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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -88 BOX 16 i,yti , , �� �� i Y." SIr 'L . , . o �� �: IN 1 , In Is IL Ili or 01749 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEW REATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 2,Y - U Located at 14 PHEA61WT 6k'6/5iH b IAHN Town or Village Owner /Applicant Name P-9) w• 110 H4' M JG130 Tax Map 'J r3 n Block 4 Lot 400 Formerly Subdivision Name 166 POND glee E%AZ5 Subd. Lot # Mailing Address IA t4 l9 K Z_ 6� W'5ro' N Zip 10,301 Date Construction Permit Issued by PCHD ml 111 oi- Separate Sewerage System built by by"i* C.oNjit"t4 1 � : Address F °D BXV41MW 16M Consisting of I "© Gallon Septic Tank and 06-7 L - Nb5 , V -EW—H Other Requirements: Cip_f�aN 0"4A) 0 1: FIi.L J NNL LC-NE IH6 Water Suliply: Public Supply From Address or: Private Supply Drilled by I411,TW 14rr Address i cif i�'C �5 1 i PffJW0JJt iKtt BuildingType ! D G' r L� Has erosion control been completed? -_ `f Number of Bedrooms Has,garbage grinder been installed? l I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County�PeRartnlent of Health. Date: I I ° 7 -a3_ Certified by __# Address qVJ O K 11- 0-0 W J P.E. X R.A. License # 1� 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 ZLIt subject to modification or change when, in the judgment of the Public Health Director, such revocati o ifica ' n or change is necessary. SiA By: Title: Date: f 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 :IF. 786343 P. 02 48 MAR -12- 03.08:44 AM PATTERSON TOWN HALL 91 fit, ... .. i �. pit BRUCE 6 .� FOLBY ..... .. * , i.Enr w,.. �.. ` .,.,, -;. , -. •..�.. � ..:. _ .., .. __. ._ /j Di7Y{i0� Ar. �. _. DEPARTMENT OF HEAL Brewster, Now York 10$04 - tsNro.�p4tW flWm (9ti}7i {•6(i0 Ftaniq m inn Nw'�lo�.�rrlw Og4jli {•6SS8 •• a'1C (011)7it .6671 .FiOr �l(1 77i •6419 , ,. .. ...:. ,.' . • • °- .. Gdr'tstur "w'ffdu•(91gi1r•6014 Praebool (91i)7TO�b077 F (91 /)l1r -664{ f OWRERSNAM: 1!<� Uj4jn, er1oM L�-6 tcs�.� v+�►� �rx rzA�e tER.. 3� •/ �. 98 .... :. E911 ADDRESS:. E° TOwx; ._��7i•� y; AUTHOR= TQWN.10MCYAlyt (Signature) j The Putnam County Department of Health WM not• issue a Certificate of Construction Compliance unless the above form h com feted; i.e. s le al Ir911 address 1s assigned by,;m authorlxed town ofti . .. cry tai -b b its y _ ►�jcba - _..._ t sial. �`Ihie •° .� .._..._ .h$ e�p..�Nt�n�for a'Cerciticste of Cow ruction C pliance, 4° i � .w PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location,. . Street.Address: .. I -- .. .. G rf O5S 11� lJ To�v�►/Valla Pu, �r54 Map 5 Block 4 Lot(s) '%j F Well Owner: Name: Address: AQ1114 GAS r&0++ On 11Ko K ( EW sail- r}`>' Use of Well: 1- primary 2- secondary _� Res' ntial Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _ Compressed air percussion Other (specify) Well Type Screened Open end casing iX Open hole in bedrock Other Casing Details Total length 5a ft. Length below grade 50.- ft. Diameter -7 in. Weight per foot j Llb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _ Cement grout _,X Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) 6 / Lei` During yield test(ft) bo--o Depth of completed well in feet ate' 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 g 6an aq,►t^ claig /t © + If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type u • Capacity /0 6VM Depth ov0 , Model Voltage X30 HP 4- Tank Type _fxt-0 I Volume _6,2A-_.(�. Date W�7;;703 Putnam County Certification No. 007 Date i7.W103 Well Drill r (signature) �' ��t NOTW Exadt location of well with distances to at least two permanedt landmarks to be provided on a sepgWte sheet/plan. Well Driller's N m AWe4 A. mjif +sa S �rA C, Address: 49' 3/1 a1^ NY- /9,<63 Signature: Date: 0 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL Well Location: Street Address: Jowlill Tax Grid # g1jo GUI /A)C d JV)0w A (I MapW -.J� Block A Lot(s) Well Owner: Name: ' Address: I/ did C, �<�'� QIrr01 14 cc a 4 dw- k P7 --0Z4.�6d O 1 a,T y Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage's gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled. Driven Gravel . Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes - No .X Name of subdivision Lot No. Water Well Contractor: Address 6YeAA;S� Is Public Water Supply available to site? .................................. ............:.................. Yes No 1� Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided n separate sheet/ lan. Date__ 2� ..Applicant.Signature: _ .. ____...._._ _ ... _.._._ PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED -FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water,. 1 driller ce ified by Putnam County. Date of Issue 3 Permit Issuin icial: Date of Expiration a Title: Permit is lion- Transferr ble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 �.�_,_.�..... �..,_.., ..��..... _ PUTl�TAJ!✓ I_ COLIN�. �.-. �' .��l�A��T�.�vT.:�F�.�HEA:L.T' -� a � ..,.. -.. _�,.y__, ..;_.�, :_- DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Reilly Construction Owner or Purchaser of Building Reilly Construction Building Constructed by 2140 Route 22, Brewster, NY 10509 Location — Street Residential Building Type 35 -4 -88 Tax Map Block Lot Patterson TownNillage Ice pond view estates Subdivision Name 6 Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules, and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except, .. _ . where t e_ a luze..tn. c�rieraie:prc� �?xly is* ra„siA l y the occupant °of. -,._ -.'..v the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month %v DaydCZ9 Year 2003 Signature: NJ Title: President eral Contractor (Own r) — Signature Corporation Name (if corporation) Address: 2140 Route 22, Brewster State: New York Zip 10509 Burdick Contracting Corporation Name (if corporation) Address: PO Box 532, Brewster, State NY Zip 10509 NORTHEAST LABORATORIES, INC. 129 MILL STREET - BERLIN, CT 06037 -9990 NORTHEAST LABORATORY OF DANBURY (Danbury S2mkle,- Qr.Off Site: PO M�I,P,/grls$o�l $rlite 34aQ(7u_CT] TELEPHONE: Toll Free (in CT) 800-826-0105 (Outside CT) 800 - 654 -1230 Berlin /Hartford Area: (860).828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 E -Mail: NELABSCT ®AOL.COM www.NortheastLaboratories.com REPORT TO: REILLY CONSTRUCTION C/O TOM BIGLIN 2140 ROUTE 22 BREWSTER, NY 10509 FAX TO: 845- 278 -0931 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: • Total Coliform (Bacteria) PHYSICALS: • Color (Apparent) • Odor • pH • Turbidity CHEMISTRY: • Nitrite Nitrogen • . Nitrate Nitrogen* 0 per 100 ml(ABSENT) 10/8/03 • Hardness • Iron • Manganese • Sodium • Lead • Chlorine Residual DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: DATE TESTED: LAB I.D. # REPORT DATE: PHEASANT CROSSING LANE WATER TANK WELL WATER NONE NOTED \rl A C 0 o q.9 O� Nn Q7 !_ . U 10/8/03 11:30 AM TOM BIGLIN 10/8/03 LAB #11471 & 11393 10/8/03- 10/21/03 REILLY CONST- 302491 10/23/03 ml= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level * "Action Level 3=Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample; -as received; cow mpk�wit all. State of New. Yorkxr gulatory guidelines, however, the underlined results exceed USPHS recommendations. -All holding times (were) met. -* = Tested by Spectrum Analytical, Inc. Lab #11393 SAMPLE, AS TESTED ABOVE: 01POTABLE or OINOTPOTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR P T LE W TELL) � 4 Laboratory Director a CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT- -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 MAXIMUM CONTAMINANT RESULTS METHOD # LEVEL (MCL) OR DATE TESTED STANDARD ABSENT per 100 ml SM 9222B 0 per 100 ml(ABSENT) 10/8/03 5 - EPA 110.2 15 units 10/8/03 5- Sulfut _ - 3 Units 10/8/03 6.89 - ASTM- D1293 -99 No designated limits 10/14/03 0.30 NTUs EPA 180.1 5 NTUs 10/8/03 <0.005 mg/L as N EPA 354.1 1.0 mg/L 10/8/03 0.478 -mg/L as N EPA 353.3 < .. . 10�ine�L .�- 10/2!113- mg/L SM 2320B No designated limits 10/13/03 40 mg/L EPA 130.2 No designated limits 10/9/03 <0.03 mg/L EPA 236.1 0.30 2 mg/L 10/14/03 <0.01 mg/L EPA 243.1 0.30 2 mg/L 10/14/03 2 Combined limit for Iron plus Manganese = 0.50 mg/L 7.9 mg/L EPA 273.1 No designated limits 3 10/14/03 <0.001 mg/L EPA 239.2 0.015 mg/L * ** 10/9/03 <0.05 mg/L - - - -- 10/8/03 ml= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level * "Action Level 3=Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample; -as received; cow mpk�wit all. State of New. Yorkxr gulatory guidelines, however, the underlined results exceed USPHS recommendations. -All holding times (were) met. -* = Tested by Spectrum Analytical, Inc. Lab #11393 SAMPLE, AS TESTED ABOVE: 01POTABLE or OINOTPOTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR P T LE W TELL) � 4 Laboratory Director a CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT- -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 NORTHEAST LABORATORIES, INC. 129 MILL STREET - BERLIN, CT 06037 -9990 NORTHEAST LABORATORY OF DANBURY `N 0o'444,4 (Danbury Sample Drop Off Site: 100 Mill Plain Road, Suite 342, Danbury, CT] e ~ °m ,_. ...,._.. .� ... .. .,.a w -. ��: �;.•'llA fL�Tn.l �:rr'.^"•. y.� .. T\ i / l�r� _. /r'_.. r•r °;,r:..-r�_1.�);'...: :.a 1. ,.., t_� ' _ t � Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 E -Mail: NELABSCT @AOL.COM www.NortheastLaboratories.COM Page: 1 ANALYTICAL REPORT NORTHEAST LABORATORIES Report Prepared For: Report Dated: 10/31/03 Reilly Construction Order Number: D0302577 Tom Biglin 2140 Route 22 Brewster, NY 10509 Laboratory _ID_ #: 0302577 -01 Descrl_Lti.: Well Water r@i Water Tank Sample #: Sample #1 SamplinaLocation: PHEASANT CROSSING LN. Collected: 10/30/03 Collector: Tom Biglin Received: 10/30/03 Test Parameters ITEM RESULT UNITS Tested LAB: Chemistry Odor ND - 10/30/03 Note: Odor is a subjective evaluation of acceptability of the water. ❑ ❑Not to exceed a value of 2 "" on a scale of 0 to 5 (tlA "a4VI,( Approved By: (Lab Manager) CT Cert. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 .. — .__..__ Telephone (845) 279 -4003 OEM NOM21 Fax (645) 279 -4567 0 November 7, 2003 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Mr. Robert Morris, P.E. RE: Individual SSTS Compliance Ice Pond View Estates - Lot # 6 14 Pheasant Crossing Lane Patterson, NY T.M. # 35. -4 -88 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of S -6, "As -Built Plan", dated 10/20/03. 2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 11/06/03. 3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System ", dated 10/27/03. 4. Well Completion Report, dated 09/28/03. _ . 5. Laboratory Reports, dated i0/23/03 and 10/3 0/03. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. 911 Address Verification Form. "If there are any questions concerning the enclosed, please call. Thank you. Very truly yours, Harry W. Ni'Ichls Jr., P.E. HWN:gav 02- 084.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 3 Street Location,c� a-L ���: _ Owner �f _ Inspected by: G -, c- V iZFr - Town r t,2�o,U Permit# TM # 35, -,q - 09, Subdivision Lot # 6 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 ...... ............................... II. Sewage System a. Septic tank size - 1,000 ...:.....1;250, ....other ................ b. Septic'tank installed level ............ ' .......................... .. c. 10' minimum from foundation .......... ............................... d. Distribution Bog 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 ee % 2. Distance to watercourse measured k- i o o Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property he - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .............el-111� 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 cap&ed .............................. 1. Size of pump chamber ............................... ....... *......... 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .....:.................... ............................... 6. C�yycle witnessed by H.D.estimated flow /cycle........... III. House4ucilding a. House located per approved plans ............. ., b. Number of bedrooms ........... ...................... /........ IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured p , _ 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 froze. STS area ............... h. Surface water protection adequate :" .. ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 A Mfg MIMENIVIRM M MEM07'• AWN I i �r OCT -29 -2003 11:49 AM HARRY W NICHOLS 914 279 4567 P.01 Public ffiralrh.. Director LORETTA MOLINARI R.N., M.S.N. Assmiate Poblta Smith Director birafor oj.PatlRnt service-1 DEPARTMENT OF HEALTH 1 (leneve Road Brewster, New York 10509 ATTENTION': a ADAM S'TIEBELING WENE REED All information below must be Ju4 completed prior to any scheduling. DATE: - EN'GINEER OR FIMI: 640 w t R64016 215 PRONE #: REASON: ` DEEPS: PERCS: )(. PUMP TEST: o ROAD/STREET: M'iLL ILDAP TOWN: _ pPr�� '� TAX MAP# : �� � r3 snDIVISI01m. �'f�iH 'V� �.�'� _,� LOT #:�. OWNER: YES NO o Proposed SSTS - within the drainage basin of `Vest Branch or Royds Corner Reservoirs. X00 fey► dP° a rservoir;'reservosr stem or control lake. y1( C Proposed SSTS within 200 feet of a watercourse or a DEC wetland. sg. Proposed SSTS design flow greater than 1000 gallons/daror SPDES Permit required, [� )L Proposed SSTS for a Commerical Project: It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answeredya to any of the questions, NYCDEP must witness the soil testing, This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP, If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP, COUN a Us$ ONLY (MLDTEST) OCT -29 -2003 WED 12:06 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 SENDING CONFIRMATION DATE NOV -20 -2003 THU 10:56 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 2/2 START TIME : NOV -20 10:54 ELAPSED TIME : 01'12" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a a Lox67TA MOUNAM ROBERT 1. sormt Awk N hh Dt.01 C-0 tt MW. DEPARTMENT OF HEALTH 1 Genova Road, Brewster, New York 10509 6artr•semtal 9edta (M278-6130 Fa (045) 278.7971 IWr>t1a 3Mke (845)278.6158 W1C (84!)278.6671 Fw(84S)p78.6081 Grly Ner.a,u•a/Frraepsy (145) 278.6014 Fal (845) 271.6648 November 17, 2003 Patterson Park, Suite 106 2050 Rota 22 Brewster, New York 10509 Re: Field Inspection - MUy Construction Andrea Place, (T) Patterson Lot A' 6, TM# 35 -4 -88 Dear Mr. Nichols; The following comments must be corrected in the field: j 1 • The SSTS can only be baekfilled with nw -of -bank gravel as specified on the approved plan. On site soils cannot be used as fill or topsoil in the absorption area due to the high amount of clay. Ifyou have any further questions, please contact me at 845- 278 -6130, mo. 2261. Sincerely, J, i Gene D. Reed ODR:cj Sr. Environmental Health Engineering Aide _ I OCT -21 -2003 09:18 AM HARRY W NICHOLS 914 279 4567 P.02 i ._ __ » >........... ._. ....,:... .. .. ��.r.._c ..• .c.. .a�_vr�: avn.nr_vnc'..a.�+'..ar.- .rv.e.s wr...c�w+.•.. .,._..e...+ w.. ,..x.... ... ...i..�t:...... � .+. .� •,.� >... ®.v .. ..._.. ,..^ ..c _ _a.....n...�+..+ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION -OF ENVIRONMENTAL HEALTH SERVICES ,fit ST F_ R ETNAL ZIISSAFCTM For:. Fill Date: Qgt 21 1Q1 Trenches ✓ PCHD Construction Permit # P. 38.02 Located: �l jAfiALtf..,,CAjXSjr,LX LeN1- ._ (T) (V) P►t'CcMr>J , . ...�. Owner /Applicant Name:.. gri Lq tq,.�es�i ld TM _35• , Block J,' Lot.- 9V Formerly: Subdivision Name: _ t zt Subdivision Lot # Is'systeafill completed ?' Is system complete? is system constructed as per plans? , Its Is well drilled? yss Is well located as per plans? _ - IQ Are erosion control measures is plasm? Date: Date: QcS:. ;Rt laa. Date: oc . Zi 193 1 certify that the system' (s), as listed, at the above premises has been constructed and I have inspected and •verified, their completion in accordance with the issued PCB D Construction Permit and ' approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. ed'by: RA Desi Professional Address, .21350 &Jfj, 22 ,r. A e- Lic. #. 567124 .� Comaaeats:. FOR: 0 ADAM GENE ❑ (NAM) OCT -21 -2003 TUE 09:35 TEL:845- 278 -7921 Form FIR-99 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2 Puhlic Health Director 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 November 17, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols; ROBERT;JT - BOND I _ .... County Executive Re: Field Inspection — Reilly Construction Andrea Place, (T) Patterson Lot # 6, TM# 35.4-88 The following comments must be corrected in the field: • The SSTS .can only be backfilled with run -of.- -bank gravel as specified on the On "site -soils cannot' be us6d' a!� fill —or f6ps`oirin the abs6rptioii --t� , _.._ " _ - , --- _w _..___ area due to the high amount of clay. If you have any further questions, please contact me at 845 -27$ -6130, ext. 2261. GDR: cj Sincerely, / Gene D. Reed Sr. Environmental Health Engineering Aide PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES - r DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner ` L61a / GoiyS Address A AUUK ,d P-A&Gg Located at (Street) Tax Map 3 5 Block_ Lot (indicate nearest cross street) Municipality eArr--6.ay Watershed Date of Pre- soakinj SOIL, PERCOLATION TEST DATA - - Date of Percolation Test /0,'00 - 10,'30 5c> /0 2�_- _ 3 4 5 . .. 2 /0,'33-/j;33 2-�Z �© 3 //;33 -/x;33 4 5 3 1 101,30 - / /:Oa 3 .rte /8 " 191a ' � 2� ,�r"✓� e `n 2 II O 3 3 0 / 7 ' a off- 4 it cl 3 It 3 3 8 1% � 5 NOTES: 1. Tests to be repeated at same depth until approximately equal;percolation rates are obtained at each et ter, 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. e��S /s9v� fc� -f'*P 4fevA 2. Depth measurements to be made from top of hole. p,f I ' /� ' .. OVA 0//'1 ie�� �- " c$e;p ¢h "No ,p�rc - �cc:K'" ��p�h �5 Pei � leep hale ,'rr4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # (- 31 -o) Located at F49�A5AH" G4-p15C21H6 LAH-r, Subdivision name iCE POHD \'le(J IM - Subd. Lot # (o Date Subdivision Approved 4 ) 1 14100°\ Town or Village FATM"OH Tax Map �i`�� Block 4 Lot 11 % Renewal Revision Owner /Applicant Name C,0H5Tp4JcilVH Date of Previous Approval Mailing Address 1515 G ' K\ NI H Zip 105 Q Amount of Fee Enclosed 00 °Q Building Type X51 D0AL-6 Lot Area 1,106 No. of Bedrooms 4 Design Flow GPD B 0D Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Tp -epl,N 1°r59 gallon septic tank and GO L.r- "5 Other Requirements: C-JKJN" DP-A1)-A) 0— r,�) r-1 w, W To be constructed by T'-1'3 : 0, Address Water Supply: Public Supply From Address _ ... .-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 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: P.E. X R.A. Date 1 110 0r0r-- Address 1,a!o y1 � � ri loraa� License # 5GUJ1i APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew permi'. Appro for discharge of domestic sanitary sewage only. By: Title: Date: /Z %�'. o L 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 ... _ phase p*irt or type , ..... .... 4r- ',Z�. _- ..u,_ .. _.. a .... _.... PCHL� eatY3it �C.� _... Well Location: Street Address: Town/Village Tax Grid # PKh"< Q20%t <q L" PA TTEP-60H Map Block 4 Lot(s) 1% Well Owner: Name: Address: r� rJLy �i�iP�ii�J LVQ10� p��p '5j Ei, M1A�1 • 1-3T° Use of Well: Residential Public Supply Air /Cond/HR eat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 054- gpm # People Served �(4 Est. of Daily Usage ICP gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type_ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No _ C� Is well located in a realty subdivision? ...................................... ............................... Yes —X No Name of subdivision ZC6 F000 V16W C 5'% AT S Lot No. �o Water Well Contractor: T60, Address: Is Public Water Supply available to site? .................................. ............................... Yes No 31; Name of Public Water Supply: Town/Village ° Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on sep ate sheet/plan. Date: Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director y revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller ertified by Putnam County. Date of Issue 12,10-10 Permit Is u ff�ci Date of Expiration '411JIgg. Title: Permit is Non- Transferr ble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH. • DIVISION OF .ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION ". RE: Property of Go H,6'rP -JC-Ti OH Located at P►��i� SPt -�� Gv i(� Lac TN p �A--' --� Tax Map # 5. Block Lot Subdivision of 1G� poNb NO ��T Subdivision Lot # Filed Map #U05 A Date Filed. -_ 4 1 i bj i° Gentlemen: This letter is to authorize �kO-P� V4 • Nl G 1}0l-6 ; 1p— ?a a duly licensed Professional Engineer or Registered Architect to apply for the. required _. . wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of:the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with -this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions -of Article 145_ a_ nd_ /or.14.7_ of the Education Law;.-the Public Health Law, and the Putnam Coun-bLSanitary Code. - - Countersigned: P.E., R.A., # _ Mailing Address r NEW �\ No. 56124 a State Zip t D % (q Telephone: S r 2 -7q 4aa�j Very truly yours, Signed: (OwnerrropeM)" / Mailing Address: 05 E. MAIN :- � State P) Zip Telephone: Form LA -97 Harry W. Nichols Jr., P-E. Patterson Park, Suite 106 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 December 16, 2002 Department of Health One Geneva Road Brewster, New York 10509 Aft: Robert Morris, P.E. Senior Public Health Engineer Re: Proposed SSTS: Reilly Construction Pheasant Crossing Lane, Lot #6 . (T) Patterson, TM # 35 -4-88 Dear Robert: In response to your letter dated December 10, 2002, we offer the following: 1. SSTS has been revised to show trenches of equal lengths. 2. Application has been revised to note "Ice Pond View Estates" road name has been revised to the current "Pheasant Crossing Lane." if you have any further questions, please call. Very truly yours, Harry W. Nic ols Jr., P.E. HWN:JM:jmm 02 -084.00d 7.. AMOUNT OF LAND AFFECTED:.: Initially„ _... i' ®Gj acres Ultimately Is 90e acres 8: WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? ZYes 0 No If No, describe briefly :611444 FA 14II 'r 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential 0 Industrial 0 Commercial 0 Agriculture Describe: ❑ Park/Forest/Open space 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, ..' STATE OR LOCAL)? ❑Yes 19No If yes, list agency(s) and permltlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes KNo 'If yes; list agency name and permlt/approval :12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? 0 Yes ®No .... , - Appllcant/sponsor 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 14.16.4 (9185) —Text 12 617.20 E.• SEQR ' PROJECT I.D. NUMBER Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM: l For UNLISTED ACTIONS Only _- PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) - 1: APPLICANT ISPONSOR 2. PROJECT NAME 3: PROJECT LOCATION: "t pvTNPsI'n Municipality �I County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: . l�l Now 0 Expansion .0 Modiflcatlon /alteration ;: 6. DESCRIBE PROJECT BRIEFLY: ' •. 7.. AMOUNT OF LAND AFFECTED:.: Initially„ _... i' ®Gj acres Ultimately Is 90e acres 8: WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? ZYes 0 No If No, describe briefly :611444 FA 14II 'r 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential 0 Industrial 0 Commercial 0 Agriculture Describe: ❑ Park/Forest/Open space 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, ..' STATE OR LOCAL)? ❑Yes 19No If yes, list agency(s) and permltlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes KNo 'If yes; list agency name and permlt/approval :12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? 0 Yes ®No .... , - Appllcant/sponsor 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 WUC X. Public Health Director December 10, 2002 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 LORETTA MOLINARI RN., . M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845)'278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Proposed SSTS: Reilly Construction, Andrea Place, Lot # 6, TM# 35 -4 -88 Reservior 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 November 8, 2002 is complete. The Department will notify you by December 30, 2002 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Depaifineiit fails 'fo notify you withiu the above referenced time frame, you may notify the Department of its failure by Certified Mail, Return Receipt Requested. The notice would 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 New York City Department of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if DEP review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Ve / y yours, i�l l Robert Morris, PE Public Health Engineer RM:cj D FOLEY Public Health Director r � �'LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (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 December 10, 2002 Harry Nichols, PE . . Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Proposed SSTS: Reilly Construction Andrea Place, Lot # 6 (T) Patterson, TM# 35 -4 -88 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1. Please revise plans to show the SSTS with approximately equal lengths. The slope in the SSTS area appears to be across the entire system 15% or less. 2. Subdivision plat shows this lot is in "Ice Pond View Estates." Application notes the subdivision as "Farm to Market Estates ", please clarify. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. . Ve ly yours, Robert Morris, PE Senior Public Health Engineer RM: cj Subdivision Lot # �O Filed Ma p # W�' )k Date Filed. -_. 41 it7 Gentlemen: This letter is to authorize 4MI, � `N a duly licensed Professional Engineer 'Y,_ or Registered Architect to apply for the, required wastewater treatment and/or water supply permit(s) to serve the above - noted - property m accordance with the standards, rules or regulations as promulgated by the Public Health Director of.tle7Pufnairi County Health Department, and to sign all necessary papers on my behalf. in connection wiii -this matter and to supervise the construction of said wastewater tretment and/or water supply systems m:.: conformity with the provisions of- Article t,,- W-a- - Law, and the Putna =ou itary Code. Very truly yours, . Countersi �'' .. �' � Signed: P.E., R.A., # .� �;�,.;6 12a �� (Own roperry) Mailing Address - �� Mailing Address:_ State ( Zip 1 Q� 0 State zip-* Q!. Telephone:��� O ©� Telephone: Form• LA -97 ..\. ; v: •:i' � �: `'li:: : is ••{: �: •.}• {. �.;' •:}} ::;:;!rxi•.v ^ �:v:: v: •••v,•;v } { ?} � ;:}; �•t•: ti^}!3.t4H �.• .:iti: • {' : {' : i }.. •:;r: : {j: :av: { -: i:•:: :•:v. tiv'• • :• •'•:•: • .; :.1:•d:�' �:�r � '•t ' St:i :. .;! . {:1 .•:.::.... i:t•.•.: :!• •:f} ? :!•:•: i:•ti •/ \\ ••::: n., • .vim }•: I. :.•'• •::.•. •.i :: . • ti:�..: •: .:;:�•;.•'1;. .. }.: •.vh'•1. � ?::�r. n•.':�w• }': i ti %ti ti •. � ::: =:� . A . rr.. {.. ;iinr+' n ,1. }:•.' •: ti . •.1. .•.:•. . :t•.r. ;i.. . i •.•r:. }; . r,.••r•'.• :�i:: ,• y. .} :}•: •: n•. . r.} • .•r..:..1, • � •• . >.•.?C {�r':vr? t�!C•rk` • ;A :� v.:'ti•:.t : .•.1•. : � i {:•:.: - •r.�Yi %iii .{;�tiv }�!} < {tiii: :: {• ::C•:r . n • ' t'•.. ••:�: � : •'Yi: { {.•• •: ;: :•: ; ";. •. 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Brewster, NY 10509 Telephone (845) 279-4003 Fax (845) 279-4567 October 29, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS - Farm to Market Estates, Lot # 6 Andrea Place Patterson T.M. #35.4.88 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS-6, "Proposed SSTS," dated 10/29/02. 2. Short EAF. 3. "Application for Approval of Plans for a Wastewater Disposal System," dated 10/29/02. 0 4. "Construction Permit for Sewage Disposal. System," dated 10/29/02. 'ite - -'��App icat-ion- to-Const a ix-t-V -, -Well,-"deted 10/29102-. 6. "Design Data Sheet." 7. "Letter of Authorization." 8. Two (2) copies of residence floor Plan(s), fbr bedroom count only. 9. Review Fee in the amount of $300.00. V If there are any questions concerning the enclosed, please call. Very truly yours, eaA-V Harry W. Nich s rJr.., V.E. HWN:JM.jmm 02-084.00 14-16 -4 (9/95) —Text 12 PROJECT I.D. NUMBER - 617.20 = SEQR Appendix C . ,. O _ _.. .... ... . .. ... .. .. _ ;,._, �__.:, . �,..,., n--- ....�,....�.J.�...,�....,�..._ Sta'e En.,,lrc�rr•► n2al ^u�l!�y .e�E.4. _.<� w__x� �,_..�._...._._._.� ,....�.......v .... SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only —_ PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR ��, 2. PROJECT NAME' 3. PROJECT LOCATION: �i1– �7 '" ' J I ®� � �H� � ! Municipality aunty 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: )ANew 0 Expansion 0 Modificatlonlalteratlon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED; :. J_ initially tely 1, �o� acres 8. W,�IILL{{L PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? IG7`Yes 0 No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? &esidential 0 Industrial 0 Commercial 0 Agriculture ❑ Park/Forest/Open space 0 Other Describe: mv 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, . STATE OR LOCAW? ❑ Yes Mo If yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes 18\No If yes;' list agency name and permlt/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes t5N0 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE MY KNOWLEDGE �BEST f �yO�+F J 1 9 ���� �. �%�urplv�l) L f G `� J �l�y�s'1 ApplicanUsponsor n me: Date: Signature: If the action'ls "1n the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER -- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH- SERVICES Y.. APPLICATION POP APPROV AL ..OF PLANS- .FQR,_ A WASTEWATER TREATMENT SYSTEM 1. Name and address of applican 2. Name of project: L (o 4. Design Professional: 6. Drainage Basin: CA"yr j?-t✓ I u.� co � 5f �6+�1 DTI o� . . , N� t os c� 3. Location TN: pl QrJ 0\00%6 3V Q�5 . Address: 7. Type._ of Proiect: SC Private/Residential Food Service Commercial' Apartments Institutional Mobile Home Park .. AP - Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status check one .................. Type I -Exempt Type II _ Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? (y 10. Has DEIS been completed and found acceptable by Lead Agency? ................ NA I l .. Name of Lead Agency - tJfl 12. Is this project in an area under the control of local planning, zoning, or other officials, of diriances .. ..........:..:.........................................: ............................... y!C 13. If so, have plans been submitted to such authorities? ........ ............................... N6.. . 14. Has preliminary approval been granted by such authorities? _�V Date granted; 15. Type of Sewage Treatment System Discharge ................. surface water tl groundwater g 1 ►�}A_ __. 16. If. surface water discharge, what is the stream class desi ation? .....:..::.:. 17. Waters index number (surface) - - -- 18. Is project located near a public water supply system? ....... ............................... ND 19. If yes, name of water supply Distance to waTer: supply J A 20. Is project site near a public sewage collection or treatment system? 21. Name of sewage system Distance to sewage system IJA- 22. Date test holes observed - 10 111 aZ 23. Name of Health Inspector 66HE �LECD 24. Project design flow. (gallons_ per day) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... �P 26. Has SPDES Application been submitted to local DEC office? ......................... _._ Form PC--97 2 .27. Is any portion of this project located within a designated Town or State wetland? At 28. Wetlands ID Number ........................................................... ............................... tiYi °Cd: ..:..: ..............:.:....- :...:::..::... ..::.......:..::.:........... .. Has application been made to Town or Local DEC office? ............................... �Q 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............I ............... Yes/No- (`�o 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 (J0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 3.4. 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? . ............................... YES 36. Tax Map ID Number ....................... ............................... Map Block �° Lot 00%._. 37. Approved plans are to be returned to ..... Applicant }... Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be,seir to the Depanfneia, and need not oe sent in duplicate to the DEP, aithough the project may require -DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans-or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. + ^` If the application is signed by a person other than the applicant shown in Item 1.,the appl"ation :must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with thw prbvis-i'n may be grounds for the rejection of any submission. 1 hereby affirm, ender penalty of perjury, that information provided on this form itrcr6-: to the best of my knowledge and belief. False statements made herein are p tin ish aPleas t a Class A misdemeanor pursuant to Section 210.45 of the Penal Ow.11 SIGNATURES & OFFICIAL .TITLES: Mailing Address: HEALTH., -N DEPARTMENT OF PUTN A, C-OU. TYDEPAR :DIVISION OF ENVIRONMENTAL, HEALTH. DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM Address. Ro, &o..x 911P ezzAP_o-tf Located at (Street) _VAv_K Aagvr go-fi,,b. Tax Mpp 35.3lock.k. Lot �f ifidicate nearest cross street) Muni. 0ipality..:.` AVAITM,40as` Watershed B2A&3e_" SOIL PERCOLATION TEST DATA Date.of Pre-soaking, Date of Percolation Test 10 1.1 •p2_ - Hole No gpsLq Time �.:Sop. '3 U101 - 11 �3 1 4 5 4 30 Depth to Water .*',.:-:-�; From Ground. (luebo) Drop .. Start 'Stop' 30 24 - 1z5 30 2-4— 25 3® .1 2LJ — 2V, 30 .. 30 2- 5 NOTES, 1. Tests to be repeated at same depth until approximately equal percolation are obt-q ined at ca" h""' perco 0. test hole, (i,e,' a t � I min for 1-30 min/inch, g 2 min for3l-60 min/inch) Alld a C submitted for review, 2, Depth measurements to be made from top of hole. .W te'Vei I erco 9ti QU: i, V4 7F- 5 NOTES, 1. Tests to be repeated at same depth until approximately equal percolation are obt-q ined at ca" h""' perco 0. test hole, (i,e,' a t � I min for 1-30 min/inch, g 2 min for3l-60 min/inch) Alld a C submitted for review, 2, Depth measurements to be made from top of hole. ... . TEST PIT DATA 7 ... SCRIPT�ON OFj$®ZLS:ENCOUNTERED, IN'TEST IiOLES • s 1�E�+� *► 1 �Ny7y� K d iiT^t � i 'r s r G �1 tl ti � •• d ��r - ���+�a1y >1� 2 - - _ , a. —,* • f f � �f (V.d �+ ri1 �� F t' 7..41 _ - +.n_w.a.r. HO ��b1✓E 110, .,� , � 6 ^���� Vii.• . T �{ j�t�ll t TOP Stv.i 1. , rr S O:S�. 'Top "AL rut T ���....�, �c � a.�� 'j rev 1�� C r +�- i,� 2�,'��*•� AM. , 2.51 • r t .ar'• 3.0' i �;. 5,511 wla 1�V( P d 3 �rl t: 1 I _ .• 1 " ` 71F �t 6.0 0r • .far 1„ dNr f�' �Yei-i ' 1 A 6.5 8.0 8 S' o { ..�. 9 _�._ ..._..; 1 , 1 _. 0,0' -------= _._..• . r,. Amin Indicate ev ; el at whic:odndwater i ! s encountered fors , Indicate.leYe� - At, w _.. hic:.:notthng is observed Indicate level toluF:. ,eater level rises after being encountered Deep hol' ob ...,1 e atior made by: �Eh� I?ate `tot esign Professional N �e•lj }" address pt1' j S atat .. Oil �' d° gnature: - s j'�I r, 'kl '. P,�I:. it \ \ \`•��jr.� No. 561.24E .k-l�.. :.asa. s t aat • I � ,'`rah' t S��'''~ .� t ,ice. { �. , I� Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DES16N�IATkSHEET = -SlU195URVAUE SYSTEM Owner caAe5-7-, Address "p7-" Located at (Street) _zmp/,,q�y Tax Map 3 6-, Block 2/ Lot 0 g5 (indicate nearest cross street) Municipality flf- Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking to &0f o Date of Percolation Test lazll NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 . .. .... . .. ... .T� ......... .... ............ .... ........ ..... ............. 2 40"U - //4 p6 3 eD 3 ('407 - 7 3 � 4 5. 2 /k 9,'3; 3 3&'> 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES I-IM E N, G.- �T B TO 1 G.L. 0.5 1.01 1.5' 2.0' ti 2.51 3.01 04 &3,-0 3.51 4.0' 4.51 5.01 60IW40 4- !!V14 5.5' 6.01 6.5' 7.0' 7.51 8.01 8.5 9.01 10.01 Indicate level at which groundwater is encountered AjpIy,46 Indicate level at which mottling is observed e!¢ Indicate level to which water level rises after being encountered Deep hole observations made by: g::9 Date ZoJaZeA Design Professional Name: Address: Signature: Design Professional's Seal 0 Pr-,/ 4-b-r-,4 P cOG ' Sheet- oaf PUTNAM_COUNTY DEPARTMENT OF HEALTH f . ; ?IYTS�O�?. F.?FN 'I�?,( AT�vl,�.'�.7�'A] �F�EA7'I�E, rFRY,�CES.,;� - c�W..Y FIELD ACTIVITY REPORT . A17iYRE�S_: vo_e. `-.rJiCT itJ - - Street Town, - State Zip �j PERSON IN CHARGE '()R TNTF.RVTFWFT�. _ -.° = _ Tlate. 1.�9 11J" %�- . Name, and Trt1e TYPE OF FACILITY v ®S!7 "de. FINDINGS ;ems �1 ui �l �t�'� JS �7 � .ev►�t - le;' - ,: Te a e. - i� �n Y , 7�0 - , tv Signature and Title RF.PQ'R 'gprVr,IVFn RZ% i" - I'acknovvledge r-edd'ipt of this report. SIGNATURE: , 02/96 Title Re_v_. w. 6 ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ . w INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project 7Zj�I/-I-X DNS �, ! (V) �jZ �/ County PU ice, 4,41 Site Location 2y"- Building construction begun 414V Extent Is property within NYC Watershed ? ................. Yes F7 No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. Q. Hilly � Rolling E Steep slope a Gentle slope F-� Flat 2. Evidence of wetlands a Low area subject to flooding F--J Bodies of water Drainage ditches 0 Rock outcrops . 3. Property lines or corners evident ....................... ............................... 4. Do water courses exist on or adjoin the property? ..at rw4.. KmwP. Ilrh�iv Ar2F49 5. Will these affect the design of the sewage system facilities ?............ 6. Do watershed regulations apply in this development ? ....................... 7 Will extensive grading be necessary? ................. ............................ .... 8.. Will extensive fill be necessary for SSTS? ......... ............ ............. ...:.... 9. Do filled areas exist within the SSTS area? ........ ............................... If yes, what is the condition of the fill? F Yes �No Yes F2"'No 0 Yes �No Yes 0 No MYes dNo No Yes No SECTION C. SOIL OBSE VATIONS 10. Appearance of soil: Sand 0 Gravel dLoam FBackhoe Clay Hardpan 0 Mixture 11. Observed fr om: a Borings F7 Bank cut excavations 12.. Soil borings/excavations observed by P,, C. -,N;'D on o O 13. Depth to groundwater /V'oN�e on 14. Depth to mottling 2 �� on 15. Are test holes representative of primary & reserve areas ..........e -f r� ...................... No 16. Soil percolation tests made by ZA1, on 17. Soil percolation tests witnessed by 4� 2E r-- 2 on SECTION D (on back) Form ST -1 r 2 F T 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? F_� Yes dNo 19. Will groundwater or surface drainage require special consideration? ..................... Flyes No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... 0 Yes 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? ................................ ............................... D Yes No Inspection data 22. Do adjacent wells and/or-sewage systems exist? ..................... ............................... Yes No 23. Additional comments 24. Site observer /inspector and title 1�� %ZFGn 6Ag ?C-, N, 1b , 25. Date(s) of observation(s)inspection(s) oo /d 2 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 - .. _ ..... _ _ .rte,. ._.. _..__.... _.�_..�...•- p .e Dep%ri°tu �ockliinp "� s 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 AUG- 29- 2002. 12:26 PM HARRY W NICHOLS BRUCE R FOLEY ?��l;c Nrot�e..Dirtctor ATTENTION: 914 279 4567 P.01 LORETTA MOLINAM RN., M.S.N. Asswiate Publk Health Director Direaror e. Patlew Servim DEPARTMENT OF HEALTH _ 1 Geneva Road Brewster, New York 10509 .. ....RIEQ `FOR SELD TESTING c ADAM STIEBELItiG ENE REED .-N 1 information below must be JuU completed prior to any scheduling. DATE; 13" ENGIi 'ER 0R FIMI: PHONE M; _a2-6Y —:J00 REASON: � _........ 1)EEPS: PERCS:X PUNIP TEST: 0 ROAD/STREET: ' V$ ftA mcA !l qt- V—P , TOWN: bir TAX AWM: u�l'" •�� 8$ SUBDIVISION: LOT#; UW,tr'ER: 1'ES NO ri rn Cld- e c t� ;Kq1Md;*'3 i. a1Q.6191 190 a 'R AV VAMMIMI'A 19"**3 UltsW &-fdl *4 IN Proposed SSTS-within the drainage basin of West Branch or B.oyds Corner Reservoirs. Proposed SSTS within 500 feet of a reservoir, reservoir stem or control take. Proposed SSTS within 200 feet of a watercourse or a DEC wetland, Proposed SSTS design flow greater than 1000 gallons /day-or SPDES Permit acquired. Proposed SSTS for a Commerical Project. I t 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= to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate ti mutually suitable time for field testing with the PCDOH, the Design Professional and MYCDEP. If a project has been determined to he Delegated based on thke above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP, FOR co*ry list oNvy DATE.- l0 he to i z TIME: i /� "� {FCLDT'EST) —. IJnIMC • DI ITK10M rnn lMTY nFPARTMFNT OF P. 1 00 A/ Ld.�;? W P LOCATION PL SCALE: I"= 2000' 1 PROPERTY SHOWN ON TOWN OF PATTEA TAX MAP: 3S. -4 -88 0+ C. .P. do* C-AisX. WCU. AD 1 50.1 0 D zS.0 LS.00' LZ S\'%g 1. to JD. - \OA. PROJECT: PROPOSED SSTS ICE POND VIEW ESTATES LOT Nj PHEASANT CRO55IN4 LANE %0 CLIENT .00, —.BIZEW RE MY CONSTRUCT101 155 gAlo-r MAIN ST. Harry W. Nichols Jr Suite 106, Patterson 2050 Route 22 Brewster NY 1050E (545) 279-4003 Fax 279 CONSULTING SITE ENGII Putnam County Department of Health Division of Environmental Health Servioed �RAWINC, TITLE FDIMENSION CHART (in feet) Number I A ! S I C 1 20 25 2 106 80 3 101 11 4 98 is 5 94 13 1 6 91 i2 7 88 TO 8 86 69 9 84 10 10 129 112 1 1 130 113 12 132 113 13 135 115 14 131 116 15 140 111 16 143 120 17 141 122 18 68 38 19 62 35 20 58 31 ?.1. _ 53 30 22 50 294 23 Al 30 24 43 32 25 41 35 MI eI tn I 1 0 01 b0