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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -4 -37 BOX 14 ro rr I fir' . ftj � Ar .� V as . 01541 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION: OF�ENYIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at CA:50 tlLLE UL� 1�0�17j Town Villa Af Owner /Applicant Name daerV ln'&Iyyikl Tax Map t5 ` Block Lot , Formerly Subdivision Name Subd. Lot # Mailing Address / f67 Zip Date Construction Permit Issued by PCHD � ;�� •c/ Separate Sewerage System built by 2EILI-1 &1t1YRUC'Tic)AJ Address /56C.14AIAl Consisting of / OV Gallon Septic Tank and e �'rci�i " xasE�c� 726V /� Other Requirements: '0 •• Cili &47-1 al 4� O , Ec L�l1,CT i c / ,172,41,rI Water Supply: Public Supply From. or: ✓ Private Supply Drilled by MJititA./ h%TT Address %D /ff Z146 " Building `Type ixI � 04: Has erosion control'beerr czimpleted? — " es Number of Bedrooms Has garbage grinder been installed? �r Address 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 r e ent of Health. Date: Certified by - P.E. L, R.A. Design F rofession Address PLIA1414 6;�IAI i1 - ® OVTC License # (09 oQovsTee,1�-I 10'1 Any person occupying premises served ywy 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 revocati m dificao*U or change is necessary. By:. Title: V/ Date: 1,013Z7 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 F ,z r,c..� .. :.e „_.,,.... ,, ..... ':r/�TwTx yTAiRLA7A7wT TA ALA T A AL A7wTw-wT.w nas — a r ;•.. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Twn illage: �� c� Marpj� Grid # Blo ck Lot(s)97 Well Owner: Name: Address: �� S Use of Well: 1- primary 2- secondary j Reside t•al 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 _ Other Casing Details Total length ft. Length below grade _ft. Diameter _7 in. Weight per foot I lb /ft. Materials: _X Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _X Cement grout _ Bentonite _ Other Drive shoe: k Yes No Liner:_ Yes e No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield 'T gprn Depth Data Measure from land surface- static (specify ft) �� During yield test(ft) {6(5- 4 G/ Depth of completed well in feet LS- 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 1-3- �t 3 } ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information (� Pump Type G-�JLD Capacity I® Depth 0ay Model Voltage 3O HP i, Tank Type)Q.20L Volume Date Well Completed -7/ Putnam County Certification No. Date of Report 70�7// Well Driller (signature) IL A _ I 1 uAt: tSxact location oI well w1tH UISMIMUS LV 4L 11,;GJt LWV VcluuuWuL iauuyuuna w v- 1, -v.-u v -... f .v •. -• - -- r a Well Driller's Narpe Signature: Address: , �.�� / /a: Date: 3 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 AUG -22 -02 10:19 AM TOWN OF PATTERSON DPL CE R FOLEY Y Puble 9148782019 P. 01 -.. , OA;ETTA -.- :MOB D;A-Pl; -X-N -, &LL3a�''._.. ,.._,v_ -,. Asaxiara Pvbl&a Ar4aleh Dfovwar Dlt`erer of Padsmi Serv!rrx DEPARTINEE iT OF HEALTH 1 Oaneva Road Browoter. Now York 10509 7tariroa,arstat iteslih (914) 279 - 6970 Fa (924) 2!3.7911 49rA t X*MG4S (9141 279 - 6139 WIC (914) 278 •66'3 Fax (914) 2711 . 6091 Carty 1494M420e2 (914) 279 •6014 ftefthaol (914) 2704092 rot (914)27!1.4648 OWNERS Navy: C e-."?T- /< eA r, � TM MAP nL vfBER: E911 ADDRESS. TOWN: _ �.�rlwoe:f o ✓ A'UMORMD TOWN OFFTCUL: (Signature) c DATE; The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a Ie, al E911 address is assigned by an authorized town official, This form is to be submitted 'with the application for a Certificate of Construction Compliance. tE911 vvines; PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES W - `CONSTR iG''ION PERMIT'FOR SEWAGE-TREATMENT- SYSTEM PERMIT # - 15-- U C) Located at B u LLCT ffo[_E 'Roa D EmownorVillage ?ftnE,(Z!5;,niJ Subdivision name CHI p LE`/ rftPE2rii�ybd. Lot # PA 6 Tax Map 3 q Block 4 Lot Date Subdivision Approved 9 -- / 2 - 9*6 Renewal y Revision Owner /Applicant Name lal2T 4 STOVE K 1 EN 0 Mailing Address 6125 C6,zA N 0E- Amount of Fee Enclosed j3c o - C) o Date of Previous Approval ` //? d Zip 33 0 9 Building Type SflJGCZ fA /yl /L�-Lot Areal No. of Bedrooms Design Flow GPD�G Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of /666 gallon septic tank and e1'32, L.F a r 2' W106 ER E-ikd Other Requirements: n. To be constructed by 7—o RG DGTEFM10eD Address Water Supply: Public Supply From Address or: ^ Private Supply Drilled by 7"it bE �Ei��R w� ri D Address G 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. 11— Signed: Address R.A. Date '616 /0 License # G 6 74(410. &W APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme t system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w n c nsidered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe i prove f discharge of domestic sanitary se a only. By; Title. �� Date: d White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 i L/TNAM =NEINEERINE,puc. ___........ r. ..._ . _ . _. _.. - nr lneers7anh Aith/tects -- - ... :.....,.__ ti.._..._,._..... .... ____.._« SEPTIC SUBMISSION FORM TO: A'20,9,6eT /�%!7`Il' /S°, P� . DATE: �• ��,• �G�?o? PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: ZZUEZI�S �11Eh1i1 60 iA i iEP ,3OIZ ENCLOSED, PLEASE FIND: u COPIES OF THE SSDS "AS- BUILT" PLAN Ll ❑ Ll Ll Ll REMARKS: CONSTRUCTION COMPLIANCE CERTIFICATE WELL LOG HEALTH DEPARTMENT FEE ($200.00) WATER ANALYSIS GUARANTEE FORMS - 3 ORIGINALS E 911 ADDRESS FORM LETTER OF EXPLANATION Ej}Ii(Tf, E�RE�fj�. Frj��ill V dlL / ' i' 1w "u a.vp� COPIES TO: _:.. . SIG 4 OLD ROUTE 6, BREWSTER, NEW YORK 10509 • (845) 279 -6789 - FAX (845) 279 -6769 • EMaiL: puteng @bestweb.net r r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 'Street Location � Owner Town ! ! Permit # P — / 5__ 4:V0 TM # j3-7 Subdivision Lot # 1 1. Sewage System Area a. STS area located as per approved plans ...:.......... - -- 3:1 barrier Lgtli. Width Avg.Dpth c. Natural soil.not stripped ....... t ........... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/ wetlands ...... ............................... II: Sewage System a. Septic tankTiz - �Ievf-]� .....1, 250 ......... other ................ b. Septic tank inst ........ ........ ............................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil.between box & trenches Junction Box roperly set ............................................. -- TZengtlpi required ...... .. �3�- Len installed ��2- 2. Distance to watercourse measured T 1a'° 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 -sur- face.-::.... 8. Size of gravel 3/4 - 1'/2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ....................... . .....:::....................... Pump or Dosed S stems Size o pump c am er ................ ............................... 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 . ............................... ... .l. ..... IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured -�" /f0 ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... I. Erosion control provided ....................... Rev. 1/97 COMMENTS e' 07!30/2002 14:09 FAX 845 2796769 PUTNAM ENGINEERING -► PITT CO HEALTH PY]TNAM COi]M DEPARTMENT OF HEALTH DIVISION OF ENVHtOle M ENTAIL HEALTH SERNgCES ATTENTION ❑ ADAM All information must be fully completed prior to any inspections being made. For: Fill 121.0-0-2..1.9.0 2 Trenches �---- PCHD Construction Permit 9 Located. L'GG 1 ( (V) Owner/Applicant Name: y 2 ► STEu�'" /l / c�'/,l $!veil �� Lot ..,. Formerly: Subdivision Name: e-' r P d Y Subdivision Lot # 10M C,-1�- Is system fill completed? ¢ S Date: 7 ��_-- Is system complete? Date: 7" &1 -a � Is system constructed as per 01 Is well drilled? Is well located as per plans? _ Are erosion control measures in Date: r , 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. 77� A,=Date. -� �- Certified by: V — Designlsro essional Address: ! ,e �t��,� G / ��S log Lie. # e-i!7i6v,1( Comments: Form FIR-99 JUL -30 -2002 TUE 14:04 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 d BRUCE R. FOLEY _:Pttblie- Wealth, Director. ,_ ._ :_,._ ..__._.._ .. ........... August 7, 2002 LORETTA MOLINARI R.N., M.S.N. "Aisociate= Public tlealth"Direc'tor Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Paul Lynch, PE Putnam Engineering 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Kiehn Bullet Hole Road, (T) Patterson TM# 34 -4 -37 Dear Mr. Lynch: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The expansion area needs an additional ten (10) feet of fill to maintain the required width. 2. .... -- Erosion control measures have not been installed below the well and house. 3. Please note that all erosion control measures must be installed prior to the start of any construction. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261, Sincerely, e). Gene D. Reed GDR:cj Environmental Health Engineering Aide d Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 August 7, 2002 Paul Lynch, PE Putnam Engineering 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Kiehn Bullet Hole Road, (T) Patterson TM# 34 -4 -37 Dear Mr. Lynch: The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: 1. Erosion control measures have not been installed below the well and house. This violation may lead to an enforcement hearing and subsequent fines. The violation is to be immediately corrected to minimiie'the number of days you are out of compliance. Please note that fines may be issued for every day the violation is not corrected. Sincerely, 40 t r4n4e Gene D. Reed Environmental Health Engineering Aide GDR: cj J, BRUCE R. FOLEY Health Director, .:. - August 7, 2002 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N . -Associate Public" Health"' Dtreclor } 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 Paul Lynch, PE Putnam Engineering 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Kiehn Bullet Hole Road, (T) Patterson TM# 34 -4 -37 Dear Mr. Lynch: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The expansion area needs an additional ten (10) feet of fill to maintain the required width. _......_.. 2. -... Erosion control measures have not been installed below the well and house. ' - 3. Please note that all erosion control - measures must be installed prior to the start of any construction. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, 0,ece_ 4�? n&7/ Gene D. Reed GDR: cj Environmental Health Engineering Aide Id' BRUCE R. —FOLEY Public Health Director .. WRETTA-=MOLINARl RX, IvLS:N Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 August 7, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Paul Lynch, PE Putnam Engineering 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Kiehn Bullet Hole Road, (T) Patterson TM# 34 -4 -37 Dear Mr. Lynch: The following items are in violation ofArticle III, Section 2C *of the Putnam County Sanitary Code: 1. Erosion control measures have not been installed below the well and house. This violation. may. lead to an enforcement hearing and subsequent fines. The violation-is to-be immediately corrected to minimize the number of days you are out of compliance. Please note that fines may be issued for every day the violation is not corrected. GDR: cj Sincerely, Gene D. Reed Environmental Health Engineering Aide r a ' SENDING CONFIRMATION DATE AUG -8 -2002 THU 13:57 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92796769 PAGES : 2/2 START TIME : AUG-08 1356 ELAPSED TIME : 0013511 MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... Dcar Mr. Lynch: The above refereaeed'acparate sewage treatment system can be baekAlled. The following comments must be corrected in the field, 1. The expansion area needs an additional too (10) feet of fill to maintain the required width. 2. Erosion control measures have not been iosta cd below the well and house. 3 -. Please note that all erosion control measures must be installed prior to the start of any construction. If you have any fiuther questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR:cj Environmental Health Engineering Aide a BRUCE R. FOLEY 4 K LORPTTA MOr -INARI RN., M.S.N. P6a& Hmah OWPra . —W, P.hlh, Health DWh- Dhrcror of Pane. Serek. DEPARTMENT OF HEALTH 1 Geeova Road Brewster. New York 10509 'a*666re l Hard' (145)27x•6120 Pu(H5)271.7921 11ar1f•x arum (t4f)27 / -6lTt "C 045)M-64576 Pa(145)276.66t5 Earl) Po1a,r[odw (145)7n -6011 Rt(14!)271.6Mt l?—h66l (115)221 -3912 ►u(665)2L.5113 ' August 7, 2002 Paul Lynch, PE Putnam Engineering - 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Mahn Bullet Hole Road, M Patterson 1MA 34 -4-37 Dcar Mr. Lynch: The above refereaeed'acparate sewage treatment system can be baekAlled. The following comments must be corrected in the field, 1. The expansion area needs an additional too (10) feet of fill to maintain the required width. 2. Erosion control measures have not been iosta cd below the well and house. 3 -. Please note that all erosion control measures must be installed prior to the start of any construction. If you have any fiuther questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR:cj Environmental Health Engineering Aide VE%NEEl INEP -A Engineers and Architects SEPTIC SUBMISSION FORM TO: d,�c�T I00RAISO +C+ DATE: 9, :V/. a`7 o'gz PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: (770 ENCLOSE] 1040=3111.4 � COPIES TO: (SpUbFanu.:001h) PLEASE FIND: _ COPIES OF THE SSDS "AS- BUILT" PLAN CONSTRUCTION COMPLIANCE CERTIFICATE WELL LOG HEALTH DEPARTMENT FEE ($200.00) WATER ANALYSIS GUARANTEE FORMS - 3 ORIGINALS E 911 ADDRESS FORM LETTER OF EXPLANATION SIGNEL 4 OLD ROUTE 6, BREWSTER, NEW YORK 10509 • (845) 279 -6789 FAX (845) 279 -6769 • EMAIL: puteng@bestweb.net NN NORTHEAST- LABORATORY OF DANBURY ` \tA ACcoq 39 MILL PLAIN ROAD DANBURY, CT 06811 CT Cert: PH -0404 , _ 203) 74&.7903: -::PAX (203)_748 -0652 - " NY Cei-t: 11471' LABS' www.NORTHEAST LABORATORIES.com LABORATORY REPORT REPORT TO: REILLY CONSTRUCTION 155 MAIN STREET BREWSTER, NY 10509 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: LAB I.D. # REPORT DATE: 250 BULLITT HOLE ROAD WATER TANK WELL NONE 08/12/2002 7:30 AM T.P. 8/12/2002 LAB #11471 & 11301 REILLY CONTRUCTION -NY 1091 08/16/2002 MAXIMUM CONTAMINANT RESULTS METHOD # LEVEL (MCL) OR STANDARD • Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml PHYSICALS: • Color (Apparent) 5 - EPA 110.2 15 • Odor ND - - 3 Units • pH 6.94 - EPA 150.1 No designated limits • Turbidity 0.27 NTUs EPA 180.1 5 NTUs CHEMISTRY: Chlorine Residual <0.05 mg/L - • Nitrite Nitrogen - - 0.39 mg/L as N EPA 354.1 • Nitrate Nitrogen <0.005 mg/L as N EPA 353.3 • Alkalinity ' 24 mg/L SM 2320B • Hardness 46 mg/L EPA 130.2 • Iron <0.03 mg/L EPA 236.1 • Manganese <0.01 mg/L EPA 243.1 • Sodium 10.3 mg/L • Lead <0.001 mg/L ml--milliliter mg/L=mdhgrams per Liter ND--none detected — Notification Level ** *Action Level 1.0 mg/L 10 mg/L No defincd limits No defined limits 0.30 mg/L 0.50 mg/L Combined limit for Iron plus Manganese = 0.50 mg/L EPA 273.1 20.0 mg/L ** EPA 239.2 0.015 mg/L * ** MCL= Maximum Contaminant Level TNTC =Too Numerous To Count COMMENTS: -All holding times (were) met. - Sample, as received, complies with all State of New York regulatory guidelines. SAMPLE, AS TESTED ABOVE: MIPOTABLE or ONOTPOTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) RESULTS BASED ON SAMPLES SUBMTED: 08/12/2002 �xj PD An Quality Control Officer Laboratory Director -NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OiTTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY DEPARTMENT-OF HEALTH . DIVISIO N OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Reilly Construction Owner or Purchaser of Building Reilly Construction Building Constructed by 155 E. Main Street, Brewster, NY 10509 Location — Street Residential Building Type 34 4 37 Tax Map Block Lot Patterson TownNillage Chipley Properties Subdivision Name Parcel B 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 it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules, and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where -the- failure to operate-properly is caused by the willful or negligent act- of-the occupant-of - the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam 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. 8 Day 8 Year 2002 Signatur 1.1-, jy Title: era ontractor (O er) — Signature Corporation Name (if corporation) Address: 155 E Main Street, Brewster State: New York Zip 10509 Cerlich Construction Corporation Name (if corporation) Address: 125 Peaceable Hill, Brewster State NY Zip 10509 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL Pe rmii # - - r........ � PCHD please print or type � ` -' ' " - Well Location: Street Address: Town/Village Tax Grid # 6uL.LC l No Or, KoA P f J+TX---'-'`G0 Map 3 y Block �( Lot(s) J 7 Well Owner: Name: Address: /v 1 t/o/2,S CEZ'-1 n1/v6 AVe. f.. uT Z F"'LA log 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 gpm # People Served . Est. of Daily Usage _ (J 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_y No Name of subdivision CHI PLE, Y P 1ZO P E, 9-116-5 Lot No. Water Well Contractor: -FO 136 DT6F fA) Of C> Address: Is Public Water Supply available to site? .................................. .........................:..... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: e JZ .ter_ E r- TtJAtJ 1- MALE Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: c616 v% Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director 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. G Date of Issue �1 ® Permit Issuing Off Date of Expiration i © Title: Permit is Non- Transf rrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 iz S To: Putnam County Health Department CC: From: Reilly Construction Date: 2/6/02 Re: Bedroom count approval Enclosed are three sets of plans for a house we will be building on Bullet Hill Road in Patterson. Please call us at W- 2794059 when they are stamped and ready for pickup. BRUCE R. FOLEY Public Health Director' _ -... v_... LORETTA MOLMARI R.N., M.S.N. -Associate Public" )health-- Direc't`or- Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Gary Tretch, P.E. Putnam Engineering 4 Old Route 6 Brewster NY 10509 Re: Proposed SSTS: Chipley Bullet Hole Road, Lot B (T) Patterson, TM# 34 -4 -37 Dear Mr. Tretch: August 22, 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. Standard notes 1 -15 have not been provided......._.. . The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, 6 Robert Morris, P.E. Senior Public Health Engineer RM:tn 4 ;I PUTNAM COUNTY DEPARTMENT OF HEALTH DWISION OF ENVIRONMENTAL HEALTH SERVICES .P __.... , _ .. LETTER OF AUTHORIZATION RE: Property of C ug,-r A sTc yr k! C H N Located at E)O L L CT t-b L6 P-cf-AO . T/V So ,J Tax Map # -64- Block 4- Loy 3-7 Subdivision of C � i ew t) wce;n e5 Subdivision Lot # e(-WWL 6 Filed Map # 1760 3 Date Filed Gentlemen: This letter is to authorize 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 Pumam 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 y' iii conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. \ Countersigned: P.E., R.A., # Mailing Address State Zip 10 5 b � Telephone: 2119 &I � q Very truly yours, Signed: rr (Owner of Property . Mailing Address: State - Zip ®� Telephone: IJTNAM NEINEERINE, PLLG Englneers and Architects SEPTIC SUBMISSION FORM TO: mo ?,K\S DATE: �. 1 PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: K. I EA (�-cjI-<("IEil-LY C HtPLEy6 BULLET kLZ 1209D T/1 � 3y y -37 ENCLOSED, PLEASE FIND: 4 `7 COPIES OF THE SSDS PLAN ❑ COPIES OF THE HOUSE PLANS CONSTRUCTION PERMIT APPLICATION (Revised) WELL PERMIT APPLICATION ❑ HEALTH DEPARTMENT FEE ($150.00) ❑ SHORT EAF ❑ DESIGN DATA FORM LETTER OF AUTHORIZATION ❑ APPLICATION FOR WASTEWATER TREATMENT (PC -97) ❑ LETTER OF EXPLANATION REMARKS: C-HfiN &c 6F l Ae-1 E COPIES TO: SIGNED: 4 Oro ROUTE 6, BREWSTER, NEW YORK 10509 • (845) 279 -6789 • FAX (845) 279 -6769 • EMAIL: puteng(d bestweb.net LYi/ iti�/ H° 1 /NyN1i11/N7W�i/N,�ilil'y1rIN1i7 W 1NV �4/ ti'►'N'vlxNVSirNlNtiti/�lilyllltil WIil Vii lH111Vti/ud�ti %NtilinilllVlil171 W °iifJilllllGfY!1/v1V vlilL`liiyi�lyii(��YH[f/1111fG; V \'11(Vt�(V 111111YV i)� PUTNAM COUNTY DEPARTMENT OF HEALTH w. DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SE MENT SYSTEM PERMIT #r /5'00 m Located at Bu- LU1=iT 1-xO -c Subdivision name Date Subdivision Approved Subd. Lot # Owner /Applicant Name (f, �A I PL—EY Town or Village rA-eg;aP-/ Tax Map 4 Block '4 Lot Renewal Revision Date of Previous Approval Mailing Address 19 A!7-019S,91\1 CpVI F 121P. S r- O- t _ a-- Zip —4 Amount of Fee Enclosed �- Building Typ Lot Area . D� 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 0 gallon septic tank and 43z L-- c--2 WXX .,Other Requirements: -. V031%I L -t- ?4b 64 oo � To be constructed by-i-z�) 51C-- iN, Address `°Hater Supply: Public Supply From Address or: mac_ Private Supply Drilled by'T .- ��,T� �/�! 1� Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the Sena *ate 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 c Signed: Address R.A. Date /1'4 D U License # LIP-744(a APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew perm' . pproved discharge of domestic sanitary sews only. By; TitleLt- U /, L-F� 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 please print or type Well Location: Street Address: Town/Village Tax Grid # Hc),X-_- eon Map34f Block Lot(s) Well Owner: Name: Address: G 1 c-4 c a/v s A a-yr2 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 Ill � gpm # People Served- , Est. of Daily Usage &eQ 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 Lot No. Water Well Contractor: -r0 F� p 7]�IN4E1D Address: Is Public Water Supply available to site? .................................. ............................... Yes NoX Name of Public Water Supply: Town/VillageZ4?T-�SoN Distance to property from nearest water main: n vw 4.. 7T4,n mV-e Proposed well location & sources of contamination to a on parate se plan. Date: 1Ab Applicant Signature: ; Li 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 wate ell driller certified by Putnam County. Date of Issue Do Permit ss ' Offic' _ Date of Expiratio a y Title: �i/ !c Permit is Non -Trans errable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 BRUCE „R... FOLEY,_.._ Public Health Director. c �` L•ORETTA ME NARl R.N., 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 TO: ' DEPARTMENT OF ENGINEERING AND DESIGN REVIEW PROJECT: DELEGATIO \T STATUS FOR\ SUBSURFACE SEWAGE TREATZiENT SYSTEM PROGRAM DELEGATED 3/ -y 3 ? --TOWN: C SE Cu PV DATE SUB'D APPROVAL: NOTICE OF COMPLETE APPLICATION DATE: -jc _ 131 _jCV � t _ BRUCE R. FOLEY Public Health DireCror DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI .R.N., M.S.N. Associate. Public Health - Director. Director of Patient Services 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 January 14, 2000 Paul M. Lynch Putnam Engineering 102 Gleneida Avenue Carmel NY 10512 Re: Chipley, Bullet Hole Road (T)Patterson, TM# .34 -3 -37 Reservoir Basin East Branch Dear Mr. Lynch: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on January 10, 2000 is complete. The Department will notify you by January 30, 2000 of its 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 of impervious surfaces, and the project applicant should contact the Department of Environmental 'R 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 Shawn Rogan ►/ SR:tn Public Health Technician PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES N DESIGN DATA SHEET - SUBSURFACE SEWAGE. TREA.TMENT.SYSTEM V. Owner L q lfLc `r Address Located at (Street) - f5W(/L� I-LI-f` c oAp Tax Map Jq Block Lot 3 r (indicate nearest'cross street) Municipality Drainage Basin'"- SOIL PERCOLATION TEST DATA Date of Pre-soaking r 7. 2 2 Date of Percolation Test Hole No. Run No. Time Start - Stop Ela se Time Min.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 1 2 2 '' 20 3 2'.3-7.3 ; 0-7 -3 a Zq - Z'S`ia 2 7_0 4 5 2 -z' 3 t� 'z-_7 2-q X-7- 7 l 3 ' Zo 4 I j. 3: G I �O 2 -2 :7",q 5 3'•-fz -9 12. '• -77- 2_4 Z �� 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 TEST PIT D DEPTH HOLE NO. 0.5' 2.0' L o ^Y01 2.5' 3.0' 3.5' mot 4.0' 4.5' C0t-0lppizT- StLTY 5.0' 5.5' ' 6.0' 6.5' ., . 7.0' 7.51 ' 1 K, 8.0' 8.5' 9 0' 9.5' 10.0' HOLE NO. HOLE NO. 3 5 l t-" 1 - EWgN7> I M 5-D. -5 r?� I 1 5l L-x"Y SANDY r i /f'RlI [. —1 fit' Ol l_... QM25,ft Pot a C-0,L-0 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered /A Deep hole observations made by:- 9",� .�a �„ Date Design Professional Name: Address: Signature. . 1� _ Design Professional's Seal ��SSIa�� i. BRUCE R. FOLEY • Public* Health Director January 21,-2000 LORETTA MOLINARI R.N., 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 Paul Lynch, PE Putnam Engineering 102 Gleneida Avenue Carmel, New York 10512 Re: Proposed SSTS - Chipley, Bullet Hole Road TM;' 34. -4 -37, (T) Patterson Dear Mr. Lynch: 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 of Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1. Neighbor notification is required for this project. 2. A minimum of 2 perc tests must be performed in each SSTS area when a split system is proposed. Please contact Gene Reed at this Department to schedule additional perc tests. . Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Very truly yours, Shawn Rogan Public Health Technician SR:cj BRUCE R. TOLEY .... _.... _ ..: _..__.. ... Public Health Director -LORET --TA !:MOL1N.,4M <R:N; M.S.N. Associate Public Health Director Director of Patient Services DEPARTIVIENg' 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 Date: TO: J— Re- Proposed SSTS: Dear: 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. s "lei UfAtJo c � ire e flit 6r '0fdpo l, Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. SR:tn sstsproposed Very truly yours, Shawn Rogan Public Health Technician Dear RE: Ple`l , (T) Reservoir Basin Date: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on %,. /0, 2a is complete. The Department will notify you by Ee± 3b -, �2o of its 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 project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 2159. Very truly yours, Shawn Rogan SR:tn Public Health Technician ws2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date I C> / 9,9 RE: Property of Located at (Town,®°CYins,- J Section aJ 4 Block + Lot Subdivision of Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize PUTNAM ENGINEERING PLLC, a duly licensed professional engineer 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 promulgated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, P.E., R.A., # Health Law, and the Putnam County Sanitary Code. 102 Gleneida Avenue, Carmel, NY 10512 Address 914 - 225 -3060 Telephone Very truly yours, S_ igned 1j' n -� Owner of Property 5-t Address Town cY D Telephon 14.16.4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL, ASSESSMENT FORM ;. For UNLISTED ACTIONS duly PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME �:q� �/J� <l�l,L' !/fir✓ � 3. PR JECT LOCATION: Municipality County /q�l 4. PRECISE LOCATION (Street address and road intersections prominent landmarks, etc., or provide maps LaA T v ^, S Tim t�LA -/�l o r� PL_A -,A4 ro S. IS PROPOSED ACTION: New ❑ Expansion ❑ Modification /alteration 6. DT ESCCRIBE PROJECT BRIEFLY: -C C-L-L t-C44 O 1\-( AI�J ESob— o- 7. AMOUNT OF 4110-4 LAND AFFECTED: ,r 4 . ! 04 Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ,ICI Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? T ILTHesidential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes CTAPlo If yes, list agency(s) and permlVapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes (p No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes XNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /sponsor Date: Signature: _7j I If the action Is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART If— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.127 If yes, coordinate the review process and use the FULL EAR ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? It No, a negative declaration may be superseded by another Involved agency. ❑ Yes ❑ No 'COULD ACTION.RESU- T-IN•ANY- ADVERSE EFFECTS ASSOCIATED WITH THE`F'OLLOWh d (Answers may be handwritten, If legible) Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or.cultural resources; or community or neighborhood,character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced.by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-05?, Explain briefly. . , C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (ro 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 occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. ❑ 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. ❑ Check this box if you have determined, based 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: Print-or Type. Name of Responsible Officer in lea Agency Signature of Responsible Officer in Lead Agency i Name of Lead Agency Date -� 2 .. is Title of Responsible Officer Signature of Preparer (11 different from responsible officer)- r u uN Aiv1 U0 U 1N `l, Y DEPARTMENT OF. HEALTH DMSION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A- WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: G t-f IF' (-- Oy � H-�� v►�,� -mot �T, ot� �� 2. Name of project: L c `{ 3. Location TN: 12Att -649 l 4. Design Professional: 5. Address: z -CW &lam Lk/C-7• 6. Drainage Basin: 7. TYpc of Project: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status check one .......................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... Exempt Unlisted .Nc:f_ /'(0 11. Name of Lead Agency J/,A 12. Is this project in an area under the control of local planning, zoning, or other - off cials-, ordinances? .... ...:........................................................................ ............ N 13. If so, have plans been submitted to such authorities? ........ ............................... tilA 14. Has preliminary approval been granted by such authorities? Date granted: /-//A 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? ....... ............................... AID 19. If yes, name of water supply Distance to water supplye''WA:t41 7%a-` 20. Is project site near a public sewage collection or treatment system? ................ �y 21. Name of sewage system Distance to sewage system 6 22. Date test holes observed t r ,qj 23. Name of Health Inspector 6.e� �?AeJ 24. Project design flow (gallons per day) ................................. ............................... Co ©tom 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... A/0 26. Has SPDES Application been submitted to local DEC office? ......................... //V /t4 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? ............................... 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, landfillin , sludge application or industrial activity? Yes/No 0 g g PP ty? ............................ 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... M—D 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 1\I 0 36. Tax Map ID Number .......................... ............................... Mapj. `/ Block V. Lot 3 ;;z 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE: All applications for review and approval of a new SSTS to. -be. located - within the NYC Watershed shall -be sertau l"ie Deoaitinent, 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 LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210,45 of t4aSmgl Law. SIGNATURES do OFFICIAL TITLES. Mailing Address- :.... ............................... a� 4� Vy J A- M 1eW4t1VrEP1q0 W rR- r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONNIE\i'AL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS .nR_FVljsWnSH�EET FOR CONSTRUCTIONi PEWNIftn' ;TREET LOCATION ' � ��s �f� /�-O` NAIME OF OW\ER Ci/LG E% EWED BY RNI, GR, AS, MB, BHS DATE ! /3 TAX TyLAP # 3 N DOCUMENTS IPERMIIT APPLICATION PC -I 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 I N YID ��� 1'1 rrml 'zT mn q SUBD SION PROVAL CHECKED PER RA FILL RE D -j' DEPTH CURT, D ' REQUIRED ST PIPES L GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATEDIO PCHD DIP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PPRCS TO BE WITNESSED O- APPROVAL SSDS ADJ. LOTS rVETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANWIJP,V1IT SAME Y N EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE -NO.OF BEDROOMS WELLS & SSDS'S W/N 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 FILL NOTES ILL CERTIFICATION NOTE EPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED Ydt 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES; TOP OF FILL— 20' TO FOUNDATION WALLS 15'WELL TO PL LETTER BULBA � ' . 100' TO WELL, 200' IN DLOD, 150' PITS 100 YP, FLOOD ELEVATION 100' TO STREAM WATERCOURSE LAKE (inc. expan) OTHER REQ'D PER.MIT(S) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER REQUIRED DETAILS ON PLANS 10' TO WATER LINE (pits -20) SEWAGE SYSTEM PLAN - (NORTH ARROW) 50' INTERMITTENT DRAINAGE. COURSE SSDS HYDRAULIC PROFILE SERVOIR, ETC. ,_150' GALLEY SYSTEMS GRAVITY FLOW ?0` CONSTRUCTION NOTES IS'MIN to CDS = >50/og- 4 0/o,25'- 3 0/*,30'- 2 0/o,35' -1 0/o,100' - <1% DESIGN DATA: PERC & DEEP RESULTS 20'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 FOOTING /GUTTER/CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES ENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS y HLOCATION OF SERVICE CONNECTION TM,.,PE/RA; NA:�IE,ADDRESS,PHONE� DATE OF DRAWNG/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET =PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS- Av / I ��J ��s ! y- e-rc� /�� L V TN-AM /1 l®lG4llE Rll Englneers and Planners January 28, 2000 Mr. Shawn Rogan Putnam County Department of Health Geneva Road Brewster, New York 10509 � D RE: Chipley Bullet Hole Road Patterson (TM #34 -4 -37) Dear Mr. Rogan: This office is in receipt of your latest comments regarding the above property and we offer the following responses: 1. The lot is from a 1986 subdivision (FM #1700B). We have added the Filed Map information to the Plan. 2. The Plan has been revised to provide one fill pad instead of the original proposal of two fill pads. Since the revised proposal does not contain a "split system ", additional field testing is not required. At this time, we would ask for your office's continued review and/or approval of the - -- - above - referenced project. Very truly yours, PUTNAM ENGINEERING, PLLC By: Ken Hurley KH:rk Enclosure cc: Robert Chipley (File L0035) 102 GLEN EIDA AVENUE, CARMEL, NEW YORK 10512 -PHONE (914)225 - 3060^ FAX (914) 225 -2955 ?r"Mafy A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner C P �yl 2- 0 Address Located at (Street) Tax Map Block Lot (indicate nearest cross street) Municipality Watershed I-j1Vpj_r__ B7z,1_j,,Vct1 SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test r t3499 . ............ ...... . ........ ........ ............ . ... ............... ...... ...... .. . . ............ . .................. ........ ............. .. ...... ......... ........................... .. ...... .. ... ........ .............. ............ ....... ....... W er:: ...... .... .. . .......... ......... ..... �G 'd .. . .... .. . ....... .. ... .......... ........ ....... ... .. ......... .... . .......... .. . . ....... ............... ...... .. .. ... ............ ..... . ............ .... . .... from�.... rogn "I" I IP tt ....... ........... H R No 'xme .. . . ...... . .. - . ................. ... .. .......... Start tart top ... .... Iuc es M 10 h /1136 - a 0 L_ 30 o - 2 1,07 — 1! 3 7 3 n 1 c20 3 a,'37 4 5 [3A 1100 2 : 0 7- '37 3 2- 4 15 5 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 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN 'TEST HOLES A'2 /Mf►T2 ,p �2 NKA 7Z�/ GX� 2 —� >- - - -DEPTH . ~ �.. 'I -�O�,ENO. _ ` HOLE NO. . oZ. HOLE SO..- G.L. 3 0.5' e , , —1,3, ` T , 1.0' a ec l' _ 1E - o 1.5 Nv s 2.0' 2.5' 3.5' 4.0' 4.5' C nM c. 5.0' s 5.5' c 6.0' S , 6.5' 7.0' Le4r 3 77.51 8.0' 62 8.5' 10.0' Indicate level at which groundwater is encountered /V D/V', I Indicate level at which mottling is observed 151 Indicate level to which water level rises after being encountered -----" Deep hole observations made by: e- L 17, i-/ , Date �&,haZz!q Design Professional Name: Address: Signature: Design Professional's Seal 5, 8'Q, W 9 V1 Q D -a 0O Q � \� lii l.scK 1V v��+rra� 1 C; pa 4- RECORD OF PHONE CONVERSATION: DATE: // rf TIME: PERSON CALLING: PHONE #: REASON' O Inspection• eps nd /o eres• SCHEDULED FIELD MEETING DATE: TIME: ROAD /STREET: //mo o Ae TOWN: a - _ TAX MAP #: SUBDIVISION: LOT #: OWNER e,^, xv / t�G�` / E3 4 7 ZA COMMENTS: SCALE 011 /10 OF AN INCH 4 5 c. ..� ._,- .._..... +_. .d... __... .. .a...- .a...vv_�. a'a..w::.. s.. .:.a-_ ...._..� .. .._.r -_. .._. ��a e3... >.: -' .-tea tnr' i...r.•.. any •:•...�...aw.. u_._:. -.. ... n..�....vv_.....o. - v..- .- .....i e: - r +- w _z�+... _ • . a s� - -- -T- r \ S 263% 37 4P/0 2 2 10 P/0 23 2 , 59 ar J' JI 4.68 AG •,, ' ' +.. 47 ' * / 3 58 x/• teasz 36 e ° M-A o ' ° •fib 2�9u "r r L: y��230 A4 zsort 283 AC. 4•, ;t` +Aii :6'''• *I 57 v r F38.TO t 3; c 39o.w 42 •►Lt* 50 36zao 46 At 31 4. •v ,. tai Hen 0 fl 14.92 AC. 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AG 1 346.2950 Is, ,� AL ® 14 Zwp32 29,a - ` ti ✓ ✓✓ .*At - = mn s 3 m4 srs.e v 1.'u A -IJ toe At a - / J s 91 i. ~ clz Tz 75.97 / 34.13 �,..• Ix C.ia / 1!x25 I� 2.47 AC. i Y % AL 3.01 AG r °'�' -, 52,.a f 21 \. �' ` •' �� \ I + m '" 3.33 AC. 694.32 R ~12 53 a rb I.S AG ' • o ' a nt• !F 6 , l.29 AC. i9TS6 a 34.1.3 4 „ °. Y L •� 266i6z 2 ti 54 \` ` 3Y 5.97 AG s1T.10r It 1 3.68' AC. r ' ` i /' 53.51 AC. CAL. 1 34.17 9.46AC. \` /•v / / AL AL I FROM PUTNAM ENGINEERING PLLC P PHONE NO. : 914 225 2955 Sep. 1 17 1999 09:10AM P1 j • �?...,� _ 'FJ! .r: ` 1 � j ... i.0 _.. ✓� i��1 }� r liG/ )/ JIFF. -'�l1_i Ls2=a bor 441, Oo �m :.o a K ,ejq �-o GeF ntt7'3a9C o» 71►76 e - - -0/7 1� 1 re -�vak `t er-c5 I <; 8 6 8/7 4,00 ?� /,/00 BRUCE �- E4LE_Y. ..- :_ ....., .._._-.. Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI. RN., ,M.S.N. Associate Public Health Director Director of Patient Services . 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 Date: T0: Re: Proposed SSTS: Dear: 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: construction of this se a disposal syste ubject to local regulations. You. shou ontact local wetlands cials in this regar If percolation t s were not tnessed represent 've of the New ty Department Environmental Protec ' n on this ot, percolation ust a witnessed by a representative of this Department. Pr 0-rolj U Grp -f � r , Upon receipt of a submission revised to reflect the above comments this a fication will be P P PP considered further. SR:tn . sstsproposed Very truly yours, Shawn Rogan Public Health Technician Shcet of - * PUTNAM-COUNT ''DEPARTMENT OF HEALTH DIVISION Or ENVIRONMENTAL il•EATLH SERVICES_ FIELD ACTIVITY DEPORT y _ e,rir�nFecuL� E T = 2 ;:Street Town State - Zip . PERSGN, 4K CHARGE �y A T1�7'i'T;,R'V'TF�x7FT1 ��e%�� 7l�!/J\ %.� � _ �• T�afP `1�'I f_B'��Q!° N a m-, 61 and te -Mt TYPE CAF FACILITY : 6 jn/�ZF rAM�G y 5e, y g3' --Sr�K t -per- FINDINGS �dE T /D�OU EEL w i A Y �TZoB[.EI�'(S - © A xl j- �¢TZou�l "t� � �-E � � YS T� M : r6 D-A wlT�cl lz_ , , c s. 2 i � _ , T MNnnR,' TRY: Signature and Title ow SIGNATRT ackn hr f 02/96 , Title. _ , - x. BRUCE R. FOLEY �.Pubhc- Health Director• : DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York .10509 LORETTA MOLINARI. R.N.,. Associate Public Health'Director y' Director of Patient Services 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 Paul M. Lynch Putnam Engineering 102 �Gleneida Avenue Carmel NY 10512 Re: Proposed SSTS: Chipley Bullet Hole Road (T) Patterson, TM# 34 -4 -37 Dear Mr. Lynch: February 3, 2000 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) Due to the presence of ledge around the septic area, this Department requires . - additional field testing- within the proposed-septic area." Contact Gene -Reed to arrange for witnessing deep test holes for this lot. Upon receipt of a submission, revised to reflect the above comments, this application will be consider further. Very truly yours, Shawn Rogan Public Health Technician SR:tn f /pJ� �TN�i`-I- M dE 9I0 E�I V�N,PLLC. Engineers and Planners r TO: 1b t---1 b 1-r- Is DATE_ PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: c-, t") _P L E Y 15(,k,L_�-T- 4cm_,c_7 �4j -_ > iW_ 9 1 W4+0 ENCLOSED, PLEASE FIND: X, JC2_ COPIES OF THE SSDS PLAN 2 COPIES OF THE HOUSE PLANS - CONSTRUCTION PERMIT APPLICATION WELL PERMIT APPLICATION - -� HEALTH DEPARTMENT FEE ($ 3�a SHORT EAF DESIGN DATA FORM LETTER OF AUTHORIZATION APPLICATION FOR WASTEWATER TREATMENT (PC -97) LETTER OF EXPLAINATION �� �:-J►L COPIES TO: SIGNED: ma- 102 GLENEIDA AVENUE, CARMEL, NEW YORK 10512 -PHONE (914)225-34-60 - FAX (914)225 -2955