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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -71 BOX 16 01733 - � Iyti II ;; 'I t6, ' ' 1 ` k-1 1,J6 01 ir I No y' ' I � r 01733 ev. 3186 r K c . s _ PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environments) Health Services, Carmel N it i6512': Engin de Permit li eer to PCO on CEBTIFICATE OF COMPLIANCE �fCONSTRUCTION PE R EWAGE.DLSPOSAL SYSTEM' Permit N hosted at VNage Subdivision Name Subd. Lot #i Tai Map�/_6 Block Let t . .. Lam) f ( 1 Y Renewal_ O Revlelon ❑ Owner /Applleant Name 1�_A�L� ( Date of Previous Approval' Melling Address `I �� ,� Town ��- Zip 1 Zr� �D ray Building Type' 7 G. Lot Area J ` FID Secdon OnIY Depth Volume Number of Bedrooms Design Flow G /P /D PCHD Notification is Regdtred Wben Flit. Separate Sewerage System to consist of Gallon Septic Tank and. . . To ba coust6eted by Address Wafer SaPP1J:_' Pabllc`Supply From `. Address or. Private Sapply'Dilled by % �_ '_Address Other, JR egalemente Y represent that I am wholly and complete) responsible for the - design and location of the. proposed 'system(s)r• .1) that. then separate sewage disposal system above County' edme^tbeo; onstructed.as shown on the approved amentlnient there to and in accordance the standard S, rules an re a ions o e.� u nam Y , Health, and that on completion thereof a "'Certificate , of Construction Compliance" satisfactory to the Commissioner of..Healthwill be, Submitted fo the Department, ,and•a wntted..guarantea will be Yu►nished the owner, his successors, heirs or assigns by the builder, that said builder will place iri •good operating' condition any• pail ofsaid - sewage disposal system:.during the period.of two (2) years Immediately following the date of the issu- ance of•. the approval. Of:.'the ;Certificate of Construction Compliarice,of the original system of any repairs than 2) than;the drilled well described above will be- Iocatea as shown:on the`a pproved. plan and that'said weU will ba- installed :in acre nce with the da s, r les and'regu ni of the Putnam County epartment of .Flealtfr:: Date Signed P.E. X R.A. Ad, dress ` rlicense :No APPROVEU FOR CONSTRUCTION: - This approval expire A year from the*'date` issued unless construction of the building has been undertaken and is revocable for cause or maybe amended or modified -when considered necessary by the Commissioner p1' Health. Any change or alteration' of construction requires a new permit. Approved for disposal of domestic sanitary sevfte, and /or rivals water supply only. Date �� /i g,�L"`�� � � � ---- -� r�� a PUTNAM COUNTY DEPARTMENT OF HEALTH ., . .DIVISION OF ENVIRONMENTAL. HEALTH SERVICES. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEW NT SYSTEM PCHD COf STRUCTION PERMIT # CJ " 7 / a- 1 Located at OL O XOP,12 (A744 IJ4� i PAD) Town or Village Owner /Applicant Name 6 T EY E 17 0 Formerly 10 1-�H f ?00H5 R009 Tax Map �'C—j Block Lot 7` Subdivision Name N9P Subd. Lot # Mailing Address Date Construction Permit Issued by PCHD Separate Sewerage System built by Bov Di wL 6lui16 Zip i G� 91 Co Address Po 6PR Consisting of 1000 Gallon Septic Tank and 'b vF AB 5 J�H Other Requirements: Water Supply: Public Supply From Address or: X Private Supply Drilled by M J W' !W" Address .1 1� pU70W` NOW40 'A46V A —Has-erosion control.been comnleted? _i n-oT c _pr P. - - - - - - Number of Bedrooms Has garbage grinder been installed? HO 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 regulatio s of the Putnam County ep ent of Health. Date: I ill-Ill y Certified b �U P.E. � R.A. Address �0 II�Ui u� R-p: (DJ*n Professional) License # S& 12-4' 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 ar subject to modification or change when, in the judgment of the Public Health Director, such revocatio V'X ification change is necessary. Y• B Ti tle: ON Date: f �� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building 16TL -v 5 0 a.'iTmo Building Constructed by 0 i- -V�1� Location - Street Tax Map Block Lot ppT rFF •50 H TownNillage K-N APP Subdivision Name 11 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 act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. - Dated: Month Day Year Signature &414-0 Title: AIU44 -� � General 6ontractor (Owner) - gnature 1--T Q a Lk ra i c k a n4V-kC+11!2 , 1-TO Corporation Name (if corporation) Corporation Name (if corporation) Address:. I?o, 13o -, 5-3 :)- 13�ews�'Q� State /V Zip Address: P61 66x s3a 13.►��s�,� State Zip 105e9 Form GS -97 06-14-1999 09:02AM FROM TO 92787921 P.01 PUTNA-M COUNTY DEPARTMENT OF HEALTH DIVISION OF E-N-MONMIENTAL HEALTH SERVICES R Obi ST FOR FINAL INSPECTION For: Fill Trenches PCHD Construction Permit Located R MT X•olp @(V) -PAT rV060m Owner/ApplicantNarn 6TF,4r- TM *h Block _4 Lot. 10 Formerly Nam- FL-10 D Is system fill completed? Date Is system complete? Yet) Date 10-" Is system constructed as per plans? -,It% Is well drilled? ycri Date ( F*1,14 Is well located as per plans? Are erosion control measures in place716 I certify that thesystem(s), as listed., at the a7bove prenuses has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plan-, and the Standards. Rules and Regulations of the Putnam County Department of Health. Date: ..—Certified by: PE X RA Address 1-* ftlfwrvw 4 A-F- Lit. Gpf I-AM9 1 71 F"-Fl - Comments., Form FIR-99 TOTAL P.01 ;I.`acknowledge receipt of this report: - SIGNATURE; 02 / 96 Title: . —" ,Wildlife Management LLI Z t z ®S Al o `•�7r� � � � � cad �Nk Ui J Brook t 12563 j " - f 1 68 Q 22 avtland OIIOW 8 A- - „ ¢ a a ,!j � p : - __ ___. ..__ • -.. S' iPA - _ J i hutnA _ n Lake rnu"' Y "teinbeck v I - Corners ir ° ' 1 Lake he tCharles 22 O f l L titb'ok„.�`;s. .9 'QeF r St 1\i J yj ► —� ique Area Mount Eho ' . rs �\ <= Corporate 65 _� .. t t A M s / Pond lit rte,. Ms `'� ® — a � (� _ T State Toa U r z Police ■Old Southeast 0 N € Church l O s ners a. �� rem � cj . m m O.Oss OM rewster o .l ' .•� c•-'. j r> Woods n ..' ^ 3 _ 5 6 SCALE 191110 OF AU INCH - 24-1-11 27 P%o 24-1 - �ii'• ,IyIS+ /arc» - 3.00 At a 1 Uzi � A ` •'� O 1141•x• /'V L99AG a 35.06 _ �'• J � i � 219.90 ah tNt Sf 9zeo 0 -,/ i i G 219.!0 24 g L84 AC. 2.66( •�, 904.72 . i �/ J AG i'� \ / 283. !�' L44 u I m At E40 x I I 13 'da At , _ \ `fit . - 1 • _ Ia,T� ntt ip� 14.00 AC, .7 4 CAL. 14.00 AC AL m 2.52 AC. ) � 4: »° ,3 �\ ' C. / 1 ° ( 1 c 4.2 = 2.67 AC. ' 82 a r 1.61 At 297 At + 72• L0! 1 1.06 s ,r 12 1. 2.66AC, CI AC. AG a: -.1.05 I i 118 29 • a rtaro y LOB o As9 a 4.1 s 250 AC.� 81 51 s A•Aar l' .p 71 g a e., _ r - euG II Ac -�• s'>> 4O g 3.02Af. ? lB .1.26 � e d 10 721.94 &:13 AC, y /1 roan ACW T7 °p I s •+a: -:, , 8 e'+ ' 129 a 2.59 AC. ro•a80 @ X79 7.x 299 AC.�,0 id lac � e. ,9 , `' t 30 � p d 1.6fi � pQO anarc'�- !tell Aj i. : X1 /n ++t+b 1p. _ r -"fR.. "- - -+ii/ AG a9' S• _ 7� L36 At iLAC- n �h tcttc tb -. ., etx p�h yctf \ AC? 7 IO 3.17 ; s I - 2.77 Aa C 277 AC... 1.68 AC 5 33 1 xl 59 a ` N4 r 29 ' a + -1.59 AC. 1.74 3 - 1166.05 ••\ e V � 1 js6.3 1.74 AC. 4st9a I \ 69 + . 68 0, s 1.5o sss.s «tr2 r 1s 34 i X1:1.50 AC e 105.7 AC. ° 'r uso� \ . - 1.24 6811.50 J Q•.,o 2.96 5 I 6B o -- At r I! / 679AG ... Ny6e 672 2.74 At CAL. 110.96 AC. CAL. 104.13 gT. QSAC a •, ' 67. I ` ac 1.45 AC. a �5 \ < `•tae I 119 AG .. Lai �:�,s /• 25° 4 1 ,2 / R 64 loll t v 1 ..44.00 r4 44.00 AC. CAL. rt �..\ ,.4.95 AC. lao�9t AL 63 ` 1 s ro •� �• Alai ,c +6 si14 i t 44.52 AC. CAL. �' ; ' . `.. c E 57' i L� 16 6gB#1 ,� . t� ' a 1�� o 4.0( 6 9.69 AC. CAL. 24.58 AC. Jo J 1'� I L %" 1i• ; e seo.os �, �•. 55 °� n7.tfi 244.e2 ' e 19.33 AC. CAL. 9etse �,at g 1 < ! 1 58 m 8.92 AC. ;F I 6.92 AC. CAL. N to •\` '� ;>; ,. A13 o5.4o 311.40 , x04.40 56 ;a r NORTHEAST LABORATORY OF DANBURY - .. ..., ... . 39 -3 MILL PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471 (203) 748 -7903 - FAX (203) 748 -0652 LABORATORY REPORT -- WATER SUPPLY TESTING , REPORT TO: NORTHRIDGE BUILDERS Attn: STEVEN DOTTAVIO 5 PROGRESS STREET BREWSTER, N.Y. 10509 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) PHYSICALS: Color Odor pH Turbidity CHEMISTRY: DATE SAMPLE COLLECTED: 7/2/99 TIME COLLECTED: 10:40 A.M. COLLECTED BY: STEVE D. DATE RECEIVED @ LAB: 7/2/99 TESTED BY: LAB# 11471 REPORT DATE: 7/9/99 OLD ROAD, PATTERSON, N.Y. WELL TANK WELL -NEW NONE RESULT: MAXIMUM CONTAMINANT LEVEL 0 per 100 ml 0 per 100 ml 0 ND 6.21 no designated limit 1.4 NTUs 5 NTUs Nitrite N <0.005 Nitrate N 0.94 Alkalinity 45.0 Hardness- :..- 66.0..._ Iron 0.051 Manganese 0.035 mg/L as N mg/L as N mg/L y mn/r mg/L mg/L Sodium 5.3 mg/L Lead 0.001 mg/L 1 mg/L as N 10 mg/L as N no designated limits - 0.30 mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] 20 mg/L** 0.015 * ** ml = milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTED:7/2/99 SAMPLE, AS TESTED ABOVE: OPOTABLE or AMNOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Direct — q or» •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037e (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Permit #P8587 WELL COMIPLETION REPORT. Well Location Street Address: Old Route 22 Town/Village: Patterson, 'NY Tax Grid # Map M0k7 °2 Lot(s) Well Owner: Name: Address: Pauline Flood Brewster, NY Use of Well: 1- primary 2- secondary xxx Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Xxx Compressed air percussion Other (specify) Well Type Screened Open end casing xxx Open hole in bedrock Other Casing Details Total length 45 ft. Length below grade 44 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: xxx Steel _ Plastic _ Other Joints: WeldedyXX Threaded Other Seal: xxx Cement grout _ Bentonite Other Drive shoe: xxxYes _ 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 _XX_ Compressed Air Hours 6 Yield6j_ gpm Depth Data Measure from land surface- static (specify ft) 45 During yield test(ft) 450 Depth of completed well in feet 665 Well Log If more detailed information descriptions or s eve.-aralyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land surface 14 Clay & cobbles 14 30 Fractured bedrock 3u 665 I Hard--black « gr °e rarJte If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 400 3/4 Pump TypeSw9, Capacity Depth € ' Model tt4 Voltage Zo HP Tank Type 81,E Volume 500 1 600 3 665 .6 -.1 / 2 Date Well Completed 06/28/89 Putnam County Certification No. 1 2 Date of Report 613:0/89 Well D ' ler (sign NOTE: Exact location of well with distances to at least two permanent landmarks to be prOvtded on a Separate sheet/plan. Well Driller's Nanw MILL DRILW-Ng. kNC. Address: 75 PUTNAM AVE., BREWSTER, NY Signature: Date: '6/3-0/89 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 July 12, 1999 Mr. Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Compliance Knapp Subdivision - Lot #2 Old Road Town of Patterson TM #35.4-70 Dear Mr. Morris: )Enclosed are the following: 1. Five (5) prints of Drawing S -2, "As -Built Plan," dated 7- 12 -99. 2. Certificate of Construction Compliance for Sewage Disposal System," dated 7- 12 -99. ;3; "Guarantee of Subsurface. Sewage Disposal,Sv e m," dated 7 2,99. 4. Well Completion and Well Log Report, dated 6- 30 -89. 5. Water Analysis Report, dated 7 -9 -99. 6. Application Fee in the amount of $200.00 payable to Putnam County Health -Department. If there are any questions concerning the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry . Nichols, Jr., P.E. HWN:JM:his 98063 LAURENT ENGINEERING ASSOCIATES, P.C. 20 Mi�lt�own \ i woad _. (914 )278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR-, P.E. V V CONSULTING SUE ENGINEERS July 12, 1999 Mr. Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Compliance Knapp Subdivision - Lot #2 Old Road Town of Patterson TM #35.4-70 Dear Mr. Morris: )Enclosed are the following: 1. Five (5) prints of Drawing S -2, "As -Built Plan," dated 7- 12 -99. 2. Certificate of Construction Compliance for Sewage Disposal System," dated 7- 12 -99. ;3; "Guarantee of Subsurface. Sewage Disposal,Sv e m," dated 7 2,99. 4. Well Completion and Well Log Report, dated 6- 30 -89. 5. Water Analysis Report, dated 7 -9 -99. 6. Application Fee in the amount of $200.00 payable to Putnam County Health -Department. If there are any questions concerning the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry . Nichols, Jr., P.E. HWN:JM:his 98063 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ... APPLICATI ®1?�.;T�Jiu�1�1AJ�' please print or type �~- PCHD Permit Well Location: Street Address: Town/Village Tax Grid # HA 1 P-00 PAM�oH Map M. Block q Lot(s) -70 Well Owner: Name: Address: J%4W +PNU1*- rL000 1=0 (o 14Aq i r D 5;RGW;i M W Use of Well: I 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 �i Est. of Daily Usage G06 _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type `3C Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: TBD Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: e Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date; -.. - l5.'.. ` g'. Applicant Sibrature u PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water 11 driller certified by Putnam County. Date of Issue Permit Is ng Official: Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 z Wzijij 1..jVrLrjLjziLU" Arlrur" DEPARTMENT OF HEALTH Services: PUTNAM COUNTY DEPARTMENT OF HEALTH office Use Only sc — WELL LOCATION STREET ADDRESS: JDWN/VILLAQAICIIY TAX GRID NUMBER: Old Route 22 atterson, New York 6 C/ WELL OWNER NAME: A.—tss: Pauline Flood Brewster, New York PRIVATE PUBLIC USE OF WELL 1 - primary 2 - secondary 92: RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR/COND./HEAT PUMP 0 ABANDONED ❑ BUSINESS ❑ FARM C3 TEST/OBSERVATION 0 OTHER (specify) ❑ INDUSTRIAL .0 INSTITUTIONAL ❑ STAND-BY ❑ AMOUNT OF USE YIELD SOUGHT 5 gpm./NO. PEOPLE SERVED 1 _t05 / EST. OF DAILY USAGE gal. REASON FOR DRILLING � NEW SUPPLY 0 PROVIDE ADDITIONAL SUPPLY 0 TEST /OBSERVATION 0 REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 665 fft STATIC WATER LEVEL 45 ft. DATE MEASURED 6/28/89 DRILLING EQUIPMENT ❑ ROTARY aCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING. xfckOPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 45 ft MATERIALS: RSTEEL ❑ PLASTIC ❑ OTHER LENGTH.BELOW GRADE 44 ft. JOINTS: ❑ WELDED JaTHREADED 0 OTHER —DIAMETER 6 in. SEALS CEMENT GROUT ❑ BENTONITE OOTHER WEIGHT PER FOOT 19 lb./ft- DRIVE SHOERRYES 0 No LINER: 0 YES ONO -EEN SGR DIAMETER (in) 'SLOT SIZE LENGTH (ft) DEPTH TO SCREEN (ft) DEVELOPED? - DETAILS 0 YES ❑ NO- - FIOURS SECOND GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH —ft. BOTTOM DEPTH It. WELL YIELD TEST -'It detailed pumping I METHOD: ❑ PUMPED i tests were done is in- COMPRESSED AIR formation attached? 0 BAILED C1 OTHER ❑ YES 0 NO it more detailed formation descriptions or sieve analyses HELL LOG are available, please attach. DEPTH FROM SURFACE Water Bear- ing Wei Dia' meter in FORMATION DESCRIPTION cooe ft ft WELL DEPTH It DURATION hr. min. DRAWDOWN ft. YIELD g p m. Land Surface 14 Clav & cobbles, 14 30 Fractured bedrock. 400 1 30 400 3/4. 30 .6651 lHard black &-grey-granite. 500 1 30 500 1 600 2 — 600. 3 665 6 — 600 6-1/2 WATEP M CLEAR TEMP. QUALITY 0 CLOUDY HARDNESS 0 COLORED ANALYZED? (RYES ❑ NO ANALYSIS ATTACHED? 9k YES ONO STORAGE TANK: TYPE CAPACITY GAL.— PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE __ HP WELL DRILLER NAME DA MILL DRILL NC. 730/89 AGORESS Putnam Avenue Brewster, NY n'test ..._ _ K _...�:.r_. <.�...__.. -. = ,..�... BFiEWSYERj LABORATORIES_ _..n- ..�„�.�.,.,._�«...._.�� .__ _:..�......_..___.�- �.._..�... :.._- Box 224 - BREWSTER, N.Y. (914) 279 -4945 SAMPLE NO. 7414 NEW WELL SOURCE: Pauline Flood Old Rte. 22 Patterson, N.Y. 12563 COLLECTED: 6- 2 8- 8 9 BY:Mill Drilling, Inc. BACTERIOLOGICAL EXAMINATION Colif6rm Count, MF Method .0 per .100 ml. This result indicates the source of the sample was of satisfactory sanitary quality when the sample was collected. 6 -30 -89 as Meyer Director 4% DEPARTMENT OF HEALTH Division of Environmental Health Services COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 _ : °kPPI`TCAT'Yt T.�TO...CONSTRUC`r,..Pi ^'�` ✓ PCHD PERMIT i �j P� O / WELL LOCATION Street Address /Village City Tax Gr, d Number WELL .OWNER Name e Mail,,}}'n.``g'' Address F 4��`l ( VO ��'("C� SC)� ,4� 'Private ❑ Public USE OF WELL Q primary 2 - secondary RESIDENTIAL O BUSINESS 0 INDUSTRIAL ❑ PUBLIC SUPPLY ❑ FARM UINSTITUTIONAL Q AIR /COND /HEAT PUMP (]TEST/OBSERVATION ❑ STAND -BY ❑ ABANDONED ❑ OTHER (specify Q AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED 5 -6 /EST. OF DAILY USAGE gal REASON FOR DRILLING JaNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY ❑REPLACE EXISTING SUPPLY ❑DEEPEN EXISTING WELL ❑ TEST /OBSERVATION DETAILED REASON FOR DRILLING - 7 WELL TYPE DRILLED ODRIVEN E]DUG GRAVEL C1 OTHER IS WELL SITE SUBJECT TO FLOODING? YES >e-' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name ��j.�. Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ?G NO NAME OF PUBLIC WATER SUPPLY: f rj& TOWN /VIL /CITY "DISTANCE -TO 'PR-OP'ERTY -FkOM1 NEARES "r WATT Rt`b A1-N: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION ON PA E H (dat ) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant 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 Date of Expiration: 19 erm�tI sui ng icia Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller { - cOr�NTS LF nIDIVIDCAL, 1WkTER.'SUPPLY `& 'SUBSITRFACE SEA. DISP06AL SYSTEMS; AUM=W SHEET CONSMRLI TioN- PERMIT r DATEl.Y.i......+.a✓ sac_ BY:L Kj er) (Street Location) '.. YES NO Permit Application Corporate Resolution Plans - Three sets s/s Engineers Authorization Design Data Sheet (DDS) SUBDIVISION Deep Hole Log Perc Consistent Perc Results (3) Fill J( Perc Hole Depth cd usd' Plans - o sets permit; PWS letter lance Request required 60 ft. max. Parellel to contours FILL SyST M —g claybarrier 10 ft. fill notes new spec . d depth gauges �l 100 GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow. Fill Profile & Dimensions ;Volume D o •Trench /Galler �Ptrnp pit details is Size",'' Detail Service`Line 'mover �N Construction Notes (grinder notes) _Design -Data: perc and deegc results Two -Foot Contours ~Existing & Proposed Driveway & Slopes Cut Footing /Gutter,Ciurtain Drains (discharge OK) Perc & Deep Holes Lccated Representative of primary and expansion Expansion Area;shean;gravity flow,suff. size If Pupped Pit & D Box Detailed e - No. of Bedr s & SSDS's w /in 20 Proposed Systems X ty Metes & Bounds Setback Necessary (Tight lot) Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN to P.:.{., Driveway, Large Trees,Top of fill to Foundation Walls to Well; 200' in D.L.O. 150' pits 0' to Stream, course, Lake Unc. exran) 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks i .10' trom Foundation; 50' to well 15' Well to PL NORTH AMERIC N FIOUSING (;AMBR!DGE II 48' 4828 TH M. BATH O' O W.I.C. MASTER BATH' W /GARDEN TUB SECOND FLOOR 4828 = 1344SF k } _ > (' . DINING NOOM , i J1 MORNING R. OM _ . .0 1 El i _ OPEN �) ABOVE .. LIVING ROOM•I u - FAMILY ROOM 1]..8.. x 18..0.. 13..0" x 17..0.. 1 ti 'FOYER FIRST FLOOR - 4828= 1344SF 'LA ALL FLOOR PLANS AND ROOM SIZES ARE APPROXIMATE NORTH. AMERICAN HOUSING CORP/ P. o. box 145 •point of rocks, matyland 21777 (301) 948 -8500 •.(301) 694 -9100 • (301) 442-1410' Plans, Prices And Specifications Subject To Change Without Notice Copyright 1985. (See Reverse Side) BATH f BEDROOM 4� ' BEDROOM] I y.e.. x.14..0•. I��l -_ _ WANK 13'-0'• 1 �'y - _ t t� mayy' ... JJJyyy!!!jjjjjj111 MASTER BEDROOM. x 16--Er- 6 . ! OPEN 4828 TH M. BATH O' O W.I.C. MASTER BATH' W /GARDEN TUB SECOND FLOOR 4828 = 1344SF k } _ > (' . DINING NOOM , i J1 MORNING R. OM _ . .0 1 El i _ OPEN �) ABOVE .. LIVING ROOM•I u - FAMILY ROOM 1]..8.. x 18..0.. 13..0" x 17..0.. 1 ti 'FOYER FIRST FLOOR - 4828= 1344SF 'LA ALL FLOOR PLANS AND ROOM SIZES ARE APPROXIMATE NORTH. AMERICAN HOUSING CORP/ P. o. box 145 •point of rocks, matyland 21777 (301) 948 -8500 •.(301) 694 -9100 • (301) 442-1410' Plans, Prices And Specifications Subject To Change Without Notice Copyright 1985. (See Reverse Side) 4 i NEW YORK STATE DEPARTMENT OF HEALTH Specific Waiver Bureau of Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75- A,10NYCRR -..., for Individual, Household Sewage Treatment Systems 1. Reason why site does not meet 10NYCRR Appendix 75 -A (check appropriate box(es)) Separation distance cannot be achieved. Excessive slope. High groundwater. Inadequate depth to bedrock or impermeable layer. Soil unsuitable. Other (explain) .................. ............................................................................................................................ ........I...................... - ........................................................................................................ ............................... ............................................................................................................................................. ............................... 2. Proposed design or conditiQns of waiver- ('4JA d -2-0 �/, ......................................................................................................................................... ............................... .............................................................................................................................................................................. ............................... 3. The proposed design may have the following limitations (check appropriate box(es)): __1 Increased risk of well or spring contamination. Increased risk of surface water contamination. Expected design life of the system will be diminished. Operation of sewage system is subject to mechanical problems. Other (explain) ..................................................................................................... ............................... Additional information attached Construction pursuant to this waiver request should not pose any foreseeable health or environmental problems. In accordance with New York State Department of Health Administrative Rules and Regulations, Part 75.6 (b), a waiver is hereby granted. This waiver maybe revoked by tPENTtl wing official for a change in conditions for which this waiver was granted. .. ............................... FiEPFi VE OF 61MISSIONEFi OF HEALTH ORIGINAL - Local Health Agency COPY - Applicant /Design Professional 1. ........................... ............................... DATE a NH -1326 (7/92) (GEN -152) LAURENT ENGINEERING ASSOCIATES, P.C. - MILLBROOKE OFFICE CENTRE Route e Milltown Road V lY?rt - ..... - :.. V V \ (914)278 6108 (FAX) 278-2658 �i HARRY W. NICHOLS JR,, P.E. CONSULTING SITE ENGINEERS July 8, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Proposed SSDS - Renewal Flood Property Hayt Road } (T) Patterson, New York - a Dear Mr. Morris: In response to your review letter dated June 23, 1998 we offer the following: - 1. The existing well. is located on the plan. 2. The primary system is proposed to be regraded to 15 percent slopes with 3:1 embankments to grade. 15 percent slopes have been accommodated for in the expansion area. The overall existing slopes for primary and expansion areas exceed 20 percent. We respectfully request a waiver on >the existing grades. 3. Prior to scheduling of witnessing one deep test . nit and one nPrc!?Ia ±o►, tPsr in the. . - primaryry SSTS area, we request confirmation that a renewal of this design is possible. 4. The subject property is part of two -lot subdivision fled as Map No. 2347 on 9/19/88 as the Knapp Subdivision, Kindly revise paperwork to reflect this -information, and the correct Tax Map number which is 35.4-70. Also enclosed are five (5) prints of Drawing S -1, "Proposed SSTS ", revised 7/6/98. Kindly review the enclosed and contact our office with your determinations at your earliest convenience. _ Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nic ols, Jr., P.E. HWN:bd 8738 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New. York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 June 23, 1998 Harry Nichols Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed.SSTS: Flood Hayt Road (T) Patterson, TM# 39 -4 -70 Dear Mr. Nichols: BRUCE R. FOLEY Public Health Director Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental or the Putnam County Department of Health on this lot, percolation test must be witnessed by a representative of this Department. ~- - If the well has been constructed the well is to be labeled as existing. 2) All slopes within the SSTS area greater than 15% and less than or equal to 20% must be reduced to 15% by the addition of fill or the SSTS trenches be designed 10 feet on center. All slopes greater than 20 %_ are unacceptable. 3) the minimum of one deep test and percolation test is required in the primary SSTS area. 4) Neighbor notification is required. Upon receipt of a submission, revised to reflect that above comments, this application will be considered further. RM:tn V . truly yours, Robert Morris, P.E. Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH SUBDIVISION 48 LEGAL SUBDIVISION SUBDIVISION APPROVAL Cl IECKED 49 PERC RATE 50 11 FILL REQUIRED DEPTH 51 12 CURTAIN DRAIN REQUIRED 52 13 STANDPIPES 53 -CENERAL 54 DIVISION OF ENVIRONMENTAL HEALTH 55 INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS 56 LM, A'REY►EW SHEET FOR CONSTRUCTION PF.RMUT; CS WITNESSED STREET LOCATION ' NA�f E OF 011'NER 17 REVIEWED Bl R, S, NIB, BH DATE _TAX MAP # 60 19 >> 61 ' - "- -20 Y N DOCUMENTS -Y`� , 1 63 22 PERMIT APPLICATION ] EROSION OL:HOUSE,� SSDS 2 23-7 S M PLAN - (NORTH ARROV06 PC -I 38 67 ERC DEEP HOLES LOCATED 3 i 267 WELL PERMIT_ PWS LETTER 39 27 EP N PRIM & EXPANSION 4 28 Y CONTOURS EXISTING & PROPOSED LETTER OF AUTHORIZATION 40 -DRIVEWAY & SLOPES, CUT CATIO 5 FOOTING /GUTTER/CURTAIN DRAINS DESIGN DATA SHEET (DDS) 41 71 XP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE 6 CORPORATE RESOLUTION 42 33 IF PUMPED, PIT & D BOX SHOWN & DETAILED 7 34 DATUM REFERENCE SHORT EAF 43 LOCATION OF WATERCOURSES, PONDS OUSE - NO.OF BEDROOMS 8 LAKES AND WETLANDS WITHIN 200 FEET 36 PLANS - THREE SETS 44 7WELLS & SSDS'S W/1N 200' OF PROPOSED SYS. 9 HOUSE PLANS -TWO SETS 45 PROPERTY METES & BOUNDS 10 VARIANCE REQUEST 46 HOUSE SETBACK NECESSARY (TIGHT LOT) FEE 47 HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE SUBDIVISION 48 LEGAL SUBDIVISION SUBDIVISION APPROVAL Cl IECKED 49 PERC RATE 50 11 FILL REQUIRED DEPTH 51 12 CURTAIN DRAIN REQUIRED 52 13 STANDPIPES 53 -CENERAL 54 LOCATED IN NYC WATERSHED 55 P ANS SUBMITTED TO DEP Ff,,'DELEGATED 56 TO PCHD CS WITNESSED COMMENTS: NO BENDS; MAX.BENDS 450 V,7CLEANOUT 1;1 LL SYSTEMS CLAY BARRIER 10- FT. I IORIZONTAL ;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSDS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TQ FOUNDATI .ON_.W..AI..LS._15'- WEL.L.TO -I?L—. 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS 15'MIN to CDS= >5 0/.,'10'- 4 %,25'- 3 %,30'- 2 %,35' -I %,100' - <I %' 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION _ J 1""R VAL, IF REQ'D 57 < 14 P TEST F OLES OBSERVED [ER 58 15 CS WITNESSED 59 16 PROVAL SSDS ADJ. LOTS 17 i" WETLANDS (TOWN /DEC PERMIT REQ'D ?) 1$ DATA ON DDS PLANS & PERMIT SAME 60 19 PRE 1969 NEIGHBOR NOTIFICATION 61 ' - "- -20 " E1"1'ER F3UZA_ 62 21 100 YR. FLOOD ELEVATION 63 22 OTHER REQ'D PERMIT(S) 64 REQUIRED DETAILS ON PLANS 65 23-7 S M PLAN - (NORTH ARROV06 247 SDS HYDRAUL PROFILE 67 25 FL i 267 CONSTRUCTION NOTES 68 27 DESIGN DATA: PERC & DEEP RESULTS 69 28 Y CONTOURS EXISTING & PROPOSED 29 -DRIVEWAY & SLOPES, CUT 70 30 FOOTING /GUTTER/CURTAIN DRAINS 31 SOIL TYPE BOUNDARIES 71 32 - TITLE BLOCK; OWNERS NAME,ADDRESS72 TM #,PE/RA; NAME,ADDRESS,PHONE# 33 DATE OF DRAWING /REVISION 34 DATUM REFERENCE 35 LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET 36 PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: NO BENDS; MAX.BENDS 450 V,7CLEANOUT 1;1 LL SYSTEMS CLAY BARRIER 10- FT. I IORIZONTAL ;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSDS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TQ FOUNDATI .ON_.W..AI..LS._15'- WEL.L.TO -I?L—. 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS 15'MIN to CDS= >5 0/.,'10'- 4 %,25'- 3 %,30'- 2 %,35' -I %,100' - <I %' 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION _ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICES C1�_AIi`T�iORIATION r......._.. _ RE: Property of J00N C4 + FRUI►Nk H_00P Located at HAT P—DAP T/V PATS' M2 02 4 Tax Map # Subdivision of Subdivision Lot # Gentlemen: ' 9- Filed Map # Block 4 Lot 10 Date Filed This letter is to authorize 14'kp. ( W` �'LNOe.�, , PF_ JR., a duly licensed Professional Engineer X 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. OF N E r� cyo 9¢ Countersigne C P.E., R.A., # No. 56124 Mailing Address Very truly yours Signed: �i (6wner of Property) Mailing Address: " (P "(11 P�bdlp A,5cv&jL,- 20 mWrjw�k P-o, w� ��, 6PLEW41 Ef, State 14F-\N 1a Zip 18 ezo°\ State HN *PIL Telephone: S Telephone: ( q m) Zip 10601 Form LA -97 HARRY W. NICHOLS JR., P.E. May 13, 1998 j \ V \ LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Bewwst @r, New York. '74509 "- •`_ , (914)278 -6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS �� -- �-w a t'•.p� ' �-� Flood Property Hayt Road (T) Patterson Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -1 "Proposed SSDS ", dated 5/13/98. 2. "Short EAF ", dated 5/13/98. 3. "Application For Approval of Plans For a Wastewater Disposal System ". 4. "Construction Permit" for Sewage Disposal System ", dated 5/13/98. 5. "Application to Construct a Water Well ", dated 5/13/98. 6. "Design Data Sheet ". 7. "Letter of Authorization ", dated 5/13/98. 8. Two (2) copies of Residence Floor Plan(s), for 'Bedroom Count Only ". 9. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURE T ENGINEERING ASSOCIATES, P.C. Harry W. Nichols' Jr. P.E. " HWN:JM:bd 8738 LAURENTENG|NEEFl|NG ASS[CV\TES.P.C. MILLBROOKE OFFICE CENTRE ` Route zz& Milltown Road �0W�M B=°°'e,.New Yom`omm CONSULTING SIT - r-4 E -ENGINEERS. V9llA JOB No. SHEET No. COMPUTED JH DATE SCALE '_--_.__._--_'---_--_ - --|'-�----+----'---------r-----r--�--�'----�-�'-'�------- - ��.'----^' ---- _'7-' - -�7 __��-'__--`--------__--�-� - - | � ------ --'-�------'-- - � - � ''-�'------- '--�'-'-'�---''- � ...... - -- � . . - - . LAURENT ENGINEERING JOB No. • ASSOCIATES, P.C. SHEET No. OF MILLBROOKE OFFICE CENTRE Jm Route 22 & Milltown Road COMPUTED BY DATE j Brewster, New York 10509 AW,J CONSULTING. -SITE: ENGINEER - ... _ - 5- . :.r.. s- - _ -- CHECKED BY- .- SCALE : • . _. u p ON! b. vF _.. _ • y : OF ,FplLTti- CoIJNTY F PLANS APPROVED �,��t Dr to i 54nature 17 10 ©'.'- A O: 11h, I-Z'-4y4' LAURENT ENGINEERING ASSOCIATES, P.C. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 RANDOLPH W. LAURENT, P.E. HARRY W. NICHOLS JR.. PE. CONSULTING SITE ENGINEERS August 3, 1987 Putnam County Department of Health 110 Old Route 6 Center Carmel, N.Y. 10512 Att: John Karell, Jr., P.E. RE: Proposed SSDS Hayt Road Patterson, NY 12563 Dear Mr. Karell: Enclosed are the following: i 1. Three (3) prints of Drawing SP -1 "Proposed SSDS ", dated 7- 31 -87; 2. "Construction Permit for Sewage Disposal System ", dated 8- 03 -87; ' 3. "Application to Construct a Water Well ", dated 8- 03 -87; 4. 5. 6. "Design Data Sheet" "Letter of Authorization ", dated 8- 03 -87; Two (2) copies of Residence Floor Plan.(s), for "Bedroom Count Only ". 7. Check in the amount of $100.00 payable.to the Putnam-` `County Health Department. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely, LAURENT ENGINEERIN ASSOCIATES, P.C. Ra dolph W. IL urent, P.E. /map CC: Ms. Madelyn J. Barbour w /1 copy each enclosures: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES,' : >Re__ ._ Property of Located at �%��(I t2pk% ' (T) xni Section (0�— Block Lot! Subdivision of Subdv. Lot # Gentlemen: Filed Map # Date This letter is to authorize 7 � 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 ; •, �t connection with this matter and to supervise the construction of said system or systems in conformity" with the provisions of Article 145 or- 147., Education Law, the.Publ•ic Health Law, and the Putnam County Sani- t` tary Code. Co ersign P.E. , R.A. , • # N11LLIA O,p'�\ • wig • t J J Very truly yours, Signed Address t12aj —k l(�i Ivk c =i�iL� fiSSc>c (�C Address Telephone (914) Town Telephone DIMENSION CHART (in ft.) No. A p I 22' 2 13' 3 m1. 4 a1' 5 h4' A4' l0 28' 21' n 90' 91' IZ 8�i' 81' 14 15 Co(p l4' 16 60' -70' r 8 411- Q,4' m N 0 2 THIS IS CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT `THE SYSTEM WAS INS- - PECTED BY ME BEFORE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED 'IN ACCOR- DANCE WITH ALL STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNTY DE- -PARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. 9U2v&,! IMFo>LMITI "r rkM A PLl4N PFWAaM 01)' TERRY PJECGENOJA_FP C_dLLIN�7, �.4 i /v — - H � 1 n t% ELF s 14 rt 9 v � c e \ DEG � � EXISYIMu 40R� \ \�'C 2 '� RESICENGE uJ a' � i I O L 0 R OA O HAyr RM -D EDWARD, P_ -D, DIMENSION CHART (in ft.) No. A B q,W1y V� 3 (oi' � � 4 co So' s *4 44' G 46, 8 3ro' 2S, 9 29' 20' l0 20' 21' II 9o' 911 . 2 al g�! ry 11' P1q' 14 15 "14' 6 Go' b' 11 54' 'is I6 41' r,41 THIS IS CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INS- - PECTED BY ME BEFORE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED *IN ACCOR- -DANCE WITH ALL STANDARD RULES AND REGULATIONS OF THE PUTNAM COUNTY DE- - PARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH.. 5GRvE'/ INFOQ- H.�TIOH Fiore A PLJ4N FWAaM E,)/' TERRY DEPAENDeA-FP GOLLIN�j, L. �J 3 m h ro Z N 23 0 9 N 9 N o' �• \mil Z '¢ EX IE�71i -IG 4 BR- itG51DENGF- \ 1 \ \ q,W1y V� a' � � I O L 0 ROA0 (A. K•A HAYT P( P I apyJARO.j f>-0 DIVISION OF ENVI11O*MML FMIM SERVICES DESIGN DATA SHEET-SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner 044t-1 tic Address U-<-( 1 -0. Located at (Street) Sec. Block '1-t (indicate nearest cross street) municipality Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre-Soaking 41-11- 07 Date of Percolation Test NUMBER CL= ME PERCOLATION PERCC'i TION .Run Elapse Depth to Water From Water Level No. TL-M Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches 1,12S' .2 /, 6, 27 oly 3 /: So - 27 V 3 2 1::IYV 2-V Ci✓ 3 4 2 4 5 N=:, 1. Tests to be repeated: at same depth until, approximately equal soil rates are obtained at each percolation test hole. All data to'be submitUd for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOIIS ENOO MERED IN TEST HOLES DEPTH HOLE NO. I HOLE NO. L HOLE NO. G.L. r i' "• CJ o L � IL :a 2' 3' i S D`i 4' I.00A 5 S 0r 6 1-!E 6' 7' 8' �o QSiU� �,)n IZGLI! 9' tilc� WPr 02 - ►JD vJk(E2 lo' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNURMR IS ENCOUNTERED -SIQtt INDICATE LEVEL TO WHICH WATER LEVEL AFTER BEING ENCOUNTERED f.I /A A DEEP HOLE OBSERVATIONS MADE BY: IVItA6" DATE: DESIGN Soil Rate Used 6-10 Min/1" Drop: S.D. Usable Area Provided ;?4171 S F No. of Bedr(oons 4 Septic Tank Capacity I2e20 gals • 1�1- C ^/C&-7j2�7 Absorption-Area Provided By _444 _ L.F. x 24" width trench Other r. F NEW / ILLI Name L2g1"r �,tj&tmepz)I1�(� /Y �L Signa t " 9 Y. ¢�\ Address 1 ?Ll -ZFI [�7 17 I fsI`L /1 �� SEA ` Soil Rate Aj.Troved sq.ft/gal. Checked by Date 14154 12187)—Test 12 PROJECT I.D. NUMBER 617.21 SEOR / Appendix C C, Slate Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION rrr tur Annll,.nt — is—; —t en.,,.r:,.A. 1. APPLICANT SPONSOR ' JOHN G+ PAVH NE 1 i-WoO 2. PROJECT NAME I =LoDO l H p i v 10 VAL :STS 3. PROJECT LOCATION: p r;L "Ill Municipality " PAMfW,&N - County Ill a. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) KA& Roap 5. IS PROPOSED ACTION: ANew ❑Expansion ❑ ModificatloNalteralion ' 6. DESCRIBE PROJECT BRIEFLY: �,oiihiRUt::.TIDH of rjlNt�E C�� yZESIDEhkEI '�Q- htENR>IL .,hlc'I.LtSrT'i� 7. AMOUNT OF LAND A�FFFEECTED: Initially acres Ultimately � acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ®Yes ❑ No It No, describe briefly 9. WHAT IS PRESENT. LAND USE IN VICINITY OF PROJECT? ®Reaidentlal ❑ Industrial ❑ Commercial ❑ Agriculture • ❑ PafklFor"t/Open space ❑ Offer Describe: S,HU&,Cf 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL) ? rah ❑ Yes (ONO If yes. list agency(s) and penniUepprovals 11. DOES ANY ASPECT OF THE ACT,: -I HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Cl Yes ®NO If yes, !Isl acency name and permlVapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REGUIRE MODIFICATION? 13 Yes 09 No 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE � W, w'oLi I fg• y ANE1-r Ij) APDIIanVSponsor, me: —NA�—W Date: Signature: . •' 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 i; s .a t} PART ll= ENVIRONMENTAL ASSESSMENT (To be comoleted by Aaency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? It yes, coordinate the review Process and use the FULL EAF. (:3 Yes Cl 4el B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 It No, a negative declaration may be superseded by, another involved agency. rl Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answer may be handwritten. it legible) Cl. Existing air quality, surface or groundwater quality or quantity, noise levels. existing traffic patterns, wild waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural. archaeological, historic, or other natural or cultural resources: or community or neighborhood character7 Explain briefly: CJ. Vegetation or fauna. fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: Ca. A community's existing plans or goals as officially adopted. or a change in use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsegednt cevelopment. or related activities likely to be Induced by the proposed action? Explain briefly. 4. Ca. Long term, short term. cumulative, or other affects not identified in Cl-CS? Explain briefly. ,q C7. Other Impacts (Inducing changes in use of either quantity or type of energy)? Explain briefly. 7 }l D. IS^T-�HERE. OR IS THER' LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes ❑ No- If Yes, explain briefly .j PART 111 — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: Fos 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) geo6raphic scope; and (q magnitude. If necessary, add attachmeMt or reference supporting materials. Ensure that explanations contain sufficlent detail to show that all relevant adverse impacts have been Identified and adequately addressed. ❑ Check this bore if you have identified one or more potentially large or slgnificant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box If you have determined, based on the Information and analysis above and any supporting documentatior, that the proposed action WILL NOT result in any significant adverse environmental impart. AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Printer name/% Responsible OffiCe, in lead Agency — Signal— Of Responsible Officer in Lead Agency Title of Responsible Officer Signal— of repare, (if different from responsible officer) l C ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: JoHt4 Ci. t PAVUNE PI_ UI) R} .YT P-OAP "(o 13REWSTM H' to6oq 2. Name of project: Fl oy )HPIVI &AL 64T5 3. Location T/V: PAMM)A h1 4. Design Professional: "W Wv N(4101A ,XPC- 5. Address: LA4EWeHWrE54 1141 i gA'-rnE X 6. Drainage Basin: LRoSaH 20 m1u,7owa P4 lrt5 Qke4i w losoq 7. Type of Project: A Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I _ Exempt X Type II Unlisted _ 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... _ No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... 13. If so, have plans been submitted to such authorities? ........ ............................... iq0 14. Has preliminary approval been granted by such authorities? — Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... No 19. If yes,,name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ 21. Name of sewage system _ Distance to sewage system = 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................. ............................... �o 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... ' rlo 26. Has SPDES Application been submitted to local DEC office? ......................... ; No Form PC -97 I �r i 27. Is any'p' ion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ........................................................... ............................... _ 29. Is Wetlands Permit required? ......................................:....... ............................... _ Has application been made to Town or Local DEC office? ............................... �a 30. Does pr. ",oject require a DEC Stream Disturbance Permit? .. ............................... _ 31. Is or wads project site used for agricultural activity involving application of pesticidfs to orchards or other crops, solid or hazardous waste disposal, landfills g, sludge application or industrial activity? ...................... .. Yes/No _ 32. Is proj�yt located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other pptentially known source of contamination? ..................... _........ Yes/No DESCI;BE: i No HO Ho He Me 33. Is there a local master plan on file with the Town or Village? ......................... `(E.r 34. Are co*unity water and/or sewer facilities planned to be developed within 15 yearsin or adjacent to project site? ................................ ............................... NO 35. Are anysewage treatment areas in excess of 15% slope? . ............................... iE5 36. Tax Map ID Number .......................... ............................... Map '�9 a Block Lot s 37. Approved plans are to be returned to ..... Applicant SC Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater.plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and subrait 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 accompariied by a Letter of Authorization (Form LA -97). Failure to comply with this provision be ° may grounds for the rejection of any submission. P 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 misdemeanor pursuant to Secli n 210.45 of the Penal w. r SIGNATURES & OFFICIAL TITLES. Mailing Adds; ss :.... ............................... UWh-tK JTMtgwEERIW,, /' SSOGtPrt65, pL ! 9 ru 1lvAivl COUNTY DEPARTMENT OF HEALTH'. DIVISION OF ENVIRONMENTAL HEALTH SERVICES y DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM J Owner JQK1 k(A -k- Ph)I,tNE PLOpp Address P(, li-) irPL A9 b(ISW 11�-rrf laia'% Located at (Street) 1fhir P-0 AV 22 Tax Map Block Lot _� 0 (indicate nearest cross street) Municipality PASev-�Px► Drainage Basin C.¢ tirDN SOIL PERCOLATION TEST DATA Date of Pre - soaking H-1111 Date of Percolation Test Hole No. Run No. Time Start - Stop Ela se Time Iin.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Dropp In Inches Percolation Rate Min/Inch A 1 f °6 I,15 i9 17) 6.,V I 2 I VA ri3 � TQ 1 3 4 5 2 ) ti° 3 ),Jr 2i° 215 4 f 5 1 2 3 4 t 5 nvi rs r. r ests to oe repeatea at same aepm unit approximately equal percoiaaoa races are voLauwu - .- percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 ; y n( t[ 0{ !y ii L TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. Z HOLE NO. G.L. 0.5' O �'1" TbEKOt� a-IZ° 1oP5o1L 1.0' 1 1.5' 2.0' `i 2.5' 3.0' riAND11 5AN0( 3.5' ? yl ° -6+1° i,oacr•�j 1'L " -��� LAP"M wI 4.0' ti> STOH� 4.5' ' 5.0' 5.5' 6.0' 6.5' x 7.0' 7.5' 8.0' :a s.s' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered ,r Indicate level, at which mottling is observed 4 Indicate level to which water level rises after being encountered Deep hole observations made by: . LNW"r A'?SCJ( P1,, Date y 1i Design Professional Name: Ft W N1tM" JE QE• — Address: LAUD -Etr 6HiAi ,,ffm* QV NEW. P, �Lo`m�w�or�d P� Orly y.1 Nf lo��q Ni� 5 CO C e w Signature: 2 No. 66124 FESS1o�10� Design Professional's Seal �A?o s a 14-164 (M?) —Text 12 PROJECT I.D. NUMBER 617$1 SEAR Appendix C State Environmental Ouatlty Review SHORT ENVIRONMENTAL ASSESSMENT FOR". For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION rro he comnleted hV Annilcent or Prnlect enonsnd 1. APPLICANT ISPONSOR ja014(A, -r PAJUNE Ft_ooD 2. PROJECT NAME. TL�� tNONIJVAL 5�iTS 3. PROJECT LOCATION: c(}�n (]� PATT`f+0N PVTHA41 Municipality County a. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, ate., or ptovlde map) I-Wr P DAO S. IS PROPOSED ACTION: Icv New ❑ Expansion ❑ Modificationlalteration B. DESCRIBE PROJECT BRIEFLY: CBK4tP -vr,T A 9P SimLia FLnote m- gE1wa`, wEw$ '5ePnL 7. AMOUNT OF LAND AFFECTED: C Initially 0-16 acres Ultlmalety 0,15 acres S. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? , ®Yes ❑ NO 11 No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? M Residential ❑ Industrlai ❑ Commercial ❑ Agridullure ❑ Park7FOreeVOPen space ❑ otner Describe: SI W a R{k}'1f Vr 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ® Yes No It yes, list agency(s) and permiVapprovals J❑ PUT}.14M Vb�NR NEM!(i1 WE1A.{�j5 TWO Dj— RMytW=4 bLOA %?T.- bJI1 -%P1k (sir, 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ONO II yes, list agency name and permlVapprwal 12. AS A RESULT OF ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? l �NP�ROPOSED ❑ Yes KEO ' I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE I+AW W,NI(44005 E. onsor ApplicanUSp me: Dale: _ Signature: tl r/ 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 E PART II— ENVIRONMENTAL ASSESSMENT (To be completed by ADencv) A DOES ACTION U(CEED ANY TYPE I THRESHOLD IN 8 NYCRR, PART 817.129 If yes, coordinate the r*A— process and use ths'FULL EAF. . ❑Yes XN. B. WILL ACTION A_CEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.61 If No, a negative declaration may ba auperaafi�d� y another Involved agency. O Yea 1Iko C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten. If legible) Cl. 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. IW" C2. Aesthetic, agricultural. historic, or other natural or cultural resources; of community or neighborhood character? Explain briefly: C7. vegetation or fauna, fish,, /shheellflah of wildlife species, significant habitats, or threatened or endangered species? Explain briefly: 1„ `f Ca. A commur,lty'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 �6 CS. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. Ca. Long term, short term, cumulative, or other.effecls not Identified In C1-05? Explain briefly. N') C7. Other Impacts (including Changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR 11 T ERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yea 0 If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, Important or otherwise significant. Each effect s1fould 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 (p magnitude. If necessary, add attachments or reference supporting materials. Ensure that axpianauons cvntam sumcront Defeo w snow —, a,, rasrava ..aver.. nnpama nave O Check this box If you have Identified one or more potentially large or significant adverse Impacts which MAY a',' /cur. Ti1en proceed directly to the FULL EAF and/or prepare a positive declaration. 3 Check :his 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 ring a/ Typp)Naammeee of Responsible officer in Lea Agency it <p I Re i e O icer igna vol. Officer in Lead Agency Signature of reparer (If different from responsible a icer) `/ N f v • i PUTNAM COUNTY DEPARTMENT OF HEALTH off°' h y 7 DIVISION OF ENVIRONMENTAL HEALTH SERVICES i / ! FINAL SITE INSPECTION Date: Inspectedfby: Street Location _ /L/,q }�% RoA[7 Owner Town PArZek6o.V Permit# TM # Subdivision Lot # 1. Sewage System Area YES NO COMMEND a. STS area located as per approved plans ........................... b. Fill section -date of placement rb , 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 ...... ...........................:... II. Sewage System a. Septic tank size- 1,000 ........1, 250 ......... other ................ JC 8':2 x S -$,x 3� b. Septic tank instal a evel ................ ............................... 7-s K s -A C. 10.' minimum from foundation .......... ............................... X ,4o r z• G d. D'stri u out tion o ets at same elevation -water tested ................. 2 -. Protected below frost .................. ............................... i �. 3. Minimum 2 ft.Original soil between box &trenches e. Junction Box -properly set ........... ............................... )G f. enc es engt required Length installed 336 X 2. Distance to watercourse measured-t 3,a o Ft.......... u 3. Installed according to4laj ..... ............................... 4. Slope .oftregplraccept /16- 1/32" /foot ............. 5. 10 ft. fr erty li e - 20 'foundations.......... P 6. Depth o ench <30 inch o 6yrfade .................. 7. Room allowed or mans �r /o ......................... .. 8. Size of gPO4 i d ameter clean .................... 9. Depth of oeel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed System /,�`� Y X T L 9" X 1. Size o pump chamber ......... ............................... l . 2. Overflow tank ................................... I........................ 3. Alarm, visual / audio .................... .............................:. 4. Pump easily accessible, manhole to grade ................. X, ;. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House�/Buildinn a. use se located per approved plans .. ............................... b. Number of bedrooms .......... .....3....M /r1S................ IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured _t- too ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship ; a. Boxes properly grouted ................... ............................... x r b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... % Rev. 6/97 orm � too � '"",• � �taSurcr.Q ovj --- - { Ta be cke�leec�% on ,- �- 1 �, 3 \� \ �� y1 a c �,_.� ?`� c . � C� �l , �` � a ,- �- 1 �, 3 \� \ �� y1 a c �,_.�