO WHICH WATER LEV���FT,,-.RISES AFTER BEING ENCOUNTERED
TESTS MADE BY (', /+/%,Lyon �'I/iL�.,� rate G/v L y /Q P z
_
DESIGN
Soil-Rate Used�MirV2:j'Drop:
S.D.. Usable-, -Area Provided sO6a
No. of Bedrooms Septic Tank
------ ��rr-- ^^^^ Capacity /6BO Gals. Type X �ro'�2y
Absorption Area Provided By 3"L.F.x24" ��
width trench.
Other
Name Signature
Address SEAL
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. Ft /Gal. Checked by Date
C. MILTON WILSON
,.LICENSED_ PROFESSIONAL- _ENG.INEER-
f
i0, /
42 LAKESHORE DRIVE R2 BREWSTER, NEW YORK 10509
Tel: (914) 669 -5290
SEPTIC AND WATER SYSTEMS .-HEAT AND POWER CONSERVATION
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION DF ENVIRONMENTAL HEALTH SERVICES
DateC46:�� 7, 7
Re: Property of glz,- �!®
e ® /C %/! �d � Av
Located at IAZAarr RQ - /3 AeGl' d
(T) f� -r71ei s'O/41 Section Block Lot
Subdivision of Rlo p O
Subdv. Lot Filed Map # �� Date
Gentlemen:
This letter is to authorize '� •' !� ?O/�' °���
a duly licensed professional engineer v or registered architect
(Indicate
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connect "ioii 'with this" matter- and to -supervise the -corist dctioh of `said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
�Si g ned
Countersigned: weer of Propert
.
P.E. , R.A. , # D /.l -s 4 ®G?
Address
Address
Telephone
Town
Telephone
�P -7.0' ell
PUTNAM COUNTY DEPARTMENT OF HEALTH
CERTIFICATE OF CONSTRUCTIONt�COMPLIANCE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # 1" ' 0 o /I A)
Located at 146 ToK� TRJ F-95P, LP(Wr Town or Village 1" A�6 01-4
Owner /Applicant Name
�- t�T4 -4 �kLii✓��
Tax Map 194, Block Lot I
Formerly
Subdivision Name
MF9
Subd. Lot #
Mailing Address �' f 4 ° Pp`�'1"
Zip 1�
Date Construction Permit Issued by PCHD
Separate Sewerage System
built by bEW J ►E�
Address
RQL l f �
Consisting of ��
Gallon Septic Tank and !!ho
Lr—''
,
Other Requirements:
Water Suggly:
Public Supply From
Address
or: Private Supply Drilled by BOM kRW WAV4 11`0-L Address I b" W S7-- T-� k)50-
V
Building Type 1 D _E H -47- a Has erosion c6hdol'been completed ?' - 167 -.
Number of Bedrooms
Has garbage grinder been installed?
I,%
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam Count Depprtfinent of Health.
Date: 1 ®/ �Q Certified by /
or
P.E. R.A.
4Ve ign Professional `
Address �� 7'� 6GT P KJ (Q� A License # 6�
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals subject to modification or change when, in the judgment of the Public Health Director, such
revocatio , m ificatio r change is necessary.
By: Title: YX Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address::/
_T'bmnt I liw r!� V_ i,. Lt ►'tom
L'OL wn/Village:
-t� ersa
Tax Grid #
Map ��• Block `'r Lot(s) 1
Well Owner:
Name: Address:
lbo v 1u.s T cdf O ek'ev P,0,9 ou 313 P' _-s &'-t -n oo—Z
Use of Well:
1- primary
2- secondary
�_ Residential Public Supply , Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock )L Other
Casing Details
Total length �b , ft.
Length below grade /ft.
Diameter in.
Weight per foot /9 lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded Threaded _ Other
/
Seal: _ Cement grout — Bentonite _ Other L/Aj
Drive shoe: '? Yes 2 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
k Bailed _ Pumped _ Compressed Air
Hours l
Yield _7_ gpm
Depth Data
Measure from land surface- static (specify ft)
ZJA
Zu
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
6//
'45 * W D
If yield was tested
at different depths
urin drillin g,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type Capacity �
Model i a1
"Depth 30d
-
Voltages HP
Tank Type4 !6D<a/ Volume 4
r'j &iYY- 0
Date Well Completed
Putnam County Certification No.
D 3
Date of epo
� /s�B4
Well Drill r (signature)
NOTE: Exact location of well with distances to at least two permanent lanamarxs to oe pruv u uu a SupaiaM, aiivc . v F. m..
-9,Y4 /gl- tz?sucy tUt_I( Cd �hct q r,r� aa�s- �iG n�.
Well Driller's N me W Qvi r k� • � k eS Address: /05-# �>{ • S 1 l oA ml4 ' A Y
Signature: Date: R - /4-Oc� �Os�
White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WC -97
Harry W. Nichols Jr., P.E.
..... ,,... Patt 106,
..._,s :.,. •- �.. .. erson °Park Sutte.. .._�._..:... �..
2050 Route 22
Brewster, NY 10509
Telephone (845) 2794003
Fax (845) 2794567
To:
Attention:��
Date: ID(Cf 00
Job No.:
Project A� NLT
1+6 VWs T "(Fa— U\H&
Gentlemen: We enclose ( ) copies of
• B/W Prints O Reproducibles O Reports O Tracings
• Specifications O Memorandum — O Copy of letter O
Description:
- �nl�Iit. Lo m4�c�tlot� d�a�T'
cdk� Geri
C. POt 4 `` N� bM /IS ; Vl
- Fff OF tqWLO
Sent Via:
VZur Messenger
❑ Your Messenger
Copy to
Revision/Date No.
1010 40
14 00
to,6joo
10 p�
O Blueprinter O First Class Mail O Special Delivery _
D Hand Delivery ❑ _
Very iNichols yours,
Jr., P.E.
NE
_ NORT.HFAS.T LABORATORY OF DANBURY
39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404
LABS (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MS. PAMELA ROTHACKER
P.O. BOX 373
PATTERSON, N.Y. 12563
SAMPLE SITE:
SAMPLING POINT:
SOURCE:
TREATMENT:
DATE SAMPLE COLLECTED: 9/25/2000
TIME COLLECTED: 8:30 A.M.
COLLECTED BY: P. ROTHACKER
DATE RECEIVED @ LAB: 9/25/2000
TESTED BY: LAB# 11471
REPORT DATE: 9/29/2000
146 TOMMY THUBER LANE, BREWSTER, N.Y.
BATHROOM SINK
WELL
NONE
TEST PERFORMED
RESULT:
BACTERIAL:
34.0
Total Coliform (Bacteria)
0 per 100 ml
PHYSICALS:
<0.03
Color
0
Odor
ND
PH
6.28
Turbidity
0.26 NTUs
CHEMISTRY:
ml = milliliter
"Notification Level
Nitrite N <0.005
. - Nltrata 4
GO.2O
Alkalinity
34.0
Hardness
52.0
Iron
<0.03
Manganese
<0.01
Sodium 1.8
Lead 0.001
mg/L = milligrams per Liter
* * *Action Level
MAXIMUM CONTAMINANT LEVEL
0 per 100 ml
15
3 Units
no designated limit
5 NTUs
mg/L as N
1 mg/L as N
N_.. ......, ._............._..
mg/L
no designated limits
mg/L
no designated limits
mg/L
0.30 mg/L
mg/L
0.30 mg/L
[Note: Combined Limit for Iron plus
Manganese = 0.50 mg/L]
mg/L
20 mg/L **
mg/L
0.015***
ND = none detected NTU =Units
RESULTS BASED ON SAMPLES SUBMITTED:9 /25/2000
SAMPLE, AS TESTED ABOVE: X or FEINOT POTABLE
(PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
1;�Ihw
��T_
Laboratory Director
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060370 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
OCT -02 -2000 96:21 AM HARRY W NICHOLS
914 279 45167 P..02
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION QF E O NTA-L- HEA T-H "SERVICES': .
GUARANTEE OF ST.IBSURFAGE SEWAGE TREATMENT SYSTEM
:10-/ kn
Location -.Street MV
Building T pe
Tax Map Block at
Town/Village
opt
tU�StC
Subdivision atr►e
Subdivision Lot #
1 represent that I am wholly and completely responsible for tho. location, workmanship, material,
construction and drainage of the sewage tieatinent, 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,''ruies and regulations of Putnam County Department of Health, and
hereby guarantee to the owner, his successors; heirs or assigns, to place in good operating condition.
any part of said system constructed by me which fails to operate for a period of two years'
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sew
age- system, or- any- made by me to such system, except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
system,
The undersigned further agrees to accept as conclusive the determination of the Public Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of the building utilizing the
system,
Dated: Month --Lo Day Year.. Signal
<A o►i�l.n.� ��i, _ Title:
General Contractor (Owner) • Signature
Corporation Name (if corporation)
Address: �� lV P�iTJiQr�
State Zil)
Corporation Name (if corporation)
Address: PO 00 /- t ?� P J�,✓
State
Farm GS•47
BRUCE R. FOLEY
"`" "i'�Public "'Tiealtli `Director " ° "" ''
LO1tETTA MOLINARI ILK, M.S.N...._.._._...
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
E911 ADDRESS VERIFICATION FORM
OWNERS NAME: 7
TAX MAP NUMBER:.
E911 ADDRESS: t
TOWN:
AUTHORIZED TOWN OFFICIAL:
(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 a Certificate of Construction Compliance.
(E911 VERFRM)
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Date: 91 S oa
~- =-Stree toe -atronw''7nM M �/` rrr8wiz'. .�a� Owner Sit 'gi b
Town pA-r Tt6coN Permit # •p - 13 -�®
TM # 3,q - # - % Subdivision Lot # a P �-
1. Sewage System Area
a. STS area located as per approved plans ...........................
b. Fill section - date of placement
3:1 barrier Lgth._7 Width ao Avg.Dpth 2 �T
c. Natural soil not stripped.
d. Stone, brush, etc., greater than 15 from STS area..........
e. 100' from water course / wetlands ...... ...............................
II. Sewage System
a. Septic tank size - 1,000 ........1,25 .........other ................
b. Septic tank installed level ................ ...............................
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
All outlets at same elevation -water tested .................
2.. Protected below frost .................. ...............................
3. Minimum 2 ft.Original soil between box &trenches
e. Junction Box - properly set ........... ...............................
f. renc es
T.Len—g-t1 required o o Length installed 5loo
2. Distance to watercourse measured-- /,9,r,> .Ft..........
3. Installed according to plan ......... ...............................
4. Slope of trench acceptable 1/16 - 1/32" /foot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface ..................
7. Room allowed for expansion, 100 % .........................
8. Size of gravel 3/4 - 1 %" diameter clean ....................
9. Depth of gravel in trench 12 ". minimum ...................
10.-- Pipe-ends -capped:.: ............
......... —.:.
.... ..........................
g. PumR or Dosed Systems
Size o 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 ........................... �/.........�
IV. Well namve'Doa.� bn A.VW je x1
a. Well located as per approved plans ......................... &.2
b. Distance from STS area measured -r /o o ft ......,....
c. Casing 18" above grade .................. ...............................
d. Surface drainage around well acceptable .......................
V. Overall Workmanship
a. Boxes properly grouted .......:........... ...............................
b. All pipes partially backfilled ........... ...............................
c. All pipes flush with inside of box ... ........................ ........
d. Backfill material contains stones <4" diameter ..............
e. Curtain drain & standpipes installed according to plan..
f. Curtain drain outfall protected & dir.to exist watercourse
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate ... ...............................
i. Erosion control provided ................. ...............................
Rev. 6/97
r orm 3 17)
k
FM
ICJ
ICS
IC=
WE
IRE
FF
c�
r orm 3 17)
k
BRUCE R_ FOLEY. :...__....._._...
Public Health Director
LORETTAF- MOLINAR% X.7::
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva .Road
z Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
Date: /o y
To: #Ay'12Y A0 e HoG � Fax #: Z7 — 15-6 7
7Z e ., 4e,7 2
From: Gene D. Reed
Putnam County Department of Health
__ZFor your information
For your review
As discussed
No. Pages '2_
- - _ -- --- _-_--_------------ - - - -- -- -- ... - -- -
-(Including cover sheet)
,p.
Please respond
Attached as requested
Please call -
Notes/Messages
In the event of transmission /reception difficulties, please contact this office at
(914) 278 -6130 ext. 2261.
-- -- c.-- MHKKT w NIUHULS 914 279 4567 P.02
.11"N'IStvYilN�L.O�I:+iV S -- D�.lC��81u71 .zV-
DMSION OF ENMONMENTAL HEALTH SERVICES
ATTENTION ® ADAM • GENE
REQUE ST FC1� F�6L INSPECTIQAd For: 'Fill
All information must be fully completed prior to any Trenches _
inspections being made.
PCH Construction Permit # P- 1_3 ` %_
Located. TO C" 64n ra ."7 - w.4 (T) (V) A
Owner/Applicant Name! 'R o *74 "t, kor TM -!I— Block �`_ Lot -4-
Formerly: Subdivision blame: ;E-,t,&jO
Subdivision Lot #
Is system fill completed? Date:
Is system complete? Date: -3 / -6c
Is system constructed as per plans?
Is well drilled?
Is well located as per plans?
Are erosion control measures in place?
Date: & --?1 0G
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 PCFiD Construction Permit and
approved plans and the Standards, Rules and Regulations of the Putnam County Department of
Health.
_._ _pate: �--4e ' ®G Certified by: PE RA
... __._ .,.,.._... °
DtiihTptofisslonal _ _... •...... .
Address: La, -xx bve_vj� Zi Lic. # S'Ze l
Comments:
Form FM-99
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
C STRUCTION PE or AGE TREATMENT SYSTEM
PERMIT # � / 3— Located at °`1M� �f:l -1 E(— Town or Village
Subdivision name �LNFP
Date Subdivision Approved
- Subd. ! 1Lot # �- Tax Map Block 4 Lot It
i2/�jo n, Renewal Revision
Owner /Applicant Name Pa qQG AS D06M H W F Im Date of - Prrevious Approval
Mailing Address P-1~4 604 1►-0 N rf-P-6, 0 N i Zip 19-4 GIA
Amount of Fee Enclosed
Building Type PZ`c7!051'1L-f Lot Area 4 `)A No. of Bedrooms *' Design Flow GPD
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of I "��J� gallon septic tank and # 00 LF- k;
Other Requirements:
To be constructed by T& g : D
Address
Water Supply: Public Supply From Address
or: Private Supply Drilled by _'T..B'nj" Address
F1 - Lw`rpirt jkNWJ?' WiA "5LIL- ON ri(4 Pe TO gLONAA- ( Ej P0�- DoM1rST
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 -74 -14
License # 5611 -4
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 ;;he onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new, pernl't pppoved for 'scharge of domestic sanitary sewage only.
By: f/ Title: -°' Date: _
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Desig1Pr fe ssional
Form CP -97
BRUCE R
Public Xialih Director.
6
LORETTA,. IWOLINAM. &N., M.&M
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF BEAU H
1 Geneva Road
Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278.6558 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648
WIC (914) 278 - 6678 Fax (914) 278 - 6085 '
Harry Nichols
Laurent Associates
Millbrook Office Centre
Route 22 & Milltown Road
Brewster NY 10509
Re: Proposed SSTS: Rothacker
Tommy Thurber Lane, Lot #2
(T) Patterson, TM# 34.4-9
Dear Mr. Nichols:
July 19, 1999
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:
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.
1) Please show location of all watercourses, ponds, lakes and wetlands within
200 feet of the property line, or simply add a note to the plans stating none
exist within 200 feet.
2) Separation distances are to be specified on the plans (i.e., 10' to driveway).
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Very truly yours,
thawn gan
SR:tn Public Health Technician
4�rQvef
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner KvJ- 11A G!lIF P7 Address 1 AA
Located at (Street) 2 c Pd�vp p Tax Map Block Lot
(indicate nearest cross street)
Municipality _ .`f�n-Eizson/ WatershedL�T
SOIL PERCOLATION TEST DATA
1
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
11136'-1.145-
19
X5
3
2
;46— '5-
11
15--
3
3a7
3
4
5
2
�- �s
X1
3
3
a — S�
3
3
4
5
1
2
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 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed _ ®A/
Indicate level to which water level rises after being encountered /10 A(
Deep hole observations made by: ee eX w Date
L.tvrewi
Design Professional Name:
Address:
Signature:
Design Professional's Seal
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST BOLES
DEPTH
HOLE O. " HOLE NO: -j ' HOLE NO: _ 5-. `
G.L.
i, J'rna , `f't� i ►� ar,�
0.5
1.0'
1.5'
2.0'
.' 'SiV
2.5'
I 5
3.0'
3.5'
Gr
a
4.5
IzeA
5.0'
e
`>' GiIGC Crave
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
10.0'
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed _ ®A/
Indicate level to which water level rises after being encountered /10 A(
Deep hole observations made by: ee eX w Date
L.tvrewi
Design Professional Name:
Address:
Signature:
Design Professional's Seal
RECORD OF PHONE CONVERSATION
DATE: l TIME: e
PERSON CALLING:- PHONE #:
REASON
( ) Inspection:
9 and /or rcs--)-
SCHEDULED FIELD MEETING
a130 T
DATE:
'evirvo
TIME: AMCW-
ROAD /STREET:
TOWN: P,2
TAX MAP#:
SUBDIVISION: Aw LOT#:
OWNER:
711
P
COMMENTS:
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1p
9.55 AC.
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64.98 AC, o
51.915 AC. CAL, I_
AC CAL / mot' 26
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_ 621.17
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14 74.41 AC.
75.97 AC.
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POND scx\
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34
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5.89AC �P 9� AC 22.27 �• 10.71 AC
CAL. eP
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LEGEND
-- eoao Ram - E.N �� ueolallr ............... wEnAros LINE AM sneol L•Y :� 22- 23 24
- - -- SiK/W�itl c R• _ �- DEVELWW LOT NAWR. J P F
Em D11a iell IDa DI 33 '35 1
fOppL N� ' Q 111E -'- SCALED DIMMICH IODIsl TO
IAX7 O< LIIE --F CALCIAATED MU L34 AC, CAL o
- - - IOli0MY = 6 YIStL1L COt1IICID 44 . 45 $ Pul
n.. - I'MCEL NAM TL
BRUCE R. FOLEY
Public Health Director
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
July 19, 1999
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee, and received by this Department on July..9, 1999 is. complete. The
Department will notify you by July 29, 1999 of'ifs determination. --
® 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 Dept. of Environmental
Protection review and approval of other aspects of a project, such as stormwater plans or the creation
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648
WIC (914) 278 - 6678 Fax (914) 278 - 6085
Harry Nichols
Laurent Associates
Millbrook Office Centre
Route 22 & Milltown Road
Brewster NY 10509
RE: Rothacker,
Tommy Thurber Lane, Lot 42
(T) Patterson, TM# 34.4-9
Reservoir Basin East Branch
Dear Mr. Nichols:
July 19, 1999
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee, and received by this Department on July..9, 1999 is. complete. The
Department will notify you by July 29, 1999 of'ifs determination. --
® 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 Dept. of Environmental
Protection review and approval of other aspects of a project, such as stormwater plans or the creation
"I,`etter to: Harry Nichol ,- •July 19, °1.999 - Y �.. _ xs. _.... _2_
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 (914) 278 -6130 ext. 2159.
Very truly yours,
q S awn Ro
� Z4
gan
SR:tn Public Health Technician
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONIIENTALHEALTH
- ,INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
':. itEVIE\ VSHEER'' FORC- OO5' Ti2JE1' IOi1�Ei2. \I�i':•= ._-- :,.�« =^---
.� ✓ j f kl/
STREETLOCATION /( y►9t/ / /f tilt L NAME OF OWNER Q '` fhttc. e
REN'TE«'ED BY RM, GR, AS, MB, B $ /� AT - %
Y N DOCUMENTS Y N L 7L
PERINIIT APPLICATION
PC - I - Pc.97
WELL PERMIT _ PWS LETTER
/ LETTER OF AUTHORIZATION
DESIGN DATA SHEET (DDS)
CORPORATE RESOLUTION
/ SHORT EAF
PLANS - THREE SETS
HOUSE PLANS - TWO SETS
VARIANCE REQUEST
FEE
SLBDIVISION
VF�LEGAL SUBDIVISION
SUBDMSION APPROVAL CHECKED
PERC RATE /0
FILL REQUIRED DEPTH
CURTAIN, DRAIN REQUIRED
STANDPIPES
\E RA
LOCATED N NYC WATERSHED
PLANS SUBMITTED TO DEP
DELEGATED TO PCHD
DEP APPROVAL, IF REQ'D
DEEP TEST HOLES OBSERVED
PPRCS TO BE WITNESSED
EX- APPROVAL SSDS ADJ. LOTS
WETLANDS (TOWN/DEC PERMIT REQ'D ?)_
'D'AT90N*DD S' PI;P.NS " &'P ERMIT' S ANI E - -`
PRE 1969 NEIGHBOR NOTIFICATION
LETTER BUZBA
100 YR. FLOOD ELEVATION
OTHER REQ'D PERMIT(S)
REOUIRED DETAILS ON PLANS
SEWAGE SYSTEM PLAN - (NORTH ARROW
SSDS HYDRAULIC PROFILE
GRAVITY FLOW
EROSIOCONTROL:HOUSE,WELL, SSDS
/
WPERC 8_-`DEEP HOLES LOCATED
REPRESENTATIVE OF PRIMARY & EXPANSION
LOCATION MAP
EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
PUMPED, PIT & D BOX SHOWN & DETAILED
HOUSE - NO.OF BEDROOMS
WELLS &: SSDS'S WAN 200' OF PROPOSED SYS.
PROPERTY METES & BOUNDS
HOUSE SETBACK NECESSARY (TIGHT LOT)
HOUSE SEWER- 1/4" FT. 4 "0; TYPE PIPE
NO BENDS; MAX.BENDS 45° W /CLEANOUT
FILL SYSTEMS
/ CLAY BARRIER
10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE
FILL SPECS f FILLNOTES
FILL CERTIFICATION NOTE
DEPTH GAUGES
FILL PROFILE & DIMENSIONS
VOLUME
FILL N EXPANSION AREA
LF TREN'CH PROVIDED 60 FT MAX.
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
SEPARATION DISTANCES SPECIFIED
ON PLAN -FROM SSTS
0� 0-P:L•:,• : L-ARGE•T -R£E; TOP- OF•FIL•L- -
0' TOFOUNDATION WALLS �15'WELL TO PL
100' TO WELL, 200' IN DLOD,150' PITS
100' TO STREAKS WATERCOURSE LAKE (inc. expan)
50' TO CATCH BASIN, 35' STORMDRAN, PIPED WATER
10' TO WATER LINE (pits -20)
50' INTERMITTENT DRAINAGE COURSE
'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS
CONSTRUCTION NOTES 151\1 IN to CD S= >5 %JW- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' - <1%
DESIGN DATA: PERC & DEEP RESULTS MIN to CD discharge /100'with 182 cons day discharge
2' CONTOURS EXISTING & PROPOSED SEPTIC TANK
DRIVEWAY & SLOPES, CUT 10' FROM FOUNDATION; 50' TO WELL
UIFOOTING/GUTTER/CURTAIN DRAINS WELL
SOIL TYPE BOUNDARIES DRMENSIONS TO PROPERTY LINE
ka:jTITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION
TM�",PE/RA; NAME,ADDRESS,PHONE
DATE OF DRAWING/REVISION
DATUM REFERENCE
LO.0 -ATL OFSWA-TERCO.URSES PONDS
L`AICES --A1ND - ETLANDS --w-rr rw-200=FEET:;,
70PROPOSED FINISH FLOOR AND BASEMENT EL.
COMMENTS:
c �y
c
f
C� W eVliafl lnaif17i11 GS�76Si /11e:ry[HLeHV +irtiitHln:in
N
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO-CONSTRUCT -A WA'I'TER WELL
please print or type PCHD Permit # i
Well Location:
Street A dress: Town/Village Tax Grid #
T0M141 V0 � LME PXYTD-60 i Map 0 •
Block 4 Lots)
Well Owner:
Name: poX+4P6 Wrz-il -1
Address:
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 _n±__ gpm # People Served `6 - C Est. of Daily Usage COQ gal.
Reason for
Replace Existing Supply Test/Observation
Additional Supply
Drilling
J< 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
Lot No. �.
Water Well Contractor: TO 0, Address:
Is Public Water Supply available to site? ................................. ...............................
Yes No
Name of Public Water Supply: N A Town/Village
NCR
Distance to property from nearest water main: 14A
Proposed well location & sources of contamination to be provided on separat she
pl
Date: `ie2� `1 - Applicant Signature:'
V 6001
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 w 'ller certified by Putnam
County.
Date of Issue 1'q Permit Issuing Off ial:
Date of Expiration Title:
Permit is Non-Transfefrablk
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
)dT_
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET -SUBSURFACE. SEWAGE TREATMENT SYSTEM.
Owner sT �%Di�e2 Address r p
All
Located at (Street) ToNtrhi TR n, Tax Mapes /3 Block Lot
(indicate nearest cross street)
Municipality V 770�A/ Drainage Basin
Date of Pre - soaking �- 3 Q' �g Date of Percolation Test
Hole No.
Run No.
Time
Start - Stop
Ela se Time
I ,n.)
Depth to Water
rom Ground
Surface (Inches)
Start Stop
Water
Level
Drop In
Inches
Percolation
Rate
Min/Inch
3
,; 5 �� a.o9
11
3a
4
5
3
/,5- �U
, . �~ ►.�
4
5
1
.
2
3
4
NOTES: 1. Tests -to be repeated at same depth until approximately equal percolation rates are outa►nee aL Ca
peecolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth rneasurements•to be, made from top of hole.
1,Q dgR1,✓l 99 0'3f Form DD -97
9004-
�6p; v S /d�./ Loy 4;
FOT >�
-- TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH .;HOLE NO..
.. . G.L. � HOLE N0� ` HOT F Nn
0.5'
1.0'
1.5'
2.0'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
9.5'
10.0'
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed Gam/
Indicate level to which water level rises after being encountered
Dee hole observations made b
P Y� DES
.
Design Professional Name: L ,
Address:
WS% �OF NE►y�;
�� AV 1050 9' ��� �. N1CN °9fi
Signature:
03 W�.l0fld3
),JNn. Pd
03n13038
Design Professional's Seal
rl
lye
No. 56124
A;?QFESSIONP�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION FOR APPROVAL OF PLANS=FOR
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant: 17o�%PtV/ pv-►�� �.siHc�K -ER
F-P- 4 �o iro
PA-mT f 60M . M
2. Name of project: La?' 3. Location: PAr•EP -5o�-4
4. Design Professional: 144/ Ry W, i-A\O o'�A P-M 5. Address: 10 HIU -TawN �,O PAD
6. Drainage Basin: r LNG H (SEWS i gyp- ! i 0 SQl
7. Type Project:
Private/Residential Food Service
Apartments Institutional
Office Building Realty Subdivision
Commercial
Mobile Home Park
Other (specify)
8. Is this project subject,to State Environmental Quality Review (SEQR)?
Type Status (check one) ....................... ............................... Type I Exempt
Type II Unlisted
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... I N o
10. Has DEIS been completed and found acceptable by Lead Agency? ............... N A
11. Name of Lead Agency N X .
Y
12.-
Is this - project in an area under the control of local planning,. zoning, or other
officials, ordinances? ......................................................... ...............................
e-5 —
13.
If so, have plans been submitted to such authorities? ........ ...............................
'No
14.
Has preliminary approval been granted by such authorities? NO Date granted:..
N A
15.
Type of Sewage Treatment System Discharge ................. surface water X
groundwater
16.
If surface water discharge, what is the stream class designation? ....................
NA
17.
Waters index number (surface)
18.
Is project located near a public water supply system?
No
19.
If yes, name of water supply N-Jk Distance to water
supply kAA
20.
Is project site near a public sewage collection or treatment system? ................
No
21.
Name of sewage system NIX Distance to sewage system NA
22.
Date test holes observed �1' 1 "�� 23. Name of Health Inspector tAENE PEED
24.
Project design flow (gallons per day) :........................
8o0
25.
Is State Pollutant Discharge Elimination' System ( SPDES) Permit required ?...
N�
26.
Has SPDES Application been submitted to local DEC office?
H
Form PC -91
q
27. Is any portion of this project located within a designated Town or State wetland? No
28. Wetlands ID Number.... :.:.:::....................................................
29. Is Wetlands Permit required? .......................................................... .... ................
Has application been made to Town or Local DEC office? ......:........................
NA
30. Does project require a DEC Stream Disturbance Permit? .. ............................. ...
31. Is or was project site used for agricultural activity involving application of
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ............................ Yes/No
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination? ............................... Yes/No
DESCRIBE: .
,
'No
NO
33. Is there a local master plan on file with the Town or Village? 'DES
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ................................ ............................... �Q
35. Are any sewage treatment areas in excess of 15% slope? . ............................... No
36. , Tax Map ID Number ........................... I ............................... Map ' 4 Block 4 Lot I
37. Approved plans are to be returned to ..... Applicant ti Design Professional
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.
If the application is signed by a person other than the applicant shown in Item l .,the application must
be accompanied by a Letter of Authorization (Form ILA-97). Failure to comply with this provision
may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this form is true
to the best of my knowledge,and belief. False statements made herein are punishable as
a Class A misdemeanor pursuant to Section 210.45 of the Penal Lq*.
SIGNATURES & OFFICIAL TITLES:
Mailing Address: ....................................
J� q WJ L- Inn U6
SAS i OV9. —H AN3
q3111-1338liid
V M l i,lr'`U N1'N ?4t-\V
0 tC,)TZP— f N' t05t,I
PUTNAly1 COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVT IR.ONIMENTAL HEALTH SERVICES
LETTER OF AUftiORIZAT Oti'___...__
RE: Property of DOUCAL-5 PJ45T 1H — R0 -r1+AC*�G -
Located at TDHOJ T14 v F A�
(V p�TT>✓fl Tax Map' f))4- Block 4 Lot
Subdivision of
Subdivision Lot r f�_
Gentlemen:
Filed Map r 1 816 Date Filed
I, i1bim
This letter is to authorize 444 e fAIe,w oL—S , J�— PL
a duly licensed Professional Engineer _ or Registered Architect to apply for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater treatment and/or water supply systems
in confocmity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code. -
N CHp09,f. Very trulyoucs,
�r
State N j Zip Inol
Signed-
Mailing Address: P" t`4
State
0 U X, I i—"
zip 1 )IS 6�
Telephone: IM • 0,16- 6iO� Telephone:
Focn LA -97
j \ LAURENT ENGINEERING
ASSOCIATES, P.C.
20 Milltown Road
_._.., \ ;Brew9er,:New.York'ti10509
n M1 HARRY W. MCHOLS JR , P.E. �� (914)278 -6108 - (FAX) 278 -2658
CONSULTING SITE ENGINEERS
July 2, 1999
Mr. Robert Morris, P.E.
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS
Tommy Thurber Lane
Rapp Subdivision, Lot #2
Town of Patterson
TM #34.-4 -9
Dear Robert:
Enclosed are the following:
1. Five (5) prints of SS -2, "Proposed SSDS," dated 7 -2 -99.
2. "Short EAF," dated 7 -2 -99.
3. "Application for Approval of Plans For a Wastewater Disposal System."
4. "Construction Permit for Sewage Disposal System," dated 7 -2 -99.
`Application to Construct a Water Well," dated._ 772
6. "Design Data Sheet."
7. "Letter of Authorization," dated 7 -2 -99.
8. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only."
9. Review Fee in the amount of $300.00.
We would appreciate your review, approval and issuance of the Construction Permit at
your earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nic ols, Jr., P.E.
HWN: JM: his
99038
617.20
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORPrl
for UNLISTED ACTI- O.NS..Qnay. .....��
rt 1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
APPLICANT /SPONSOR:( 2. PROJECT NAME: iNr�IpV�L
PROJECT LOCATION:
Municipality County purN��
PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map)
ToHOI T144-bEi L)I0.4+ d 16E 900) R-oAU
PROPOSED ACTION IS:
ANON OExpansion OModification /alteration
DESCRIBE PROJECT BRIEFLY:
lia9k\1M\JAL '�a rS
AMOUNT OF LAND AFFECTED:
Initially -46, acres Ultimately A acres
WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND US =_ RZ- STRICTIONS?
,k(es ONO If No, describe briefly
WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
AResidential Olndustrial...`. OCommercial OAgricultural OPark /Forest /Open space OOther
Describe: 504(4Lfr �-p kA�L-
. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIt`.IATELY FRONI ANY OTHER GOVERN%1ENTA'-
AGENCY (FEDERAL, STATE OR LOCAL)?
JYes ItPlo If yes, list agency(s) name and permit /approvals
DOES ANY ASPECT OF THE ACTION HAVE A CURREiJTLY VALID PERMIT OR APPROVAL?
]Yes '$QNo If yes, list agency(s) name and permit /approval
AS A RESULT OF PROPOSED ACTIOi•I WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
]Yes *t o
I CERTIFY TH.aT THE li i= 0EP.1:,TlOf: PROVIDED ABOVE IS TRUE TO THE BEST DF 1.1Y KNOWLEDGE
W., 81 110 j, J(-' P6 AV5 AIAF-H'r
If the action is ill a Coastal Ar =a, t!nd you a:a A stata agency, com, -!- a
coat":: Fr' :ll t)efora pwcdedin•3 this a:SC�Snt_
I
LAURE ASSOCIATES, P.C.
MG
20 Milltown Road
-...,,
\ • r" .: Brewster, New York 10509.
(914)278 -6108 - (FAX) 278 -2658 .-
HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS
July 22, 1999
Mr. Shawn Rogan
Putnam County Health Department
1 Geneva Road
Brewster, NY 10509
RE: Individual SSTS
Rothacker
Tommy Thurber Lane, Lot #2
Town of Patterson
Dear Mr. Rogan::
In response to your review letter dated July 19, 1999, we offer the following:
1. A note regarding wetlands, etc. has been added to the plan.
2. 10' from driveway to trenches has been added to the separation distance chart.
We trust that the above adequately addresses your concerns and we request the issuance
of the construction permit at your earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nib ols Jr., P.E.
HWN: JM: his
99038
BATH r
BEDROOM 4
% DRESSING-
BEOROOM,3 WALK'
131
-0** x 10' -0' I N
CLOSET
JL
MASTER SEOROD.M
BEDROOM 2 OPEN a C 'gomw
JNTY DEPART" '
13* 0" x 15'.8-
Aos PPR OVED POP
HOUSE
<: � ouv, . ONLY
BEDIrploom c
wArl
UUNU t -LU.Uh
-- -4 7 ll,- 3 4 4 S F
KITCHEN
DINING ROOM
MORNING ROOM
tr
13'0 "• 12*.0-
F
N
OPEN
4. ABOVE t
LIVING rIOOAA
Ir.o.." Is..o..
FOYER
FIRST FLOOR
FAMILY ROOM
13' 0• • 17* 0**
4R28
.y ya
2
`ol�
9 ►�
a9,
L
a
5
to
11
I � W`
111
S
% Y