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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -97 BOX 16 01758 III, OWN 'i�� . i,. � H r ' ''. � �� T, r I Nis r AL E 11111 111 11 IL-3r-M 01758 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .._.. _=:_,, - CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P % 02— Located at 12— Co /' 1 h i jz a j & v e— Town or V,i�ge 102� vs e c, Owner /Applicant Name, ig", 1 a,, '4 Cor/1,Tax Map 3 5` Block �_ Lot q % Formerly -- Subdivision Name D A joa Subd. Lot # Mailing Address i, c-4ict'., . ��_ Zip 1.6 tj Date Construction Permit Issued by PCHD Cc ) © Z Separate Sewerage System built by Gti, /��,.,t I,e k., e,01 I C Address ��hie 1' 2' Ai- � 1 Consisting of JZS�l3 Gallon Septic Tank and d - / r�&2 Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by %Q, 1 vrt 4 S 'Si i Address Ao/r Ave. Has erosion control beer "..completed? ._ . Number of Bedrooms Has garbage grinder been installed? ,A)c 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 a ment of Health. Date: /d 0 Certified by P.E. Z R.A. sign rofession 1 Address o License # - Z l �� 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 7mi&a bject to modification or change when, in the judgment of the Public Health Director, such revocatio ' or change ' necessary By: Title: dA— Date: CL a 3 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUT' M COUNTY DEPARTMENT OF F .LTII DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Locatio>c - - -- I�treet- Address (�p lly�,ip 0M �JOi2 dd al ToWn//Vrillage: FAQ i 1i� Tax Grid # Zvi Map S6 Block-4 Lot(* ),.T. Well Owner: Name: ��dflress: ,�J• ` ejp l r/ rnbrrn�i 7Z9. ` t ,r IV , Use of Well: -prjma 2- secondary _�/ Residential . Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well 'Type Screened Open end casing Open hole in bedrock _ Other Casing Details Total length _4ql ft. Length below grade _ #� ft. Diameter _ in. Weight per foot /7 lb /ft. Materials: js Steel Plastic _ Other Joints: _ Welded Threaded _Other Seal: )�_ Cement grout _ 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 Comp. ssed Air Hours �i Yield o,24 gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet 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 a / –T' 1Qi Z -/ llAV &� �AN7 a - _(;TZ_ _ wrre 4,0 AZ-5— (o " Q, z GRAvn -� Ifyield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity __7 Depth 10 Model GS07 Voltage Z a HP Tank Type Gager Volume Date Well Completed Putnam County Certification No. Date of Report Well I r (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller 's e iS/� o�� NS Address: 4w"k Signature: Date: !o 'zd P_3 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Forth WC -97 PUTNAM OUNTY DEPARTMEN'x OF H )EALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building.. Tax Map 'Block Lot - Building Constructed by Town[Village iJDi�VI 1 4 1 t: �V`vt S� _ INP 'soF- Wtoi4 Location - Street Subdivision Name Building Type Subdivision Lot I represent that I am wholly and completely responsible for the location, orkmanship, material, construction and drainage of the sewage treatment system serving the above- escribed 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 ' 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 thb building utilizing the system. b _ . 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 t9e failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing'the system. Dated: Month _ Day I p Year 03 Signaturq� A-4 , — Title: General Contractor (Ow - Signature s rtP., Ja Corporation Name (if corporation) Corporation Name (if corporation) Address: Address:, ;�-- State tN Zip d State 1y Zip 5 a Form GS -97 A yML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Hei N � - ' ~^-~^ ~---'- Albert H. Padovani, Director LAB ON 93.301533 CLIENT #: 114 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~r~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ TORLISH & SONS BOX 271, 45 MAPLE AVE. ATTENTION: DWAYNE TORLISH ARMONK, NY 10504 DATE/TIME TAKEN: 06/10/03 11:45 DATE/TIME REC'D: 06/10/03 12:50 REPORT DATE: 06/18/03 PHONE: (914)-273-3448 ABSENT SAMPLING SITE: LOT 5, WINSOR WOOD DEVELOPMENT SAMPLE TYPE..t POTABLE : KITCHEN TAP PRESERVATIVES: NONE COL'D BY: TORLISH TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF ~~~~~~~~~~=~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..-~~~~ DATE FLAB PROCEDURE: pUTNAM CNTY PROFILE for Sodium are proscribed. Suggested guidelines state that for peop1e on a 06/10103 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 06/10/03 LEAD (!ME) <1 ppb 0-15 ppb 910l 06/10/03 NITRATE NITROG 0.20 MG/L 0 - 10 9139 06/10/03 NITRITE NITROG <0.01 MG/L N/A 9146 06/10/03 IRON (Fe) 0.094 MG/L 0-0.3 mg/1 2037 06/10/03 MANGANESE (Mn) <0.010 MG/L 0-0.3,mg/l 2037 06/10/03 SODIUM (Na) 2.15 MG/L N/A 06/10/03 pH .8 UNITS 6.5-8.5 9043 06/10/08 HARDNESS,TOTAL 76.0 MG/L N/A 06/10/03 ALKALINITY (AS 72.0 MG/L N/A _ 06/10/03 TURBIDITY (TUR____� 1-�NTU COMMENTS: 7;;E BACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTJON. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. iblic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for peop1e on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium ' YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 ' — ' '- ` - � (914f 245n2800 ' Albert H. Padovani, Director l-AB #: 93.301533 CLIENT #: 114 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~r~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.....~. TORLISH & SONS BOX 271, 45 MAPLE AVE. ATTENTION: DWAYNE TORLISH ARMONK, NY 10504 DATE/TINE TAKEN: 06/10/03 11:45 DATE/TIME REC'D: 0600/03 12:50 REPORT DATEi 06/18/03 PHONE: (914)-273-3448 SAMPLING SITE: LOT 5, WINSOR WOOD DEVELOPMENT SAMPLE TYPE..: P8TA8LE THE IMPORTANT AND FREQUENTLY : KITCHEN TAP PRESERVATlVESt NONE COL'D BY: TORLISH TEMPERATURE..: < 4C NOTES...: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLIFORM 1111'--Ti-it MF IS 6.5 TO 8.5. DATE FLAG PROCEDURE . RESULT NORMAL - RANGE METHOD is suggested, PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS lN WATER CHEMISTRY,, WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM O TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERWHARD WATER: ABOVE 300 MG/L HARD -WA�TBR:'-70-14O'M8/Lr----MG�t�-����lqIO.I0FAM' PER ^71 l_ '— HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert Direct M.T.(ASCP) ELAP# 10 323 BRUCE R FOLEY LORETTA MOLRJARDirector. Public Health Director . �,� �� = . - - :.tuoclol:' Pubftc:; Hto(th , p.(rtcrar, •. _.. .. . - ; . 4,,.. ti.. ..:,;:.,,• . - -.. „~ Director of Patient Service _:._.. _.. __.DEPARTMENT OF ' HEALTH _.. 1 Geneva Road..... _. Brewster, -New York 10509 L'aM.amtatal Halth (914)219.600 Fuc(914) 278.7921 Nursing. Services (914)211.655S• WIC (914)4786671 .FikQN) 278.6093 EerlyTdte 4tT6a "(914)111'. 6414 Freulool (914) 279-6082 Fuc (914)179% 6648 E911 ADDRESSNERIFICATTQN FORM OWNERS NAME: G,J '� r �i Y.4�t,r5 --'3 r' ''� .._ \!'f'1 �) L . TAX MAP NUMBER. ° ... E911 ADDRESS -., �'Z C�•G G-C� ✓,�iJ00/J ,®/j„Z—Vy� TOWN: AUTHORIZED TO WN_OMCUL: . _ _ _ _ _ - :.•.... (Signature) ...:DATE: ©3 The Putnam ,Cau4ty.. Department -of Health W111" not issue -a Certificate -of Construction Compliance unless the above form is. completed, i.e., a legal E911 address is assigned by an authorized town official. This form, is to be submitted with the application for q Certificate of Construction Compliance. (E911 VEPIP.K. . I Harry W. Nichols Jr., Patterson Park, Suite 10:. + 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 r Fax (845) :�- 79-4sG7`_.- ;. July 10, 2003 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance — GJ Development Corp. 12 Collinwood Drive Deer-wood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-6W 97 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -5, "As -Built SSTS ", dated 07/08/03. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated - 07/10/03. -3. Three (3)'66pies of "Guarantee of Subsurface Sewage Treatment System ", Dated 07/10/03. 4. Laboratory Report, dated 06/08/03. 5. "Well Completion Report", dated 06/20/03. . 6. Application Fee in the amount of $200.00 payable to Putnam County Health Dept. 7. "E-91 Address Verification Form ", dated 07/10/03. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. NicrsJr.,. P.E. HWN:gav 02- 006.05 ENVIRONMENTAL PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF t G 2 SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # 10- 19- 0 Located at D ,-r- lor"u Subdivision name ia, Date Subdivision Approved Owner /Applicant Name Mailing Address Town or Village P*�eTS-47 L7 Tax Map Block_ Lot Renewal Revision Date of Previous Approval Zip Amount of Fee Enclosed G d Building Type Lot Area d 12- No. of Bedrooms _ Design Flow GPD 860 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of J 1(C-Q gallon septic tank and I7Vp �Ll` Ace r n �J f l&q Other Requirements: To be constructed by l' is ll Address Water Supply: Public Supply From Address s or:_ Private Supply Drilled by T j) Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date -f -1 °i -0 2. License # Sz, ( 224 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 y6eAconsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p ' t. jAppprov or discharge of domestic sanitary se7)�� By: / Title: Date: Z- White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 w... BRUCE —R. -,:.1 OLEY' .:. _ .. , .... - .:.. _.. .. s .. Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 - :LORET A " MOL;INAIiI , R:N: -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 (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 May 30, 2002 Harry Nichols, P.E. . Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 4 Re: Proposed SSTS: G.J. Development Corpbration Deer Wood Lane, Lot #46 (T) Patterson, TM# 35 -4 -129 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: 1. The minimum of two feet of fill is to be provided for the entire SSTS. 2. Minimum distance from the curtain drain to the trenches is 15 feet. 3. Erosion control methods for the house, well and SSTs has not been shown. 4. Curtain drain stand pipes and standpipe detail has not been provided. 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. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, /f /nom, P. c. Robert Morris, P.E. Senior Public Health Engineer RM:tn 6 .1 V BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., 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 (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 May 30, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 RE: G.J. Development Corporation Deer Wood Lane, Lot #46 (T) Patterson, TM# 35 -4 -129 Reservoir Basin Bog Brook 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 April. 30, 2002.is..compl.ete. The Department will notify you by May 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 Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the .above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a proj ect, such as stormwater plans V if -L- etter- to:.Harry� - is o s .,,. ay . or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166: RM:tn Ve y yours 7&10 Robert Morris, PE Senior Public Health Engineer Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 .. ,. ..2050 R66te °22 .: .... y Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 April 22, 2002 Putnam County Health- Department One Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Re: Individual SSTS Lot # 46, Deerwood Subdivision Deerwood Lane Town of Patterson, T.M. # 35.4-129 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -46, "Proposed SSTS," dated 3/27/02. 2. "Short EAF," dated 4/19/02. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 4/19/02. 5. "Application to Construct a Water Well," dated 4/19/02. "Design.Data, Sheet." 7. `2,etter of Authorization & Corporate Resolution," dated 1/30/02. 8. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." 9. Review Fee in the amount of $300.00. / We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. ichols Jr., P.E. HWN: JM: jmm 02- 006.46 PUTNAM COUNTY DEPART NlE \T OF HEALTH .. DMSION OF ENN- IRON\IENTAL HEALTH INDMDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERNITT NAIAE OF OWNER: STREET LOCATION: /REVIEWED BY: RBI, GR, AS, SRD ATE: TAX MAP =: (CONFM%IED) 1' DOCUMENTS N? (REQUIRED DETAILS ON PLAN' C _N__,Dl s PERMIT APPLICATION HOUSE SEWER -'/1' FT. 4 "0'; TYPE PIPE CAST IRON • )WELL PERMIT ORPWS LETTER L -)(_JNO BENDS; MAX BENDS 45° W /CLEANOUT ( )( _ )PC -97 REhE«:gLS (�(/ILETTER OF AUTHORIZATION SITE NOTE (NO CHANGE) rl DESIGN DATA SHEET (DDS) FILL SYSTEMS CORPORATE RESOLUTION 1 ' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE SHORT EAF ILL SPECS! FILL NOTES 1 -5 PLANS -THREE SETS HOUSE PLANS -TWO SETS f1LL PROFILE & DIMENSIONS VARIANCE REQUEST UUFILL LN EXPANSION AREA FILL GRE.ATER TN.-tV 2 FEET SUBDIVISION (� CLAY BARRIER LEGAL SUBDIVISION U FILL CERTIFICATION NOTE. LjSUBDIVISION ROV�cLCHECKED (X(__)PERC RATE_ U DEPTH GAUGES Q _�� DEPTH U VOL. ON PLAN FOR R. O.B., UNCLASSIFIED & IMPERVIOUS UUFILL RE . UIRED `��D SEPARATION DISTANCE FROM TOE OF SLOPE UUCURTAIN DRAIN REQUIRED I L'J U GENERAL LF TRENCH PROVIDED GOFI MAX. L�LOCATED IN NYC WATERSHE PARALLEL TO CON TOURS PLANS SUBMITTED TO DEP - (� ,10MVEXPANSION PRQVWtD _ .. . DELEGATED TO PCHD ( (IDETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL DEP APPROVAL, IF 1tEQ'D COVER ( DEEP TEST HOLES •OBSERVED SEPARATION DISTANCES 0 PLA\ = FROM SSTS PERCS TO BE WITNESSED - 10 TO Pl. DRIVEWAY, LARGE TREES, TOP OF FILL . EX- APPROVAL SSDS AM LOTS LA J20' TO FOU \D tiON WALLS 1VETLANDS (TOW,N/DEC.1rERMIT . Q.'D ?) 100' TO WELL, 200' IN.DLOD, ISO' TO PITS (DATA Oi`I DDS:FLANS.& PERiIIIT SAME .• � 100' TO STREAIN WATERCOURSE, LAKE (4c. ezpaQ) PRE 1969 NEIGHBOR NOTIFICATION �0' TO CATCH BASH, 35' STORbIDAAIN, PIPED WATER LETTERBI/ZBA6'TOWATERLL`tE its -20' . Y 100 YR. FLOOD XLEVATION W/I 200'. K�l )1JL��0' 1N ?ER,1111TENT DRAINAQE COURSE . (�(.�SOIL TESTING LOTS >10 YEARS OLD _00'1500' RESERVOIR, ETC_ 150' GALLEY SYSTEMS. REOUTFtED DETAILS ON PLANS ` �� O'.tiILYTO LEDGE OUTCROP .. L_}SEWAGE SYSTEM PLAN - (NORTH ARROW) , SEPTIC TANK SSDS HYDRAULIC PROFILE (J(�10' FROb1 FOUNDATION; 50' TO WELL ( _JGRAVIIY FLOW WELL. _ ... )CONSTRZJ CTIOY .NQTE.S_1- 15..-- .-- ._---- . - - - -- ._._.. .--. - - - - -:- -.. (__)DESIGN DATA: PERC & DEEP RESULTS �-- )�-- )DItIE- NSIOYS TO PROPERTY LINES U2' CO.; TTOURS EXISTING &PROPOSED UU- )LOCATION OF SERVICE CO ii IECTION DRIVEWAY & SLOPES;. CUT ' (--)L- )ti1L`I 15' TO PROPERTY LZ!`IE FOOTINGIGUTTER/CURTAIi i DRAINS SLOPE ( USDA SOIL TYPE BOUNDARIES UUSLOPE IN SSTS AREA (S20 %) - S TITLE BLOCK; OWNERS NAME ADDRESS UUREGRADED TO 15%, IF REQUIRED • TM9, PE/RA; NAME, ADDRESS, PHONE# DOSE/PUbIY SYSTEMS DATE OF DRAWING/REVISION UUPUb1P NOTES - �DATUM REFERENCE . U(�DOSE 75% OF PIPE VOLUbIE/DOSE VOLUME NOTED (/_) LOCATION OF WATERCOURSES, PONDS UUDETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) LAKES,WETLANDS WITHIN 200' OF P.L. U UPIT AND D -BOX SHOWN & DETAILED ( L�PROPOSED FINISH FLQOR ANA UUl DAY STORAGE ABOVE ALARM BASEMENT ELEVATIONS CURTAPiDRATN WELLS & SSDS'S W/II`I 200' OF SSTS U )U 6�5.B(__)P F ERTY METES & BOUNDS 2 5 %, (___)EROSION CONTROL FORHOUSE WELL & U(— )20' bIIN to CD DISCHARGEI100'tirith 182 cons day discharge SSTS, EROSION CONTROL NOTE UU10' blL`i to NON- PERFORATED PIPE COMMENTS: (REVSI{EET)09101100 14.16-4 (91 6) -rTul 1= PROJECT LD. NUMBER State Envlronmentil Cuillty SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTEP ONS Only- PART I— PROJECT INFORMATION (To be completed by App110.0t or PrOjow spots".:.. ; .. 1. APP,rLICANT R tr" . TI fir J,.. PROJECT LOCATIO .�j [ : - .. - ..._ =.•t._ ;; •._ ; .. �IunklpatRy 6J'riY�'� Oounty 4. PRECtSE LOCATION (Street e4drese and road Intnrswtlona, prorNnnt landnwka. mo. or Provide map) /°z e S. lS PROPOSED ACTH'.. . ❑ ModlflaatbNaltarstlon _ ...._ .... _ _ . .y..... - -- _- .• 6. DESCRIBE PROJECT BRIEFLY'- _._. Y�Pli3 :.J S t J G7 n- G- o t; �rs� 2r• S� �. Q�+...G f., i'GC � c+^�L. -•� 7. AMOUNT Of LAND AFFECTED: _._. __. ....... -.- ..._... ions, Inliwry Uiuny 6. WILL PROPOSED ACT10N COMPLY WITH E OMO ZONING OROTHER EXISTING LAND USE REBTRICTIONSf..: 9. WHAT LAND UU IN W ma OF PIOWW t - 0Ao'rliotuia .......�ParWForaNOPan6paw., InduatW_. h _GC, hmirolil-.:..__ 0" Dow" 10. DOES ACTION I/iVOLV[ A MWWR APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL. STATE OR LOCAW v" . ONo - IYysa, Itit aoY(a) gild Dvapprow 11. DOES ANY ASPEOT OF TK A0901 NAVR A CURRENTLY VAUD PRUI T OR APPROVAW . Y-04144Mw4y ww sltd Pi WI14wovsu —' /•j � - 12. AS A RESULT OF PRO?iFD AQi10N WILL EXISTiNO Ff. WRMPPROYAL #tr.= E MOCUWTW O Yes M<—"" , , - I WnPY THAT THE INFORMXT ON PROVIDED ABOVE IS TRUE TO THE BEST Ol YY KNOWLEDG! `' ' :^, °1 Appltoartt/sponaor C1 l/ ev v+ `. y r Dat« '� ° 1 6 c,._ a. Slonatura t If the atctlon is In tha.Coastal Areal and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART 11_�ENVIRONMENTAL ASSESSMEFIT (To be completed by Agency) — - - the revlsw proosae and u&e4he FULL 7E Alf A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN a WORN PART 511,47 If yea, coordln&te ..O Yea:, - - D.NO e. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNUSYED ACTIONS IN f) NYCRR,1 ART 511.57 If No; lt:negatke'deel ^ar6tlon " may N superseded by anothef.InYOfllYd agen0yt O Yes ONo , C. COULD ACTION RESULT IN ANY A0VER86 E /FEGiS ASso01ATED WITH THE FOLLOWING: (Anowero My bo hwWw(ltt ®n, .111901010) C I. Eslaung. air guallty� iurlao® or ptoundw4tpr quality a ®uantlty, noloo Ivvvlo, ex.101" tralll4: pagvrgo, .00ll� Ysoet® °du°akn a drapoa8l, PowII&I for eroalon, drainage or flooding problems? Explain briefly: C2. Aesthello, agricultural, archaeological, historic, or other natural or culturol raaourcae; W community or n©lghbortwod character? Explain brlelly: CJ. Vegetation or fauna, II&h, ohollllah W XIWIIIo species, eignllieant habitato, or threatened or ondangorod opocloa7 Explain txielly; • Ce. A community's existing plans or goals a& 911lo by adopted, or a chango In use or intensity of use ol.Iand.or.other na weil.resources9.Expi4in C5. Growth, suoaoquont development, w related aotMtlss IMly to be Inducod by Iho proposed action? Explain briefly, C6. Long term, arlort term, oturuelathre, or other effects not Idantltled In 01-051 Explain Wally, - — C7. Other Impacts (Including changes In use of either Quantity or type DI onergy)7 Explain briefly. D. WILL THE PROJECT. -HAVE AN,- IMPACT 0N.THE.ENVIRON gHTAL CHARACTERISTICS THAT-CAUM THE_lgsTABUSHMEW. -OF-A CFA? E. 15 THERE, OR IS THERE LIKELY TO BE, OOKtROYERSY_RIELATU To POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes 0 No If Ya, oxptaui txl.tly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by'Agency) INSTRUCTIONS: For each adverse effsot Identified above, determine whether It la substantial, large, Important or otherwise significant. Each effect should be- assessed In oor�neotlon with Ite (a) Betting (I.e., urban or ruralk.�bLprobablilty .of•.q.*rdnp;.- (oj.duritton; -(d)- irrever&lbility;'(e) pewgraphlo *cope,, and M magnitude. If necoaaary, add ettachrnents or referonce eupponlnq motodolts. Ensure that explanation& contain sufficient detail to allow that all relevant odver*o impacte have been Identified and adequately addressed. It Question D of Part II was checked yes, the determination and slgnifidance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box If you have identified one or more potentially large .or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive deciarstlom O Check this box if You ..have. detsrmtnedr *aced on tb® Information and analysis . &Wve and any supporting documentation, that the proposed action WILL NOT result' in any significant adverse environmental Impacts AND provide on attachments as necessary, the reason@ .supporting this determination: Name *I Lead AdrKy _ tint ot Typc Name of 90—P-0—m—Wo Qllkef.jW Uad my 7100 Q raipwilik Officer. .. . rputwe of es Veto repdrot orent tpfn tespona er Data rn G7 0 • v 'Z3 7 cl D. WILL THE PROJECT. -HAVE AN,- IMPACT 0N.THE.ENVIRON gHTAL CHARACTERISTICS THAT-CAUM THE_lgsTABUSHMEW. -OF-A CFA? E. 15 THERE, OR IS THERE LIKELY TO BE, OOKtROYERSY_RIELATU To POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes 0 No If Ya, oxptaui txl.tly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by'Agency) INSTRUCTIONS: For each adverse effsot Identified above, determine whether It la substantial, large, Important or otherwise significant. Each effect should be- assessed In oor�neotlon with Ite (a) Betting (I.e., urban or ruralk.�bLprobablilty .of•.q.*rdnp;.- (oj.duritton; -(d)- irrever&lbility;'(e) pewgraphlo *cope,, and M magnitude. If necoaaary, add ettachrnents or referonce eupponlnq motodolts. Ensure that explanation& contain sufficient detail to allow that all relevant odver*o impacte have been Identified and adequately addressed. It Question D of Part II was checked yes, the determination and slgnifidance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box If you have identified one or more potentially large .or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive deciarstlom O Check this box if You ..have. detsrmtnedr *aced on tb® Information and analysis . &Wve and any supporting documentation, that the proposed action WILL NOT result' in any significant adverse environmental Impacts AND provide on attachments as necessary, the reason@ .supporting this determination: Name *I Lead AdrKy _ tint ot Typc Name of 90—P-0—m—Wo Qllkef.jW Uad my 7100 Q raipwilik Officer. .. . rputwe of es Veto repdrot orent tpfn tespona er Data rn G7 0 PUTNAM CG,.,NTY DEPARTMENT OF x,.LALTH -,.,DIVISION: OF; ENVIRONMENTAL .HEALTH -'.SERVIC-ES.. rJ APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM _0 A AA f • IC allit, c ^ ul a LVOO app 2. Name of project: P)-- 4. Design Professional:' DrainapBasin: 0 Location TIY:. Address: a-o�o 7. Type of Project;%'. ___L,/?rivate/Residential Food Service Commercial. —Apartments Institutional Mobile--Hom'e Park Office Building Realty Subdivision Other (specify) 8. Is this project subject -to State Env:irorunental Quality Revi'e'w (SEQR)? IType. Status (check one) ....................... ........11.......,.,.01.....:.. -Type Type II:` n i§tbd 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... AZa A.-Ilds DEIS beeh'completed and found acceptable by Lead Agency? .... 11. Name of Lead Agency ,12,K br6iect- in an area under the control of local planning, zoning ..or oth .....officials; ordiha`n'ce'sT.*...,.'.,.'.,, ........ ........... ........... •......... ............. 13 If so, have plans been submitted to such authorities? ............. 14.. Haspreliminar' approval been granted by such authorities ?. v. Date, granted: :- 0, 15. Type of Sewage Treatment System Discharge ................. surface water i.,' groundwater 16. "If surfa discharge,- what is the stream class desi" ion?' pat ........ 17: Wat ers index number ( surface) 1.8.._. Is project located. near a public water supply system? ........................ 1111.. .19; If Distanc yes, name o water supply q to water supply r. 20. Is project site need a public sewage collection or treatment system ........ ...... A J wage system 2 1 .Narne of st' L14- DisU=6 0 ge'system'-� 22.i.. Date test ho'ies observed 23. Name of ealth InspectorJ_A-(&LYJ 24. Project design flow (gallons per day) ............................. :1 ...... ....... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required?... d 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 wettand? o 28. Wetlands ID Number .............................. ............................... 29. Is Wetlands Permit required? ...... .......................__.:._ `... ............................... Has application been made to Town or Local DEC office? ................:.............. 30. Does project require a DEC Stream Disturbance Permit? ............................... __L 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? ............................ Yes/No 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 bd DESCRIBE: 31 Is there a local master plan on file with the Town or Village? .............:..... ........ Y�J 34. Are community'water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 0 ash 35. Are any sewage treatment areas in excess of 15% slope? . ...................:........... 36. Tax Map ID Number .......................... ............................... Map 3S Block -f Lot 2. 37. Approved plans are to be returned to ..... Applicant Z/ Design Professional N.OTE._All ap licatlons:for::rcview arid.:approval -of a new SS.TS .to be. located withi* h6N. .YC:Watershed -shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may qu* DEP approval of the SSTS prior to final approval b the Department. Projects within the waters —, also PP P PP Y P J ��.. require DEP review and approval of other aspects of a project, such as stdrmwater plans or tZcregjWi impervious surfaces,, and the project applicant should obtain the appropriate forms for such a t vitre,s� Q'1 DEP and submit those. forms to DEP for review and approval.`" ZZ, If the application is signed by a person other than the applicant shown in Item 1.,the applitatig i t be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with tl ption 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 belief. False statements made herein are - punishable as a Class A misdemeanor pursuant.tc - - SI GNA T URES & OFFICIAL TITLES: Mailing Address: ............................... 5'r,/ P UTNAM • C.O�J'N'TX'P,AtTNI NT' OF T D SIQN ENVIRONMENTAL HE4,TH SERV TCES DESIGN DATA SHEET SUBSURFACE SEWAGE TREATMENT-.SYSTEM Owner�L Address !! LV���c�►,a�LrJt,10 oY�� ..Tax MaP "3 Blodk Lot i� ..oca�ed at (Street). •��� oar- �:� �_ .011.1jcat.c.nWest cross strcct) 'vet nicipaI4 j17 &hot -i Watershed.. • %3o i�rur�/L M ...... ...... .SOILTERCOEATYON TEST DATA Dace of Pre - soaking ._.. Date of percolation -Test 8�r =9� 96 h ) percolation tost hole. (i.e. s l Min for 1.30 mWinch,�sv2 min for 31.60r *CC11n h) All d ea ao be cach suW ud for roviow, >..: W:.Hole '.3 No; '' y MiWIocl}: 91.-4v -�; 5 �`' l� Iii `�z�� ��:�.• :� 1,,, - �j. : r 4 ,.. . ...r... 5 � L l/ 1 L. J : .I .. �71 percolation tost hole. (i.e. s l Min for 1.30 mWinch,�sv2 min for 31.60r *CC11n h) All d ea ao be cach suW ud for roviow, >..: es P s 1 N gn ro 11 ona ame. _ I ; N j< Address: 205-0 R z , 2.z Signature: �.%., Design Professional's Seal 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST. HOLES DEPTH HOLE NO. I HOLE NO. 2 H HOLE NO G.L. . ...... .. �... ; 0.5' � i i T TOPS 11, 1.0'IZ�Aes1.� P Sit -'t`t �N S �JAt�1 P �O N 1.5' - - LL. 15 R , SA N !`( 2.0 L LOA 2.5' 3.0'' 4:5' 5.0' _ _. �x 54 61 8.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered -- Deep hole .observations made by: ; Ll T(� (iii =P, . >.�1 , Pau �Z I uSK I t t�fl� -Date . . 2' ' RM ■ ■■■ !ems s ■ ona ame. _ I ; N j< Address: 205-0 R z , 2.z Signature: �.%., Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1 t APPLICATION TO CONSTRUCT A WATER WELL pAease prmf or type ° PCHD P -eriit # �- Well Location: Street Address: Town/YAta -ge Tax Grid # 06tr 1U00 J hc'� A GTr-gef , Map 3�-, Block Lot(s)12-`J Well Owner: Name: Address: Use of Well: _IZ Residen ial 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 1�- gpm # People Served _Q Est. of Daily Usage 0 00 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling / New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type L Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No z.i Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision ,_,�r Waal Lot No. 1 _ Water Well Contractor: 1-13 D Address: - Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: A) J1+- Town/Village --- Distance to property from nearest water main: NZA Proposed well location & sources of contamination to be provided on rparate sheet/plan. Date: °1 -02 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 ell driller certified by Putnam County. Date of Issue d Permit Issuing ial: Date of Expiration Title: Permit is Non - Transfer •ab e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH _._ v_IVISI.ON. OF. ENVIRONMENTAL HEALTH-SERVICES.: LETTER OF AUTHORIZATION RE: Property of _ GJ Development Corp. Located at 31 old Road TN Patterson Tax Map # 35 Block 4 Lot . 12.01 Subdivision of Deer Wood Subdivision (AKA Windsor Woods) Subdivision Lot # _Ite Fil'ed Map # 2: eclj r3 Date Filed Gentlemen: This letter -is to authorize Harry Nichols 14 duly- licensed Professional Engineer or Registered Architect to apply for the required ;' stewatertreatmernt and/or water supply permit(s) to serve the above -noted property in accordance "Vi Lh the standards, rules or regulations as promulgated by the Public Health Director of the Putnam. Counry Health Department, and to sign all necessary papers on my behalf in connection with this manor and to supervise the construction of said wastewater tretment and/or water supply systems ![,, ion ►orrn(ty wiih the of Article 145 and/or 147 of the Education Law, the Public Healt- and the Put _ � P ary Code. cc Very truly yours, -- GJ Develo nt 1QQrj6. Countersigned.- Signed: 56124 F , R. A., # wncr of Propcn y) r s ident E5 . '•1ai!ing Address f?L as Mailing Address: 11 White Birch Road Pound Ridge p State Zt 1Q�0 State New York Zip 10576 Telephone: OQ9 _60 3 Telephone: (914-) 764 -4080 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: I, Gilbert-. Johns.on..... . represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: GJ Development Corsi Having offices at: • 11 White Birch Road, Pound Ridge, New York 10576 Whose Officers-Are: President - Name: Gilbert Johnson Address: 11 White Birch Road, Pound Ridge, New York 10576 Vice President - Name: Ad ress: Secreta6; -Name: Eleanor Johnson dclieSs; 1 1 White'- - Birch `Road, Pound Ridqe, New York 10576 Treasurer - Name: Gilber.t Johnson Address: 11 White Birch Road, Pound Ridge,-New York 10576 and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating theret 1� orn to before me this day-of Vklf di-- (month) - 3 (year) - ➢'a'k� Notary Public M P,. ANi ' NOTARY NO MK lSTAATE OFi7 WV YORK Corporate Seal QUAIJffED IN11 STCFIESTER COUNTY ^�?R MISSION EXPIRES JUNE 15, 19: &C Form CA-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Stredt A dress:'j� e�Oi'j b DM W I N YId1Z 6d ar Towr/Village: FATT�f l Tax Grid # ` $1 Map 6 Block 4 Lot(' Well Owner: Name: f d�dr/ess: ; 6w. (� f W�l C� A 1:Y7 nq, j7b (.BNB -R e Use of Well: -prima 2- secondary X Residential . Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Casing Details Total length ft. Length below grade _ ft. Diameter min. Weight per foot -L2-lb/ft. Materials: 'X_ Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: A 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 cad gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet 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 -F/4 AAVC-o(,S ,4P,J ...2 _._ _ .... �� TZi_ 7ZJWI'r�. (A " C-,Rjl C,7VWM� If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth / 40 Model 7 � Voltage Q HP �_ Tank Type "o, ?g Volume Date Well Completed Putnam County Certification No- of Report 1well i I r (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's e f�� /s', dzJ N� Address: ACM40,M/c Signature: Date: vZd a.3 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 a PUTNAM COUNTY DEPARTMENT OF HEALTH �..DIVISIQN.OF..ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COc�MPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # F ° Located at Town or VMaggeO-SIDH Owner /Applicant Name 6- J' Pg"4 a.0?ftW C*?'. Tax Map '�6 ° Block 4 Lot rAllq Formerly Subdivision Name pEERW— 01) Cdy1N('w— wecoO Subd. Lot # Mailing Address P' 0, &u Date Construction Permit Issued by PCHD O'a'f' JQ/)' Separate Sewerage System built by% -J' D61f5W C8? ?' Zip t ®soq Address F,0* liL icaol Consisting of 'I Gallon Septic Tank and 60D � x`66' 1 P6A4 Other Requirements: Py�AP �5461-611 Water Supply: Public Supply From Address or: Private Supply Drilled by Address MKfL6 MF--, W10l is M Building Type__ Has erosion control been completed? Number of Bedrooms /t Has garbage grinder been installed? HI) 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 )Pepartment of Health. Date: 011 iy,D'�5 Certified by P.E. A R.A. �aia.ea�ai a ivaw�iw�ai 1 A `� Address 9-4�® �O� '�'1��T� J yr.j1 License # '156 I Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 _eTelephone (8.45)_279 -4903 _ Fax (845) 279 -4567" .. July 10, 2003 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance — GJ Development Corp. 12 Collinwood Drive Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-69 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -5, "As -Built SSTS ", dated 07/08/03. 2. "Certificate of Construction Compliance for Sewage Treatment System ", �_.�a..,.....r_.v : ..dated 0740/03.'_ _..:_:. _ ::.. �_... ..... . . 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", Dated 07/10/03. 4. Laboratory Report, dated 06/08/03. 5. "Well Completion Report", dated 06120103. 6. Application Fee in the amount of $200.00 ayable to Putnam County Health Dept. 7. "E-911 Address Verification Form ", dated 07/10/03. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic s Jr., P.E. HWN:gav 02- 006.05 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH ,SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building. Tax Map Block Lot Building Constructed by TownNillage 1�_ C,0i-1._1 H W OojD D ¢-(\J F" Location - Street Building Type Uv000 (VmHp,�Oq_ Subdivision Name Subdivision Lot I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County .Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. a The undersigned further agrees to accept as conclusive the determinatio Director of the Putnam County Department of Health as to= whether or not t to operate was caused by the willful or negligent act of the occupant of tr system. of the Public Health failure of the system building utilizing'the Dated: Month_ Day I o Year 4b 3 Signatureimz(!A Al. Ao�Title: 0vj Hv�. General Contractor (Ow - Signature G ;[ T)Ey sLaetkeNr Cc m, P. Corporation Name (if corporation) Corporation Name (if corporation) Address: .0 _L:P_0k \ �'�. CZ.�' g`l-� p Address: V1 I- bqe l -- t State N y Zip+ ©S Q State Zip i Q� S Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH,SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Ddilding.. Tax Map 'Block Lot Building Constructed by TownNillage -R Location - Street Subdivision Name Building Type Subdivision Lot I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in gobd operating condition any part of said system constructed by me which fails to operate for 4' period of two years immediately following the date of approval of the "Certificate of Constructidn 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 thJd building utilizing the system. r. The undersigned further agrees to accept as conclusive the determinatioil 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 riegligent act of the occupant of th4 building utilizing*the 9 system. Dated: Month Day I o Year 0 :1 Signature- -&e2 Title: 0' 115�- General Contractor (Ow no - Signature G'T -'DEV SLc(2 t4p. NT- CQ MIR Corporation Name (if corporation) Corporation Nam (if corporation) Address: Address: State Zip Cft E; L State Zip Form GS-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH ,SERVICES GUARANTEE OF S' i Owner or Purchaser of Bi:iilding.. Building Constructed by UBSURFA CE SEWAGE TREATMENT SYSTEM 3 /4 Tax Map Block Lot Town/Village j V',J cQgD 1) P--( "fit Location -Street Subdivision Name _ Building Type Subdivision Lot # Y I represent that I am wholly and completely responsible for the location, orkmanship, material, construction and drainage of the sewage treatment system serving the above- escribed 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 4 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 th4 building utilizing'the system. Dated: Month Day 1 o Year p 3 Signature e2 A AZ Title: or, General Contractor (Ow - Signature G S v �_hP tale t�T 0 MI" Corporation Name (if corporation) Corporation Nam (if corporation) Address: ►,:Ng1`I✓ P Address: State lei y Zip in S Vi State Zip Q� Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street it�_�� (914) 245-2800 Albert H. Padovani, Director LAB #: 93.301533 CLIENT #; 114 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NON STAT PRDC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ TORLISH & SONS 06/10/03 DATE/TIME TAKEN: 06/10/03 11;45 BOX 271, 45 MAPLE AVE. DATE/TIME REC'D: 06/10/03 i2:50 ATTENTION: DWAYNE TORLISH REPORT DATE: 06/18/03 ARMONK, NY 10504 9101 PHONE: (914)-273-3448 SAMPLING SITE: LOT 5, WINSOR WOOD DEVELOPMENT SAMPLE TYPE..: POTABLE :'KITCHEN TAP PRESERVATIVES: NONE COL'D BY: TORLISH N/A TEMPERATURE..: 040- NOTES...: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLlFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 06/10/03 MF T. COLIFORM ABSENT j100 ML ABSENT 1O08 06/10/03 LEAD (INS) <1 ppb 0-15 ppb 9101 06/10/03 NITRATE NITROG 0.20 MG/L 0 - 10 9139 06/10/03 NITRITE NITROG <0.01 MG/L N/A 9146 06/10/03 IRON (Fe) 0.094 MG/L 0-0.3 mg/1 2037 06/10/03 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/1 2037 06/10/03 SODIUM (Na) 2.15 MG/L N/A 06/10/03 pH 6.8 UNITS 6.5-8.5 9043 06/10/03 HARDNESS,TOTAL 76.0 MG/L N/A 06/10/03 ALKALINITY (AS 72.0 MG/L N/A 06/10/03 ^ TURBIDITY (TL? <1 NTU 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDINE�-;HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS ' TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more. than 15 ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe/Mn If both iron and manganese are present, their total value combined shal1 not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street Yorkt�wn Heights, N.Y. . , � . � Albert H. Padovani, Director LAB #: 93.301533 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CLIENT #: 114 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ NON STAT PROC PAGE 2 TORLISH & SONS ' 6ATE/TlME TAKEN: 06/10/03 1i:45 BOX 271, 45 MAPLE AVE. DATE/TIME REC'D: 06/10/03 12:50 ATTENTION: DWAYNE TORLISH REPORT DATE: 06/18/03 ARMONK, NY 10504 PHONE: (914)-273-3448 SAMPLING SITE: LOT WINSOR WOOD DEVELOPMENT SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES, NONE. COL'D BY: TORLISH TEMPERATURE..: < 4C NOTES...: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLlFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD is suggested. pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH lS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS lN WATER CHEMlSTRY., WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, lN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF M8/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. - SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L — MODB�ATELY HARD WATER: 70-140 MG/L' ' MG/L = MILLIGRAM f,ER LITER` HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert 24 Padovank M.T.(ASCP) ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES • FINAL SITE INSPECTION r' Date: 6 o :.. - cte b - = Inspe .. y Street Location .. _ Lam. D Owner 126::i1,E 4,, n,ylG1u7 coTLi?, Town &r:2Sd 25onl Permit # p-- y - o� TM # 3 5 . - 4 - 6 9 Subdivision Lot # 1. Sewaee Svstem Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... H. Sewaze System a. Septic tank size - 1,000 ...:.... 1, 250. ......other ................ b. ' Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... - -1-=•- "All outlets = gat- same�elevation- water tested .......: '"— 2. Protected below frost .................. ............................... 3... Minimum 2 ft. Original soil between box & trenches e. Junction Box -properly set .......... ............................... 6. reT nl es 1. Length required 5-00 Length installed 5--cla 2. Distance to watercourse measured.- CO a Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... ends capped .... ...........:..::.::. .. .......... .. , - • - -- -- r--- - -r ----------- ................ ............................... 2. Overflow tank ........................... ............................... 3. Alarm, visual / audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flo /cycle.........�..,; M. House/Buildink Aade- ( , �A,'+�e �« yr a. House located.per approved plans.,, IV.Well Well located as per approved plans _s . ::.................:....... b. Distance from STS area measured ;L 13' ft........... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ..........0............ V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ...... ..0 ......................... i. Erosion control provided ................. ............................... Rev. 12102 Z COMMENTS JUN -02 -2003 08:31 AM HARRY W NICHOLS 914 279 4567 P.02 �.� . ,., PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RI~QIIE.9T FSZR FNAYNSpE. For: Fill Dater 1104:1 ae)42A _ m � Trenches ✓�, ," . , PCHD Construction Permit # 0Z " Located: lnwhk" ec Is as V&A b.0 (T) (V) Pi►MC a611 Owner /Applicant Name: ,S cage._ TM 3S Block 4, Irot _�_ .• Formerly: Subdivision Name: Subdivision Lot # 5 , Is system "fill completed ?' vies Date: jja t %1212 yf _ Date: N� 103 I's system complete. ;. �. �3L� . - . Is system constructed m per plaai7 Yt� Is well drilled? VC5 Date: H&I %0)0.3 Is well located as per plus? its Are erosion control measures in plans? Yes -- I certify that the system(s),.as listed, at the above premises has been constructed and I have inspected and .verified their completion in iccordance with the issued PdHD Construction 'permit and approved plates and the Standards, Rules and Regulations of the Putnam County Department of Health. Doke: _ h!► �o Jo„ Certified by: RA De Professional Address-..,,2050 -RO EL zz &R -I&A =Mz 14�/ 19 Lic. # 56129 :. Commet :. FOR: a ADAM GENE CJ - -. (NAME) f . Form FIR -99 TI 1" -1 -Inn-- MflAl Mf . n= Tel f•/IC '•I�f1 �rl•'1A . .�wwr_ �..r. .i•... .-.... . ...... ...�.........- ..�...- �- - T'_ . W LORETTA ' MOL-INARI R.N., Acting Public Health Director Director of Patient Services ` ROBERT "J. 'BONDf County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 June 6, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: G.J. Development Corp. Old Road, (T) Patterson Lot # 5, TM# 35.4-69 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. _ 1 1. The finished basement has an extra room, which is considered a potential bedroom. Revisions must be made to either the room in question or the Separate Sewage Treatment System in order to comply with Public Health Codes. If you have any further questions, please contact me at 845- 278 -6130 ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR: cj r SENDING CONFIRMATION DATE : JUN -6 -2003 FRI 14:32 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE 92794567 PAGES 1�1 START TIME JUN -06 14:31 ELAPSED TIME 00'40'v MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED. LOA67TA MOLVARI A.N., M.B.N. ROBaRT 5. BONDI Ad* Pa6nc If.M D6ac4v Caaray B. 0.1v Dwa- of NOW Sw)trr DEPARTMENT OF HEALTH 1 Geneva Road, Rrewelet, New York 10509. . EnNrnawndl q..M (845)171.61]0 Fu (845)!78 -1911 Nursing 8ervkp (a45)178.6558 WIC(US)718-6679 raa(845):76.6085 Barg Ines dwVPrnr 40 (845) 371.6014 Fla (845) 178 - 6648 June 6, 2003 Patterson Park Suite 106 2050 Route 22 Brewster, Now York 10509 Re: G.J. Development Corp. Old Road, (T) Patterson Lot # 5, T.J# 35.-4 -69 Dear W. Ktchola. The above re1krenced scpamte scwege treatment system can be badmad The Following comments must be corrected in the Sell. 1. The fudshed basement has an extra room, which is considered a potential bedroom. Revisions must be made to either the room in question or the Separate Sewage Treatment System. in order to comply with Public Health Codes. If you have any further questions, please contact me at 845- 278 -6t30 ext. 2261. Sincerely, Come A Reed 8avironmontal Health Engineering Aide GDR:cj P1 LORETTA MOLINARI R.N., M.S.N. Acting 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 Harry Nichols, P. E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive August 11, 2003 Re: G. J. Development Corp. Old Road (T) Patterson Lot #5, TM #35. -4 -69 The following - information must be submitted to this Department.. Results of the pump test along with proof of electrical inspection for ejector pump components. If you have any further questions, please contact me at (945) 278 -6130 ext. 2261. Respectfully, Gene D. Reed GDRJjp Environmetnal Health Engineering Aide 3 SENDING CONFIRMATION DATE : AUG-11 -2003 MON 12 :57 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME : AUG-11 12:56 ELAPSED TIME : 00'40" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... P J 4 k t LORMA MOLINARI R.N.. M.S.N. ROBERT J• BONDI Milan FW1. H-IN Dbaso E -0. Dlraw f Pmfnl Sa W— DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 6awaaa -W Beale) (3451276.6130 Fa(645)276.7921 Nmatat sm.lts (345) 278.6553 WIC(145)278-6678 FO(445)279-6093 warty laufveaase?r mciml (645) 278.6014 Fat (345) 278 - 6648 August 11, 2003 Harry Nichols, P. E. Patlerson Pork Suite 106 2050 Route 22 Brewster, NY 10509 Re: G. J. Dovelopment Corp. Old Road C) Patterson Lot 05, TM#35: 469 Dcar Mr. Nichols: Tbc following tannation must be subm(tted to this Department. Results of the pump test along with proof of electrical inspection for ejector pump contponenta. If you have any further questions, please contact me at (945) 278-6130 cit. 2261. RespectfuUy. , 19 4:t j Gone D. � Environmotnal Health ptt t mring Aide GDRfjp p� .t BRUCE R FOLEY LORETTA MOLINARI• R.N., M.S.N. Public Health- Dlrcctor• - 0� .4rroe/ats Pablk:.lfaclth .Dtn4ta.,- --- .. . w Dlncta q/' Pad'ent &Pvka _.. _.. DEPARTMENT OF HEALTH • 1 Geneva Road _ Brewster, New York 10509 Eavkc,amcatal Health (914) 271.6(30 Fax (914) 278- 7921 Nurdas. scrrlca ( 914) 278.6538 WIC (914) 278.6618 . FkL (914) 278.6083 " -' " E+rly•Totcrreodoo -(914) 211•• 6014 Prexeool (914) 2786082 Fax (914) 218'• 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: Y Cfii;'r -►j co? (t,tai7 TAX MAP NUMBER:. V2 E911 ADDRESS.;... G,tAl) 110 099, ,®/?,Z Vgr TOWN: .. .__.._.. .. AUTHORIZED TOW - N_OFFICIAL:. �' l ya°'� _ - .... (Signature) ,.:DATE; The Putnam County Department of Health will not issue a Ceirtificate of Construction Compliance unless the above form is completed, i.e., a legal E911 _ address is assigned by an authorised town official. This forme is to be submitted With the application for a Certificate of Construction Compliance. (E91 I VERFRM). , l PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT F REATMENT SYSTEM PERMIT # 9 ° as Located at �1— 1`' 0 AD Town or Village Subdivision name PE IOW flog Subd. Lot # Tax Map �6 Block 4 Lot G1 Date Subdivision Approved Renewal Revision Owner /Applicant Name Date of Previous Approval ' ' a �-i v Mailing Address �LV N V F OQ 1� P - U - p Amount of Fee Enclosed Building Type �- e5 106-�46'2� Lot Area No. of Bedrooms 9" Design Flow GPD �00 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of TF-6NC P Other Requirements: POW P z` M' G M To be constructed by T-6-P, i22*e, Water Sunnly: Public Supply From or°i "' Private Supply Drilled by- gallon septic tank and Address Address �aD yH ,4135 _........_.......Address ,....... ........ , ..z ......,. I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. „ Signed: Address R.A. Date 2 /11 /OV License # 6612,q 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 onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new perm pprov or discharge of domestic sanitary sewage only. By: > Title: �J Date: 3 �� �-- White copy - HD: File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., 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 (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 March 8, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 RE: Application to Construct a Subsurface Sewage Treatment System at G.J. Development Old Road, Lot #5 (T) Patterson, TM# 35 -4 -69 Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced applicat =_ -n; .received•by-th€ Department on February 22, 2002 is- incomplete. - Please be advised that the following information is required before the Department may commence its review. ® A filed map number has not been provided. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166. ry y yo Robert Morris, P. E. RM:tn Senior Public Health Engineer BRUCE R. FOLEY Public ,n- ealth''Dii &ibr LORETTA MOLIN.ARI R_.N.,-_M.3._N,. _.,. " AssocuitePublic falth Dir'ector`' .<..., '_' Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva. Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW PROJECT: DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED TOWN: C S C PV - .-DATE SUB'D APPROVAL: _ NOTICE OF COMPLETE APPLICATION DATE: /0 S a.Z J"II- G71 ^L47"DL ri-). #( r- III HHK KY W N14. H 1.)L'<. 914 279 45ti'! P._.01 PUTNAM COUNTY DEPARTMENT OF HEALTH D I-V1S1'0.N.0_F:.ENVJRONMENTAL HEALTH. SERVICES LETTER OF AUTHORIZATION RE; Property of . GJ Development Corp, _ Located at 31 Old Road, Patterson, NY TN FRT1_I%R-6bM Tax Map #sect 35 Block 4 Lot 69 Subdivision of D��R�nf oaf Subdivision Lot # Fifed Map 4 2 'I Date Filed t7�_ Gentlernen: Iris !ester is to authorize Harry Nichols del; licensed Professional Engineer__ or Registered Architect to apply for the reyuir:i astew ater treatment and/or Water supply permit(s) to serve the above -noted property in accordam �� th the standards, rules or regulations as promulgated by the Public Health Director of the Putnam �_ounn- Health Department, and to sign all necessary papers on my� behalf in connection ir.aaer and to supervise the construction of said wastewater tretment and/or water supply syst<<nS orniiry with Article 145 and/or 147 of the Education Law, the Public 311cl the 1) -y Code. . _ ... .. . /ay � .ter.._ -,� ��S ' .t• \. ... -..... .. �. _ .. ._..... - .. �.... .... _ .. ...- .... .., ....._ .. .... . Countersign P F., It A., h Very truly yo , Signed: '-- --/ -- (Owncr orProperry) Mailing Address J :y- I.-i `yi_ Mailing Address: 11 White Birch Rd^ — SIate ' ".1 Zip fir') o� Telephone: _(945 ) I: " - 4 00-� Pound Ridge- State NY Zip 10576 _ Telephone: 914-764-4080 f 011r• PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL o ., ...,Please printor~type _.. _.....,. -� .. �,:_: _ 'PCHD'Permit # : 1 Well Location: Street Address: Town/Village Tax Grid # ODD j R9 PA -r'r5P -/DDH Map fo"3 • Block 4 Lot(s) 6� Well Owner: Name: 6 j , przv5 -� Y K'E -J LDR Eddress: 1N iA 1T &-6k R" povao R rv4iir, N'rl �51� Use of Well: X Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 05T gpm # People Served q - b Est. of Daily Usage b010 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type X Drilled Driven Gravel Other Is well site subject to flooding? Yes No Is well located in a realty subdivision? ............. ............................... Yes X No Name of subdivision Lot No. F Water Well Contractor: T F5 D Address: Is Public Water Supply available to site? .................................. ............................... Yes No x Name of Public Water Supply: — Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separ et/pIan. Da_ te: 01-1 11-1"L Applicant Signature: PERMIT TO CONSTR CT 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 well driller certified by Putnam County. low Date of Issue 3 2 -. , � 2- `.Permit Issuing: ial: � Date of Expiration 12,6,1 Title: Permit is Non- Transferr ble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 -Brewster, ,.NY.10509 Y: (845) 279 - 4003,. Fax 279 -4567 CONSULTING SITE ENGINEERS JOB No. �i 'COG, SHEET No. ! OF COMPUTED BY .._.. ._..., . DATE CHECKED BY i- W DATE d . PUA't P SL_L.FGT'I O g _— -- - -. --- —._ j)jSZ'R I Ru Tto - -- UM P G bfAAI S ER 130 TTO M iE -Ev, = G- STi4T[ c_ b, Fj TT I n c-,y, 9Q i ntT_ ^PIYr -1 T 4 -- C l7' — -- r! -Z 9O° v -- - - -- - ?-� - -= - -- —P v.N P - _ - ........ ........... .. - - - - -- - -- - -- ....._ – � FT Harry W. N Jr., P.E. JOB No. Park, Patterson Park, Suite 106 2050 Route 22 SHEET No. 2 OF Brewst6r,,NY 10669 COMPUTED BY DATE (810279-4003-,Fak -279-4--ro7 DATE'-0 CONSULTING SITE ENGINEERS CHECKED BY (7SIlp ofi sYsreM yo L, UAMF A85ogpriog -mg tqLc, y gS -K 'x 0,- -7 CrhL /pose p c'1+ArAeA8ER- S IZI N6-'. A F869� A] P- SPACE 6 N E J)A joRAC-F- 0A, Q Pvx�p o 4, — ;e e rare y'. i Curve fVIETERS FEET - s 16 5 14 40 12 0 1 1 = 10 3 0- ° $ rill �11A 6 20 4- 10 2 0 0 - s 0 - 10 20 30 CAPACITY IM 40 m3 /hr _ c O � i 01985 Goulds Pumps, Inc. Effective July, 1985 1 1 �r� YAP Woo Emm sib— Mira 11 • ME 1 1 41 140 160 180 0 - 10 20 30 CAPACITY IM 40 m3 /hr _ c O � i 01985 Goulds Pumps, Inc. Effective July, 1985 0 T ' I MODEL 7 71 1 C ; ��upmersi ewage Di mm MODEL 7 71 1 C ; N• 'f. -�a ',7 W�X 2"; 1, A, nti io Vqz j; nm !f 71k!l ti M. mlle at 774T T. i T. �d "., T N• 'f. -�a ',7 W�X 2"; 1, A, nti io Vqz j; nm !f 71k!l ti M. mlle at 'V;rl OULIM : t, Cjft� t ll-bew Pm'mc ag 4w J I jj jj I 5 r .� O 'U� 0, itGk- s r "4:il i -01P 7, ■ Ij Ts �,jj J,; r _r '.7r1 4 n loll r7 TIT it ' Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Fax (845) 279A567 February 19, 2002 Putnam County Health Department One Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Re: Individual SSTS Lot #5, Deerwood Subdivision Old Road Town of Patterson, T.M. # 35.4-63 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -5, "Proposed SSTS,11 dated 2/19/02. 2. "Short EAF," dated 2/19/02. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 2/19/02. 5. "Application to Construct a Water Well," dated 2/19/02. 6. 'Design Data: Sheet.", A '-- -C' tlf6hiit f& & 6rporate eso 8. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." 9. Review Fee in the amount of $300.00. 10. Pump Calculations. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W . Nichols Jr., P.E. HWN:JMjmm 02-006.05 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES I O QI-T-f: 0iN N,ER- AP-ELI:GA'1'.[,O:X.- ._. _. FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT - To: Public Health Director In the matter of application for: GJ Development Corp. 1,_ Gilbert Johnson represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation. GJ Development Corp. Having offices at: 11 White Birch Rd Pound Ridge, ntv 1 Q576 _ Whose Officers Axe: President-Name: Gilbert Johnson Address: 11 White Birch Rd-,.' Ralinrl Rid N-Y 1057-6 Vice President - Name: None Address: Secretary -Name: Eleanor Johnson Address: 11 White Birch Rd , Pound Ridge, __NY_ 1 n 576 Treasurer -Name: Gilbert Johnson- and that I am and will be individually responsible for any and all acts of the corporation with respect w the approval requested and all subsequent acts relating theret Signed: Title' Pres ' d S��orn to before me this 30 day of 4,wCL474' (month) -,9-- Fxd_ (year) A WK S MW NOTARY STATE OF VW Corporate Seal K IANN12117 Quo COMMISSION EXPIRES JUNE 15. Form CA-97 11 14-164 (W95) —Tad 12 - PROJECT I.O. NUMBER • . >, _ ... �...., .. . -. Appendix .0 State EniWnm'ntsil 'Ou 'Allty. R�rl�tw SHORT ENVIRONMENTAL ASSESSMENT FORM. For UNUSTEP ACTIONS Only PART I— PROJECT INFORMATION fro be oombleted by ADP110ant -Or PTOJ00t 4PQnwd - = 1: APPLICANT WON80Fi OEVELp P! 1C =tom Car -T" 2. PROJECT NJWE— :;. .. • : °_. ....._. 3. PROJECT.LOONTP0. ,P TA - - -`- " 1 � M County 4. PRECWE LOCATION (8traat +ddre" and road Intersaotly% promUant landmarks, eta. w provtda map) S. IS PROPOSED ACTIM':. �.Nwr......._._oEzpan+bn ❑Modlll0atlonlaltsratlon ,..__.........._ -- . ._,........_ -- •_ -.- • 6. DESCRIBE PROJECT BRIEFLYt . WW- iUJR;L 7. AMOUNT OF LAND AFFECTED: - %A 5" 415 leltlal Tana U!tk*WY acm 6, WILL PROPOSED AMON OOMPLY WITH EK 9MG ZONING 08 -OTHER EX MG LAND USE RESTRICTOW. ::_ ..:.:. • ..... .: ::: .... �.Jq ❑ No It Nor OUGM0 WO wttHr�1ATtBPRE $E1±T;WiD_twJ0.YK�'i111�O%,.M. EOT?,'<..:...:_.._.__:...__.___ _.___......w:;__:_�--- k_.___. =M ...r._....G;.._�w. _ .- KrRaal wual 13 O ComnWalal ❑ Agriculture ❑ ftWoratlOpen apaw ❑ Ottw 10. DOES ACTION INVOLVE A PQJ X APPROVAL, OR FUNDING, NOW OR ULTIMATELY (room ANY OTHgR GQVE1WM (rAL AGENCY (FEDt.RAI, STATE OR lACJ1lj4� ._ ❑ Yes o p Yµ W an t agom and panNUapprovalb . 1 t, DOES TINY..... QF14 �Qt" NAVE A GUiiAE1iTLY VAL10 PEFtMMR OR APPROVAL? . . Yq.. U,1% 11"AG loY W" and p"11141ppro".1 12. AS A RESULT OF PROPOW ACT)CN WILL EXl8TIN0 PV.WTiAI MWAL R6W= MOiFICAT1jW ❑ Yaa , 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE 18 TRUE TO THE BEST OF- tr1Y•1C10WUNg. I i o11 Appkanuapono nb AuE Date: .. lgnatura: If the actlon.ls.In the.Coastal Area, and you are a state agency, complete. the . Coastal -Assessment Form before proceedlnp with'this assessment PART ]k- ENVIRONUENTAL-ASSIMMENT [To lea completed by AaencV) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 1 WOM PART 617,47' II yea, 000rdlnale'tlie review process end us® FiJLI' EAF: : Ogee S. WILL ACTION RECEIVE COOROINAT90 REVIEW .PROVICEO FOR UNLISTED ACTIONS IN 6 NYCRrtr PART 617.67 It No, '-d neoativo doclaratlon may be superseded by another Involved spenoj► oyes O No ;:. • ,a a = ► C. COVLO ACTION RESVLT.IN ANY ADVERSE gFFtIOTS ASSOOIATED.WITH THE FOLLOWING: (Anowwo may be hendwritton, II loplble) C.t. Ezlating. air Quality, .eurltioe Or grounOwatpr guolty or quantity, noloe levois, existing traff.I9_ PaganB, ,taolld west ®' produoUon of 416p94e6 potenit&) for erosion, drainage or flooding prob OM? Explain brolly: - C2. Aesthetic, agricultural, arohaooloplcal, historic, or other natural or cultural resourcoa; or community-or nolghborhood characloi? Explain briefly: CJ. Vogotauon or fauna, fish, shellfish or wlldlllo species, significant hobltalo, or threatened or ondangor®d specl ®a? 6plain brioily: Ca. A community'aaxial" plans or goals as officially adopled, w a chango In use or Intensity of use of.land.or.oWor mWal.rsmrm ?:ES9l4In brleUy Cs. Growth, suosoQuont development, or related sotlrllloo likely to bo Induood by the propoeod action? Upkain briefly. C8. Long term, short term; cumulaws. or other ellecta not Identiflud In C145? Explain b(I011y. C7. Other Impacts (Including changes In use of either quantity or typo of onsr9y)? Export briefly, - D. 'THE RWECf? IL WIL - .__.._. _ .. ___.II. YE_ �► NllilPAlt' fON_ Tl1E. lfNl! I�ON�fFI�A. L- CNAR�:CTgA18T!CSTFCA?'OA!��T�I EEL'-" l.". SLl8: ihllS� !'T- OF,:.- 'l:h ?..- . :� :p._; ❑ Yea ONO E IS THERE, OR IS THERE LIKELY To BE, CONTROVERSY RELAT TO POTENTIAL ADVERSE ENVIRONMgNTAL IMPACTS? ❑ Yes ❑ No " If Y .. ` - rAHT III — DETERMINATION OF OIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determino whether It Is substantial, large, Important o(otherwWo significant. Each effect should b' assessed In conneotlon with Its (s) setting p.e, urban or Pu(a*- frobabllity .of.00cyladng;. (c) dulstlan: (d) irreveralbliity;'(e) peoprsphlc scope; and (1) magnitude..;lf necessary, add attachments or reference supWing.materials, t:nsui®, that explanations contain sufficient detail to show that all relevant adveno Impacto.have bean Identified and adequately addressed. it 06311101`10 of Part II was chocked yes, the determination and signifidance must svraluate the potential rac Impact of the proposed action on the environmental chatodstics of the CEA O Check this box If you have Identified one or more potentially large.or significant adverse Impacts which MAY occur, Then proceed directly to the FULL EAF and/or prepare a positive declaration: O Check this box. If . you��havi . determined, paced on the Information and anal y$is 'above - and any supporting documentation, that the proposed action WILL NOT reault' in any significant adverse environmental Impacts AND provide on attaghments-as neoeasary, the reasons supporting this determination: tint or yve anW C ;S(.1114 Lead ,Ky ipwtute of tore ropers, vront reef �espoiu e o e< PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION. OF: ENVIRONMENTAL-HEALTH SERVICES"'' ti v... APPLICATION -FOR APPROVAL OF-PLANS' F(�R. A WASTEWATER TREATMENT SYSTEM 1. Name and address of.applicant: (':. J L- PPJ R-I D, 2. Name of project: �� y � 3. Location TN! rr ? ► 4. Design Professional: 144 5. Address: ' -O vo 'i Z� 6. Drainage Basin: V- t�-►i� �oo°� 7. Type. of Project:: , Private/Residential Food Service Commercial Apartments __ - . Institutional Mobile Home Park Office Building eal Subdivision Others eoi (P fY) ... _._. g tY _. 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? ......................... M° 10. Has DEIS been completed and found b Agency? acce table .,........, < i :� P Y Lead .....: ,. 11. Name of Lead Agency tJ 12 Is this project in an area under the control of local planning, zoning, or other officials; ordinances? ...: .... ... 13. If so; have plans been submitted to such authorities ..... ........... ►� 14: 'Has preliminary„approval been Jgranted by such authorities? OP Date granted: 15. Type of Sewage Treatment System Discharge ..........:..:... surface wader x groundwater 16. If surface; water discharge; what is the stream 'class designation ...... ...... .. 17: Waters index number ( surface) ....................... .......... ....... ;I. .. 18. Is project located near a public water supply system? ....... ............................... i, 19. If yes, name of water supply ( Distance'to water:supplyt _ 20. Is project site near;a public sewage collection or treatment system? 21. Name of sewage system ! Distance to'sewage system``'' 22. Date test holes observed �'1-1 1-1 ''1 '23. Name of Health Inspector M%g VJW OPT 'I v 24. Project design flow (gallons per day) __. _ 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... �D 26. Has SPDES Application been submitted to local DEC office? ......................... t4A Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland ?� 28. Wetlands ID Number... _....;: 29. Is Wetlands Permit required? .............................. Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. ............................... N-D 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? ............................ Yes/No N 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?' `DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... �tS 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to.project site? ................................ ............................... N 35. Are any sewage treatment areas in excess of 15% slope? 36. Tax Map ID Number ........................................................... Map Block Lot tl 37. Approved plans are to be returned to ..... Applicant X Design Professional _:..:.� NC)`fE: All.pplitic>nsor:rv�i�w and approval of anej`SSTS to le:locatedcithin the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation. of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item t 1.,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, underpenalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal L* „ SIGNATURES & OFFICIAL TITLES: Mailing Address:...,.......... E.;,�,,�r�a; �Sa� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner J Address 1i -V4hVM Pte; NJNP t kid 155 i ItSIC Located at (Street) 0t-D POND 1 FLT- `1- Tax Map r� 'S, Block -4 Lot (indicate nearest cross street) Municipality I�T-rF -60H Watershed 1,ipla SOIL PERCOLATION TEST DATA Date of Pre= soaking _q. it Date of Percolation Test Q liIJ °IG Depth to Water > VVa #er Fro roun d Level Percolation: Time Eta se Time Surface (Inches) Dropp In hate Hole No Run No; Start :Stop Min:) ' Start St ap Inches Min%Inch.; NOTES: - 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 411 � 2 q �� _ �ti� �5 51 3 IDim, vvl 5 2 �pIE _�p4� �a `L?�l� 9A►i2 2 15 I 1 4 5 1 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 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA 2 .DESCRIPTION--OF SOILS ENCOUNTERED IN TEST MOLES _ DEPTH HOLE NO..... HOLE NO. __HOLE NO. G.L. ..... 0.5' T 5 .1.0' 1.5' 2.0,E � oRm 6i.��-• 2.5' 3.0' 3.5' 4.0' ... . 4.5' ...... . 5.0' SAND 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' .. 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: M ; U-°Y 0 (DES) Date qH Design Professional Name: h r\¢94 W , 14 kt qti, J(� PE Address:'° i3f NE NICti Z 03J ZO Signature: i.�R x;13, AINMO WMIiiid 4 ��, 03n 4I 3 � No' 56134 �r ! n`"t' Desi t rofesseona s eal �,9 pw / g '`�. �r,rss;�, eet - Sy�N.CI�ART.CnD I�VEN 5 C Number A 1$ 1 33 2 25 95 3 Ip5 4 90 92 5 85 TS � 85 80 7 $0 16 8 So T8 9 76 5 1 10 77 T9 1 T3 T6 31 I L 31 13 34 30 37 1`1 30 15 42 32 35 �` yJ All 16 38 1Ziy2 52 1 7 Goo 41 r1 is 5G 61 45 19 65 44 ao 21 67 50 90 61 23 24 so 72 25 13 56 26 81 T3 30*,!- M• .1 :9e.OJ' Ix� roi oY c CY[`f` 5 B:'7�•�9' C 1x0.00' I n x• � c es 'tl IN a <a. %`\� \ \ 0� is Y A i 6 ;c :i :I• i PUMP CLAMBER 410 Solia Pvc SDR 3 1250 JL 5/ / I SlfTIG Tr►1JK 0'- �� - Pa�� Q u 1 C EXISTING 4 Bf�. Ic °► �LFAes Tafwc RESIDENCE 1 L Ty iq a 7 '9" o S I %I —L. u N s 'a vve- 2S lu 5 WAY P. Box 1 .i.e Ne (-rye) o z �i � 1 J a W 00® I PRO, D CLIE