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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -77 BOX 16 11,11 WIN 1 }. T J IN �, , ,,.I... , I '6 A. 01739 a s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: E South Acorn Pass Town/Village:. iMap T -ax Grid # Patterson Block + Lot(s),� Well Owner: Name: Address: JGC Associates 22 Tulip Road Brewster, NY 10509 Use of Well: 1- primary Kxm 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Irk Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 42 ft.. Length below grade 40 ft. Diameter min. Weight per foot 1 Ab /ft. Materials: Steel _ Plastic _ Other Joints: Welded X Threaded Other Seal: _ Cement grout X Bentonite Other Drive shoe: X Yes No Liner: Yes _": No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours 4 Yield 40 gpm Depth Data Measure from land surface - static (specify ft) 70 During yield test(ft) 100 Depth of completed well in feet 405 Well Log If more detailed information descriptions or sieve analyses are available --------- --- .._ please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 7 Sandi Soil — cobbles 7 405 ;.iar Grey Granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 405 40 Pump Type sub Capacity 7 Depth 220 Model 7GS07412 Voltage 230 HP 3/4 Tank Type d a 11 Volume 62 Date Well Completed 3/10/04 Putnam County Certification No. 2 Date of Report 4/20/04 W er NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. WellDriller's i Inc. Address: 75 Putnam Ave., Brewster, hTY Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 a NAM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREAT ;; PCHD CONSTRUCTION PERMIT # P ° '01 _ 01 _�.2 Located at $ g50 r4 ACO W PA- Town or Village i)'TTi5W50H Owner /Applicant Name 004�e CA I-- V LA H Formerly Mailing Address M Ti VIP ZA Ii Tax Map t5, Block 4 Lot Subdivision Name AM klLL E %A-17�5 Subd. Lot # ff-6 w 5- -r,5P- ,jr, Date Construction Permit Issued by PCHD Separate Sewerage System built by Address Consisting of 196" Gallon Septic Tank and 4-44 u r A- lam% rg.ewclt4 Other Requirements: '�' 5- P-.0.6, rlq, (q O) 0), Water Supply: Public Supply From, Address Zip (.6 50 or: Private Supply Drilled by H 1W DF410.101Q i iH6, Address-75 PvintAfA AV' 6W• f - . Building Type .. lZC;!� 3 C iFNC-E _ Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed? 00 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 De nt of Health. Date: J 2.6 01 Certified by P.E. LK R.A. e i Professional) i i o�v i cense # 5,c t Z Address I-010 p% 2,1— OR-6 I -a IQ 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 are subject to modification or change when, in the judgment of the Public Health Director, such revocation odification on ch ge is necessary. By : Date: ° White copy - HD File; ellow <opjy- Building Inspector; Pink copy - O ner; Orange copy - Design Professional Form CC -97 L�G J � a t .< BRUCE R FOt EY L,ORETTA MOLD ARI RN., USX. Public Health D:rectet '� Anociate Public Health Diracter � Atractor of pat:ant Servius_. . P .?' Pr i ems ' - O PMALITI 1 Geneva Road Brewster, Now York 10509 Inricoamental Health (914) 278 - 6130 Feat (9 14) 278 - 7921 Nurslnfi Services (9141277.655E WIC (914; 273 -667E Fax (914) 278.608= Early Interveatiaa (914) 278 - 6414 Preschool (914) 278.6082 Fax (914) 278 - 6648 V / 7 .4L t►itiry nc+c, % rn" r'TrrT . r'r+T a %lamT .'0 H144-1 M (MW MILL (,of V) OWNERS NAME: _ TAX MAP IN FIBER: 3 � , �% 7 7 E911 ADDRESS: S Soar- A C e> le Al R4 SS TOWN: : po,� i rr,Cle S o &% r AUTHORIZED TOWN OFFICIAL: (Signature) DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted v�ith the application for a Certificate of Construction Compliance. (E9 : 1 ERiRl Ms MAY -11 -2004 12:07 PCI HARRY.W NICHOLS 914 279 4567 1A. zz . . Q1 A P.01 ?UTNNAM COUNTY DEPARTMENT OF HEALTH Dr.MWON.OF EN'VIRONMEN'TAL HEALTH SERVICES RFQJMST FOR FjN;& INSPECTION . For:, Fill Date: `..,H ►L,4 or 4ad Trenches ✓ _...,... PCHD Construction Permit -61 Located: 9 SOJjW A Goei) PAT: (T) M Psi =L) Owner /Applicant Name: CA1QYQ - -LQ4 kjj h) TM. Block,!_ Lot :77 Formerly, SubdivisionNa�ue:` .tPp� �}Ju s^:scjs' Subdivision Lot # 20 Is systeD fill'contpleted? Date: I's system complete? its Date: a.,i+- 04 Is system constructed as per plans? s . Is well drilled? s a Date: 0S.- if - Qom,_ Is well located as per plans? y =s Are erosion control measures iu placo? I certify that the syste60), as listed, at the above pfemises has been constructed and I have inspected and - verified their obmpletion in accordance with the issued PCHD Construction Permit and .approved plans and' the Standards, Rules and• Regulations. bf the Putnam County Department of Health. Date: Cer+iPd ham: Y h , r ,y RA ..'DesigoTpfessional Address: 2cl, 5 a 2oaR 22. U 124 _, ... FOR: El -ADAM o Form M -99 MAY -11 -2004 TUE 12:24 TEL:845- 278 - 7.921 . .....NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 cL s •e ._W...._ . .--- fILORFI t'1 IMVLYi°ii"lM" - - - ' .j, �. 'ROBERT J. BONDI Public Health Director �� YG� 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 30, 2004 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Conklin South Acorn Pass, Lot #20 (T) Patterson, TM# 35.4-77 Dear Mr. Nichols: A re- inspection of the fill pad at the above referenced project has been completed. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the separate sewage treatment system. Please note that a field measurement by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM C. 7 7 Owner or Pujchaser of Building Tax Map Block Lot Building Constructed by TownNillage —r 8 5ovy Gcr� aS� � Location - Street Sub i ision Name fi,—rc k j 2-6 Building Type. Subdivision Lot # I represent that I am wholly" and completely responsible for the location, workmanship, material, construction and "drainage of the sewage Ireatment system serving th'e'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 "Kystern constructed by me which fails" to operate for 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 Z-o Year 2-a Ai�� Lot, Cr C-Q, - Title: eneral n actor'(Owner) - signature Corporation Name (if corporation) Address: /L a Kc,,_J State 1- z���,, Zip Corporation Name (if corporation) Address:. /?Oj State Zip Form GS -97 gip/ e : Harry W. Nichols Jr., P.E. Patterson Puic, Suite 106 2050 Route 22 Brewster, NY 10509 _.Tel -p%=4 (5.45) 279 -4003 Fax (845) 2794567 Date: �2_0 —Olt To: Job No.: 01 -031 /?© .. Project xi i ea ( 5 Attention: & V YV Q f), L , Gentlemen: We enclose (copies of- )46[W Prints Reproducibles Specifications Memorandum Description: a Reports Tracings. Copy of letter Revision/Date No. Sent Via: Our Messenger Blueprinter First Class Mail Special 'Deli-very Your Messenger 7kjiand Delivery. Copy to Very tq4y yours ` Ha 7�1':j�Iich f' VI -. G )MS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET STAMFORD, CONNECTICUT o6905 NELAC, CT and NY State Certified Environmental Laboratory Mailing Information: Name: Mill Drilling Co. Address: 75 Putnam Ave City: Brewster State: NY Telephone: Sample's Information: Site: Top of Well Preservative: HNO3 Temperature: <4C Client: JGC Associates Zip: 10509 Fax: 845 - 279 -5075 Collector's Information: Name: Russ Address of site: 8 South Acorn Pass City: Patterson State: NY Zip: Telephone: Date Collected: 4/26/04 Date Received: 4/27/04 Time Collected: 4:30pm Time Received: 2:30pm Lab No.: J044031 Date Analyzed Test Name Result MCL Method 4/27/04 16:00 4/27/04 4/27/04 4/27/04 4/28/04 4/28/04 4/28/04 4/28/04 4/28/04 4/28/04 . " 4r 28/0410.00 10:00 4/27/04 4/28/04 4/27/04 4/28/04 Total Coliform Absent Absent SMWW 9222B Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG Color ND 15 Units SMWW 2120 B Odor ND 3 TONs 3MWIIV 2150 B Iron <0.050 mg /L 0.3 mg /L SMWW 3111B Manganese <0.050 mg /L 0.3 mg /L SMWW 3111 B Sodium 16.2 mg /L N/A SMWW 3111B Chloride 43 mg /L 250 mg /L SMWW 4500 Cl C Hardness 7.23 mg /L N/A SMWW 2340 C Nitrate...._,_... _ 1.50 mg /L - -10 mg /L - SMWW 4500 NO3E . _ -. Nitrite <�:1._m9��_�_,._. -1 :0 mg /.L ..__..._ SMWW 4500 NO3E pH 7.23 S.U. 6.5 -8.5 S.U. SMWW 4500 H B Sulfate 24.0 mg /L 250 mg /L SMWW 4500 SO4F Turbidity 8.52 NTU 5 NTUs SMWW 2130 B Lead 1.71 ug /L 15 ug /L SMWW 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable S.U.= Standard Unit MCL- Max. Contaminant Level ug /L- micrograms per Liter mg /L- milligrams per Liter ND- None Detected NTU- Nephelometric Turbidity Unit TON- Threshold Odor Number Reviewed by:1� Sharon Houlahan, Director t . Signature: State #: PH -0218 Michael Lapman ELAP M 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �"` _ "`�OVSTI�iUCT�(��VrtPER1VIIT FOR SEWAGE TREATMENT SYSTEM PERMIT # _3 --0 1 EF'� Located at '50U i o A-1 -flP-H F A-06 Subdivision name MWE 1A1 IL E5 Subd. Lot # Date Subdivision Approved 04� 1AJ i� Owner /Applicant Name L4 fly -i C.0 Date of Previous Approval Mailing Address T y �-1 P B PV6To— le` Zip Amount of Fee Enclosed Building Typed 1bt�U Mr- Town or Village PPaTeM3 Tax Map Block A- Lot Renewal Revision Lot Area 1/° 1 No. of Bedrooms 4 Fill Section Only Depth to consist of i 5 o MGt+ Other Requirements: J-2V ?-'D' Design Flow GPD 4 Volume gallon septic tank and '44-4"-- To be constructed by i i N Address Water. Supply: Public Supply From Address Private. S,' pply Drilled -b - Address I represent that I am wholly and completely responsible for the design and location of the proposed systems) and that the separate sewage treatments sY tem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. „ Signed: Address P.E. X R.A. Date 0-4 1 1-1 0+ !� `1' I OSO � License # 6 6 � APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued. unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe X e of domestic sanitary sewa only: By: Title: Date: 1.0 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 4567 P.01 APR -20 -2004 03:10 P,M HARRY W NICHOL6 914 279 r PU`]C!•itM CO C)NT'Y DEPARTMENT OF 11EALxI1 DIYMSION•OF EN MONMENTAL HEALTH SERVICES REQUEST EQR ErNAL INLS. EC oN For: Fill Date: A;vA.L_ zg jA!d Trenches ...,.... „ -� PCH7 Construction'ermit # P•1 -Q� Located: ~ 'A&aus (T)(V)..� -- OwaerlApplicaat Name: 46U, C,► Le, TM , 35'B104.4' , . Lot -11_ Formerly; Subdivision Name: _ AMC " Subdivision Lot* 2,a i .....�.�.. p �s 'systeW fill completed?'. r._._ .� y" bate: , &3 .______,_..�. Is system complete? .�;. _ _ Date; tea: .�._._ — •- ...�._, .. Is system consU;ucted as per plans? Is well drilled? , Date: .Is well located as perplans? Are erosion control, measures is place? I certify that the systems), as listed, at the above premises has been constructed and I have inspected and verified their cdmpletion in accordance with the issued ,1�CHD Construction Pemtit and .approved plans and' the Standards, Rules and Regulati; • `tti z County Department of Health. x F. X•,� Daic; FPM L- 2j2_191 :. Certified b Address: 2a.56 &s +ct Comments_ FOR; O pppAq }�G� OPR -PO- ?004 TUE 15:35 TEL:845-278 -7921 a ' 1 - RITiritY'� 1#01715T . Public Health Director L Y ��� 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 22, 2004 f Harry Nichols, PE Patterson Park, Suite 106 2050rRoute 22 Brewster, New York 10509 Re: Conklin . South Acorn Path, (T) Patterson .Lot # 20, TM# 35.4-77 Dear Mr. Nichols: An inspection of the fill pad at the above referenced project has been completed. Comments are offered as follows. . 1. Rocks and boulders must be removed from fill pad slope. 2. 3:1 slope must be completed along with clay barrier. Y Please note that field measurements by this Department in no way suggests the exact size, .depth and location of the fill pad. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj PUP . COUNTS DEPA TN ENT;U :HEAL TH I'l DIVISION OF ENVIRONMENTAL HEALTH SERVICES r URFACE SEWAGETREATMENT ,... � ' SYSTEM Owner': / 10D Located at (Street) =`1'� �N4?S .P�$& Nl► tz'4'� Tax Ma aJ J _ -- - (indicate nearest'cross stree Municipality. - PC 0V Watershed E A"11' , �R-A r1 LM SOIL. PERCOLATION TEST DATA Date of Pre- soaking 04(1,V OA Date of Percolation Test .. f. { %'ir4:0 ..••- :.•,;::::. lr : .::...:r. .:.:.!r+f r:..:. +•i: +i:;i�Y:!. v,.:` :.�...�4HFr•/ '�•.' :v :.. ... -: ..v': %:'., :ry ^:4 :v; ... ...:r 4r %,.. ..... .v. n ...:..:�::.r...... ;:..,...::.} ..:...... ..,.:. .:r..�:... !iF.i �:�1•i:ifl ': j3'j�i /'a :. i !.;:. .4 •: -• �r,: fi� +.off'/ ... ,{.I : f.+/ .ry. .q !...:. k. : 'tv i•:. •. 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Depth measurements to be made;from -top of hole. - -97 Form DD �1)1 Harry W. Nichols Jr., P.E. Patterson Parr, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 9. 'rax (t4 ) 2794567 - -w April 27, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Mr. Robert Morris, P.E. RE: Individual SSTS Apple Hill Estates, Lot # 20 8 South Acorn Pass Patterson T.M. # 35. -4 -77 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Dwg. SS -20, "Proposed SSTS ", revised 04/27/04. 2. "Construction Permit for Sewage Disposal System ", dated 04/27/04. _ 3. "Design Da -a- Sheet" t - Perc;olation:' T ests in Fill: Pad. - If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nich s Jr., P.E. HWN:gav 01- 034.00 PUTNAMCOUNTY DEPARTMENT 1 " A fi HEALTH DIVISION ENVIRONMENTAL HEALTH a t PERMIT # Located at �^ T A T` T S s T �: e. p _,f� J Town or Village PAT i5V—,id PJ Subdivision name KW K14, E% Subd. Lot #1-0 Date Subdivision Approved 4) �� I brD Owner /Applicant Name 67A9T X- C&41,10 Tax Map 7'Block 4- Lot —7-7 Renewal Revision Date of Previous Approval Mailing Address ''1 Q P 9-OA-0 A-0 ����� A J i (iii Zip 10 *M Amount of Fee Enclosed Building Type P*5112eh1C6 Lot Area No. of Bedrooms 4 Design Flow GPD 9W Fill Section Only Depth �l `z_ Volume PCH D NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of «7D gallon septic tank and �S T2ENG� Other Requirements: '72,"5' To be constructed by TB P Address Water Supply: Public Supply From Address or: _._ Private Supply Drilled by T73D Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: VJ k Address 10 '�G 7— P.E. X R.A. Date 5 / ,� o 101 License # 1561/-11 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved o discharge of domestic sanitary sewage only. s 1 1 By: Title: i /►� Date: � .o White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL y� _ - _ please print or type -. _ _ ., _ .. __.PCHD Permit - ,° ✓- y Well Location: Street Address: Town/Village Tax Grid # 5ckmh PM0-60k Map 'b5' Block 4 Lot(s) -7--7 Well Owner: Name: Address: &W (z _ C04LIH Z2, Y'vuP flcr10 695w�16-9- f-�i 10*cot Use of Well: X 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 "7'0"f- gpm # People Served __4 -6 Est. of Daily Usage S,v gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type X Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision_? ...................................... ............................... Yes iC No Name of subdivision APP( µf (.C� 57 -�4TL� Lot No. 20 Water Well Contractor: 19 fl Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: -` Town/Village Distance to property from nearest water main: Proposed location & sources of contamination to be provided on separat she t/plan. swell Date: `�6 `�� /1 Applicant Signature: L J-1 d 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 wat well driller certified by Putnam County. Date of Issue Permit Issuing Official: Date of Expiration d Title: Permit is Non- Transf ra e LJ White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 BRUCE R. FOLEY _.__..��- '�_:�'ubu�C �ffea tth-- [iir'ector"��""'°''� ° ° "` �.•�'""�- " "' °"'" DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN.,, M,S.N. , Associate Puss Meal firector Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 Harry Nichols, FE. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Conklin South Acorn Path, Lot #20 (T) Patterson, TM# 35 -4 -77 Dear Mr. Nichols: June 22, 2001 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. The minimum of 3.5`feet of fill is to be provided for the entire SSTS. -... 2. ' —Fill is to extend '10 feet horizontally past the edge of any trench. 3. Subdivision plat notes that a curtain drain is to be provided. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. . Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Vn truly yours, Robert Morris, P.E. Senior Public Health Engineer RM:tn 0 " - 6 BRUCE R. FOLEY "i olle °i eaitii Di -eciur I LORETTA "MOLINARI' R.N., M.S.N. - ' - Associate Public health Dfr'ector "--` _` Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster. New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 June 22, 2001 Harry Nichols, P.E. Patterson Park Suite 105 2050 Route 22 Brewster NY 10509 RE: Conklin South Acorn Path, Lot #20 (T) Patterson, TM# 35 -4 -77 Reservoir Basin Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on June 5, 2001 is complete. The Department will notify you by July 12, 2001 of its determination. ., ._......�,.- ....- ... -... y, ...- ..�.....- ... - -..: .. u.. _..._ . _ ....: ..�_.... .... ._._ -. ..._..__.. _.....�.. �. ..-. ...- a - -... e.�.....- .- . ........ .. ... .... . <._.. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the,guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify.the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a proj ect, such as stormwater plans Letter to: Harry. Nichols, P.E. - June 22, 2001 -2- or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Very t 1 yours, Robert Morris, PE RM:tn Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRON\IE \TAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PEPW _ %fAl OF O�;INER: STREET LOCATION: / REVIEWED BY: tz-wl AS, SRDATE: Y N DOCUMENTS PERMIT APhICATION )WELL PERMIT OR PWS LETTER PC -97 LETTER OF AUTHORIZATION (__) - DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS -THREE SETS ,ACJHOUSE PLANS - TWO SETS (__) VARIANCE REQUEST SUBDIVISION U LEGAL SUBDIVISION SUBDIVISION APPROVAL CHEC ' �PERC RATE (__)FILL REQUIRED DE / UUCURTAIN DRAIN REQUIRED ' GENERAL L�f�i)LOCATED IN NYC WATERSHED 7U(QPLANS SUBMITTED TO DEP ELEGATED TO PCHD �DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ, LOTS WETLANDS (TOWN/DEC PERMIT REQ'D'.) DATA ON DDS PLANS & PERMMIT SAME j! PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA 100 YR. FLOOD ELEVATION W/I 200' ( 50JL.TES:rIiXG.b.OTB>t0•YEAI WAGE SYSTEM PLAN - (NORTH ARROW) DS HYDRAULIC PROFILE tAVTTY FLOW C--) ONSTRUCTION NOTES 1 -15 fDESIDATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT • FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES GN TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# (DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. (Z) PROPOSED FINISH FLOOR AND // BASEMENT ELEVATIONS (�(�WELLS & SSDS'S WAN 200' OF SSTS ( W )PROPERTY METES.& BOUNDS (�6 EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01/00 TAX IAAP =: (CONFIRMED) ( REOUIRED DETAILS ON PLANS CO\T'Dl HOUSE SEWER -%" FT. 4 "0'; TYPE PIPE CAST IRON. . NO BENDS; IN BENDS 45° W /CLEAN0UT RENEWALS �LSITE NOTE (NO CHANGE) FILL SYSTEMS ( 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS' FILL NOTES 1 -5 FILL PROFILE & DIl1ENSIONS (_)FILL Lr EXPANSION AREA /FILL GREATER TMAN2 FEE - CL -kY T (` BARRIER FILL CERTIFICATION NOTE C-06DEPTH GAUGES VOL. ON i PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS ( JLJSEPARATIOti DISTANCE FROM TOE OF SLOPE TRENCH LF TRENCH PROVIDED LOFT MAX. ( ) ,PARALLEL TO CONTOURS 4,L-IJIDETAILIDUST 00% EXPANSION PROVIDED FREE CRUSHED STONE OR WASHED GRAVEL (UGEOTEXTME COVER �SEPARATION DISTANCES ON PLAN - FR QM SSTS 10'TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (� 20' TO FOUNDATION WALLS 100' TO WELL, 200']N DLOD,150' TO PITS U 100' TO STREAM, WATERCOURSE, LAKE (inc. espaa) . 50' TO CATCH BASIN, 35' STOR�IDRAIN, PIPED WATER. 10' TO WATER LINE (pits - 20') L\TERIITTTEN7.IiLNAGs- f,013i1SE �..�200' /500' RESERVOIR, ETC. 150' GALLEY SYSTEMS 10' lIIN TO LEDGE OUTCROP SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES LOCATION OF SERVICE CONNECTION 1 �IIL, (� 15' TO PROPERTY LINE / SLOP `LOPE IN SSTS AREA (520 4/6) U( JREGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS PUbIP NOTES U( DOSE 75% OF PIPE VOLUMEIDOSE VOLUME NOTED U DETAIL FOR FORCE MAIN, (PIPE TYPA, ETC.) U PIT AND D -BOX SHOWN & DETAILED U DAY STORAGE ABOVE ALARM CURTAIN DRAIN ( ,STANDPIPES, 5' BOTH SIDES, DETAIL (J15' MIN to CDS = >5 %, 20'-4%,25'-3%,35'-1%, 100%-<I% (-_-)20' MIN to CD DISCHARGE /100' with 182 cons day discharge 10' MIN to NON - PERFORATED PIPE i Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 .a 2050.Rp,ute.22 r .:_• :: �� _. -..-�- - _ -- ter Bfe i4s, N Y 10509 Telephone (845) 279 -4003 Fax (845) 2794567 May 30, 2001 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Applehill Estates, Lot # 20 South Acorn Path Patterson T.M. # 35.4-77 Dear Robert: Enclosed are the following: 1. Four (4) prints of Drawing SF -20, "Preliminary Design for Fill Placement only," dated 5/30/01. 2. Two (2) prints ofDwg. SS -20, "Proposed SSTS," dated 5130101. .3. Short EAF, dated 5/30/01. 4. "Application for Approval of Plans for a Wastewater Disposal System, dated 5/30/01. 5. "Construction Permit for Sewage Disposal System,' dated 5/30/01. 6 A ,-p iitipn.:to- Conte st- a-Vater%ll; -date& - 5-/30/01: Data Sheet." 8. "Letter of Authorization." 9. Corporate Owner Application. 10. Two (2) copies of residence floor Plan(s), for bedroom count only. 11. Review Fee in the amount of $300.00. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni oI Jr., P.E. HWN jmm 01- 034.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - "I�.�l�]l�J��V�I'I` "- t;�RPORATE OWNER APPLICATION OW FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director a� In the matter of application for: NDLE. represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: C-1 Having offices at: da . -7a 1p 9/ C-�e W5-w Whose Officers Are: President - Name: Address: �u�� �� � it�4S �.� AOQ:V Vice President -Name: Address: :5C:)U -" ybp-.K_. . Secretary -Name: Address: Treasurer - Name: Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating there Signed: Title: 6:; i`� `f?�rnv�-�Z . Sworn to before me this I� day of c� -(month) 2-6 (year) Notary Pub lc Cathy L.Bookleaa Corporate Seal Notary Public, State of New York He®latratlon #01 B06044037 Qualified In Putnam County My Commission Expires June 28, 20 Form PUTNAM COUNTY DEPARTMENT OF HEALTH DWISION OF ENVIRONMENTAL HEA..LTHSERVICU, LETTER OF AUTHORIZATION RE: Property of Located at TN ''� -' � Tax Map # q)i ;- Block 4 Lot Subdivision of AP FL- E 141uL EJS51'KM ► Subdivision Lot # 1_0 Filed Map # 5© Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer, or Registered Architect to apply for the required wastewater treatinent and/or water supply permit(s) to serve the above—noted—property in accordance with the standards, rules or ragWadons as promulgated by the Public Ifealth Director of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection .with this maner and. to supervise the construction of said wastewater-.taretment..andlor wa:e: supply-systems-in - ccwforinity with the 'provisions if Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam 'tary Code. Countersigned: P.E., R.A., # Mailing Address On �y, NIC/1C �1� 5 _d f... 0 N, Very truly yours, z ua Signed: s (Owner otPtgpe State zip Telephone: �� — '0L_1q — 4 �i Mailing Address: Z2'iu,(p �1041 State N GvJ oe- v— zip 10 ",50" Telephone: 14 7 (pO -7-7 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: To -: 8 South Acorn Pass Patterson Map Block + Lot(s) Well Owner: Name: Address: JGC Associates 422 Tulip Road Brewster, NY 10509 Use of Well: 1- primary XXXXX 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 42 ft.. Length below grade 40 ft. Diameter _min. Weight per foot 1 "lib /ft. Materials: � Steel _Plastic _ Other Joints: —Welded X Threaded Other Seal: _ Cement grout X Bentonite Other Drive shoe: X Yes No I Liner:_ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours 4 Yield 40 gpm Depth Data Measure from lands ace- static specify ft) 70 During yield test(ft) 100 Depth of completed well in feet 405 Well Log If more detailed information descriptions or sieve analyses please attach. Depth From Surface Water Bearing Well Diameteron) Formation Description ft. ft. Land Surface 7 Sandy Soil — cobbles 7 405 Hard Grey Granite - If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 405 40 Pump Type sub Capacity 7 Depth 220 Model 7GS07412 Voltage 230 HP 3/4 Tank Type d � a ,1 Volume 62 Date Well Completed 3/10/04 Putnam County Certification No. 2 Date of Report 4/28/04 W er e NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's i Inc. Address: 75 Putnam Ave., Brewster, NY Signature: Date: S '3 —0y Ft White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 r'= BRUCE R FOLEY 714 279 4567 P.02 LOR,i3'I'Til. 1V1At�Pl_.M.�.�i�:- �...-- - = ;�_ c .Raf/r tNh Dfreetor DWWor r/ PaNnu Smku DEPARTMENT OF HEALTH 1 Geneva Road RM"ter, New York 10509 REQUEST 1E.QR FIRLD:EESTING ATTENTION: o ADAM STIEBELIItiG ENE REED All information below must be fvU completed prior to any scheduling. DATE: r ENGINEER OR FIRNI: H AW ... vi, P L j A oL ¢ if,. PHONE N: 2.� �..:1,00� REASON: DEEPS:.( PERCS: ,% PUMP TEST: o ROAD/STREET: TOWN: TAX MAIW: SUBDIVISION: LOT #: 2-0 OWNER: C.04�.! -.1 N (God Ncsmom YES NO O Proposed SSTS within the drainage basin of West Branch or Boyd$ Corner Reservoirs. o )d Proposed SSTS within WO feet of a reservoir, reservoir stem or control lake. a )l Proposed SSTS within ZOO feet of a watercourse or a DEC wets" o )A Proposed.SSTS design floe. greater-than- 1000 ptloga Ay.. or.SPD!ESS fed. T S fors a "Commerl al Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered y„gt to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for held testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP b required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY Ust ONLY TaiE: , „ S Cam. (FMLDTMT) 12563 To R ,'Mmakl Pond 164 Haines Corners Tz- C-ranbeny Mountain s _'O Wriagement rea - LU. z p J' aviland Ir 65 j T, 67 j J! Putna Neo _t _ - - 3 Lake 4•um 4 Reinbeck Corners Lake harks 22 ique Area Mount Ebo CA r—&O' moss -1 i ate oA dice Old Southeast church f# NoN Qe"r r, st r rs Corner Pond > z jL LL. En m m 0 t.� eT'�T-i� -•��iu ._.._tea- ....r..r... -.�.a m... -: -..i _... - <•� a.. ., .v...s v •`. s � ^s n . -+�,. -. - .- ... ..r..ua�• � „yi#- ^��y�,. ... ..c ,. -..�.. ,. x... ._.. .♦ �. ... � -.n .n: r_..n. i BI ' SCALE IN 1110 OF AM INCH � � ^• 24-1 -��__ £ d3 P/0 24.1. 100 AC. / �} R e� pq0 • LBBAC• � \ � . i 35.06 _ r 24 1.84 AC. � - - \1� 400.52 AG -- 285.96� �V AL 240 !' s4514 'I ta° i 14.00 �y �1 N 4.3 _ `++r �o9t� /7 4C CAI. ' : • '` -- 14 OO AC Y �`� 252 AG , > , 4 t 73 e\ 4; CA4 m Y 4.2 Q 266AC 1 = 26T AC. • B2 Let 4G `291 AG ' 72.I.m'�'la IiB LOB 4.1 ' 'sn 250 At 81 s - ' 29 ' A / 1zs r »`a, i 7; al, 4 r -?'�� -i ,qK 1 337 0 3.02 AC. E a i! 721.94 6513 AC, y it t7 259 AC. • 80 a . s c ► 0 e ' 125 I y.� QO rein A' 79 ix tee AG. ; 71 K' / O e1a4 ii ':?i+ • �/ IL 7 z - - .- 4 I q a of 3.17 4 , 31 AC i 17 _; o 17.02 A Elf Lii AC.� , 11 &. 32 ` IM ` 5 f.18 A� 33 2.22 1166.01 _ 1.59 AC 4 457.99 356.3 1 1.14 AC. 1 69 a 68 i t, ent . 2' % ' Lz4 i n.3o - - : N } e 1.50 A �ii.ie s � 34 105.7 AC. u. ' i i rl AC. 110.96 AC. CAL. MIS e%z � 274 AC8 CAL. 35 L45 65 p 1.19 AG • 4 48 " V / 49 0 �4 64 .Qi - - /• G :Leo 14.00 AC. CAL. CAL 4.95 AC. s fit. � .. ��' _,• e► - `e, • � � 44.52 AC. CAL. C •�.' \ '° � a99 ?4 �r s 62 16 57 y pw , a 4.00 AC. 24.58 AC. 69 ►9.69 AC. CAL 1 5p139 55 �� % :I a 737.76 244 82 f 1 • ! ' B 61 9.33 AC. cal 99239 �'� ! 5B �� / 3.67 R PUTNAM COUNTY DEPARTMENT OF-HEALTH DIVISION DEE , � : RONMENTAL HEALTH SERVICES'- APPLICATION•FOR APPROVAL OF PLANS Pt3R v � 'WASTEWATER TREATMENT SYSTEM ! �. 1. Name and address of applicant: M Li 1•'l '� ; .ADO L • , !� ,'�t1 t.�t' • (LO PAD • . . ... �.� �► �T�� -.- fit. l o�o� .,., 2.. Name of project: `" 3. Location 4. Design Professional: �'°' "'(Jo' r wrt�5. Address: �0 6. Drainage Basin• 7. Type of Project; Private/Residential Food Service Commercial Apartments , .. Institutional .. Mobile Home Park Office Building Realty Subdivision Other.(specify) 8. Is this project subject to Stat4rivironmental Quality Review (SEQR)? Type Status (check one).... . ........: : :Type I Exempt Type U Unlisted x_ 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... %1p 10. Has DEIS been completed. and found acceptable by Lead Agency? ............... 11. Name of Lead Agency MQ 12. Is this ro'ect in an area under the control -of local m lann , zontn or other -' _ ...�.� ... - •riifrci�is, ordinances? .............: Q � . 13. • If so, have plans been submitted to -such authorities? ::..: : ::.:... : ...................... p 14: Has preliminaryapproval been granted by such authorities? R Date granted . .... . • Pi N 15. Type of Se wage_ Treatment System Discharge ......:.:.::.::. surface water Lgrou ndwater 16. If surface water discharge, what is.the'stream. class 17. Waters index number ( surface) .: .............:.....::................... ........ ................. ...... t� . _. 18. Is project located near a public water supply system? ....... ............................... NO 19. If yes, name of water su 1 ` ' pp y' �(( „ Distance to water supply -O�N 20. Is project site near:a public sewage.collectioa or treatment system? . : ......:...:..: 21. Name of sewage system N Distance to sewage system P� 22. Date test holes'observed 71 23. Name of Health Inspector 6EP5 24. Project design flow (gallons per day) ................................. ..........................::... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... _ 0 26. Has SPDES Application been submitted to local DEC office? .................. 2 27. Is any portion of this project located within a designated Town or State wetland? MO 2 -8. Wetlands ID Number ........................ .............. ...,.....,.......$ a.. .�.�....:�.......:.:.........., . _.....b ,....n.... ... _.._ .w. .._.. -. _.. � _ ..: v.., sie:.;. a. Y.. -. _...� ..�.t.w.a:�•hcna..... i¢.. ✓: vn -¢ — �•..`...c....0 ....:✓:.. �. iv. LVmrw�J.J+a>' »2L+� +YOraaC._r'o �....u.._.��••.•r•• 29. Is Wetlands Permit required? .............................................. ............................... hi Q Has application been made to Town or Local DEC office? ...................:....... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used f& agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, - landfilling, sludge application or industrial activity? ............................. Yes/No 1`iQ HO 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Xown or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within . 15 years in .or adjacent to project site? ............................................................... =� = 35. Are any sewage treatment areas in excess of 15% slope? . ................. .I............. 36. Tax Map ID Number ...:...................... ............................... Map `�J'�, Block Lot 37. Approved plans are to be returned to ..... Applicant Design Professional _ - -- ______:: ?COTE: -All appi-oaiions °forzcevfew, aiid -wppcoval oTa riew, rg to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review. and approval. I f the application is signed by a person other than'the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. 1 hereby affirm, under penalty of perjury, that Information provided on this form -is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal 4aw:; 0 ° PUTNAM COUNTY DEPARTMENT OF HEALTH DMST®N.,:OF ENVIRONM- E.N' -kt.1 HEALTH SER' gCES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project C..oiy <Z //V (T)(V) 'PA--rF�1Zso -4.., County Site Location ApT---Z I_ N/G L j1 ,f1, Building construction begun iI& Extent --- Is property within NYC Watershed ? ................. dyes 0 No SECTION B. TOPOGRAPHY (Please/check all appropriate boxes) 1. F--] Hilly F--] Rolling Steep slope F-I ,Gentle slope ©Fat 2. Evidence of wetlands Low area subject to flooding 0 Bodies of water Drainage ditches El/ Rock outcrops 3. - Property lines or comers evident ....................... ............................... F-� Yes � No 4. Do water courses exist on or adjoin the property? ............................ Yes ENO .VCAI 5. Will these affect the design of the sewage system facilities ?............ F--] Yes �No 6. Do watershed regulations apply in this development? F�/Yes [---I No 7 Will extensive grading be necessary? ............................... 7� 0 Yes f-:] No -Will -exteitsive -fill be necessary for �5�1 S`� :........'..� � ~ � ---I Yes No 9. Do filled areas exist within the SSTS area? ........ ............................... Yes �NO If yes, what is the condition of the fill? SECTION C. SOIL OBSERVATION ' 10. Appearance of soil: dSand Gravel . F-� Loam 0 Clay F--J Hardpan 0 Mixture 11. Observed from: a Borings F--J Bank cut F--J Backhoe excavations 12. Soil borings /excavations observed by 13. Depth to groundwater 14. Depth to mottling 15. Are test holes representative of primary & reserve areas ................. on on on ......... 0 Yes 0 No 16. Soil percolation tests made by on 17. Soil percolation tests witnessed by SECTION D (on back) on Form ST -1 2 { --..SECTION D. DRAINAGE..rti 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? 0 Yes F--J No 19. Will groundwater or surface drainage require.special consideration? ..................... F-� Yes D No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... '..F--]Yes F-� No SECTION E. REMARKS 21. If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... F-� Yes a No Inspection data 22. Do adjacent wells and/or sewage systems exist? ....................... ............................... a Yes F--] No 23. Additional comments 24. Site observer /inspector and title 25. Date(s) of observation(s)inspection(s) TEST PIT PROFILES Hole # Lot # Hole # Lot # Hole # Lot ## Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling eptn to rock/imp. ` Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. 0.5 0.5 0.5 1.0 1.0 1.0 2.0 2.0 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0' 3/" PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES.,. DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner C6dtl Address Located at (Street) 0 t" Tax Map 3 Block 3 Lot 7 7 L fl �'— (indicate nearest cross street) Municipality t�5?7"r,4F9 so/t/ Watershed oy�,,.r: gjQ,4, eg is Date of Pre - soaking SOIL PERCOLATION TEST DATA Date of Percolation Test 1 1 /,0.o 3 3 a 6;12- 3 8,73 . 4 5 2 :37- - /7 2q -a-7 7 . 3 /:6 7— all/4 17 ;z q — ;1,7 _5 s ,7 4 , 1 _ 2... 3 4 5 NOTES: 1. Tests to be reneated at same depth until approximately eaual percolation rates are obtained at each percolation test hole. (Le. s 1 min for 1 -30 minfinch, 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 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' r 4:0' . . 4.5' 5.0'- 6.5' TEST PIT DATA Q 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. M Indicate level at which groundwater is encountered-----'-,--- ncountered - - - -,— � /-pAVG -- - -- - - - - - -- - - ---------- - - - - -- ------------- - - - - -- - - - - -- - - - -- - - -- -- Indicate level at which mottling is: observed __ ._ �VniV Indicate level to which water level rises after being encountered - -°' Deep hole observations made by: _ 2�E� � _ ,i 7, c ;T! Date 5-/-7/o/ Design Professional Name: Address: Signature:. Design Professional's Seal 14.184 0195) —TIM 12 PROJECT I.D. NUMBER :...; : 617.20 -SEOR Appendix C 777 - - ; <; StaWlEftbhhiintal `Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For. UNUSTED ACTIONS Only. PART 1"PROJECT INFORMATION (To be completed by Appilcant or Projeot'sponsoD 1. APPUCANT (SPONSOR A t" 2. PROJECT NAME Lmr 14 J. PROJECT LOCATION:tnO `1 n Munlolpaiity 4. PRECISE LOCATION (Street addnaa and road intermllons, prominent landmarks„ eta, or provide map) 00 ?t E KILL- PA-D 5.:13 P NFOSW ACTION::,: - Euew , ❑ Expanslon Q ModlflcatIWWteratlon 6. DESCRIBE PROJECT BRIEFLY: �L/h� fi . d?IZtVEW'f�j _ • ... • . .,. , ., 7. AMOUNT OF LAND AFFECTED: ' inittally ` -•9� WM UltimatSIY �"` `� &CM 8. M4 PROPOSED ACTION OOMPLY WITH DUSTING ZONING OR OTHER EXIBTWG LAND USE RESTRICTIONS? ss ❑ No If No, dacrlbe brlellr 0.. T 18 PRESENT LAND USE IN, VICINITY OF PROJECT. . 2941mae4w:'. 13 IndustMl ❑ Cornrnerclal 0 Ap_rlculture 13 ParklFomuom space 1:10%w DoWb 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAQ ❑ Ya if ypt Ilpt apenay(s)_snd pertNt/approvpls _.: .... . 11. DOES'ANY AVECT OF THE ACTION HAVE,A CURfiENTLY VAUD PERMIT OR APPROVAL.?; _ ❑ Yes C11019 41 ww nuns and pem Wapproval 12. AS A RESULT PROP(%W ACTION WILL EXi8T1NG PERMIT/APPROVAL REQUIRE MODIFICATION? ❑ Yes I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE - 15.1 HAW' _ K_ A ' t 1. ,- i'L /T�L, �s 9)n J 0 I ApplicanUsponsor nam Date Signature: If the action Is In the..Coastal Area, and you are a state agency, complete the . -•� Coastal Assessment Form before proceeding wlth'this assessment OVER De DT II_91JVI12f%IJ 8:IJTAI ACCRSSMENT fTn ha completed bV ADencv) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 8 NYCRR, PART 817.4?' If yes, coordlnats'.the review process and use the FULL EAF• S. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 817.8? If No, a negative declaration may be superseded by , another. ; Involved agency, ❑Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Cl. Existing air quality, surf6m or groundwater„ quality or Quantity, noise levef 1. existing traffic pattemrs, sotW waste. production or disposal„ potential for eroslon,.dralnage or. flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans Or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. . CO, . C, EJf.':' V `. C8. Long term, short term,.CumlllaUve, or other effects not IdenUlled In C1-05? Explain briefly. T "� C7. Other Impacts (Including changes In use of either quantity or type of energy)? Explain briefly, C4 �\ F D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS* THAT CAUSED THE ESTABLISHMENT OF A CEA? O Yea ON _ . E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yea, 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 should .be assessed in connection with Its (a) setting (i.e. urban or rural);, (b) probability. of _occurring; (c) duration; (d) Irreversiblllty;'(e) geographic scope; and (f) magnitude. If necessary, add attachments or'reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. It question D of Part II was checked yes, the determination and slgnIfidance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box If you"have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. C1 Check this box' if you have., determined, 0ased on the Information and analysis above and any supporting documentation, that'the proposed action WILL NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of espons a Of ... flcer.yi 40 ncy Title of espons a Officer Signature of es e t ency Lure or rep rer 111 daterent from responsible officer) Date la� PUTNAM. COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEAL TH SERVICE DESIGN DATA SHEET - SUBSURFACE ,SEWAGE TREATMENT SYSTEM Owner C C ti C 1► ,i� ( 1 '� Address % �- ��' "�. Located at (Street) _ C o u c, PP9�"( -� Tax Map 35 � Block 4- Lot E (ind' to nearest cross street) Municipality e g ,-c A L, Watershed FA-Ari SOIL PERCOLATION TEST DATA Date of Pre - soaking �'� , `�.� Date of Percolation Test M Uktk 2 - -••••• •� • submitted for review. , s z min for 31 -60 rn[Winch) All data to be Depth measurements to be made from top of hole. V c5\ co Indicate level at which groundwater is encountered �O Indicate level at which mottling is observed. r4c05 Indicate level to which water level rises after being encountered Deep hole observations made by; � Date Design Professional Name: H-PtF4� w. H%Gvk _( d�-PE Address: S-0 Signature: .Design Professional's Seal ,���y, N CNp s �" _ ' w No. 56124 OAA0FES340NP� '. .. TEST PIT DATA '- DESCRiPTION OF'.SOILS ENCOUNTERED IN-TEST HOLES D'Er Tai= ' G.L. '% T , 0.5' 1.0' 1.5' ��'� ��" ���' 0E`"b` 3.0' 3.5' LOW 4.0'rti� ^� _. PLO 6.5' 7.0' 7.5' 8.0' r c� 9.0' 10.0' -. .. s Indicate level at which groundwater is encountered �O Indicate level at which mottling is observed. r4c05 Indicate level to which water level rises after being encountered Deep hole observations made by; � Date Design Professional Name: H-PtF4� w. H%Gvk _( d�-PE Address: S-0 Signature: .Design Professional's Seal ,���y, N CNp s �" _ ' w No. 56124 OAA0FES340NP� P� SI'*'F� _L?�TSPI•C'I'T�?. JF��2.�L: Date: Inspected by: Fill pad located per the approved plan Fill Pad Length Required Length_ Fill Pad Width Required Width Fill Pad Depth Required Depth . Run -of -Bank Fill Quality Slope from Top to Toe:.. - Impervious Layer Installed - Erosion .Control Installed Sieve Test Results (if applicable. Additional Comments: Reserved for Field Sketch if Applicable i v xi' ttivi I,VWN 1 Y D- rAKIWIL1V 1' UY BiZA -UI'ti DIVISION`OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Street Location Town 1. Sewage Svstem Area a. STS area located as per approved plans ........................... b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size - 1,000 ...:.... ,250 .....other ................ b. * S eptic tank installed level ................ ............................... c. 10' minimum from foundation .......... ...........................:... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. .. Minimum 2 ft.Original soil between box & trenches ,. e. Junction Bog - properly set ......................................... 6. renc es . 1. Length required -� Length installed Y!Z 2. Distance to watercourse measured f Id 49 Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1%32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface............ 7. Room allowed for expansion, 100 % .................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends capped ........................ ............................... g. PUmn or Dosed Systems ,...1.z Size-of pump chamber.......... ........ .......*....................... 2. Overflow tank ............................................................. 3. Alarm, visual/ audio ........:.....:..:.. .......................:....... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .....:.................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildirig a. House located per approved plans............ b. Number of bedrooms .............................. .... f�....... 1V. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured � ft........... c. Casing 18" above grade ................ ............................... d. Surface drainage around well . acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter ............ . e. Curtain drain & standpipes installed according to pl f. Curtain drain outfall protected & dinto exist water s� g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 Date: V oaf Inspected by: l', 2Eg�v Owner C owlk_-, Subdivision Lot # �2_ p ,R SITE INSPECTION FOR FILL PAD Date: 2 2 Inspected by: 1� Fill pad located per the approved plan Fill Pad Length Required Length_ 8 8 Fill Pad Width f 7 Required Width / D -7 Fill Pad Depth el, O Required Depth Run -of -Bank Fill Quality Slope from Top to Toe 729 Impervious Layer Installed !O 6-e Erosion Control Installed Sieve Test Results (if applicable) - Additional Comments: S e c _ �_ �o►-► fe -fie -3 ^1.�_s ^- 16d, Reserved for Field Sketch if Applicable DIVISION-OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION All Date: Inspected by: Street Location SwTH AcdltAt t'/i55 Owner Town PA- rrg7rsaic! . ernut #_ - 777- _ x , - 'I'iVf`# % s` ySubdivision Lot # V_ O 1. Sewage System Area a. STS area located as per approved plans .......... :................ b.. ' Fill section - date of placement 3:1 barrier Lgth. Width .Avg.Dpth c. Natural soil not stripped ....................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size - 1,000 .......... 1, 250 ......... other ................ b. Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ...........................:... 3... Minimum 2 ft :Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. renc es . .. 1. Length required Length installed 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ............. 4. Slope of trench acceptable 1116 - 1/32" /foot ............. -5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................: 9. -Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends ca pped ........................ ............................... g. Pump or DosedpSystems 1. Size ofpu_mp k chamber:. _ ................. . ....... .................... ............................... 3. Alarm, visual/ audio .................:.. ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .....:.................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildiiig a. house located per approved plans ... ....................:.......... b. Number of bedrooms ....................... ............................... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured . ft........... c. Casing. 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area............... h. Surface water protection adequate ........ :........................... i. Erosion control provided ................. ............................... Rev. ?2/02 661— 5293734, W 327.74,r .1 i { q SITE LOCATION PLAT SCALE: V- 2000' PROPERTY SHOWN ON TOWN OF PATTERSON TAX MAP: 3 5. - 4 - 11 o , r Z a. N � 01-'A 9 . y t o 'p _• FF, PS Z ,1.0ox `,YP) ko N ,tipl t2 a5� dc� 5 0 P /7-014 SOLID 4VO SDa -SS /f ? Z / s PROJECT SSTS PROPOSED HILL ESTATES LOT N" 20 SOUTH ACORN PATH YOG ExEL L IE"T GARY CONKLI N WEL 22 TULIP ROAD N20 °0620" E r.._. N rutaam County Department of Roalth Division of Mvirenmental Health Serviep Approved conformance With applicable Roles and Regulations of the Put am County He th Department. C mature iE fitIOM "to I larry:W.:Njq ols Jr Suite - att©rson 2054 Roate:2.2 Brewster, NY 1050 (6? 279 - 4003,. Fax 27 I , NSULTING SITE ERG DRAWING•TtT.LE AS -BUILT - SSTS LOT Na 20 SCALE: ["=W' A� - ��pFNEWpO TE: 05 if -0 Ail k1 # HECKE� B16 : H W 1 DIMENSION CHART (in feet) Number A B I 1 7 31 y31 X104 B THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE 12Z 4 106 125 5 Io8 129 6 111 133 7 114. 137 8 Ill 141 9 93 123 10 Be IS i I 83 12 12 79 107 13 74 102 1 4 70 9l IS 145 159 1 6 146 161 7 148 164 18 150 167 >a+�� �n+z1 0RJ Ie1 1RfD m 1111\ loC NOTES j i THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS ow PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER $� as uc B THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE i WITH ALL STANDARD RULES ANIl REGULATIONS OF z THE DEPARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. e SURVEY INFORMATION FROM SURVEY PREPAREDBY 78RRy 6ERGEND02FF COLLIN5,I -.5. i N/pR0,70 AMA - 2.9w pCMY. uba-x'1 x� �wczarn,�wu R HILL t2�A17 P-,mwr�Rrl ow $� as uc z Kepi IIL. i �N�. CRIB! N]0•C6']0"CI 9163f' � 1/ 6/01 1C IJt 0•H � 1 I I 1 I A 99 I 18 R � �n 'U �wczarn,�wu R HILL t2�A17 P-,mwr�Rrl