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HomeMy WebLinkAbout1753DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -92 BOX 16 y .. L me T , #. . '.,,, , f � � I �r I' I� 01753 PiJTNAM COUNTY DEPARTMENT OF HEALTH TE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at AMrocl Race Cff yevsafv b%tl wn oY �It OkTMJZ�L[ Owner /Applicant Name r llw ej c Map �J�, Block �r Lot Formerly 's h1 �Pr Subdivision Name 1:c-e. I M Vi t?� , Subd. Lot # 10 Mailing Address Zip _121� Date Construction Permit Issued by PCHD U 1Z , U Separate Sewerage System built by Oy gVe4AilA C0 C-0. Address 9(o Q­11*Consisting of 2�p Gallon Septic Tank and a LF � 1 / �7 Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by I I P(J I i C . Address �S 1� 1 e _ 'Building yp Has erosion ontroi been completed? �> Number of Bedrooms Has garbage grinder been installed? D 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 of the Putnam County ep ent of Health. Date: 10 O Certified by r P.E. X- R.A. (21n rofession 1) Addressor i , cp License # 5CPI 2-4' Any person occupying premises served by the above systems sh 1 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 revocationxTodificatiQ4 or change is necessary. // B y. Title: �lL Date: & [ � I- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 LAURENT ENGINEERING .ASSOCIATES,, P.C. _ MILL BROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)278- 6108.- (FA)n 276 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS r November 3, 1997 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road ' Brewster, NY 10509 RE: Individual SSDS Compliance Andrea Place (Pheasant Crossing) (T) Patterson Dear Mr. Morris: Enclosed are the following: 1. .,Four (4) prints of Drawing S -10 "As -Built Plan ", dated 11/3/97. 2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 10/30/97. 3. "Guarantee of Subsurface Sewage Disposal System ", dated 10/30/97. 4. Well Completion and Well Log Report, dated 7/22/97. u d 5. Water Analysis Report, dated 10/20/97. 6. Money order in the amount of $200.00 payable to Putnam County Health Department. If there are any questions concerning the enclosed, please call. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Qti Harry W. Nibhols, Jr., P.E. HWN:TR:bd 93046 -10 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Q5Ti N cysT/Jmjj:id.ff5 Building Constructed by 15 { I- l Tax Map Block Lot. �� f s KITAW MR! _Ali ogg-n- (�112ASAWI CgaOJ N_) tG9 IP01 0 \t (t-EvU F STA- E-S Location - Street Subdivision Name Building Type Subd iv iv is on Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system- The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the, system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Mont 0,01D ay Year l�� 7 Signature: 104100/ ym Title: -.11— Ye General Contrac or (Owner) - Sifnature ,p ,�j DTI l�l CfiSTO tom/( N�}�/i 5 (� 1?y R v ry /'tt C'oly -S u t Ti a A- Corporation Name (if corporation) Corporation Name (if corporation) Address: 2� . T Address: 8 6 �a��wr ,' !� ��0 State ''( Zip per' State 1? w Nv Zip 14-5-Y Form GS -97 .c0A/G, WLLL VvrlrLLiiVv r%r ..rvnl DEPARTMENT OF HEALTH .. �� Division Of Environmental Health ... Sdivices-` Y PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION STREET ADURESS: 'NNE t GKICI ly TAX GRID NUMBER: Andrea Place Patterson, NY WELL OWNER Austin Custom Homes, PO Box 525, Bre ster, NY 0 PRIVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary )GxRESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND.IHEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED --!—/ EST. OF DAILY USAGE gal. REASON FOR DRILLING OREPLACE EXISTING SUPPLY TEST /OBSERVATION []ADDITIONAL SUPPLY 3�'IVEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH 880 ft. I STATIC WATER LEVEL 36 TftDATE MEASURED 7/19/97 DRILLING EQUIPMENT ❑ ROTARY )0xCOMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED O OPEN END CASING V OPEN HOLE IN BEDROCK ❑ OTHER CASING DETAILS TOTAL LENGTH 41 _ ft. MATERIALS: )9 STEEL ❑ PLASTIC O OTHER LENGTH BELOW GRADE 40 ft. JOINTS: O WELDED A3 THREADED ❑ OTHER DIAMETER _ 6 in. SEAL: UCEMENT GROUT ❑ BENTONITE OOTHER WEIGHT PER FOOT Ib. /ft. DRIVESHOE.DYES ONO LINER:OYES ONO SCREEN DETAILS - DIAMETER (in) SLOT SIZE LENGTH (It) DEPTH TU SCREEN (It) DEVELOPED? FIRST O YES ONO .01,10_ SECO;:O . ...... GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE. DIAMETER OF PACK In. TOP DEPTH ft. BOTTOM DEPTH It. WELL YIELD TEST pumping I If detailed METHOD: O PUMPED i tests were done is in- X3 COMPRESSED AIR , lormation attached? O BAILED ❑ OTHER :OYES ONO IELL LOG II more detailed formation descriptions or Sieve analyses are available, please attach. DEPTH FROM SURFACE Water pear- Ina We11 D'3- meter FORMATION DESCRIPTION coal ft ft WELL DEPTH ft. DURATION hr. min. ORAWOOWN ft. YIEt.D ggm. Surface 0 12 Brown sandy loam Jbb 665 2 _ 665 1 2 00 Medium to-fiard black white granite.] 800 2 - 800 -85T 1 .800 .880 Soft soapstone (talc) dark green t o 850 868 2 2- = 1Z 8 6 _ 700 2 15 WATER 19 CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS O COLORED ANALYZED? X99 YES ❑ NO ANALYSIS ATTACHED? ®RYES ❑ NO STORAGE TANK: TYPE D' ° hragm CAPACITY 86 k 23 PUMP INFgHMATIQ(! TYPE s u me rs i l e 7 CAPACITY MAKER GOULDS DEPTH 500 7GS15412 230 1 MODEL VOLTAGE HP . 2_ WELL DRILLER NAME MILL DR I L G ADDRESS Putnam .Avenue Brewster, NY F ` r LJOATF/2,2/97 r ' t S/ tSy eyo TESTED RY: LABY 07, Q A) 7T - 777,77-77, PUMAMC0UMTD*AZrMIiff0FiZAi3& cu"N.T.14512 ftabbeow to Ptoylde ft prC8R77FICATB OF COBUILANCZ DWOM UnM A, ir r_­L Plr,- c -e - Teirs w'VMfte TOM 9, 0 Date Of *PMId_I :3 71 P4, - I Ave - TOWU 7 0, Area )a Flow G P D e '06 Sep—le sewevow sydm to Comm d GOOM SqP& T"k a" rII02 To be combeclied by A111600111— Wall- SWtMPWft Sappy Flien Ad&vu an Sw* DOW by --AM. O&w It"pkeiiinuft I represent that I am wholly and dcomplitelly responsible for the design and location -of the Proposed system(s). 1) that the wM diqul system u;; suns above described will be constructed as shown on the approved there to and in accordance with the standards, rules 0, p the Flutnom County Department of Mmith; arid -,thostoncomplet;oonthereo L f a "Certificate of Construction Compliance" satisfactory to the Comm Sao . I nor of H"Ith will be submitted to the Depa"ioneont, And a written . rjaiantee, will be furnished the owner, his succesms, helors,or assigns by the WNer . that said builder will peace in good'oPerating condition'sny part of. Sala a, -'s disposal system during the period of two (2) years Immediately fol"ifm ilie4ate'of the lam- &IKG Of the approval of the Certificate, of Construction Compliance of the original system or any repairs It o, 2) that the drilled well described above WHO be located as shown on the -approv" plan and that aid well will be installed accordance with the standards. Iso; food egulat Ions of the Putnam county Owart nos I Of Health. oat Signed P.E.— RA. L Addre m 1.'nse N 17 vv U . 0- APPROVED FOR CONSTRUCTION: :r his. approval GKPIrGS two years of t_ftS_Ajlt6 issued union construct; the Igbas been undertaken and is ievocibie for cause or may be ame . rolled or modified when considered no — b - the Co Health. Any change or alteration of construction npuir KY y 0 9_—Approved for 41500mi,of dornestic sanitarv,sewage —VRICIAM PrlYAI&-*uAer-I9Mfy'on Rev. �:, / — I 10/88 Date- :�P73, By LAURENT ENGINEERING NA. ASSOCIATES, P.C. Route 22 & Milltown Road Brewster, New York 10509 914 278 -6108 - (FA)() 278 -2658 RANDOLPH W. LAURENT, P.E. HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS December 4, 1995 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS - Renewal Ice Pond View Estates - Lot #10 Andrea Place Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4).- prints of Drawing SS -10 "Proposed SSDS - Lot #10 ", revised 11- 29 -95. 2. "Application For Approval of Plans For a Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 12 -4 -95. 4. "Application to Construct a Water Well ", dated 124-95. 5. "Letter of Authorization ", dated 12 -4 -95. 6. "Corporate Affidavit ", dated 9- 24 -93. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:bd 93046 -10 cc: Mr. Steve Banker w /enc. �YJ•TN,A.N� COUNT'X" D�PAR.'T'i�JuT7T. Off' HLAL`T� -3C APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL.SYSTEM 1. Name and Address of Applicant: STPc'(FS 7 Ill 1 e d r'-T G �6 2. Name of Project: No/G�) /D 58275 3.._. Location T/V /C: /�%l F— r 4. Project Engineer: tt7>eP LS �� 5. Address: %J F�7 /�FIEL P ENr GAIL A ss�c, c . PA TTY S o /� �� 5� / ; License Number: ��� Phone: G 6. Type of Project: Private /Residential Food.Service - ...Commercial , Apartments Institutional Mobile Home Park Office Building, Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt X Type II. Unlisted, 8. Is a Draft Environmental Impact Statement (DEIS) required? .............. ✓�� . 9. Has DEIS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency �A ti: -Is this...project•.in._an area under the control of•16cal planning, zoning, or other officials, ordinances? C' 12. If so, have plans been .submitted to such : author :ities ?.. ................. . 13. Has preliminary approva11'been granted by such authorities? 9� Date Granted: 14. Type of Sewage Disposal: System* Discharge...... Surface Water x Ground Waters 15. If surface water discharge, what is the stream class designation ?........ /J�� :6. Waters index number (surface) ............................................ i7. Is project located near a public water supply system? /V O 8. If yes, name of water supply N /�i- Distance to water supply 9. Is project site near a public sewage collection or disposal system ?..... 0. Name of sewage system NCI" Distance to sewage system AlEl- KEK I- Date observed: 'R- z 23. Name of Health Inspector: i. Project design flow (gallons per day) ..................................... �G'� • . 2. 25. Is State Pollutant Discharge Elimination -S stem (SPDES) Permit required ?.. A) 61 __ __.. 26.! Has SPDES Application been submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State wetland? ................................:.. ............................... vli0 28. Wetland ID Number ......................................................... 29. -Is Wetland Permit• required?.............................................. . NO Has application been made to Town or Local DEC Office? .................. J) 30. Does project require a DEC Stream Disturbance Permit? ................... 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste disposal',``` landfilling,•sludge application or industrial activity? ........ YES or NO�� 32. Is project located-within 1;000•feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known•source of contamination? .....'.........YES or NO DESCRIBE: 33. Is there a local master plan or file.-with the Town or Village? ........... 34. Are conmunity water, sewer facilities planned to be developed within 15 years? �C 35. Are any sewage disposal areas in excess of 15% slope ?- ....- ..........- 36. Tax Map ID Number .............. ............................... . - ........ 37. Approved Plans are'to*be: returned to: ................ . Applicant Engineer If the application is signed by a person other than the applicant shown in Item.1, the. application must be-accompanied by•a Letter of Authorization: Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury;- that information provided on this form is true to the best of my knowledge and be 1 ief. Fa Ise statements made herein are punishable as a Class A Xisdemeanor pursuant to Section 210.45 of the Pena 1 Law. ;IGNATURES & OFFICIAL TITLES: :AILING ADDRESS: j, �4 t t DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION, TO.*, CONSTRUCT A WATER WELL PCHD PERMIT # P WELL LOCATION Street ddres To Vi lage City Tax Grid Number WELL OWNER Name `�. Ma' l 9 Address in u•. la Cj` aG0 rivate !"� _ (s'���,�,ic Public I,SE OF WELL - primary 2- secondary RESIDENTIAL 91BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O FARM O INSTITUTIONAL ❑ AIR /COND /HEAT PUMP 13 ABANDONED O TEST /OBSERVATION O OTHER (specify O STAND -BY Q AMOUNT OF USE YIELD SOUGHT_ gpm /11 PEOPLE SERVED-3 -5— /EST. OF DAILY USAGE OOG gal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 12-ADDITIONAL SUPPLY 604EW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL DETAILED REASON FOR. DRILLING , WELL TYPE [%DRILLED DRIVEN ODUG GRAVEL D OTHER IS WELL SITE SUBJECT TO FLOODING? YES (i'' NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 7TZ I Lot No. /I WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES sue' NO NAME OF PUBLIC WATER SUPPLY: %� TOWN /VIL /CITY a DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED _ CON SEPARATE SHEET (date) (s ig ature) 6F PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt- (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: Date of Expiration Permit is Non - Transferrable 3/89 Fes1 19 Permit Issuing Official White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTP T -OUNTY DEPARTMENT OF HEP)rl DIVISIOIN,OF ENVIRONMENTAL HEALTH SERVICES D Re: Property of 16C-V Located at FJ-AG' (T) Section Block Lot Subdivision of i Subdv. Lot # Filed Ma p Date Gentlemen: This letter is to authorize a duly licensed professional engineer or registered architect (Indicate) to-apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules. or regulations as promulag4ted by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf' in connection with this matter and to supervise the construction of said system---o-r'- 7- sy-_s--t-ems—in-- conformity with the provisi-ons-of Ar-t.ir,.le-- 1,45. or, 147, Education Law, the Public Health La-or, and the Putnam County Sani- tary Coc Count is P-E., R. Address Telephone Very truly Signed V Ot.Tner of Property Address 6 v. q Ci-. 0('2'30 T o wm L? Telephone Putnam County D-- part'meni of Health Divisic Environmental Sanitation AFFIDAVIT - CORPORATE a,, NER APPLICATION ' ' FOR PERMIT. A PPL_ICAT•ION �.PUX A-tq COUNTY 11EALiH- DEPARTMENT TO:' Commissioner of Health - In the matter of application for I, �6Vr� _ 151^N — _'_ — — -- — — _ -_ _ — — — represent that J am an officer or employee of the corporation and am -. authorized' to act for. G'TA-f (name of corporation) t' having offices at — 7 w� °''i'n's`", ;,�,�� _ ��cc ��- ' ^�e- i� —CC'^ oGg3o Whose officers -are President — ^— ----- _'AIame andKddress) — Vice - President — 1�C'c�►�cW �v..�S �. _. — _ — '(Name and Address) r Secretary _ _ -- — -- - — — — (ar,:e and Address) -- l� Treasilrer' --- -^' - -- '.(Name and Address)-. � u�--- '- -' --'~ and t:,at I= am-and will be individually responsible fan any' or all aptp� of. the- corporation with respect to the approval requested and-all .sub- sequent acts relating thereto. _ sworn to before me this day .Signed of Title 1�F,g Notary P0b1 ' BONNIE J. DAVIS NOTAW PUBUJC, SPATE OF NT : ?rl REGJ49c.r305 QUALIFlED 1'� GJ'`�ricSS CC .,4;TY MYcommISslof,; a(PIFIE G. i2, L Corpor4te Seal T"I t COUM11MM ot, ML1� W Dlil) �tBr ai�sle�W See�Oeeo.Cs el NY DOSU w %%--:: i Loaded as -tom :FS' ass e__;� QwiMe /A eon Nor �7 ��ITCIL! A. X r-'p 1 Dale of Prevkns Approval Nefte cameed ?7:7 6tt iPt�tJtli� �Vt A/r-- Town im ►iV ! � C�� W Arm Dotl4o,tiUwG P.D To be:. by 7%% Addrean wafer �4l17 nsse. Sip Fse� 2t Addeeoa an x'- wa..e.� Sappb.Dr®ed,W Ofber Fegb4�eob, 1 representAhat f am wholly and. completely "sponsible for thl design and location of the Proposed system(s); i) that the separate saw di' i em above descfibed.will be constructed as shown on the approved amendniant there to and in accordance with the standards, rules a _ reyu ns o na County Oeparfmant .of MMlth. and'that on Combie:losi.UlpeOf a "Certificatfl, of Const ruction Compliance" satisfactory to the Coramissioriw of Meslthwill be. submitted_ to tf�e ,Oepakfr ► . and Y written yuariittes will be furei)ffied the owner. his sucoasaors. heirs a,apitnii by the bulkier. that said -bull" will pHCe. lei pod b" No CO'WHion, aiy cart of, saki 'siara4a dkia4l system during the period,of; two (2) years Immediately followittPtMd•N'Of the sw- at of the ipprovat of 4h.9 Certificate' of Construction Cinioisf" of t original system. or.any: repents t , eto; 2) that the "drilled welLdescribad above wo be located ai,shcwn oll,theAwovod plan snd that stile well will Oe M 1 in acoordono0 with tlw sta Ms; ba nd rpu ns . of the Putnam County MGM of RO - '}}(( D ` Signed P.E LlL P.A. - Address' 1 Lleeme No IMPROVED FOR CONSTRUCTION: This appoval expMaf twoywrs from the data i unless eonrt'ruetlon of the bulging Ives been undertaken and is "vocable for CAUSe -or may he amended or-modified wMn con'siM►ed,necesssry, .by, the Commissioner' of M_ealth. Any change or alteration of construction retufies a now Permit., Approjtlid for disposal of do'iriest,k Mn a •wa PPM only. - Title �88 Oate G �' 9 10/88 r�Jrrrrr � 48' ....... _._. BATH ►.J .._ v . _ __ • 'r`• I r BEDROOM c •• J� 1 0 %` 91.13 x 12',0" DRESSING. BEDROOM 0r WALK' 131-0"x 10•-0' IN CLOSET MASTER BEDROOM BEDROOM 2 = OPEN N 17•-0 x 16••8'• 13 O' STUDY CON FLO'O'R" - -1344S _ 4828 . F ` ,• Il KITCHEN • I • ' ,vii K � . `/ MK.v r DINING ROOM p �� '• MORNING ROOM 13* 0' x 12 %0• l . �J �• IN/�. �--� PuTpdA(+,1 GO LTIV Ty 10 „i us-F Pt �jn _ ENT 0 r _ OPEN — J ABOVE I a LIVING nooM � , �• S {�n � ` •• 1 � `f A I L Y iyo-44 Z to••o ta••o t�. o.. �. o.' fOYER �. ST FLOOR 4828 LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 (914) 278-6108-(FAX) 278-2658 LAURENT, RE, -- , Voi-a 60"i 'T -E`NG1NEER8-- RAND&LPH W 'HARRY VA- CONS N I E September 24, 1993 Mr. William Hedges . Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Ice Pond View Estates Lot #10 Andrea Place Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS-10 "Proposed SSDS - Lot #10",, dated 9-14-93. 2;. "Application For Approval of Plans For a Wastewater Disposal System". 3. "Construction Permit for Sewage Disposal System", dated 9-22-93. 4. "Application to Construct a Water Well", dated 9-22-93. 5. "Design Data Sheet". 6. "Letter of Authorization", dated 9-22-93. 7. "Corporate A++idavit", dated 9-24-93. G. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only". 9. Check in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. ,41a" 0, cn&1iz&b � - C-kb) Harry W. Nichols, Jr-, P.E.- HWN:bd 93046-10 CCC Mr. Steve Banker w/enc. DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 PCHD PERMIT WELL LOCATION Street Add .ess " i tDr's Z CF To Villa a City Tax Grid NumbAF i 'T Ze k) : - WELL OWNER Name Mailin j'P 77 Addre s _ W� ' W. LTLIALI i vF T -)r Wrivate O Public d lSSE OF WELL - primary 2- secondary (� RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND HEAT PUMP D BUSINESS O FARM (]TEST/OBSERVATION 0 INDUSTRIAL O INSTITUTIONAL O STAND -BY 0 ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHT L;- gpm /# PEOPLE SERVED:- 5 /EST. OF DAILY USAGE Sn Sal REASON FOR DRILLING 13 REPLACE EXISTING SUPPLY 0 NEW SUPPLY EW DWELLING ❑ TEST /OBSERVATION GI ADDITIONAL SUPPLY O DEEPEN EXISTING WELL DETAILED�/� REASON FOR DRILLING BSI T,�f C WELL TYPE [DRILLED DRIVEN ODUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: t No. WATER WELL CONTRACTOR: Name % fjJ� Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES rX NO NAME OF PUBLIC WATER SUPPLY: /JIA TOWN /VIL /CITY -.. DISTANCE. TO. PROPERTY FROM NEAREST WATER MAIN:— _ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED. (SON AN SEPARATE SHEET (date) signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt, (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue 19��"�_ lit Date of Expiration 19�i Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller ' PUTP' 'AkCOUNTY DEPARTRENT OF HEP'- F DIVISION OF ENVIRO- *IENTAL HEALTH SERVICES Re: Property of i I ��"f 1(.;G -. Located at F-A,/­� (T) �T� ��OIV Section Block Lot C� Subdivision of le VI�JTf� 1� Subdv. Lot ' Q Filed Map # ate Gentlemen: - This letter is to authorize a duly licensed professional engineer or registered architect_ (Indicate) to. apply for a Construction Permit for a separate sewage system, to serve.the above noted property in accordance with. the standards, rules. or regulations as promulaga.ted by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf• in connection with this matter and to supervise the construction of said system or-systems in conformity with the provisions-of Article 145 or 147, Education Law, the Public .Health Law, and the Putnam County Sani- tary Coc Count s P.E., R. :-�21 Address ' Telephone• t Very truly yours, Signed \ v Owner of Property S�a4 tray Address G. t c q Ci . O G a'3 c Town Telephone 1�iJTIVr.A.M COUN'r'X' DEP,C��TMEN'T O>E:' HEALT%i - APPLICATION .FOR- APPROVAL OF..PLANS .FOR_ A:.�s'A.STE'�'ATrR •QTSI?OSAI: SYS=i E "i �:; - ._ . x... _.. 1. ' Name and Address of Applicant: \' EM s-1 T�s T TI 1 N �r 1'K-- C� hl l SEN ICI 1 C r-�" 2. Name of Project: S8i75 3.._. Location T/v /C: /P/4 /-Fr-4 61 A) 4. Project Engineer: AA9142 LS \V PE, 5. Address: % F�J,rP�IELn �'Etil r EA1 S670) C ! ; ��RTTaSOA) ��1 License Number: %`t Phone:a2 G 6. Type of Project: Private /Residential Food-Service - ....Commercial , Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject' to State Environmental-Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt ,�_ Type II. Unlisted. 8. Is a Draft Environmental Impact Statement (DEIS),required? ............... �)O 9. Has DEIS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency ti. Is this project _in_._an .area.. under the- control of -local plannirrg,- zoning, -- -or other- -of"c sass, ordinances? '......................................... tted to such: author .sties ?.. .................. f2. If so, have plans been..submi 13. Has preliminary approval been granted by such authorities? �v /f Date Granted: _ 14. Type of Sewage Disposal_ System Discharge....... Surface water X Ground Waters 15. If surface water discharge, what is the stream class designation ?........ /J�� :s. Waters index number (surface) ........... ............................... A) :7. Is project located near a public water supply system? /y S. If yes, name of water supply di 4 Distance to water supply c_ 4. Is project site near a public sewage collection or disposal system ?..... 0 0. Name of sewage system Nei,- Distance, to sewage system A) I /0 CL- KEK t. Date observed: 'R- z 23. Name of Health Inspector: $.Project design flow (gallons per day) ...... ............................... �l� 2 . 25. Is State Pollutant Discharge Elimination- System (SPDES) Permit required ?.. A) G 26. Has SPDESSApplication been submitted to local DEC Office? .............. 27. Is any portion of this project located within a designated Town or State )JO wetland? .................................. ............................... 28. Wetland ID Number ....................................................... /J))4 29. 'Is Wetland Permit - required?. .............. ............................... A)Q Has application been made to Town or Local DEC Office? .................. ,4 30. Does project require a DEC Stream Disturbance Permit? 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste disposal;``` =" landfilling,•sludge application or industrial activity? YES or NO 90 32. Is project located-within 1;000•feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge .disposal site or any other potential known'source of contamination? ..............YES or NO �G DESCRIBE: 33. Is there a local master plan or .file:with the Town or Village? ... ....... % S 34. Are community water, sewer facilities planned to be developed within 15 years? DUG 35:- -A -re- any sewage disposal areas- 1n--excess of -154' slope. - ._........ - - ••-- 36. Tax Hap ID Number ......................................................... ��•" 37. Approved Plans are'to''be; returned to: ................ . Applicant Engineer If the application is signed by a person other than the applicant shown in Item.1, the. application must be-accompanied by y-a Letter of Authorization. Failure to comply with this Drovision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury;- that information provided on this form is true to the best of my knowledge and be 1 ief. Fa Ise statements made herein are punishable as a Class A HW67?eanor pursuant to Section. 210.45 of the Pena 1 Law. SIGNATURES & OFFICIAL TITLES: 'AILING 1•;, y`� III _. - .:.�.*,.2'�;: :.. DRESS ___ ,'��._:.� ,;,:, •,t •;'�: ;: , , .' .: -.:. �'tJIiTAM CaOUNI'Y DEPAR�7T OF BFI. " S ;. • • . - .f µ..t..4. ;'• :_. _.. :'DIVISION :OF: = HEALTH SIIZtiICES. DESIGN' DATA -SHEET-- SURSUFACE , SEWAGE :-D'ISPOSAL' SYSTEM ..Owner �'C. `2"• --��5.. Address 7;ocated =at �{ Street) - 8. :1 ri t `2��'�? Sec - Block.: Z %t _28 (indicate nearest.cross street) t,oY ro� Municipality w N op Watershed _ Gi2•o-7 o, IJ - SOIL PEEtC1 rMCN TEST ; DATA �PJD0UIRID TO BE SUBMITTED WJIt.S APPLICATIONS Y. ,. -Date of Pre- Soaking 5 % 5 % g 8 Date of Percolation Test HOLE CIACR TIME ... ::.:.:. _.._ >:_ _PERO0=0N Run (Elapse Depth to Water From Water Level . No:...._.._. __......... _. _ ' Tine : ' Ground Surface- - In Inches - - : ,Soi1 Rate. T- Start Stop }Min. Start Stop Drop In Minfln Drop;: C(, o'L't"��,......__ ............:. ..._...... ... ........:....:_.Inches ._:_.......:.::::.Inches .:� .._.Inches ..._. _...... . • 1 0►: 3 NOTES: 1. Tests to be repeated• at same depth until appradmately equal soil rates are obtained at each percolation test hole. All data to'be submitted' for review. 2. Depth treasurements to be made from top of hole. rev. 9/85 -2, _ ....... 3 ......._...... 1 • 1 0►: 3 NOTES: 1. Tests to be repeated• at same depth until appradmately equal soil rates are obtained at each percolation test hole. All data to'be submitted' for review. 2. Depth treasurements to be made from top of hole. rev. 9/85 ' `SE SUBiIITI k. ' i APPLICATION PI9 _ETA I MUIRED.IO DEMON OF. SOUS E9COUN MED IN, 9= HOLES DEPZi3 HOLE No. ( _ `ROLE l NO. 2 <::.: ROLE ND... . v+_ .r. _ 1�� ... - { - .1.'.7"'_ .. .F.I •�L'�It. }4�_i- .1 (n. � l.Y' y� ..ff n:. v•r.r_M4.1 .. . .. _ • .. ... .. •vtt•i �•^;.^ _.; .�'Lt:•!la•e % /ya '.: rn[pw...•._ _r•�F: l:",. -.r.:. .. .. , :i >:j 'AiJ.'`��'::' :c• >�i. 4js �7�' ;y :Srti. ``'�•��g��, �(i''Y•.:'j� • ^;?r;F;} s!'7 ''.fj °J' "' _ _ . •: ;i•:.i' > ?vX'' <'`4 •� _'�r.�li�3.:i���� -.r.^r :.r.. .�5••!- i:r% =�`: ci'i; :;J<<• dhik 6° 7e 9° 10° ll° 12° 13° 14° INDICATE: imm AT WHICH GROUmmTER IS E+NUOUNM. -M .... INDICATE LEVY. TO WHICH WATER LEVEL RISES AFTER BEING ENOOUNTERED d f Q- DEEP HOLE OBSERVATIONS MADE BY: vtLK P c. T% o, tF , BATE: 5 2 DESIGN Soil Rate Used 1 15�' MirVI" Drop:.. b,0.0 ' S.D. Usable Area Provided . . No. of Bedrooms Septic Tank Capacity - 125U gals. Type Ce,n/G Absorption Area Provided By 59 O L.F. x .24" width trench Other Nane L&MeW7 9M(:z1e)&K42IN6t ASUC Pe- Signature Address m FI gtp D 121 y r,. SEAL, - No.56124 \iC� • �'A77��bIU iJ�• IZS(v3 ��A � _ • �—" '�QFESStie��. THIS SPACE FOR USE BY HEALTH DEPAPMMfi ONLY: Soil Rate Approved sq.ft,/gal. Checked by Date Bitnam County Department of Health Divisic f Environmental Sanitation' AFFIDAVIT - CORPORATE a-MER APPLICATION FOR PERMIT. A PPLICAT•ION :P SUBMITTE}, T'- O -•I. ;T ?A i�LI� DEPARTMENT - T0: Commissioner of Health. - In the matter of application for x, N -4 —• _ _ r _. _ _ — _` — -- — represent. that .1 am an officer or employee of the corporAtion and am; authorized ' to act for* c _ro�S, A-T •• i ti1�' CCU � yam' > � (.� G _ _ (name of corporation) Y having offices at GS3o _ � — — — — _ — _ _ — ^ _ ; _ _ — �• _ — — _ — Whose officers are President — _ Cc'i4Y �'..• ' Name and address)- . Vice - President - ^(Name and Address) ^ :Secreitary - — --- — — ^ (Nar,e and Treas)i rer' _ _ _ _ .... _ .. "• _ - -- - -- .. ame and Address) .. _ ........ .._.> , and that I= am-and w� ll be individually responsible fon any' or all actp . of. the-corporation with respect to the approval requested and- all .sub- seque it acts jrelatin*g -thereto. Qworn= to before file this !,! / day Signed of 19L3 Title 'Y I .,0b Notary R.ibl ' BONNIE J. DAMS NOTW PUBLIC, SPATE OF \'E 7 i'OPZ REG 449E M- 5 QUALIFIED W UU 'r.ESS CC N 1Y MY CokjmjSc110N EM10 AUG. 12, Corporate Seal , DIMENSION CHART (in ft.) No. A B Al 35 2 27 = 65 3 33- 70.5 4 39 77 5 45 5 83 7 (08 53 8 72, 59 9 74 /O 79 : 74 /� B© 79 /Z gB /05 15/ i /07-_ . 14 5& //Z., /S 40 I I