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34.4-52
BOX 14
01553
ty ,Departmant of FNHtl, and .tl at4n con
iOmm" to the tlpartnient. ind'a'writtei
lei good.o0watigg condition any :`pat Of_
of the approval. of tab - CortNkato of con.
county Clwartamm"er` ' I(+�.Neh
ApPftb4EO FOR CdkiTkkilbNt ihis'sWoveLexl►iret
revocable for cause or n1 Y'tq- amines. or modNied!wlwri r
requires • now - pormit.: APtiroved for WINDOW Ol dOrnef
0
t disposal system duririp -the period
ormplience of..tl► orilim4f systern or
NI willl a instal id in ac ordanoa ��wii
slpo,A l.
- .I
ire Year{ =from tab date i u.m
MidereA Mtef/fry by tab Commissi
aanitary err
*all
mplianp",satisfactory to the CommhNOrNr of. Health *111
ssor he" or assiins by tab 0ulldiii that Bald- buildlir will
F- two (2) y w$ immediately folloirhip the data of the lav-
sy repairs thsrat 2) that the drilled well desorltied above
tab ridard les and. m7 qnT s of the Putnam
P.E. R.A.
io1R! -11160 My License No
construction of . the building, has been undertaken and is
or of Wealth. Any change or alteration of, construction
s• M only.
Tide
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 #ftmg
WELL LOCATION
Street Address Town/Village/City
-Act —Me -
Tax Grid Number
'19 — z - . 2eZ��
WELL OWNER
Name Mailing Address
sotto n , 1 V"4
UPrivate
D Public
USE OF WELL
1 - primary
2 - secondary
r![3 RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP ® ABANDONED
BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify,
® INDUSTRIAL U INSTITUTIONAL O STAND -BY
AMOUNT OF USE
YIELD SOUGHT Mi" S gpm /# PEOPLE SERVED 1 En± /EST.
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION
NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
OF DAILY USAGE __g2g gal
CE ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
t�l,.l �.-►�t�+.�.. �u,�P�.Y
WELL TYPE
DRILLED
®
DRIVEN
®DUG ®
GRAVEL.
O
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES >C NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
V, "i os,.E' L-im I Zom-L.L. Lot No. 2
WATER WELL CONTRACTOR: Name -ro fam l�eumztm_ 1e: , Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: J141 TOWN /VIL /CITY
bISTAPCL TO PROPERTY FROM NEAREST WATER MAIN:��
LOCATION SRE CH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
(ate)
PERMIT
TO CONSTRUCT A WATER WELt"�> - -° ; •. -Y:.- :_
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 requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County
Health Department.
Date of Issue: dtp,_- 19� OffietIT
1' Date of Expiration: 19 -6 Permit sluing
White Dopy: H.D. File
Permit is Non - Transferrable Yellow copy: Building Inspector
"Rev. 10/88 Pink Copy: Owner
Orange copy: Well Driller
DESIGN DATA SHEEN- SUBSUFACE SEWAGE ' DISP+0.SAL SYSTEM'.
FILL NJ.
Owner ' �J,�
�QEL�c
Less -6o3 - I
rte P�- c�so.1. 1.1i 0-151
Located at (Street)
Sec. i_.Block 2 Lot
(indicate
nearest cross street)
� w- 2
Municipality
-Watershed. �� -rg,J
901L PERWL,ATICN Tj ST
DALE ,RDWUMW-
TO BE STIED WITH APFLICATICNS .
Date of Pie- Soaking ,o • e ea
-Date of Percolation Test 10• 9 e�
HOLE
NUMBER CLACK
TIME
PERCOLATION
PE RC0i=ON . .
Run
Elapse
Depth to
Water From
Water. Level•-
No.
'Time
Ground
Surface
In Inches Soil Rate
Start Stop
Min..
' Start
St6P ''
Drop In Min/In Drop
Inches
Inches
Inches •
21
3 g 2-I 9:42
4 q :42-- Te,
IS
21
2q
3 5
2q
3 8
2 9 3g - 9 s l
21
2'1
' •Z,q, •
3 9
3 'J:51- 10118
2-1
2T
z4
3 9.
4 �p•�Q - io:4S
'
2-1
27
2q
3 9
5
2
5
Nl7TFS: ' 1.' Tests to be repeated' at same depth unhi.l .approximately equal soil rates
'rt,FR i r,prl at each vercoiation test hole. All data to' be . suhmittbd
TJE8T PIT DATA REQUIRED TO' BE SUBMITM WrM APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPM HOLE • NO. I HOLE M. 2 HOM ' N3. S..
G.L. ,
1 ° 1 oP_.�o 1 ���• .
'-ToPSCIC. �o(kagc.._
3�
4
6;
9 ° .v(. G.
10°
12'' -
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED S' , 9' 0 9' -
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFI ER BEING ENMMERED
DEER' HOLE OBSERVATIONS •MADE BY: caM ° ' DATE: r•9 z6 e8 .
DESIGN
soil Rate Used s -1 o WWI! Drop; S.D.. Usable Area-Provided- Soto to .
No. of Bedrooms q Septic Tank .Capacity i gals. Type ► Ry
Absorption Area Provided By 41AS L.F. x 24" width trench
Other .���TfZ16UTlOr.� QoY, � i,�"' .x\
Na1i1L �-°�►1 II.11 '3�gG /ATE_ � 1� . C . qigna.ttire
Address P�o�TE S2. i SEAL `r\
• �f- 1E1... 111' I�.SI� - -- �fE ^SfA��' '
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH'SERVICES
Date
Re: Property of TUoQKc� 1-�a tc
Located. at 1� c�L.l�i C Y)
(T). i�4- rTEo,.► SectionBlock__ Lot,
Subdivision of j Dti� l-ll
Subdv. Lot # �c Filed Map .# Date
Gentlemen:.
This letter is to authorize
a duly licensed.professional engineer i� or registered architect
(Indicate
to apply for a Construction Permit for a separate sewage system, to
serve the.abo.ve 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 nece4isary,papers on my behalf in
connection with this matter and to supervise.the construction of said
._. _...._..�__.....sy, sterq, or.,systems_ .in.,..conformit.y,.. with. -the - provisions -o-f-.-Article' 145- or. .......' ."..
147, Education Law, the Public Health Law, :and the Putnam.County Sani-
tary Code.
Countersigned
P.E. , R.A. , 0
Addr•e s s
Ro�n� s2 �cze -��. t�lY iostz..
(91q� WZS - Bc86
Telephone
Very truly yours,
Signed i! 4 I ,�
er of Property,
Address
r, Town
LIZ ol) 3 �Z -3.
Telephone
I
cashin associates, p.c.
design professionals
route 52
Carmel, new york 10512
(914)�25 -8088
I O ot_ > RouTE !v <::&VMAt 3
���* tJY IDSIL
a ii i ... �
DATE
JOB. NO.
ATTENTION
to . 13 i L-1- 1-lc: s
RE:
E---. TZOA
12--a-BF;
704-1
o 2 A010 . Oc5
I
WE ARE SENDING YOU "&Attached ❑ Under separate cover via the following items:
❑ Shop drawings XPrints Plans ❑ Samples ❑ Specifications
❑ Copy of letter ❑ Change order ❑
COPIES
DATE
NO.
DESCRIPTION
I
12--a-BF;
704-1
o 2 A010 . Oc5
I
LZ 8 ' �
C�of/�772.�1G•Ty /�h� Bt;M I �1'
-7- ^-T 11oo
O • 7-8 - Be
THESE ARE TRANSMITTED as checked below:
For approval ❑ Approved as submitted ❑ Resubmit
• For your use ❑ Approved as noted ❑ Submit_
❑ As requested ❑ Returned for corrections ❑ Return
• For review and comment ❑
• FOR BIDS DUE
REMARKS
copies for approval
copies for distribution
corrected prints
19 ❑ PRINTS RETURNED AFTER LOAN TO US
COPY TO:
SIGNED:I- �•�'m.L- .�wlaw
It enclosures are not as noted, kindly notify us at once.
cashin associates, p.c.
design professionals
\� route 52
Carmel, new York 10512
............ . _ . -- - (914) -_2�� =$088 _. _ ._ - • --
TO ?��`I :.puAITY �efT. oV= WMf &kZ-N
LETTER OF TRANSMITTAL
DATE
19
DATE
JOB. NO.
ATTENTION:.
-i
RE:
t2t�ls�� Sgas t,�►.I
WE ARE SENDING YOU XAttached ❑ Under separate cover via
• Shop drawings Prints Plans'
• Copy of letter ❑ Change order ❑
❑ Samples
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
-i
o •Zs
t2t�ls�� Sgas t,�►.I
THESE ARE TRANSMITTED as checked below: _.....:..:.._..... - ,._._ .. -_. _.... _.- ...___._:..... , ..._. ;_. _...,_ .__.,.� .:....
XFor approval ❑ Approved as submitted ❑ Resubmit copies for approval
• For your use ❑ Approved as noted ❑ Submit copies for distribution
• As requested ❑ Returned for corrections ❑ Return corrected prints
• For review and comment ❑
• FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS
COPY TO:
SIGNED ._ ^6y'1a., -,,a
If enclosures are not as noted, kindly notify us at once.
PETER C. ALEXANDERSON
County Executive
ENID L. CARRUTH, M.P.H.
Public Health Director
JOHN KARELL Jr., P.E.
DEPARTMENT OF HEALTH Director
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Mr. Christopher Maravelas
Cashin Associates P.C.
37 Fair Street
Carmel, NY 10512
Dear Mr. Marvelas:
January 4, 1989
Re: Proposed SSDS
Hrelic - Holmes Rd.
(T) Patterson
TM 479 -2- 11.212 -
Lot #2
Review of plans and other supporting documents submitted at this time
relative to the above captioned project has been completed. Comments
are of red as follows:
Show on plans the 10' minimum from. property line to fields.
Show on plans the 10' minimum from driveway to fields.
) Show on plans the 20' minimum from foundation to fields.
4) Show on plans the 10' minimum from septic tank to foundation.
House and fields are at same .el_e_yation. Profile doesn't
appear suff'i7d1 -i'it tb 'ma`iiifain t e mi.ni.mum slope "required
gravity system. (house may need to be set back.)
Show on plans the 15' minimum from roof and footing discharge
s� to tiles.
Fields don't appear to be parallel to contours.
Clearly cross out the details that aren't applicable.
Label adjacent properties to the South and W6st.
I have enclosed a copy of the plans with the above comments on it,
and a copy of our review sheet.
If you have any questions or comments, please contact me.
Very truly yours,
Marianne Burdick
Environmental Health Technician
MB;jr
GEPA�-U-EW CF EEAL'Ei - OP71SICN CF �N HEAL-,H -,T-.CES
-a=-- Dic�.Ei-L sys=.�.S
--7-- -i S= C--iqE7-=TCN
4 _7
'.7
of
P°_-Si Ax_ 1? cation
BY
Plans - Three sits S/-
c:n
DCS )
CE-=--Icn Data E'-- (7-
acl-a Lcc
ccr,s
Ps--c Ecle Ce-sth
TZ
CC
100 v--.-f--'Cc--; e? _v.
200 fz. r=sarva i r, etc. L_j
j:z () C":-
Ecussia Seat k Necessary (Tigi.-It .-Ict)
77- Hcu-cze &F.,ier - 1/4 "/ft- 4"0; Ty-.= pir-E
==—L
No Be--r:c-; M=-<. EEnds 45" ; /cl It
N DIETF-2-\=- SPECE--= Cy SERkRATICL
.0 to P.L. Drivewav, L----ce T-.:a-zs,To;-- q-
%
90' to FctLn(:!:-t;cn Walls
Stra=in, Wat--arc=.-Se. Lak-=
C, Fcc-'
151, to urtain,
Ll
10' to ,,ester Line (pits -20'
50,
a- 1. c
fran Four ;cn; 50' to
(la- L
Ecuse Plans - T-7..;c --------
•
4-
EF AL
A =r-va I C-:
Ty
Cam Cr, Cc's p e
R:-Q,=--E::) z1=1 cq 7
r
S=
D Cr J
L
Well Seervic- Line if c-,7=-r
Ccrstnuctticn r-=-'=)
Desian r
&
Driveiav & -Slcc=c: c2t
Perc & Deaeo H—c-i-ES Lcca--=,;
Re✓rasantazlve Cr p=*m=�- a:d
P; - ___: , - � %-- &
D E,� S_ 5NZ De t
1,1c. af Eea-,=Ls
& SS—S' .Z w/ --;.1 '2 00 ft. c' Frocczaa Sy:
& Ecurr::c
az
60 ft-
-'TT:T. 57 =.'IS
10 f -
f; I -r-oc=-s
na-i szec.
d-=rth cauczs
100 v--.-f--'Cc--; e? _v.
200 fz. r=sarva i r, etc. L_j
j:z () C":-
Ecussia Seat k Necessary (Tigi.-It .-Ict)
77- Hcu-cze &F.,ier - 1/4 "/ft- 4"0; Ty-.= pir-E
==—L
No Be--r:c-; M=-<. EEnds 45" ; /cl It
N DIETF-2-\=- SPECE--= Cy SERkRATICL
.0 to P.L. Drivewav, L----ce T-.:a-zs,To;-- q-
%
90' to FctLn(:!:-t;cn Walls
Stra=in, Wat--arc=.-Se. Lak-=
C, Fcc-'
151, to urtain,
Ll
10' to ,,ester Line (pits -20'
50,
a- 1. c
fran Four ;cn; 50' to
(la- L
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
print or type PCHD Permit # C%' �%
Well Location:
Street Address: Town/Village Tax Grid #
6'046 -T
/I./ Map
Block 7 Lot(s) .52_-
Well Owner:
Name:
Address:
U&PJr461 az�-
lz��
Use of Well:
Residential Public Supply
Air/ ond/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 OW gal.
Reason for
Replace Existing Supply
Test/Observation
Additional Supply
Drilling
New Supply (new dwelling)
Deepen Existing Well
Detailed Reason
/V&50
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 STW, -HV0G E 15 6-MfS
Lot No.
Water Well Contractor: .7"0 fF- pi"IL-ad" <<tk�)
Address:
Is Public Water Supply available to site? ..................................
...............................
Yes No
Name of Public Water Supply: kA
Town/Village
Distance to property from. nearest water main:
Proposed well location & sources of contamination to be
se p heet/plan.
Date: 2G1N _ 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-..,Aqy revision or alteration
of the approved plan requires a new permit. Well to be constructed by a wate well iller certified by Putnam
County.
Date of Issue % A 0 Permit Issuing
Date of Expiration 3110, 3 Title:
Permit is Non-Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH 1-07-
DIVISION OF ENVIRONMENTAL HEALTH SERVICES -0`0-
7
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Q�
iOwner Address
Located at (Street) Tax Map 3 Block Lot ��
(indicate nearest cross street)
Municipality Watershed M/p-oLF
Z,4 hjCg
SOIL PERCOLATION TEST DATA
Date of Pre-soaking g) Z31 Z 0 rs Date of Percolation Test
-FfiW'11
;Zo (/
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. :g I min for 1-30 min/inch, :5 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
c,
-30
/0-
1A
2
/3
3
h9,'318
3
3
/0
5
//;1:3— //;lf3
30
91V - ;ZIyf
A%
1313
9"' 3i
ga-
3
4
la"#f
30
;Z0 — �l
/7,/-
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. :g I min for 1-30 min/inch, :5 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 BOLES
'DEPTH ....- . *-" `HOLE NO.
G.L.
0.5'
1.0'
1.5'
2.0'
2.5'
13.0'
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'
HOLE NO: • a .-::.HOLE,NO: - -
Indicate level at which groundwater is encountered n ewv 5
Indicate level at which mottling is observed &a y&
Indicate level to which water level rises after being encountered
Deep hole observations made by: la; 1Z�t (�'. G, �, f, Date ;-7 J/
Design Professional Name:
Address:
Signature:
Design Professional's Seal
2i
PUTNAM COUNTY DEPARTMENT OF HEALTH
lit WiNbF ENVIRONMENtXi HEALTH SERVICES.
INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM
SECTION A. GENERAL INFORMATION
Name of Project L (T)(V) �,.¢Ty,cg-
,o,/ County T'yTi%
Site Location 5 1z,,1 -3 2
Building construction begun ^�o Extent
Is property within NYC Watershed?., ................ dyes F--] No
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. 0 Hilly 0 Rolling 0 Steep slope ffGentle slope F--J Flat .
2. Evidence of wetlands 0 Low area subject to flooding F--] Bodies of water
FIDrainage ditches F—� Rock outcrops
3. Property lines or corners evident ....................... ............................... F-� Yes
4. Do water courses exist on or adjoin the property.? .............................. Yes
5. Will these affect the design of the sewage system facilities ?............ 0 Y s
6. Do watershed regulations apply in this development ? ....................... Yes
Will extensive adin be�necess ...... !...o�:..F Yes
8. Will extensive fill be necessary for SSTS ? .................. .... ........ F--] Yes
9. Do filled areas exist within the SSTS area? ........ ............................... 0 Yes
dNo
- -No
dNo
No
�No
�No
If yes, what is the condition of the fill?
SECTION C. SOIL OBSERVATIONS
10. Appearance of soil: LJ Sand ffGravel E] Loam F--J Clay F--J Hardpan F--] Mixture
11. Observed from: F--� Borings 0 Bank cut F--J Backhoe excavations
12. Soil borings /excavations observed by 41 t J7 on L7 Z/ o
13. Depth to groundwater Al gAyE on ' -7 Loo -
14. Depth to mottling lv"16 on as
15. Are test holes representative of primary & reserve areas ...... ............................... Yes No
16. Soil percolation tests made by �cf�/.4M/�/I/l�j�/,�ET(� /yG on
17. Soil percolation tests witnessed by on 9 i z,,v
SECTION D (on back)
Form ST -1
SECTION D. DRAINAGE
18. Will proposed grading-materially alter the natural drainage in this or adjacent areas? 0 Yes EZfN o
19. Will groundwater or surface drainage require special consideration? ..................... a Yes EEfNo
20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... F] Yes ffNo
SECTION E. REMARKS
21. - If a common water supply is proposed, has an inspection been made of the
existing or proposed source and facilities? ................................ ...... .......................... 0 Yes ffNo
Inspection data
22. Do adjacent wells and/or sewage systems exist? ..................... ............................... ffY es a No
23. Additional comments r g � sip _ PJ2o1:0aT 16S
24. Site observer /inspector and title Gkwo ;E;;, 26 6p .r..0 G� N
25. Dates) of observation(s)inspection(s) .__ -._..
TEST PIT PROFIILES
Hole # Lot # _ . Hole #. Lot # Hole # Lot #
Depth to water Depth to water Depth to water
-- - Depth- to-mottlirig Depth to mottling Depth to mottling
Depth to rock/imp. Depth to rock/imp. Depth to rock/imp.
G.L. G.L. G.L.
0.5
0.5
1.0
1.0
2.0
_ _ 2.0-
3.0
3.0
4.0
4.0
5.0
5.0
6.0
6.0
7.0
7.0
8.0
8.0
9.0 9.0
10.0 10.0
0.5
1.0 -
2.0 -
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
FROM : PUTNAM ENGINEERING PLLC
BRUCE - .1 FOLEY `
Public Beoltk Director
PHONE NO.
914 225 2955
DEPARTMENT
1 Geneva
Brewster, New
OF HEALTH
Road
York 10509
FITZIM&IS
0361411-3m)XV _
Aug. 22 2000 04:44PM P1
LORir'i'TA IAOLINARI R.N., M.S.N.
Director of Patten{ Services `
ATTENTION: c ADAM STIEBELING XGENE REED y��--
All information below must be fta11Y completed prior to any scheduling. DATE: AtT(•o i
ENGINEER OR FIRM: 8M PHONE#: b7
REASON:
DEEPSX PERCS: u PUMP TEST: n
ROAD/STREET: .mss fi-70�to
TOWN: A9-f fiZ72S 0 TAX DAPS:
SUBDIVISION: ,___ ! l &C &J T F� LOW:
OWNER: �ViAle6 -W r Z t & -z'G-
YES NO
O X Proposed $STS within the drainage basin of West Branch or Boyds Corner Reservoirs.
o to( Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.
Proposed ,SSTS within 100 feet of a watercourse or a DEC wetland .
❑ Proposed SSTS design flow greater than 1000 galloaslday or SPDES Permit required
Q Proposed SSTS for a Commerical Project.
It is the responsibility of the design professional to provide the above information prior to soil testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the
response. If you answered ya to any of the questions, NYCDEP must witness the soil testing. This
Department will coordinate a mutually suitable time for field testing with the PCDOH. the Design
Professional and NYCDEP.
If a project has been determined to be Delegated based on the above response and then subsequent
information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility
of the design professional to schedule re- witnessing of the soil testing with NYCDEP.
�q
FOR COUNTY USE ONLY
DATE:. D Il 31c, c, C)
C'O�l�lE1tiTS:
'rI�1E• _ �� � � L ,t d �
BRUCE R. - FOLEY
- Public Health Director- -- -
LORETTA MOLINARI R.N., M.S.N.
' Assoccidte '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 Preschool (845) 278 -6082 Fax (845) 278 - 6648
Gary Tretch
Putnam Engineering
4 Old Route 6
Brewster NY 10509
RE: Leibell
Holmes Road, Lot #12
(T) Patterson, TM# 34 -4 -52
Reservoir Basin. .
December 14, 2000
Dear Mr. Tretch:
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee, and received by this Department on December 4, 2000 is complete. The
Department will. notify you by January 3, 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 Department 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
Letter to: Gary Tretch - December 14, 2000 - : -2- .,
Environmental Protection regarding such activities to see if Department of Environmental
Protection review and approval is required.
If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166.
Owt
Very rICA, �l�D
Robert Morris, PE
Senior Public Health Engineer
u
BRUCE R. FOLEY
Public Health Director
Ali
LORETTA MOLINARI R.N., M.S.N.
Associate _ Public .Health Director
~' - Director of Patient Services r v
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Service-, (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
Putnam Engineering
4 Old Route 6
Brewster NY 10509
November 27, 2000
6
C4¢3
RE: Application to Construct a
Subsurface Sewage Treatment'System
Leibell
Holmes Road Lot #12
(T) Patterson,�TM# 34 -4 -52
Dear Sir:
U
The Putnam County Department of Health (Department) has determined that the above referenced
application, received by the Department on October 31, 2000 is incomplete. Please be advised that
the following information is required before the Department may commence its review.
• Subdivision plat titled "Stone Hedge Estates" shows a watercourse adjacent or on the
above regarded property: This - watercourse must be shown on the plan.. _
® 'The Subdivision plat also shows a wetland area on or adjacent or on the above regard
property. This area is to be shown and designated as a unclassified Town or DEC
wetland.
• Title block is to note subdivision lot number.
• Subdivision plat notes that a curtain drain is required.
• The slope in the SSTS area is approximately 20 %. An equal distribution must be
utilized.
• Distances from the well to two property lines must be shown.
• Erosion control measures for the well have not be shown.
• Proposed contours are to be shown.
• USDA soil boundaries or soil type has not been shown.
• Basement elevation has not been provided.
• Water line from the house to the well has not been shown.
The review of your application will commence once the Department receives the requested
information and determines that the application is complete. The Department will notify you within
10 days of its receipt of the requested information as to the completeness of your application.
N —.
Ile
Letter to: Putnam Engineering - November 27, 2000 -2-
10 days of its receipt of the requested information as to the completeness of your.application. Please
be advised that to liire to submit information to the Department or to follow procedures is sufficient
grounds to deny approval, pursuant to the New York City Department of Environmental Protection
Watershed RegWlations and Putnam County Department of Health regulations.
Should you haveZazny questions or care to discuss this matter, please contact me at (845) 278 -6130
ext. 2166.'
- Very truly yours,
r'- Robert Morris, P. E.
RM:tn Senior Public Health Engineer
e%I
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JUN -1 -2005 09:53 FROM:INSITE ENGINEERING 845225971 TO:2787921
PUTNAIV)1 COUNTY DTPARTAGNT OF IMALTU
DIVISION OF XNVIRONNWJ1 'AL HEALTH SERVICRS
AITENHON ❑ JOSEPH 6P GENE
REQUST..WR FIN El T Four: rill
All .infbimation must be fully completed prior to env Trenches
inspections being made.
PCHD Construction Pemait #. �
Lomted:
PP l�nitrrtcn. —( adm4 �rnr 'i'Wl _ of
(�WllCr /A 1�C�t �T�RIe n f ' k i7s c a _Bloc! Jot
.
Formerly: 1 %11 t_ai'l x_!l Subdivision Name: roiA Is system fill oompleted? yv 9 Date: 1 1 o S'
Is system complete? :; fie s Date: I 10
system constructed as per plaw? 1
Is weli dri wd ' Ye S Daze: �1,I _
is weir lomed as per glens? V(
Are erosion coa rol measures in ace? c
... 1
I rertafy that the systems); ga listcd 'st the above premises has'beeu constntcted and X leave inspected
and., v i ed.their comp on in - acaeordence with the issued .PCHD Construction PcrrQit and
approved. plans and the standards, Rules. and Regulations of the Putnam County Deparlment of
I�eAlth.
Date:: ^a Ccr�cd by: PE K Rh
,,. .. , . �.' Ihrat� ` Profct ' al
Insite En�lneennyy;�urvey�ng &
landseape Architecture, P.C.
Address.:,, #
Carmisi, NOW York 105.1
Coimments:, g Y 1 In � 11�C�— .��.�i .-� Qa!
r S « r
R
rhp.��rn�v,�srtl iA ! U Al, r iA.�.ai .'4rw%S.4 n .. /4-u ems. QL+ Aj. 11%.SQ
For7n:FTR -99
TI IN -1 - PVIMCS wpn in, Gil TFI : P4S- P7A -79 ?1
P: 1/2
NAMF: PI ITNAM rni INTV nPPAPTMI =NT nr7 P 4
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENV1RONMENTAL IIEALT H Y SERVICES.
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # 10 4 - 01
Located at L,r es lwao - — own or Village
Subdivision name SV9614r'rj66 a—r Subd. Lot # Tax Map j4'-_ Block 4- Lot 5z-
Date Subdivision Approved 12-11016 Q Renewal V/ Revision
Owner /Applicant Name vin Cam-'" L G 16 LL� Date of Previous Approval i 3 "1 O 1
Mailing Address e6 C6K 160 1 A p► MAN VA41 C 4 ?ZM . NUML L-kj PSI -Z Zip A05 1 ?.
Amount of Fee Enclosed C400 .00
Building Type [ 1 *I, 9 Lot Area 5,1k-No- of Bedrooms 4- Design Flow GPD
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage Svstem to consist of 12�c� gallon septic tank and I L
Z i W 106 A &S�Iclk) -TV-e- k)C-i, -¢ AtJO 1, 5 (a r - 20 (j F%Lk,
Other Requirements:
To be constructed by -M &' !l,--TIAL but t-/00 Address
Water Supply: Public Supply From Address
or: V/ Private Supply Drilled by 'M 6—E Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
agparate 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
Addre;
R.A. Date PiJ5 t33W4
License # 0 6-74"
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified w n c nsider ecessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new pe prov r discharge of domestic sanitary �j$ only.
By: Title: Date: �- �- . o
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL ^
please pript octgpe : - _ - , = CHD.Permit # • . ``:. `i _
_ ... -
Well Location:
Street Address: Town/Village Tax Grid #
44bCW&S Q.e P"o P N Map 54- Block 4--- Lot(s) z, Z--
WellOwner:
Name:
Address: —%Amm Av\y 1.1*vu exyAO
V'1 KCr�
pct 66x 7601 CAO%JL- i Al 1 05 t -z-
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 5 gpm # People Served _ �– Est. of Daily Usage (DO gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
S 1 1,�6t4, C;P^t tq V`5 1 f)0.�
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 5 -Iv1 t11 6i5- EFS'l-A '-5 Lot No. j Z
Water Well Contractor: --VA (3-6- f� Address:
Is Public Water Supply available to site? .................................. ............................... Yes No
Name of Public Water Supply: WA Town/Village 03/A
Distance to property from nearest water main: j M i L45,
Proposed well location & sources of contamination to be provided on separate sheet/plan.
Date: AO 13 i q&4— 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. revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water 11 ller ified by Putnam
County.
Date of Issue Z , O Permit Iss ' Official:
Date of Expiration Title:
Permit is Non- Transfe able
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
LORETTA MOLINARI
Public Health Director
March 1, 2004
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Putnam Engineering
4 Old Route 6
Brewster, New York 10509
Dear Sir or Madam:
ROBERT J. BONDI
County Executive
Re: Proposed SSTS — Leibell
Holmes Road, Lot 12 ,
(T) Patterson, TM# 34 -4 -52
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.
Please specify on the plans if the wetland is unclassified, local or DEC. Plans state unclassified
or DEC.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
V ly yours,
Robert Morris, PE
Senior Public Health Engineer
RM:cj
LITNAM
NGINEERINE. PLLE.
- Engineers and Architects
SEPTIC SUBMISSION FORM
TO: eo6e-ej- - S
PUTNAM COUNTY HEALTH DEPARTMENT
PROJECT:
DATE: C6 . � 5, 266 4--
1
ENCLOSED, PLEASE FIND:
4- COPIES OF THE SSDS PLAN "Xlb'WAL'
❑ COPIES OF THE HOUSE PLANS
Lla CONSTRUCTION PERMIT APPLICATION
lld WELL PERMIT APPLICATIO q'-
HEALTH DEPARTMENT FEE
V
❑ SHORT EAF
❑ DESIGN DATA FORM
�ETTER OF AUTHORIZATION
❑ APPLICATION FOR WASTEWATER TREATMENT (PC -97)
❑ LETTER OF EXPLANATION
REMARKS: _ GU aolb7 �L " ui _
COPIES TO:
SIGNED-
4 Olo RouTE 6, BREWSTER, NEW YORK 10509 • (845) 279 -6789 • Fax (845) 279 -6769 • EMAIL: puteng @bestweb.net
PUTNAM'COUNTY DEPARTMENT OF HEALTI1
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of V I L-i:—:t�
Located at "A
T / V Tax Map # Block - Lot
Subdivision of
Subdivision Lot # �� b� �'t 1 4 J
Gentlemen:
This letter is to authorize �. N Mv) u�b 00�-,Yt-c cc/uc-
a 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 conformity
with the provisions of Article 145 and /or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
®� NEB 1'�
A�< ,p,¢ Very truly yours,
Countersign ,� Signed: J��y ✓/
P.E., R.A., # i (Owner of Property)
Mailing Address: - ailing Address: 0
State: Zip: (�SG State: Zip: ��eJ12-
Telephone: 2q Telephone: 2 2L2 - 4o c)
DEPARTMENT OF HEALTH
Division of Environmental Health Services
110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310
- "APPLICATION TO CONSTRUCT A '. ATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address Town/Village/City
0c.M4mS
Tax Grid Number
`19 - 2.- 11. Z,12
WELL OWNER
Name Mailing Address
r+
tlPrivate
Public
USE OF WELL
1 - primary
2- secondary
,� RESIDENTIAL O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP D ABANDONED
0 BUSINESS O FARM ❑ TEST /OBSERVATION p OTHER (specify,
0 INDUSTRIAL d INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT tA," S $pm /# PEOPLE SERVED 1 e2t /EST.
E3 REPLACE EXISTING SUPPLY O TEST /OBSERVATION
NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
OF DAILY USAGE _g22 _gal
M ADDITIONAL SUPPLY
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
� -IW,.J
WELL TYPE
WDRILLED
DRIVEN
[]DUG
GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES 'C NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
V, uJ GEt.rT Lm 1 Lot No. 2
WATER WELL CONTRACTOR: Name -t � —1��e MtnlE� Address
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
-DISTANCE *TO PROPERTY ' FROM NEAREST WATER MAIN: M1k.a
LOCATION SKE CH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET
i'
(date)
PERMIT
TO CONSTRUCT A WATER WELT;:�-
This permit to construct one water well as set forth above is granted mAder 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 requirements of the Putnam
County Health Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County
Health Department.
Date of Issue: 9� ~—�"�
Date of Expiration: 19 _` ermit ssuing
White copy: H.D. File
Permit is Non - Transferrable Yellow copy: Building Inspector
Rev. 10/88 Pink Copy: Owner
Orange copy: Well Driller
PUTNAM COUNTY DEPARTMENT OF HEALTH
XN DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1.
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # e- y -. 0 1
Located at 464eei � zs A?d)ta Town or Village 91�--axol
Subdivision name �«h 6�' ,6rSubd. Lot # Tax Map Block '!f Lot
Date Subdivision Approved
Owner /Applicant Name
Mailing Address
Renewal Revision
Date of Previous Approval
Amount of Fee Enclosed Z(-.)6 ----
Building Type LotArea,9j No. of Bedrooms -4--' Design Flow GPD
Zip
Fill Section Only Depth Volume
PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of Z�L) gallon septic tank and 571,' LF u (�
Other Requirements:
To be constructed by !Z Address
Water Supply: Public Supply From
Address
I - resent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
se ate sewage treatments sl tem described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repail th�e�e,� �"
Signed: P.E. y R.A. Date
Address - &ZZZ 0 C4 9,. License # d6
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modified whe sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
anew, perm] . A roved ischarge of domestic sanitary sews a only.
By: Title: Date: 1131 D
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
UTNAM COUNTY DEPARTMENT
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT
PCHD CONSTRUCTION PERMIT # P -q-0 L
Located at :ram ,i(( 2_ Townillagegtqz,} -,n
Owner /Applicant Name mo.h,(` h / an4 mg✓'K n� :utTax Map Li, Block tl Lot S--
Formerly y;nr_ertj I,nj"P'11 Subdivision Name A,i,+
Subd. Lot # SUM
Mailing Address T f)- jap y � ?j 5- n .-� kin a- , N Zip
Date Construction Permit Issued by PCHD ;off /.5 k)�j
Separate Sewerage System , built by -A�!ran L &ndma rk- Dosju�, Address Pa. i�oY37S- ii ot,n�� , yvy �LSb/
Consisting of /, �.� Gallon Septic Tank and 5-7 t,- L:,F 2-1
Other Requirements: C'a r LJ h n
Water Supply:
Public Supply From
Address
or: �_ Private Supply Drilled by 'R�Tr( iar }Q.Sicin �e�j1 r c,. Address /d.Sy � T- 53 C��,-„� -G � I os- 1Z
�...Building -Type �� � � ����i � E - "Has-erosion comrot been cornpletedd? 5..
Number of Bedrooms &/ Has garbage grinder been installed? NO
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Deparnent of Health.
Date: �ZII t1 Certified by
Address
P.E.X R.A.
License # &/I
3 (_� air dace Cavm�l� ry y /d51 Z
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 qnubject to modification or change when, in the judgment of the Public Health Director, such
revocatio , ifi io change is necessary.
By: Title.
Date: D
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
Aug 06 04 02:01P TOWN OF PATTERSO 845-878-2019
13FLUCE '& FOLEY
-QRB- -MCU�iAEd-
PUN., fream-D,
A=Ociata AcUk HdcljA Dirsaar
P
D J. T,
EAR MENT OF 11EALTH
I Geneva Road
Brewna. Now York' 10509
HWC4 (914)279.JI30 Fm (914) 278 -'921
.Nvri4rM S.O,-V'.C4S (914127: .6558 WIC k914,1 273 .667l PAX (914) 273 -6013
Earty luceryeztlaa (914) 273 -6014 ?rnChad (414) 1.19-6082 Fax (914) 278 -- 6449
E211 AT)TIRFSS VFRjFjCA.TT0j-4 FQjJ-:jVj
OWNERS NAME: 4/. -4 MA,? /<s
TAX MAP N*UNMER.-
E911 ADDRESS.'
TOWN-. 7 r, 0
AUTHORIZED TOWN OFFICIAL:
(Signature)
DATE -
The Putnam County Departmeat of Health will not issue. a Certificate of
Coastruction Comptiance unless the above form is completed, i.e., a legal Egli
address is assigned by an authorized town official. This form is to be submitted
-Aith the applicatiM for a Certificate of Construction Compliance.
CE9 t 11 VERX-IM, �
p.1
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Welt --Street
Address-,,
n, f age'
ax ri
Block Lo
Map t(s)
Well Owner:
Name: Addres's:
LIM
Use of Well:
1- primary
2-9econdary
Residential PU61ic Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary _ Cable percussion _2!�_ Compressed air percussion _ Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock Other
Casing Details
Total length ft.
Length below grade eft.
Diameter in.
Weight per foot Lib/ft.
Materials: � Steel Plastic Other
Joints: Welded _->-r Threaded Other
Seal: _x Cement grout Bentonite Other
Drive shoe: > Yes No ILiner:
Yes g 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 ;6 gpm
Depth Data
Well Log
If more detailed
information
descriptions or
sieve analyses
are . available,
please attach.
Measure from land surface-static (specify ft)
Depth from Surface Water
ft. ft. Bearing
During yield test(R) Depth of completed well in feet
Well Formation
Diameter(in) Description
Land Surface
Se,�& &_Jaal
6", 4 :P- If ARIA
If yield was tested
at different depths
during drilling,
list:
Date We Com I ted
Feet
Gallons Per Minute
Pump/Storage Tank Information
Pump Type Capacity Rq _:7�,
Depth ray Model
Voltage 2-30 HP J
ITank Type Volume ele-1
bv 64rrs
Putnam County Certification No. Date of Report Well Dri ler (signature)
NOTE: Exact location of well with aistances to at
,e �112 , �X�/-, � 1/,
Well Drillees Name
Signature:
[lent ninuindir's tu ut; Fluv
6° , A
White copy: liffFile; Yellow copy - Building Inspector; Pink copy -
Qk�
—A
copy - 7�el�'
Form WC-97
T
ENG /NEER /NO, SURVEY /NG &
LETTER OF TRAiVSirAITTAL -
3 Garrett Place (845) 225 -9690
Carmel, New York 10512 Fax: (845) 225 -9717
TO: Putnam County Health Department
1 Geneva Road
Brewster, NY 10509
Date: 7 -1 -05
Job No. 04139.100
Attn: Robert Morris, P.E.
Re: SSTS for American Landmark Design, LLC
260 Tammany Hall Road
TM# 34 -4 -52
WE ARE SENDING YOU ®, Enclosed ❑ Under separate cover via
❑ Shop Drawings ® Prints ❑ Plans ❑ Samples
❑ Copy of Letter ❑ Change Order ❑
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
5
7 -1 -05
AB -1
As- Built Drawing
1
7 -1 -05
CC -97
Construction Compliance
3
6 -1 -05
GS -97
Guarantee
1
6 -15 -05
Water Test Results
1
6 -30 -05
037478931 -3
$300.00 Fee
1
8-6 -04
--
E -911 Address Certification
1
6 -28 -05
WC-97
Well Completion Report
THESE ARE TRANSMITTED as checked below:
®For approval []Approved as submitted
❑ For your use ❑ Approved as noted
❑ As requested ❑Retumed for corrections
❑ For review and comment ❑
REMARKS:
COPY TO:
Iot2002.dot
❑ Resubmit
❑ Submit
❑ Return
copies for approval
copies for distribution
corrected prints
SIGNED:
Oohn Watson, P.E.
Project Engineer, Associate
IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE
PITTNAM COUNTY DEPARTMENT OF HEALTH
DI"SION..OF- ENVIRONMENTAL- EALTI --SIER ;ICES � r.: —.
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
e v�'CGn rjlkma vl,�. 1��c�Tn LL C 34.1 2--
Owner or Purchaser of Building Tax Map Block Lot
�'YlP yi CQYI h p�l� tGcv 1 �]� t1 LL .0
Building Constructed by Tow illage
Tn I (Zeot !Vl/9
Location - Street Subdivision Name
R ,PSi d &1-h'0J /V /,
Building Type Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is has been constructed as shown on the approved plan or approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition
any part of said system constructed by me which fails to operate for a period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system, except where the failure to
operate properly is caused by the willful or.negligent.4ct_of the- o=pant.of .the - building, utilizing the- ° ' - -�
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 t!� Day Year �S� Signature:
Title:
- Signature
AnUV�taf\ LCi n &ry\ cLrk, StpV�. LLt
Corporation Name (if corporation)
Address: -�>, C-.,. -pr^x1S
Corporation Name (if corporation)
Address:
State � ��; � ,y Zip 17, 6�i State
Zip
Form GS -97
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights, N.Y. 10598
245��2800`����`^
Albert H. Padovani, Director
LAB #: 9.501260 CLIENT #: 58517 NON STAT PROC PAGE: 1
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
AMERICAN LANDMARK DESl
PO BOX 375
PAWLING, NY 12564
DATE/TIME TAKEN: 06/15/05 08:30
DATE/TIME REC'D: 06/15/05 08:55
REPORT DATE: 06/22/05
PHONE: (845)-721-3826
SAMPLING SITE: 266 TAMMANY HALL ROAD, PATTERSON SAMPLE TYPE..: POTABLE
: 1ST FLOOR SINK PRESERVATIVES: NONE_
COL'D BY: RAY MAGUIRE TEMPERATURE..:
NOTES... COLlFORM METH: N/A
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
RESULT
NORMAL - RANGE
METHOD
PUTNAM CNTY
PROFILE
06/15/05
MF T. COLIF8RM
ABSENT
/100 ML
ABSENT
1008
06/16/05
LEAD (INS)
2.4
ppb
0-l5 ppb
9003
06/17/05
NITRATE NITROG
0.66
MG/L
0 - 10
9052
06y17/05
NITRITE NITROG
<0.01
MG/L
N/A
9162
06/17 /05
IRON (Fe)
O.233
MG/L
0-0.3 mg/l
9002
06/21/05
MANGANESE (Mn)
0.083
MG/L
0-0.3 mg/l
9002
06/17/05
SODIUM (Na)
6.57
MG/L
N/A
9002
06/15/05
pH
6"7
Uhl ITG
6.5-8.5
9043
06/17/05
HARDNESS,TOTAL
118
MG/L
N/A
06/17/05
ALKALINITY (AS
56.0
MG/L
N/A
9001
06/21/05
TURBIDITY (TUR
1.4
NTU
0-5 NTU
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE
WATE
(WAS
NOT) OF #
SATISFACTORY SANITARY QUALITY ACCORD
HE
NEW YORK STATE
AND EPA FEDERAL DRINKING WATER
STANDARDS, FOR
THE PARAMETERS
TESTED, AT
THE TINE OF COLLECTION.
Pb /Cu LEAD limits for p
EPA Lead & Copper
than 10% of their
than 15 ppb and a
treatment must be
potential.
.tblic schools are set at 15 ppb.
Rule for Public System--, requires that no more
distribution points have a LEAD value of more
COPPER value of 1.3 mg/L, else water
undertaken to reduce the waters corrosive
Fe/Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg/L.
Na No limits for Sodium are proscribed. Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg/L of Sodium. For those on a
moderately restricted diet, a maximum of 270 mg/L of Sodium
' YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heights, N.Y. 10598
'(914).245�280C'
Albert H. Padovani, Director
L.AB #: 9.501260 CLIENT #: 58517 NON STAT PROC PAGE: 2
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~-~~~~~~~~~~
AMERICAN LANDMARK DESI
PO BOX 375
PAWLING, NY 12.564
DATE/TIME TAKEN: 06/15/05 08:30
DATE/TIME REC'D: 06/15/05 08:55
REPORT DATE: 06/22/05
PHONE: (845)-721-3826
SAMPLING SITE: 266 TAMMANY HALL ROAD, PATTERSON SAMPLE TYPE..: POTABLE
: 1GT FLOOR SINK PRESERVATIVE'S :t NONE
COL^D BY: RAY MAGUIRE TEMPERATURE..:
NOTES...: COLlFORM METH: N/A
DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
is Suggested.
pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5.
Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESlUM
CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE
HARDNESS MAY RANGE FROM O T8 HUNDREDS OF MG/L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L
'--- -M8BERATEl.4'HAFAQ- WA'- R: 70-140 MG/L 'PEB,LIJ[ER.,..
HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L)
SUBMITTED BY:
Director
EL.AFI# 1032.3
Z V 11144 VL ,..V v l A i i -A 1 V1' ALl'IAl /liL
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION
Date: 8 J73 Joe,
7 ,� Inspected by:
Street Location ,�o�N1 E 5 - - -� /' -.Owner
:Town_: -�►�s�ri • :.. _ : -:: :.Permit.: #:�.
TM 4- 3 y, - - s' ;2- Subdivision Lot # 0
1. Sewage Svstem Area
a. STS area located as per approved plans .......... .. ................
b. Fill section - date of placement
3:1 barrier Lgth. Width . Avg.Dpth
c. Natural soil not stripped ................:
.. ...............................
d. Stone, brush, etc., greater than 15' from STS area..........
e. 100' from water course /wetlands
a.C- Septic= tarik`size =` f;000 ..... 1,250 ......... other....... �'
b. Septic'tank installed level ................ ...............................
i
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
1. All outlets at same elevation -water tested .................
2. Protected below frost ................... ...............................
3... Minimum 2 ft. Original soil between box & trenches
e. Junction Box - properly set .......... ...............................
6. Trenches
1. Length required 5 % Length installed 5_76
2. Distance to watercourse measured- t.9 d Ft..........
3. Installed according to plan ......... ::.............................
4. Slope of trench acceptable 1/16 - 1/32" /foot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface .... :..............
7. Room allowed for expansion, 100 % .........................
8. Size of gravel 3/4 - 11/2" diameter clean ............... .... :
9. Depth of gravel in trench 12" minimum .......:...........
10. Pipe ends ca pped ........ ........................... I....................
g. Pump or Dose dpSystems
1. Sized pump chamber...*...
.................. I ........................
2. Overflow tank ............................. ...............................
3. Alarm, visual/ audio ........:........... .......a.......................
4. Pump easily accessible, manhole to grade .................
5. First box baffled .......................... ...............................
6. Cyycle witnessed by H.D.estimated flow /cycle...........
M. House4u'ilding
a. house located Der approved plans'........,.„ ..............,,
IV.
b. liistance rrom biz) area measurea -;,5-1 U ............ r
c. Casing 18" above grade ............ ...d,... yob
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...- ..Curtainndraint,outfall:pro ected " &.duto-existwatereou
g. -tooting aratns cuscnarge away from
h. Surface water protection adequate..
i. Erosion control provided ................
Rev. 12/02
r/.
MINE
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Film
AM
WAVE
/ANNON
Mm►
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MINE
AUG -2 -2004 14:58 FROM:INSITE ENGINEERING 8452259717 TO:2787921 P:1/1
PX3')r.'NAM COUNW AEPARTM ENT OF FEALTIE1 y
DIVISION OF ENVMONMENTAL HEALTH SERVICES
ti
ATTENTION . 0 ADAM
1094 i .;yl.► .� !►
All information must be fully completed prior to any
inspections being made.
For: Fill
Trenches
PCHD Construction Permit # r g
Located; lZr?Q�_.�rQ�, �r 1-h it am4 T 1'L P n
Owner /Applicant Name :. -.wo lrsn -,WA-Block �._ , Lot
'Formerly: Viac )l L' 6, tl, Subdivision Name: Ij&— ,.
Subdivision. Tot t"r
Is system fill completed? �P,S Date: 617-10H.
Is system complete? YPS Date: B Z�Qy
Is system constructed as per plans?
Is well drilled? nl o Date: N (A
Is well located as per plans? ivJA-
Are erosion control measures in place?
I certify that the system(s), as listed, at the above premises bas 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
Hcaltb.
Date: 1912-k q - -- .., -- certified by: PE �� RA ... ........ �......_...
Insite Enginearing, Surveying Desi Professi
Landscape Architecture, PC.
Address: 3 Garrett Place
Carmel, Ndw ork 10512-.:
Comments:
Form. FIR 99
AUG -2 -2004 MON 15:01 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1
LORETTA
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 16509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
August 9, 2004
Jeffrey Contelmo
Insite Engineering
3 Garrett Place
Carmel, New York 10512
Dear Mr. Contelmo:
S
`RMERT -1 ' BONDI
County Executive
Re: Field Inspection — Leibell
Holmes Road, Town of Patterson
Lot # 12, TM# 34.4-52
The above referenced separate sewage treatment system can be •backfilled. The following
comments must be addressed.
1. Pipe connection from the house to the septic tank has not been completed.
2. An inspection of the well must be completed by this Department upon
completion of construction. _ ._ _.. .. .
3. A bedroom count must be performed by this Department upon further
completion of construction.
4. The curtain drain and footing drain outlets must be relocated outside the
reserved area along Holmes Road.
5. Stand pipes need to be installed at both ends of the curtain drain, five feet to
each'side.
If you have any further questions, please contact me at 845- 278 -6130, ext. 2261.
Sincerely,
Gene D. Reed
Sr. Environmental Health Engineering Aide
GDR:cj
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORET:TA MOLINARI, RN, MSN
Associate Commissioner of,Health
June 7, 2005
Insite Engineering
Jeffrey Contelmo
3 Garrett Place
Carmel, NY 10512
Dear Mr. Contelmo:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Re: Field Inspection — Leibell
Holmes Road, (T) Patterson
Lot #12, T.M. #34. -4 -52
ROBERT J. BONDI
County Executive
A re- inspection at the above referenced lot has been completed and found to be in
compliance with the approved plans. There are no further comments to be addressed at
this time.
'If you have aiiy f ifher questions, please contact meat (845) 278 -6130, ext. 2261. "
GDR: cw
Sincerely,
Gene D. Reed
Sr. Environmental Health, Engineering Aide
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
-- BRUCE..R.. TOLE
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road .
Brewster, New York 10509
LORETTt�:...Jy1OLINARI R:N, M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845) 278 -,6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
December 14, 2000
Gary Tretch
Putnam Engineering
4 Old Route 6
Brewster NY 10509
Re: Proposed SSTS: Leibell
Holmes Road, Lot 912
(T) Paterson, TM# 34 -4 -52
Dear Tretch:
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-o €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) SSTS hydraulic profile has not been shown.
2) All proposed contour line elevations are to be noted.
3) The subdivision plat also shows a wetland area on or adjacent or on the above regard
property. This area is to be shown and designated as either unclassified, Town or
DEC wetland.
Upon receipt of a submission, revised to reflect, the above comments, this, application will be
considered further.
RM:tn
Verylly yours
Robert Morris, P.E.
Senior Public Health Engineer
'All
BRUCE R, FOLEY -- w ..... _ __
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 (845) 278 , 6130 Fax (845) 278 - 7921
Nursing Service; (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648
November 27, 2000
Putnam Engineering
4 Old Route 6
Brewster NY 10509
RE: Application to Construct a
Subsurface Sewage Treatment System
Leibell
Holmes Road, Lot #12
(T) Patterson, TM# 34 -4 -52
Dear Sir:
The Putnam County Department of Health (Department) has determined that the above referenced
application, received by the Department on October 31, 2000 is incomplete. Please be advised that
the following information is required before the Department may commence its review. -
® -Subdivision plat titled "Stone Hedge Estates" shows a watercourse adjacent -or on the T ^�
above regarded property. This watercourse must be shown on the plan.
The Subdylsio p
ri lat also shows a wetland area on or adjacent or on the abode regard
_ _.__,J.., _ _w _ h
propertyThls,area rs °to be °shownand designated as unclasslfiedTown gr DECt
Fwetland
Title block is to note subdivision lot number.
Subdivision plat notes that a curtain drain is required.
The slope in the SSTS area is approximately 20%. An equal distribution must be
utilized.
® Distances from the well to two property lines must be shown.
Erosion control measures for the well have not be shown.
Proposed contours are to be shown.
USDA soil boundaries or soil type has not been shown.
Basement elevation has not been provided.
Water line from the house to the well has not been shown.
The review of your application will commence once the Department receives the requested
information and determines that the application is complete. The Department will notify you within
10 days of its receipt of the requested information as to the completeness of your application.
—.-Utter to: Putnam Engineering. - November 27, 2000 � -2-
10 days of its receipt of the requested information as to the completeness of your application. Please
be advised that failure to submit information to the Department or to follow procedures is sufficient
grounds to deny approval, pursuant to the New York City Department of Environmental Protection
Watershed Regulations and Putnam County Department of Health regulations.
Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130
ext. 2166.
RM:tn
Very truly yours,
r
Robert Morris, P. E.
Senior Public Health Engineer
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
-; ._ �" _ �• INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTiO"E-AMIi':� - -: - -
NAIAE OF OWNER:
TREET LOCATION:
REVIEWED BY: RM, GR, AS, SRDATE:
TAX MAP #: (CONFIIZNIED)
N DOCUMENTS
(REQUIRED DETAILS ON PLANS CONT'D)
�PER141TT APPLICATION
HOUSE SEWER -' /a" FT. 4 "0'; TYPE PIPE CAST IRON
_)WELL PERMIT OR PWS LETTER
�NO BENDS; MAX BENDS 450 W /CLEANOUT
CPC -97
RENEWALS
_)LETTER OF AUTHORIZATION
OTE (NO CHANGE)
DATA SHEET (DDS)
FILL SYSTEMS
_)DESIGN
CORPORATE RESOLUTION
10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
_JSHORT EAF
FILL SPECS/ FILL NOTES 1 -5
_JPLANS -THREE SETS
(_) FILL PROFILE & DIMENSIONS
HOUSE PLANS - TWO SETS
L,FILL IN EXPANSION AREA
_JVARLANCE REQUEST
FILL GREATER THAN2 FEET
SUBDIVISION
CLAY BARRIER
LEGAL SUBDIVISION
FILL CERTIFICATION NOTE
_)SUBDIVISION APPROVAL CHECKED`
ERC RATE �" /
VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS
lu"I DEPTH GAUGES
FILL REQUIRED DEPTH (
SEPA RATION DISTANCE FROM TOE OF SLOPE
CURTAIN DRAIN REQUIRED
TRENCGENERAL
LF TRENCH PROVIDED 60FT MAX.
LOCATED IN NYC WATERSHED
PARALLEL TO CONTOURS
PLANS SUBMITTED TO DEP
100% EXPANSION PROVIDED
$C—JGEOTEXTILE
DELEGATED TO PCHD
DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL
--) DEP APPROVAL, IF REQ'D
COVER
DEEP TEST HOLES OBSERVED
SEPARATION DISTANCES ON PLAN - FROM SSTS
_)PERCS TO BE WITNESSED
L� 10' TO P.L. DRIVEWAY, LARGE TREE_ S, TOP OF FILL
SEX- APPROVAL SSDS ADJ, LOTS
20' TO FOUNDATION WALLS
/,WETLANDS (TOWNIDEC PERMIT REQ'D ?)
L /' 100' TO WELL, 200' IN DLOD, 150' TO PITS
,DATA ON DDS PLANS &PERMIT SAME
(`J) 100' TO STREAM, WATERCOURSE, LAKE (inc. expan)
Z)PRE 1969 NEIGHBOR NOTIFICATION
�50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
�LETTERBI/ZBA
(� 'TO WATER LINE (pits --20')
100 YR. FLOOD ELEVATION W/I200'
0' INTERMITTENT DRAINAGE COURSE
i—DSOIL TESTING LOTS >10 YEARS OLD
W200'/500'RESERVOK 150' GALLEY SYSTEMS
ETC.
REQUIRED DETAILS ON PLANS
_
MIN TO LEDGE OUTCROP
SEWAGE SYSTEM PLAN - (NORTH ARROW)
_`0'
SEPTIC TANK
�SSDS HYDRAULIC PROFILE
10' FROM FOUNDATION; 50' TO WELL
GRAVITY FLOW
WELL
)CONSTRUCTION NOTES 1 -15
DI TO PROPERTY LINES
DESIGN DATA: PERC & DEEP RESULTS
t )( OF SERVICE CONNECTION
)2' CONTOURS EXISTING & PROPOSED
77DRIVEWAY & SLOPES, CUT
FOOTING /GUTTER/CURTAIN DRAINS
USDA SOIL TYPE BOUNDARIES.
,ZjTITLE BLOCK; OWNERS NAME ADDRESS
TM #, P LRA; -N E, ADDRESS, PHONE#
AKTE OF DRAWN EVISION
)DATiI1VI REFERENC
L—i C �'ERCOURSES, PONDS
TLANDS WITHIN 200' OF P.L.
( OPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS
CWELLS & SSDS'S WAN 200' OF SSTS
PROPERTY METES & BOUNDS
(EROSION CONTROL FOR HOUSE, WELL &
SSTS, EROSION CONTROL NOTE
COMMENTS:
(REVSHEET)09/01/00
U(_JMIN 15' TO PROPERTY LINE
SLOPE
(--)(__) PE IN SSTS AREA (520 %)
(_) EGRADED TO 15 %, IF REQUIRED
DOSE/PUMP SYSTEMS
PUMP NOTES
DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED
DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
PIT AND D -BOX SHOWN & DETAILED
1 DAY STORAGE ABOVE ALARM
I/ CURTAIN DRAIN
STANDPIPES, 5' BOTH SIDES, DETAIL
15' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % -<I%
20' MIN to CD DISCHARGE /100' with 182 cons day discharge
10' MIN to NON - PERFORATED PIPE
I acknowledge'ieceipt of this report = SIGNATURE:
02/96 Title:
Date:
TO:
RE:
(T) i
Reservoir Basin AN,t 6 -m" -
Dear
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee, and received by this Department on MV /i - Z is complete. The
Department will notify you by ;Ood 9'� 97&zra of its determination.
Z7 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
offi6e' )Mth -M ch you filed't`he 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
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 meat (914) 278 -6130 ext. 2159.
Very truly yours,
Shawn Rogan
SR:tn Public Health Technician
ws2
PUTNAM COUNTY DEPARTINIENT OF HEALTH
DMSION OF ENVIRONINIE TAL HEALTH
SUPPLY & SUBSURFACE SENV?:GE': TREATMENT' °SY - STEMS.: ; s _> •: �.� -. ::- - __�.
REVIEW SHEET FOR CONSTRUCTION PERMIT
NAME OF OWNER: 1�-r Q STREET LOCATION: &4,M ES t bb"
REVIEWED BY: R� L OR, AS, ATE: 4 D `TAX MAP -: (CONFIRIAED)
DOCUMENTS
( JC_JPERMTf APPLICATION
f/-JWELL PERMIT ORPWS LETTER
(ULJPC -97
( )(—)LETTER OF AUTHORIZATION
()L )DESIGN DATA SHEET (DDS)
LJ(-[)CORPORATE RESOLUTION
(vUSHORT EAF
( ) (_)PLANS -THREE SETS
U)UHOUSE PLANS - TWO SETS
(_JC_6VARIANCE REQUEST
SUBDIVISION
(_/ ( _}LEGAL SUBDIVISION
C-:�)C-_)SUBDIVISION APPROVAL CHECKED
(j)L)PERC RATE ` ((✓
UUFILLREQUIRED t' DEPTH
L )L )CURTAIN DRAIN REQUIRED
GENERAL
CI)(__)LOCATED IN NYC WATERSHED
(ZjUPLANS SUBMITTED TO DEP
(_)(_JDELEGATED TO PCHD
(_)LJDEP APPROVAL, IF REQ'D
C_JUDEEP TEST HOLES OBSERVED
C___)UPERCS TO BE WT-NESSED
(_)L_)EX- APPROVAL SSDS ADJ, LOTS
UC__)WETLANDS (TOWN/DEC PERMIT REQ'D ?)
UC. JDATA ON DDS PLANS & PERNUT SAME
--- •UUPRE 1969 NEIGHBOR•NOTIFICATION -
_
U(___)100 YR. FLOOD ELEVATION W/I200'
UUSOIL TESTING LOTS >10 YEARS OLD
REQUIRED DETAILS ON PLANS
LJLJSEWAGE SYSTEM PLAN - (NORTH ARROW)
(__)LJSSDS HYDRAULIC PROFILE
LJ(_)GRAVTTY FLOW
(_)L,CONSTRUCTION NOTES 1 -15
(_J(__)DESIGN DATA: PERC & DEEP RESULTS
C_)(__)2' CONTOURS EX15MG & PROPOSED .
L-)(—)DRIVEWAY & SLOPES, CUT
(_)( JFOOTING /GUTTER/CURTAIN DRAINS
( —J( _JUSDA SOIL TYPE BOUNDARIES
(_JL,TTTLE BLOCK; OWNERS NAME ADDRESS
TM#, PE/RA; NAME, ADDRESS, PHONE#
L)( _JDATE OF DRAWINGIREVISION
( _J( _)DATUM REFERENCE
LJ(__JLOCATION OF WATERCOURSES, PONDS
LAKES,WETLANDS WITHIN 200' OF P.L.
LJ( —JPROPOSED FINISH FLOOR AND
BASEMENT ELEVATIONS
(—)(__)WELLS & SSDS'S WAIN 200' OF SSTS
( )(_JPROPERTY METES & BOUNDS
COMMENTS:
Y N (REQUIRED DETAILS ON PLANS CONT'D)
U(_JHOUSE SEWER -/I' FT. 4 "0'; TYPE PIPE CAST IRON
C)(_ _)N 0 BENS; MAX BENDS 450 W /CLEANOUT
RENEWALS
LJL)STTE NOTE (NO CHANGE)
FILL SYSTEMS
_J(___)10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
LJ(_)FILL SPECS/ FILL NOTES 1.5
UUFILL PROFILE & DIMENSIONS
C_)(_JFILL Lti EXPANSION AREA
FILL GREATER TWA _N 2 FEET
L_)C_j CLAY BARRIER
LJLJFILL CERTIFICATION NOTE
L)LJDEPTH GAUGES
LJL VOL. ON PLAN FORRO.B., UNCLASSIFIED & RVIPERVIOUS
LJ(_)SEPARATION DISTANCE FROM TOE OF SLOPE
TR NC
GULF TRENCH PROVIDED 60FT MAX.
(__)(__)PARALLEL TO CONTOURS
( _)U100% EXPANSION PROVIDED.
(_)UDETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL
C_)UGEOTEXTILE COVER
SEPARATION DISTANCES ON PLAN - FROM SSTS
LJL )10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL
C_)U20' TO FOUNDATION WALLS
(_)(__)100' TO WELL, 200' L 1 DLOD,150' TO PITS
(__)(_J100' TO STREAI'I, WATERCOURSE, LAKE (Inc. eapan)
-
C—)(U10' TO WATER LINE (pits - 20')
L _)L.)50' INTERMITTENT DRAINAGE COURSE
( _)(_J2007500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS
(_JL.)10' MLN TO LEDGE OUTCROP
SEPTIC TANK
LJ(__)10' FROM FOUNDATION; 50' TO WELL
WELL
LJLJDIivIENSIONS TO PROPERTY LINES
C_JULOCATION OF SERVICE CONNECTION
L,L�MIN 15' TO PROPERTY LINE
SLOPE
(_)L )SLOPE IN SSTS AREA (520 %)
UC_)REGRADED TO 15 %, IF REQUIRED
DOSE/PUMP SYSTEMS
UUPU-,1'IP NOTES
(_J( jDOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED
LJLJDETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
LJLJPTT AND D -BOX SHOWN & DETAILED
LJL)1 DAY STORAGE ABOVE ALARM
CURTAIN DRAIN
L j(_)STANDPIPES, 5' BOTH SIDES, DETAIL
(_ (_JI5' MIN to CDS = >5 %, 20'4%,25'-3%,35'-l%, 100%-<l%
(____)L )20' MIN to CD DISCHARGE 1100' with 182 cons day discharge
( )( )10' b1IN to NON - PERFORATED PIPE •
P UTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
a
- DESIGN DATA SHEET -SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner /7Cr L Address AW , �2�'�o�✓;_N-1
Located at (Street) Tax Map Block Lot 5 Z.
(indicate nearest cross street)
Municipality 77Z-0LC;:W- Drainage Basin IY112,.0G&� 6
SOIL PERCOLATION TEST DATA
Date of Pre- soaking %1 L Date of Percolation Test 712AZ . .
Hole No.
Run No.
Time
-Start - Stop
Ela se Time
(pMin.)
Depth to Water
rom Ground
Surface (Inches)
Start Stop
Water
Level
Dro In
IngI
Percolation
Rate
Min/Inch
a'�
_.
5
4*13 11-'Y 3
o � %
o�/f/
1--3
C5/
!l a3
2
ad-I
Z.
a._.. /6 .
3
/o: /i /d:�/z
3a
26 �/ 3
/3�
�7
4
/o.. ,/
��
�d /3
��
5
1
2
.3
4
5
NUTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. .(i.e. -< 1 min for 1 -30 min/inch, _< 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
DESCRIPTION OF SOILS ENCOUNTERED IN TEST BOLES
DEPTH
HOLE NO. HOLE NO. � HOLE NO.
G.L.
1.0'
1.5'
2.0'
Ilk
2.5'r
3.0'
fC
3.5'
4.0'
4.5'
l�ivl
5.0'
5.5
6.5'
7.0'
7.5'
8.0'
8.5'
9.0'
10.0'-
Indicate level at which groundwater is encountered JOe�I�
Indicate level at which mottling is observed A/C/ A116f
Indicate level to which water level rises after being encountered dlb .
Deep hole observations made by: Date
Design Professional Name:
Address: T e-)69 AOV/2��-
Si
Design Professional's Seal
HAQ
OF hb\
PUTNAM COUNTY DEPARTMENT OF.HEALT11
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
w..,APPLICATION FOR APPROVAL OF PLANS FOR
A WASTEWATER TREATMENT SYSTEM--=
I. -Name and address of applicant: VlAff8W 7—
2. Name of project: f I C T" G� /�v�'ZC_ 3. Location TN:.
4...:.Design
Professional:
40?I Al 1 �TJ&Aja?z iy7r'S. Address:
6L�
6.
Drainage Basin:
7.
8.
9.
10.
11.
Type of Project:
_ Private/Residential Food Service
Apartments Institutional
Office Building Realty Subdivision
Commercial
Mobile Home Park
Other (specify)
Is this project subject to State Environmental Quality Review (SEQR)?
TYPe Status (check one) :...................... ............................... Type I Exempt
Type II Unlisted
Is a'Draft Environmental Impact Statement (DEIS) required?
Has DEIS been completed and found acceptable by Lead Agency? ...............
Name of Lead Agency
12. Is this project in an area -under the control of local planning, zoning, or other
officials, ordinances? .......... ............................................ ............................... �
13. If so, have plans been submitted to such authorities? ........ ............................... 1A10
14. Has preliminary approval been granted by such authorities? Date granted: ICI
15. Type of Sewage Treatment System Discharge ................. surface water Xgroundwater
16. If surface-water discharge, what is the stream class designation? .................... /J4
17. Waters index number ( surface) ........................................... ............................... N4
18. Is project located near a public water supply system? ....... ............................... /Vy
19. If yes, name of water supply. /VA Distance'to water supply NA
20. Is project site near a public sewage collection or treatment system? ................ /VD
21. Name of sewage system, Distance to--sewage system A4
22. Date test holes observed UV 23. Name of Health Inspector 6we ��G/
24. Project design flow (gallons per day) ..... ............................... o
25. . Is State - Pollutant Discharge Elimination System (SPDES) Permit required ?...
1A unz. cpT)Fe Annlication been submitted to local DEC office? ......................... /1�
27. 1s any portion of ttus project located wittnn a designated Town or Mate wetianu., fy v
28. Wetlands ID Number ............................. ....................... ...............................
29. Is Wetlands Permit required? ............................................... ............................... v
I3as
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,
landflling, sludge application or industrial activity? ............................ Yes/Noy
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 gw
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? ................................ ...............................
35. Are any sewage treatment areas in excess of 15% slope? . ...............................
3b. Tax Map ID Number .......................... ............................... Map �- Block Lot 5.2
37. Approved plans are to be returned to :.... Applicant _ 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 -tray 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 Sectign 210. 1, ,pf t�!p Penal Law.
SIGNATURES & OFFICIAL TITLES.
Mailing Address: ....................................
14.16 -4 (2187) —Text 12
PROJECT I.D. NUMBER 617.21 - SEGZR
u Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
_ -
For.
UAI�LSTEQA
r PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR
2. PROJECT NAME
3. PROJECT LOCATION:
Municipality iT County
4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map)
C i S /!JE �/`DC�NIE.S A17* A)PWOYl/",* .4-�?
5. IS PROP SED ACTION:
ew ❑ Expansion ❑ Modification /alteration
6. 0 CRIBE PROJECT BRIEFLY:
A ZZ 7 Arira 156
010"
�✓ e.'
7. AMOUNT OF LAND AFFECTED:
Initially S acres Ultimately acres
8. ILL ROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
AI�Yes ❑ No If No, describe briefly -
9. VV TA,T IS PRESENT LAND USE IN VICINITY OF PROJECT?
(,24esidential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park1Fore3VOpen space ❑ Other
Dese lr be:
'•10:-
- DOES -ACTiOWiMLVE-A- PEA MIT `APPROVAL, OR FUNDING, N01N'O9 ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE 0 LOCAL►?
Yes •❑ No If yes,J list agency(s) and permlvapprovals
Y
11. DOES ANY ASP5CT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
(] Yes o If yes, list agency name end permit/approval
U. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes o
I CERTIFY THAT.THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant /sponsor name: 'P�� �L�C-- Date:%
Signature:
U
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 II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF.
❑ Yes ❑ No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration
may be superseded by another Involved agency.
❑ Yes. _. ❑ No. ;
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:'(AnsWers may 'belhaodwrltfen; 161eglble► ; -J -=
C1. 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; agricullural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: I
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;
C6. Long term, short term, cumulative, or other effects not Identified in CI-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 QE, 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 (q 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 andlor 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:
Name of Lead Agency
Print or Type Name of Responsible Officer in kead Agency Tiffie—of Title-of Responsibiq Officer
Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer)
Date
6
PUTNAM COUNTY DEPARTMENT OF HEALTH
• DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of
�C6-W T
Located at 4vw-
T/V 12M7234sdAi411 Tax Map # k_9 Block Lot
Subdivision of cTZ�I�E� /<s�•��'
Subdivision Lot # lc�'— Filed Map # Date Filed l /6
Gentlemen:
This letter is to authorize
71
a duly licensed Professional Engineer or Regigiered Architect to apply for the required
wastewater treatment and/or water supply permits) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health 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
-- -
in-conformity-with e,: , r risions- of -krticle�- 145- andlor- =1.47 -of the - Education. Law,. the. Public - Health
P �i
Law, and the xnarn�Co�iinty`'�S`an•tary Code.
eI Ci i y� '?f
Very truly yours, ,
Countersign ;'tai; Signed:
P•E•, R•A•, # `- (Owner of Property)
Mailing Address
/v 050
State /ke/ Zip
Telephone: 2Z 22 %
Mailing Address: �Q ,609 7 & O
State Zip /o 571 Z
Telephone:
gUUT—NAM
NGlii/EEf,�INGo Pric.
Englneers and Architects
SEPTIC SUBMISSION FORM
TO: Cl 7 S � DATE: . ro
PUTNAM COUNTY HEALTH D PARTMENT
PROJECT:
ENCLOSED, PLEASE FIND:
5- COPIES OF THE SSDS PLAN
COPIES OF THE HOUSE PLANS .
CONSTRUCTION PERMIT APPLICATION (Revised).
WELL PERMIT APPLICATION
goo
HEALTH: DEPARTMENT FEE ($}xM )
a._ ,... _ .._� ._....._. _� --
••SHORT "EAF .. _... _.......... _.._ ._.. _...:_ :.._�.^_....__. _ ..____....... _ .... .: :.._, . > _.._
DESIGN DATA FORM
LETTER OF AUTHORIZATION
APPLICATION FOR WASTEWATER TREATMENT (PC -97)
®
LETTER OF EXPLANATION
REMARKS:
COPIES TO:
SIGNED:
4 Oro RouTE 6, BREWSTER, NEW YORK 10509 - (845) 279 -6789 - FAX (845) 279 -6769 - EMAIL: puteng @bestweb.net
501951
34, l
` UTNAM COUNTY - DE PART MENOF HEALTH
:"Dwision of Environmen[a/ Health" Services, Carmel k Y 10512 p�
g
'LL SECT-19P-ONLY'
CONSTRUCTION; PERMIT FOR':SEWAGE DISPOSAL SYSTEM Patterson,
•. r . �. ..._ _Y ... z. :. Vivagen . -..1._ _.
Town or �. G
Located at N01meS� -,Road Tax Map Block
Stone kled a Estates, Lot #.12, Ff1ed Ma X1786 11.212 S01951 11 subdivision.' 9 p Lot Job
Owner Bonny ban �d1 grotFiers Address 1.37E Main St:
Frame._` 3. "250 A. Brewster, NY 1.0509
Building Type CLot Arrea CA
Number of Bedrooms Three `Design 'Flow 600 .Gal . Total Habitable Space 1259 Square Feet
Separate Sewerage System to consist. of 1000 Gal. Septic Tank and 300 L.F. X 2411',Wtdth trench
Address `
To be constructed by _
Water Supply: Public Supply From
Private Supply to be drilled by
Address
Other Requirements
R -o -B Bill .:SectlOo 1 211 Deep x 4160`r (130 Yds.)' & 120' �of 1'8 wtde`60" Deep
Cu
rtafn Drain
I represent that 1 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 thereto and in' accordance with the. standards, rules and. regula ions o e u nam
County Department of Health, 'and that on completion the►eof a'.Cer,tificate .of. Construct ion'Corripliance" satisfactory to the Commissioner of. Health 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 disposal .system during the :period of two (2j years immediately following thedate 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 'i accordance with' the standards, rules and regulates of the Putnam
County Department of Health;
Date 17 Decgober 1980 Sid /V/- x P.E ` R.A.
Address
R. D.. 9 fat � St' C NY` 10512 License No. 29206
APPROVED`FOR CONSTRUCTION: This approval expires.one year 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 missioner of Health. Any change or alteration of construction
requires a new permit. Approved for disposal domestic wage;. d /or ate water, supply only.
Date �_�' �i By Title
m
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
�i
Town/Village:
-
Tax Grid #
Map 3 Block Lot(s) J
Well Owner:
Name: A dress:
Use of Well:
1- primary
2- secondary
-,X— Residential Pu is Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion _ C Compressed air percussion Other (specify)
Well Type
Screened Open end casing ° C Open hole in bedrock _ Other
Casing Details
Total length I ft.
Length below grade
Diameter in.
Weight per foot lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded,,X Threaded _ Other
Seal: Cement grout _ Bentonite Other .
Drive shoe: Yes No
Liner: Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
Bailed _ Pumped ,X Compressed Air
Hours /p
Yield gpm
Depth Data
Measure from land surface - static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve - •analyses- w
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description .
ft.
ft.
Land Surface
c
I f
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
A*q
Pump Type juh Capacity _-26, ,
Depth _5LIZ Modell -Z3ij
Voltage Z_3D HP L yiy +(��)))'j
Tank Type W L)JU - Volume 1 q,.1
Date Wee Compl ted
/P�!
Putnam County Certification No.
Date of R��eeJpor
cJt
Well Driller (signature)
Nm 1 r;: "t:xact location with
distances to at least two permanent landfnarics to be pry
Well Driller's Name _ >` Address:
Signature: Date:
Ar
White copy: File; Yellow copy - Building Inspector; Pink copy - Owner, Or
a
l
copy - Well driller
Form WC -97
Jr. -,g /1•
COUNTY DEPARTMENT OF HEALTH
-ENVIRONMENTAL. HEALTH. SERVICES-.- ........ - ...:.... .. � ,
>' COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA,, -SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM
FILE NO.
Owner aanir / L. e`�a.9.�u S. �rd��er�Address
7` v Af
Located at ( Street On . Z„ Block Lot
indiicca neare t cross s ree .tea 40,600, "
w6O: z
F.
Municipality. %� prs p y Watershed C,-o � Frei 14
SOIL PERCOLATION TEST DATA'REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK`TIME PERCOLATION PERCOLATION
apse Uepth to water,, Water Lev e
No. Time From Ground'Surface in Inches Soil Rate
Start -Stop 'Min. Start Stop. Drop in Min. /in drop
Inches Indies_ Inches
5
Notes: 1) Te'gts 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 STJBMITTED.WI.TH,APPLICATION
DESCRIPTION OF SOILS NCOUNTBRED-IN TEST' -HALES
. -
DEPTH- HOLE....,.NCJ.. HOLE.. NO -,:� - .. ... HOLE" NO
G.L.
6"
1811 i `� - $a#o' -"� `:'"'Sr�S� •v i t a, .:4; N
T) Ar �~r
-_--
30,1
"611
,.•k b
4211
4811.
54 11
• tj�'
t, _ "
6011
66'►
.7211
78 -
8411
INDIC LEVEL AT WHICH, GROUND`uWATER, IS,. ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVFT, RISES AFTER BEING ENCOUNTERED
m ..._ _. -TESTS MADE -BY Date
DESIGN
Soil Rate Used 6r7 Min/111Drop: S.D. Usable..Area', Provided no 0,0 t
No. of Bedrooms Septic Tank Capacity:. ® Gals Type Md go
Absorption Area Prov ded Bye O0 L.,F x24' width rent:. '—
/B"ie Other.
Wti
iraui�. _1A Q94 Oct . C—r�.r4^ +��, <r :!f" • ....
Address .���''..' .� L�r.�► pf/1 Z° /d $'/
a
THIS,SPACE FOR USE BY HEALTH DEPARTMENT ONLY
- "Soil Rate Approved Sq. Ft /Gal.
`�r THE cT'
�o
Date____
Vvr_fTA" rIL.Aly
SCALE. • 1' = 60'
5
DRIVEWA Y
CO
co
SrP77C TAN .
(Typ.) /// ��
C / rr/ 2.
A
9 2—WAY
29* DIS 7RIBU 77ON N4
BOX Q r/ g / 30 •
IRY ABSORP77ON
CH (T)P.)
2
// XPAf VCH tr Department of Health
,N'51 ASSORP77ON 77 ,
/ /h' OOZ EXPANSION PROWDED ou Of
FAVIronmentalj,-Health SeIV14
i
vest as noted fore
4 Oiformance wit
able
leS and Reguiations 02
ftv -"eO
untY Health be
part nt
ENLARGED PLAN 828►aturG Title-
SCALE:- 1' = 30• Date
NO.
TCORNER OF
DYEUJW
D� Di
ONEWNG
CORAER OF
MUM
COR IE OF
DMELM
REMARKS
1
23'
48'
—
—
1250 GALLDN SIPAC TANK
2
34'
60'
-
-
12 WAY D>SrRBIRfGNf Bar
3
30'
63'
=
-
OW OF >x1NM
4
37'
66'
-
-
am OF 1rzUiCH
5
43'
69'
-
-
END OF MENT+
6
50'
73'
-
-
OW OF ndNaf
7
56'
77'
-
-
00 OF WVaf
8
62'
82'
-
-
AND OF tea+
9
35'
56'
-
-
9w or veavo1
10
41'
60'
-
-
00 of MENCH
11
46'
65'
-
-
aD OF MiNp1
12
52'
70'
-
-
00 OF nmvm
13
58'
75'
-
-
a0 OF MOVq1
14
64'
80'
-
-
EW OF RENCH
15
46' 1
98'
-
-
Ow of nwr c-
16
48'
99'
-
-
so OF nmpgw
17
52'
100
-
-
EW OF rROa1
18
56'
103'
-
-
EW OF M09+
19
61'
106'
-
-
E)W OF RMOf
20
67'
110'
-
-
END OF Vaal
21
74'
50'
-
-
EAO OF nOia71
22
78'
56'
-
-
am 01` 7mai
23
82'
63'
-
-
EW OF >aNw
24
85'
69'
-
-
'm OF 1 w'm
25
91'
76'
-
-
EW °` n?mC H
26
96'
83'
-
-
VVV OF TRENCH
27
-
-
81,
74'
'u
28
39'
-
38
-
anRTAN a?"'ID
29
13'
-
25'
-
SrA m PFE OPAW
30
22'
-
37'
-
DRAW
S TAW APE
31
53'
19'
-
-
a IRT Dr"
32
140'
123'
-
-
�ANOur
33
156'
166'
-
-
MWHAl W OF CURTAlk
DRAW
NO. I DA 1E REMSION
"14-i-i 11/S /TE
L NEER/NG, SURVEYING &
LANDSCAPE ARCHITECTURE, P.C.
q
PROJECT
BY
3 Garrett Place
Carmel, NY 10512
(845) 225 -9690
(845) 225 -9717 fax
www.insite— eng.com