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HomeMy WebLinkAbout1709DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -30 BOX 15 r ir IN I, jr Lml 1 16 Ire 01709 0, . SITE i p i PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL, i OFFICIAL USE ONLY LOCATION 47a, Q11 TM# S `Y ' OWNER'S NAME M&4 15c&— PHONE gKK15 2 . KW MAILING ADDRESS; PERSON INTERVIEWED PCHD Complaint # Name & RelationsHip i.e., owner, tenant, etc. DATE TYPE FACILITY A< PROPOSED INSTALLER � (I� °2►�- — PHONE S)L%� ADDRESS REGISTRATION# TC .Y (fr A- Pr (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. c� I, as owner, or, reported ag nt of owner agree to the conditions stated on this form. SIGNATURE TITLE PifgS ~ DATE 64-1m?, Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved 1 Inspector's Signature & Title ATE COPIES: White (PCHD);;Yellow (Town BI); Pink (applicant) PC -RP 99M. A-P I M4A en� Av mmmw vtz-Twood Sw w Nez -7—�/Ov (-va7wp Wiz/ J" vk)- 0 61� m ,q r LORETTA MOLINARI bl' !h ROBERT J. BONDI Pu W Nea t Director W — U. County Executive 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 April 15, 2004 Joel Greenberg, RA 2 Muscoot No. RFD. 2 Mahopac; NY 10541 Re: Addition - Beal, 30 Indian Hill Rd. No Increases in Number of Bedrooms (T) Patterson, ,TM #35 -4 -30 Dear Mr. 'Greenberg: I have received and reviewed the .plans for the proposed addition to the above- mentioned residence:. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated April. 15, 2004. The addition is approved with the following conditions- 1., The total number of bedrooms must remain at four without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low Rush toilets, restrictors, for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Y DEPARTMEI\TT OF B EEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 TeL (914) 278-6130 . Far (914) 278-7921 PROPOSED ADDITION APPIJ:A' 1L0N_ (RESIDENTIAL ONLY) �Od. / /°,f ,e/n BRUCE R. FULE -,Y Public Health Director _R STREET Indian Hill Road T0WN2& won TX MAP # .35 -4 -3Q NA]VIE - A ' dam Beal PP10NI32Zg, 2 4 f 0 PCHD # MAILINO ADDRESS 30 Indian Hill Road, 13rewster, N Y. 10509 DESCRIPTION OF ADDITION NUMBER OF EXISTING BEDROOMS_ 4 PROPOSED # OF BEDROOMS 0 (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) 'Any addition which is considered a bedroom requires formal approval of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the folfowing o Putnam County BeaTth Dept., 4 Gi neva Rd-., Brewster, NY 10509, Phone 278 -6130. 1. Certified check or money order for $100.00 2. Sketches of existing floor plan (drawn to scale, all living area including basement) * Non- professional sketches are acceptable 3. Two sets of proposed floor plan (drawn to scale, with name, street, and tax map #) * Non- professional sketches are acceptable 4. Copy of survey showing well and septic location, to the best of your knowledge. include elate of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Cert. of Occupancy from Town or Ce1•tification from Building Dept. with legal bedroom count of dwelling. Comments Feb 98 i „, <Opr 06 04 08.51a TOWN OF PRTTERSO 645 -878 -2019 0.1 Cie �..._ . ..�.. ,..b..w .. .. ,..a 1-z: t: TOWN OF PATTERSON PUTNAM COUNTY Telephone PATTERSON. NEW .YORK 12563 e78 -63t9 Buitd ing -De;pantment TO: JOEL GREENBERG FROM: Chenyt L. Smith, SecAetany, Btdg. Dept. DATE: Aptit 6, 2004 i RE: Adam Beat - 30 Indian Hitt Road, Bnewbten, NY lT /Patterson) Number ob pages including coven: 3 Joet, I cannot � nd the Health. Dept. Comptiance; however, I encto4ed a copy o4 the N.D. Permit - # P -74 -88 OuA neconda indicate thus iz a 6ouA bedroom dwe.tting. Any queationb, ptease catt me. _ "..r _.. S PUTNAIMr COUNTY D$P _A&T.4NT OF HEALTH 'Dli EeWn eif FAn* amemtal Health Se> s•Io w. Carmel. PI.Y. IOSII? Bngilteer to Provide Permit N 1 on CEBT1FIC4TE OF COMP CE Permit M . evONS ON PERMS' PoIIEBEWAGE DISI►os SYSTEM IL lemted "al 4 Tatra : orge I"uwvhlon Nome "C'Fr_t dCj1t5 �C i-#t L Subd. Lot N- `�+ ' ?as Map Blame Lot /igQiUYdo& rf ;"r!`13. He>jewal �_O IRevlaloa ( 1 . Clstver /AppIIcaat Name_' , �t Date of Prev (oas.Appeoval ,sue t Ilgalllag Address _i! ©. �a .+ I� Y' Town . e., A1z /A Kv . m" ap 1051 H Type Ldt Arta FM Section Only Depth... Volume r' Nisimber of Bedrooms Design F1oW G P D '� PCHD Not)fleatloa to Re,,Wrell Wh. FM )a completed' Separate Sewe Qe System to.coaglat oQ 1'2 Genoa SeptlgTtaak Sad__%.��"ti�°�lC Ln V To. he eowt6eted• by O Water SaPPIV—Pd1ille Supply Pram ; A�dd�rrew i or: ✓ Private Supply Daw by "W V "'D lM � �iresa r i then Redakemebta I, , prnssnj that I am wholly and completey'responsible for the design and location of the proposed system(s); 1) that the separate se Wage disposa('systAm J spore described wilt be constructed as shown on the approved amendment•there to and •tn accordance with the standards, niies and regUse ons o e., ..0 nam CpuntM' Department of Nealttr,' an6 that on completion thereof a' certificate :of Construction compliance•' satisfactory to the Commissioner of Hailthwill ' trtrLy 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 . pace in good opera,ing.condition any part of laid sewage disposal system during the period of tyro (2) yeari Immaddately following the date of.the'issu• ' _ ��cs of the approval of the certificate' of Construction Compliance of: the original syflem'orany repai 'thsroto;21 that *the drillbd wall described alcove O i�,111 be touted as shown on the approved and that said well will be Ins al ed. in• accordance wish the• a' s, r as iand regu a ons of the Putnam i Ui Cbunty Depa tmdn •o1 Health, LLI Oil j .� l "'. art Signed :1 1 P.E.; R.A... aa-- Address / 3 0—i`• W& 1� -O ' , lC rG)N %�Sret_icense No APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construw'. of the twiding has been.undertaken and is`.' s (L .40cable for cause or may be amended or modified when considered necesiiiry' by the Commissioner of Health: Any change or alteration• df construction _ flipuires a new permitf• Approved for disposal of domestic ranitary_'sewage. a�aorr.Jwvate water suppiy only' LL 1%87 • ,O to 1 F? c. / 1: `. ' ' By -- --'— -'. �„r1'- — �±.y,' - -: .. -L `T.it•le . '•''ff' -/7`' ': 3 O H il) V) C t0 .. ! . (D O t,( 1 Fi-pr 06 04 08:51a TOWN OF PATTERSO 845 -878 -2019 �o ,44/05/2004 .01:33 8456282807 PAGE 02 p• 3 JOEL GREENBERG r ' !r �F BRUCE R. FOLEY, A.S. Acting Public .Health Director DEPARTMENT OF HEALTH Di,Asion , Of Environmental Health Services 4 Geneva' Road, Brewster, New York 10509 (914) 278 -6130 Putnam County Dept, of Health 4 Geneva Road B{ewster, NY 10509 Re: REAL -� Resid nce Tax Mapa.a -4-3e- Town won Gentlemen: According to records maintained by the Tom, the above noted dwelling ! IS IS NOT in eomplia a with Tour code and the total number-of bedrooms on record is This information has been obtained from: CERTIFICATE OF OCCUPANCY: ASSESSORS RECORD: OTHER.rc��'�� Building Inspector I CD N -v b- Fr P 12,E Oj ktaQ o .� .® a .7GD . - .3%4 �t�' • "xt� CD 01 `S 1.'eLP O Agic 40,02gs.10t , OA1q AG.± t9 N 0 0 � a o c z t 1 NOV II'IR "W 53.3°1' I : 9 J• rJRC N A �, v►c 2E� oEme E Y z 0 y 0 ZiuRvEY OF PKol°aml --1 PIe�PAle�p Po1� THOMAS N ANC ' SIN N& llo-r N0. 25 AS SNONN ON P^FM --CO - MAI -Kmf SUSOIVISION , !aIL*O MAP ++ 225 1 PILGO 0�3t- S? Sl'fUPcTB ►N TOWN OF pA-rLr�resON 1°UTNAM GO., NY SCALE. 1"-- 50' MAY +, lgg2 IN�fz' cOAN'f�/ SAVINGS pip.NK � I-(S S060P5SOOZ AND /OFz A"tG+M AND . cON►MONWEgL --fN LAND llli e INS . c0. cr:�ncZctno�:t� u..taic�-rFC Ne.�_u,i s��LUN -T+LIT �+�ti sv¢.,EV VJAh ae�.a IL! ACf..OQD�AJ -iCE kUTtl Adoprm, 9@i-we t Iw ` w- .6wts- Airs a/s nw cF PIZCCPAI%Cx1AJ_ Ldl,lp SUE%A- . y/dD CeZn 1CAT -M. +SAL" Wuw CWLV '1b 'ME mw- V1t106(-4m 6uevf-,/ 6 FQEVAMM A►-ID OU ►J6 ng& 10 "ME °u TM& C0UPAF3`I AAJD LEA= LA. F�[j b1.J L � uFJ�F1�L1. ' lt= 1C.A'i7o�lK �P�. !ll<1r'i?i41%�CEPJIBLE '7� �DOfrtoLL4L 111�3i'ilVT1Of -lb C]e S"5 - OklWEye a La-LALmr.tat zj;.E� AmF -SIC U ee a comou -To -N%e7 MAp Ih A\Jim.9>;ilml C.CSECnOLI•k T1D5 CF -nF— LP-W `&)eld "m EDA'11oIJ LAW L*4veg %mLIJU 6TZ.C7UCE.S, IC,Aij,y, IJf3±- -.eA4Ok1L.1. ALL C6MCrAC'IG J? 4EZ J Aar. .aA-Ip Poo- 'WVP d,IAV A+-ID C SPIES IW -error OWL`{ IC hA to MAP oe. CcvIES MAP- -TUFF- IbIPPFfshED 46AL Cir- NE �x>eV�IC2 WA40- E51C4JAR.PZF- APPEAZe, -TE>'ZY >�GEt..IDOeIx Got�L:lUy W. E8o coep va¢W- 82e.WSlae. .q. Los59 PUTNA COUNTY DEPARTMENT OF HEALIS o ivlelon of Envlrotimental Health Services, Carmel, N.Y. 10512 Englueer Meet Provide; fJ tt GATE OF CONSTRiJClION. COMPLIArTCE FOR SEWAGE DISPOSAL SYSTEM own o lliag lacit�at,. Via, Tax`Map hr Owner/ ' ' Ucant•Name K11' (1�[1 a l(ir f app t'*- S FonaerlY Sandtvieioa Name aSabdr. Lot q j MaWng Address Wit' "'"`" �p Date permit Iesaed Separate.Sewerage'System befit by Address 0.' ,• Conefsting,of �` Z- !, Gallon Septic ssik and Water Supply. Public Sapply From Address or Private Snpply Dtllled liY V4 Address �s= - .-- -P-�► o���►ia -is Building Type "—� �'�- Has Erosion Control Been CompletedY � � } Number,of Bedrooms Has Garbago Grinder Bean Insta edt Other,Ri nire'nepte 1 certify that the:syetem.(s) as listed' serving .the,, above p remises: were consructed,eeaentiallyae shorn on the plans of the completed work (copies of -which are attached) and in accordance with the standards, rules and'r "'lations in, accordance with e'f ed plan, and the-permit issued by the Putnam County Department Of Health: Date ! (� " C tifi d;;bY P.E. y R.A. .. Address' License ivo. Any perfon occupying premises served by the. above systems) shall promptly t8ka such abtiOn is qwy be necessary to secure the corr®ction of •any ul, ssnitary condition ;';resulting; from `such usage ADP ►oval of he separate sewerage system shall become null ind void ai loon •i a pubs;: isnitery sewer becomes available and the .epproval'of the private water wpp1Y, shat( become Hutt and void when„ a pupl1c water 'supPly !becomes avallable. : Such approvals are subject 4o.,modifftetion.or cha ;whsn,,in-_the,judgment ot_Tthe.Corn.n iCh'er of`HealtA `T revocation; motllflcation or change is necessary, Date ��G /�• � ���- f PUTNAM COUNTY DEPAMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Tr r 0 e,r Owner or Purchaser of Building Building Constructed by �Z_S- 11 � Location - Street R.GJY�v G � Municipality ii, w B ilding Type C9 6 2 241/ Section Block Lot s e, l Al Subdivision Name Subdivision Lot # GUARUPPEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal 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 disposal system, or any repairs inade`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 Director of, the Division of Environinental Health Services o Department of Health as to whether or not the failure of the caused by the willful or negligent act of the occupant of the the system. Dated this a 6 day of Q a 19 Signature Title General Contractor (Owner) - Signature y Gt.o!�—lC—o�Y Pz-,4. c� Corporation Nanfe (if Corp.) l0 v 0 Y 9 0 Address rev. 9/85 mk the determination of f the Putnam County system to operate was building utilizing . ..,, . - 01 L'i r 'Ie 2 LLCi FYI K NDAR HOMES �ADORNO BWLDERS, INC. fk 914.526 ® 3005 4 NON-MLftCIPAL WATER REPORT 3 .... ........ ...................... 1g_ ........ . OWNER'S ftAVAE . . .. ........................ SIZE AND LENGTH OF CASING ... .......... A. AOE S DEPTH OF PUkWIF()OT VA-LVF ............ ............. ...... ..... ,QA S .............. a a ........... ................... .... . ,5 rl 'S ......... STATIC WATOR LEVEL 0 T 0 Of MOPERTY . ...... ........ ... ...... iGALL(UmlS MR IdINUTIE WE L t. Ufq ILLF A 'SXAMF-.A 49t .. .......... TYPES OF SOILS ENCOUNTEW:0 ACID APPRf>-XW r AT OFPTH ..•....... --- --- ---------- --------- 01F EACR ADORES - --------------- TYPE: OF MILLING -1/ --------------------- ---------- ---------- 11c . ;! T � �4a I . .. . ... ..... . ............................ ...... LL. R O S. ---------- S' mto of owwoer ............... . ................. signatwa of Wdt Driller W. n 01 L'i r 'Ie 2 LLCi FYI K NDAR HOMES �ADORNO BWLDERS, INC. fk 914.526 ® 3005 4 NON-MLftCIPAL WATER REPORT 3 .... ........ ...................... 1g_ ........ . OWNER'S ftAVAE . . .. ........................ SIZE AND LENGTH OF CASING ... .......... A. AOE S DEPTH OF PUkWIF()OT VA-LVF ............ ............. ...... ..... ,QA S .............. a a ........... ................... .... . ,5 rl 'S ......... STATIC WATOR LEVEL 0 T 0 Of MOPERTY . ...... ........ ... ...... iGALL(UmlS MR IdINUTIE WE L t. Ufq ILLF A 'SXAMF-.A 49t .. .......... TYPES OF SOILS ENCOUNTEW:0 ACID APPRf>-XW r AT OFPTH ..•....... --- --- ---------- --------- 01F EACR ADORES - --------------- TYPE: OF MILLING -1/ --------------------- ---------- ---------- 11c . ;! T � �4a I . .. . ... ..... . ............................ ...... LL. R O S. ---------- S' mto of owwoer ............... . ................. signatwa of Wdt Driller W. El I-MORATORIES, INC 7--74- ANALYSIS DATA SHEET / COUNTY: Putnam �-- O AS LOCATION: Treuer residence REPORT TO: Tom & Nancy Treuer ADDRESS: 25 Indian Hill Rd.. CITY, STATE, ZIP: Brewster, NY 10509 J I DATE COLLECTED: 12 -1 -92 TIME COLLECTED: 9:50 COLLECTED BY: Client REPORT DATE: 12 -02 -92 SAMPLE: DW 9092 I SAMPLE�--SOURCE: Kitchen tap - °- I DATE ANALYSIS RESULT UNITS METHOD ANALYZED Total Coliform Absent COLILERT 12 -01 -92 i THIS SAMPLE AS RECEIVED AT THIS LABORATORY MET ' THE REQUIREMENTS- OF NEW YORK STATE DRINKING WATER STANDARDS. 4 oratory Director NEW YORK STATE ELAP CERTIFICATION NUMBER: 11218 618 CLOCK TOWER COMMONS, RTE 22, BREWSTER, NY 10509 / 914 - 278 -7600 / FAX 914 - 278 -7754 t PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Camnissioner of Health - FIELD ACTIVITY REPORT - Sheet of NAME ��,,,�,.. -,..- �� � INSPDCTION / r°'`i ` -0rig . Routine n ADDRESS ,��/� -i,�� ;/�' Orig. Request No. Street Town TH No. — Compliance MAILING ADDRESS e, %G Canplaint Comp Final P.O. Box Post Office Zip Code _ Group Illness TELEPHONE y� ,e! �, Construction _ Reinspection PERSON IN CHARGE zz _ Field, Sampling Only OR INTERVIEWED _ Field Conference Name and Title Other DATE S ���� TYPE FACILITY TIME ARRIVED TIME LEFT �;© Explain FINDINGS: INSPECTOR: PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: TELEPHONE: _ ,.._.. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health L01• 2 - FIELD ACTIVITY REPORT - /fi% * ,;;2J- 0 0 v .. MAILING ADDRESS P.O. Box Post Office Zip Code. PERSON IN CHARGE OR INTERVIEWED Name and Title DATE Q ,� TYPE FACILITY �M u[ -- LQ f TIME ARRIVED TIME LEFT FINDINGS: � Q _--- Sheet I of TA .q'DPY PTOW Orig. Routine Orig. Complain Orig, Request Ccgnpl iance Ccmplaint Canp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference_ Other �- Explain INSPECTOR- 30l ��� Z� TELEPHONE, Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Reports SIGNATURE: 6/86 TITLE- RANDOLPH W LAURENT, PE. HARRY W. NICHOLS JR.. P.E. De.-.c.ember 116, .1988 LAURENT ENGINEERING, ASSOCIATES, PC. 73 FAIRFIELD DRIVE Iunul rATTERSON. NEV YORK 12563 914 •278-6108 CONSULTING SITE ENGINEERS Putnam County Department of Health 110 Old Route 6 Cdnter Carmel, New York 10512 Att: John Karell, Jr.,­P.E. RE: Steinbeck Hill Lot # 25 Farm To Market Road Patterson, NY Dear John: Enclosed are the following: 1. Four (4) prints of Drawing SS,_25 "Proposed SSDS- Lot 25"!, revised 12-16-88; We would, appreciate your continued review, approval and issuance of the Constructio . n'Permit at your earliest con- venience. Sincerely, LAUktgT'--FKG'INV,-ElZI'N(;--ASSOCrA'I'ES9. P Harry W. Nichols -Jfi;., HWL/mt ENcl. cc: Mr. David Cioccolanti w 1 copy each DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL,.N.Y. 10512 (914) 225 -3641 "- APPLICATION TO CONSTRUCT A WATER WELL �f PCHD PERMIT. WELL ':LOCATION Street Address Town -T-p fLa�ep A'tZ Tax Grid Number Ohl ,. 12S'7o3 •.�- .`2" -,2�0 WELL OWNER Name :. Mailing Address �1ilON2ofz. H7S P,o,.6 i'-70 rivate IoS'12.OPublic USE 'OF WELL - primary .10 .2 -- secondary .9 RESIDENTIAL ❑ PUBLIC SUPPLY 13 BUSINESS 0 FARM ,O INDUSTRIAL O INSTITUTIONAL Q AIR /COND /HEAT PUMP O ABANDONED ;. p TEST /OBSERVATION ❑ OTHER (specify O STAND -BY O AMOUNT OF USE YIELD-SOUGHT 6,0 . gpm /# PEOPLE SERVED /EST. OF, DAILY .USAGE ioaa gal --REASON-'FOR DRILLING NEW SUPPLY ❑PROVIDE ADDITIONAL .SUPPLY ❑TEST /OBSERVATION .OREPLACE_.EXISTING SUPPLY ODEEPEN EXISTING WELL DETAILED REASON FOR. DRILLING �1 WELL TYPE DRILLED DRIVEN 0DUG GRAVEL OTHER .IS WELL SITE SUBJECT TO FLOODING? YES _ X NO WELL IS LOCATED,IN'A REALTY SUBDIVISION; NAME OF SUBDIVISION Lot No. WATER WELL CONTRACTOR: Name -jZ g nrz,-(("gg!2 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES XNO NAME OF PUBLIC WATER SUPPLY: 1A TOWN /VIL /CITY 'DISTANCE TO PROPEM"FRaM' NEAREST WATER MAIN: _...__._... LOCATION SKETCH &SOURCES OF,CONTAMINATION PROVIDED 0 ON 'REAR OF THIS APPLICATION SEPARATE HEET 4s� -g� (date)' (s' ature LA_ PERMIT TO CONSTRUCT A.WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 =2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant s.hall: 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: 19 Permit trss ng 07 c—ia� Date of Expiration :; c* 19 %d Permit is Non- Transferrable White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 2/87 Orange copy: Well Driller Re: Property of MOt�I(Z� "�CFaGt� -CS �1T Cam.. ('f0. Located a t —Section Block Block Lot Subdivision. of t4(LL Subdvo Lot # Filed Map # ZZ�'7 Date 8 S I MW Gentlemen: This letter is to authorize 14.t XZYY C06z)L-S Az. a duly licensed professional engineer ✓ or registered architect (Indicate to apply for a Construction Permit for a separate. sewage system, to serve. the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf. in connection with this matter and to 'supervise the construction of said system'6k­- systems "in conformity' with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. 1. . OY^I/T Countersign P.E., R.A.I -73 Dyk VE� Address (g -z 7S t Telephone Very truly yours, Signed C (/ Owner of Property ?o .60 x '7770 'Address Town qd -�-� �- q 4 3 Telephone r Putnam County Department of Health Division of Environmental,Sanitation. AFFIDAVIT,-, CORPORATE OWNER APEhICATIONs_ FOR PERMIT. APPLICATION SUBMITTED TO PUTNAM COUNTY F[EALTH DEPARTMENT ! :� Tb: Commisaioner,of Health - In the matter of application for QoE . �f I � ZS EvELo� IEuT_ , 'l�l��-,�, � L 7b -- - - -- I, L t�._. ( {COL ,NT,�` — --- --__._ • .represent that I am an officer or employee of the corporation and am authorized, . to, act for .K'L���O_C_ .�.�'�� Z% 06i r�l'1�i+�7'&6 �.L7� .(name of corporation)- orporation) ~ ^. having offices atQ�('� :�_ .�1 /�. �_ ?4- Q J'VLC� Whose officers -are President o j %L 7 eE�v_SC?Q AJ Name and Address) Vice- President f{ Cf�c.� (Name and Address) G Secretary 1 _ GLo�GC_o [- %�vt7/ _ _ ? 1'Li - (Name and Address) - :i7easurer —_ -- - -- (d Address)_ — -- - - -___ Name and and that I am and will he individually responsible for any or all :_acts of the corporation with respect to the approval requested and all sub- sequeht act8 relating. thereto. t Sworn to before me this day Signed of 198' Title /7Z otary Public ANNE S. COhRIDAN 'r Y.ln NN CWWh46n r" o Corporate Seal PLFT'(`M COUNTY DEP.ARMAIM OF HEALTH - DIVISION OF ENVIIROM AL HEALTH SF-RV-r= INDIVIDUAL MM SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT DATE BY: (dame of Cwner) (Sheet Location) S COM_MF -i�TTS YES NO DCX'IIlOM (, Permit Application Corporate Resolution Plans - Three sets /s Engineers Authorization Design Data Sheet (DDS) Su':DIVI ION Deep Hole Log P`rc Consistent Perc Results (3) Fill Per-c..-Hole Depth cd FILL OR new t 100 yr I ° required 'S 60 ft. max. Parpllel to 100% e=. r . reservoirfl etc. . triQall /loll. House Plans - Two sets Well permit; Prow lettar Variance Reauest Cr,NII2AL Lecral Subdivision Subdivision Anoroval Checked Ex-approval SSDS Adj. Lots Checked Wetland (Tcwn /DEC Pennuit R & D) Data On DDS Plans & Permit Sam REQUIRED DETAILS ON PLANS Swage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Voluia D or J Box;Trencb /Gallery; Pump pit devils Septic Tank - Size, Detail .Well Detail, Service Line if over - Cortst_tuctiori Notes -(grinder rate) Design'Data: perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing/Gutte_r,Curtain Drains (discharge Oil) Perc & Deep Holes Located Representative of primary and expansion Expansion Area; shown; gravity flow,suff. size If Pmved Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's w /in 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pica_ No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED CN PL-2N Fields 10' to P.L., Driveway, Large Treees,Too of fit 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Strom, Watercourse, Lake ( inc. 15' to Drains - Curtain, Leader, Footing 35'to catch basin, stormdrain,t)ipe;d watercours 10' to water Line (pits -20') 50' intermittent drainac7e course Septic Tanks 10' from Foundation; 50' to well LAURENT ENGINEERING ASSOCIATES, PC. L PATTERSON, NEW YORK 12563 914.278.6108 RANDOLPH W. LAURENT. P.E. HARRY W. NICHOLS JR.. PE. CONSULTING SITE ENGINEERS April 11; ;1988 Putnam County Department of Health 110 Old.Route 6 Center Carmel, N.-Y. 10512 Att; John'Kare.11, Jr., P.E. RE: Steibbeck Hill Lot #25 Farm to Market Road Patterson, NY 12563 Dear Mr. K,arell: Enclosed a're the following: 1. Four (4) prints of Drawing SS -25 "Proposed SSDS" Lot #25, dated 4 -8 -88; 2. ",Construction Permit for Sewage Disposal System ", dated 4 -8 -88; 3. "Application to Construct a Water Well ", dated 4 -8 -88; 4 Design -Data Sheet"; . 5. Letter of Authorization ", dated 8- 11 -87; 6. Two (2) copies of Residence Floor Plan(s), for "Bedroom count Only". 7. in amount of $100.00 payable to The Putnam County Health Department. 8. "Affidavit - Corporate Owner Application ", dated 8- 11 -87. We would appreciate pp your review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely,i LAURENT ENGINEERING ASSOCIATES, P.C. Ha ry�hols, Jr., P.E. /map cc: Mr. David Ciocciolanti w/ 1 copy each enclosures'. PUnW4 COUNTY ::DEPARMW OF. H EALTH :' ..'DIVISION':OF•.� HEALTH SERVICES <ry ...., -DESIGN; DATA SiiEEfi- SUBSUFACE SEWAGE DISPOSAL `SYSTEM -/fit ti �t2a?L ` (-i' �t� 175. .., , � - ,<..:... :• < -. ' t�. Li°D'; Address p O, 13 o1a q %fl -r; T•'G�4i2aV16,L Ill u ' ``IeS�(2 , Owner• :_ Dat/15rc(3�tzNT-° Go,t. . Fq-(L',v� , Tro M 7 Located--at- ( -wG—io i ,.�Q Block ; Lot'. (indicate nearest cross street)r(Lo7. 25 MunicipalityTbW OF �o`nl . Watershed ~C -i7oti! SOIL 'PEROQT MON MST DATA RDQU= ' TO BE SUBM= 'WITH APPLICATIONS Date ^o£ Pre - Soaking l o (► "7 Date of Percolation Test w.i° 17. a 7 NCIBgt t�,OCR TIME = PERCQLA7ZON - PERCOLATION Run iElapse Depth to Water: From water Level No, :. Time Ground Surface.:. __:In Inches ,, r..w ..._._._:'Soil Rate. . Start-Stop Min. Start Stop Drop In Min/In Drop; Inches- = Inches _ Inches 2 10 k•eG - . NO'IIS: 1. Tests to be repeate6 at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made fran top of 'hole. rev. 9/85 30 .:..;.,y 2 3 -.. `.3D... ..30 2 11 i.�.�. �� ��• ... 3a 3d 42 : 3" ...... �o`. 3 11145' - (2i 1S r; ,... �,.... m . 1 - NO'IIS: 1. Tests to be repeate6 at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made fran top of 'hole. rev. 9/85 3.19 12 No. of Bedrooms Septic Tank Capacitir 12;'D gals, Type Ggtm C Absorption Area Provided By 4"40.' - L.F. x 24" width trench.. Other Nam LA0a N7 f-1,4 WEEEM9, MSd e i tsignature Address `13 r:A I P-FI f -►D D V \/f, SEAL • • (J��Z.�i2.�01�% N� I�S�O3 THIS SPACE FOR USE BY HEALTH DEPARUMM ONLY: OF NEW. Y„..- . W3 V1, Cta No. 56124 A'90FESS10'� Soil Rate Approved sq.ft/galo Checked by Date TEST PIT DATA :RDQUIItED TO BE SUBNiITTF.D :WITfi APPLICATION DESCRIPTION 'OF SOILS-ENCOUNTERED IN =,:HOLES DEPTH HOLE .M).. HOLE..N0 HO NO. `} r ......., .r .n ..u... .. :•' . .!.`':' \'. .:.�4. ct�.ea3.�.: ::.r:..rra ... ... .. :� u. «ac..a.. ......a ..._. .. —. .1 � .. ..w:Y.Pr.'.r•. -� '`Mr..r'S G.L. .... 1 ° r rdo (Lrn _ - 2 7' g° 3.19 12 No. of Bedrooms Septic Tank Capacitir 12;'D gals, Type Ggtm C Absorption Area Provided By 4"40.' - L.F. x 24" width trench.. Other Nam LA0a N7 f-1,4 WEEEM9, MSd e i tsignature Address `13 r:A I P-FI f -►D D V \/f, SEAL • • (J��Z.�i2.�01�% N� I�S�O3 THIS SPACE FOR USE BY HEALTH DEPARUMM ONLY: OF NEW. Y„..- . W3 V1, Cta No. 56124 A'90FESS10'� Soil Rate Approved sq.ft/galo Checked by Date