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HomeMy WebLinkAbout1767DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35.-4 -106 BOX 16 01767 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL _HEALTH SEitVIC CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P- D8- D 15 Locatedat 'F>0 4'2UAI L LAK1> Town or Village PATTERSOI Owner /Applicant Name W YN c)dm HwE-57 Tax Map Block 4- Lot I 0L Formerly /A Subdivision Name V� /, ODDS Mailing Address Subd. Lot # 1B Zip �� Date Construction Permit Issued by PCHD 0!�; Separate Sewerage System built by A MAXX LAN I GA P1= �r- Address �T'� ZZ (jam �yJS 2 i . , Consisting of 12. �50 Gallon Septic Tank and r Other Requirements: N D1 Water Suunly: Public Supply From Address ` i 0x511. 1�7 E �a or: Private Supply Drilled by %--(OA W=51A h WELL AddressGA IZ K I F l.. , N-,Y� 1 0512 -T Building Type a FAN(. 2F-:-5i O -F, Has erosion control. been completed? 71 E-S - - Number of Bedrooms Has garbage grinder been installed? (J O 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 accordanc Yt PCHD Construction Permit and approved plans and the standards, rules and regulations of the �:.Cu partment of Health. CDate: �J ' i 4- - �% Certified by ? P.E. R.A. P,AL m4 (D i rofess n Ij TLDM' �.v Address Qcana Go o pLicense ' # Any person occupying premises served by the above s ��p,amptly take such action as may be necessary to secure the correction of any unsanitary conditions res jB4fiuch 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 revoc tion, modificatio or change is necessary. r By: L Title: Date:; White copy - HD File; Y6 v5Jcopy - Building Inspector; Pink copy - OJ,ner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT W611 Ldcation " - freet Address: °'" °T ........ r �' �� L % Town/Village: �� Tax Grid # Map 3 5 Block 4- Lot(s)10( Well Owner: Name: /Address: Use of Well: 1- primary 2- secondary y 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 LK Open hole in bedrock Other Casing Details Total length / ft. Length below gradeL, ft.. Diameter _in, Weight per foot lb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded ZC Threaded _Other Seal: X Cement grout ` Bentonite Other Drive shoe: Yes No Liner: Yes _x No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed Pumped L( Compressed Air Hours 12 Yield Z.-Z 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 N) � � 721 2 91 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information ,u Pump Type Capacity Depth Model Voltage HP Tank Type -4,v/ Volume C,"A Alt x /Onr� (� ` 5t wn' AA Date Well omelet d Putnam County Certification No. Date of po Well Drille ( ign e) . NOTE: Exact location of well with distances to at least two permanent landmarks to be provid- on a separate sheet/plan. Well Driller's Name �� Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT We1116cation Street Address: - � L Town/Village: �jt/ Tax Grid # Map 3 5 B lock 4- Lot(s) �b Well Owner: Name: /f Address: � , t,0 JD /� J� ✓ D� / Use of Well: 1- primary 2- secondary V Residential Public Supply Air cond /heat pum p( Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _�X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock . Other Casing Details Total length =ft. Length below grade ft. Diameter in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded.>L Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped _C Compressed Air Hours Yield Z,2 gpm Depth Data Measure from land surface- static (specify ft) 3 During yield test(ft) Depth of completed well in feet D 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 T" ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information �� Pump Type !j Capacity Depth , %lam Model Voltage HP J�- Tank Type Volumet,1 /IZ M 141 i A 14 ON� ;t WjQAA Date Well Yompleyd Putnam County Certification No. Date of po ;ZD4 Well Drille ( igna e) NOTE: Exact location of well with distances to at least two permanent landmarks to be proviI on a separate sneevplan. Well Driller's Name Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 2006 -01 -24 15:51 BRUCE ' FubYte HeaGth DN�rar 8452792332 wm P 5/11 Aaadoo PnbW HMM Zftw v Dkww of P (011VERR " 'k—<>* Vi6 YML ENVIRONMENTAL SERVICES 321 Kear Street ---' Yorktown Hei�gh ,~ ..10598_.-`�~�'-� (90) 245-2006 - Albert H. Padovani, Director LAB #: 1.601134 CLIENT #: 57197 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 DATE/TIME TAKEN: 02/21/06 04:30 DATE/TIME REC'D: 02/21/06 05:50 REPORT DATE: 02/28/06 PHONE: (845)-279-2022 .'. � SAMPLING SITE: 50 QUAIL LANE�m�\��5-4~/��� SAMPLE TYPE..: POTABLE : WELL TANK ' PRESERVATIVES: NONE COL'D BY: JOSE TEMPERATURE..: < 4C NOTES...: COLIFORM METH: NF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE-* RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 02/21/06 MF T. COLlFORH ABSENT /100 ML ABSENT 1008 02/27/06 LEAD (IMS) 9.5 ppb 0-15 ppb 9003 02/23/06 NITRATE NlTROG 1.41 MG/L 0 - 10 9052 02/22/06 NITRITE NITROG <0.01 MG/L N/A 9162 02/28/06 IRON (Fe) 0.060 MG/L 0-0.3 mg/l 9002 02/28/06 MANGANESE (Mn) 0.011 MG/L 0-0.3 mg/1 9002 02/28/06 SODIUM (Na) 2.38 MG/L N/A 9002 02/21/06 pH 6.9 UNITS 6.5-8.5 9043 02/28/06 HARDNESS,TOTAL 66.0 MG/L N/A 02/28/06 ALKALINITY (AS 48.0 MG/L N/A 9001 02/28/06 TURBIDITY (TUR <1 NTU 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WAT WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD 11, THE 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 shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,t `'` A�r���hould contain no more than 20 mg/L of Sodium. c�'r`''^ose on a moderately restricted diet, a maximum of 270 mg/L of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street -,'-'Yorktown-he , N.X~nI0598 (914) 245-2800 Albert H. Padovani, Director LAB #: 1.601134 CLIENT #: 57197 NON STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 DATE/TINE TAKEN: 02/21/06 04:30 DATE/TIME REC'D: 02/21/06 05:50 REPORT DATE: 02/28/06 PHONE: (845)-279-2022 SAMPLING SITE: 50 QUAIL LANE SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COL'D BY: JOSE 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 IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN 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 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT' UATER:'%20-/i9/L ,- '.---VEF0UHARD WATER: ABOVE-300_MEi/[` MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert,Hjadovani, M.T.(ASCP) Direct r ELAP# 10323 . -.a. •- .,o -.,o i c : c t e Ka i pn u. MasZromonacc PE 914 271 4762 P. 03 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM .y or Purchaser of Building Tax Map Block Lot Building Constructed by Town/Village 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, Hiles and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, hews or assigns, to place in good operating condition any part of said system eonstmeted 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 syst to operate was caused by the willful or negligent act of the occupant of the buildin' . ' e system. . M Day Year29's.2k.p Signature �'F}s00 m a x weu, S. C `/ /0/rf Title: Gen ral Contractor (Owner) - Signature Arc�c�xx cs�Mzz�,1\ KACS -cZ Corpo ion Name (if corporation) Corporation Name (if corporation)V�, Address: �Ec�:Je—Nk " �-i Address: \28 o�_ 27- 7. State Zip 19 State c.— x >S Form GS-97 RALPH G. MASTROMONACO, P.E., P.C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 (91'4) 271 =4762 (914) 271 -282 Fax Mr. Michael Budzinsky, P.E. Director of Engineering Putnam County Dept. of Health 1 Geneva Road Brewster, NY 10509 a Re: SSTS AS -built for Wyndham Homes, Inc. Quail Lane, Patterson, NY (Map 35 - Block 4 - Lot 106- R.S. Lot 18) Dear Mike: Please find enclosed the following materials: March 15, 2006 Client Pickup 1. Five (5) signed and sealed copies of the drawing entitled SSTS As -Built Plan R.S. Lot 18 of Deer Wood Subdivision (Map 35, Block 4, Lot 106) Prepared for Wyndham Homes Inc., Located at Quail Lane, Town of Patterson, NY, dated March 14, 2006 2. Four (4) signed and sealed copies of the Certificate of Construction Compliance dated March 14, 2006 3. Four (4) signed copies of the Well Completion Report dated March 8, 2006 4. Three (3) signed copy of the Guarantee of Subsurface Sewage Treatment System - dated-March-8,2006 5. One (1) copy of the Well Water Analysis dated February 28, 2006 6. One (1) copy of the E911 Address Verification Form 7. Check #490420 payable to PCDH in the amount of $300. We are requesting your review and approval of the completed works. Please call me if you have any questions. Si cerely, Ralph G. Mastromonaco RGM /jl Enclosures Cc: Joe Darnell SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Ralph Mastromonaco 13 Dove Court Croton -on- Hudson, New York 10520 Dear Mr. Mastromonaco: February 27, 2006 ROBERT J. BONDI County Executive Re: Field Inspection = Wyndham Homes Quail Lane, (T) Patterson Lot # 18, TM# 35.4-106 The above referenced separate sewage treatment system can be backfilled. There are no open comments to be addressed at this time. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental. Health Engineering Aide GDR:cj Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE: NSPECTTON Date: 2-11- 3 0a Inspected by: a, "-:StmetLocation % c Ownei - .: ham 1- low:es Town Pest's ®,.. - T1V1 Subdivision Lot # 8 :1. Sewage Svstem.Area a. STS area located: as- per ,approved . plans .......................... b..: Fill section "date of placement 3:1 bam. er Lgth. Width Av.g.Dpth c. Natural. oil not Stripped.. d: -Stone,brush,.etc„ greater-than T from STS :area......:... e. 100' from water course/ wetlands ............................... • ... ... IL "Sewage `$vstem a..Sep#c.:tank size - 1;000..:: ;25 ..:..: .. . other ::. ... b. ' °Septrc tank'ii stalled 'level .................._.. ......... c. 10' . minimum :from:foundation ........................... . ...... d. 'Distributi:on'Bog 1 M,outlets:atsame�elevation -water tested. .... .2 Protected below frost ........ . .......... ...................: 3 Minimum '2 ft.Original:soil. between box & trenches e. Junction Bn properly :set ......................................... 6. rent es 1. Length required Ift Length installed f zly 2. Distance to watercourse measured _ -. jo0 Ft.......... 3. Installed according to p lan........................................ 4. Slope of trench acceptable 1/16 - 1/32" /f6ot ............. 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 - .I lk" diameter clean ...................: 9. Depth: of gravel.in trench 12" minimum .......:........... 10. Pipe ends ca ed......:.:..._.:..... g- ""Puinn.zor Dose vstems 1.. Size of pump chamber ................... . ............................ 2. Overflow . tank ............................ ............................... 3 'Alarm, visual/.audio.-.. .. ... 4. Puinp easily "accessible, manhole to .grade ................. 5. First box baffied ......................... ............................... 6. C� ycle witnessed by H.D..estimated flow /cycle........... EOL House/Building :a. house located per approved plans.........:.. b.: Number of bedrooms ........ ................:............., IV. Well ' Well located as per approved plans . ......:........................ b.. Distance from STS area measured ft........... c. Casing .18„ above:grade ................ ............................... d. Surface. drainage around well . acceptable ....................... V. Overall Workmanship . a.. Boxes properly grouted ................... b. All pipes partially backfilled ........... ............................... c. All.pipes flush:with inside of box ... ............................... d.. Backfill material contains stones <4" diameter ............... e. :Curtain drain & standpipes installed according to plan.. f, Curtain.drain outfall protected &,dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 Feb -21 -06 12:56P Ralph G. Mastromonaco PE 914 271 4762 P.01 !"4C_z 1-1921 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION ❑ JOSEPH XGENE REQUEST FOR FINAL INSPECTION For: Fill /A All information must be fully completed prior to any Trenches inspections being made. PCHD Construction Permit # "0 '0!5 Located: Q (T) (V) P T rE R -5O Owner /Applic t Name: TM_ Block Lot I D% Forrnedy: Subdivision Name: W0OM Subdivision Lot # Is system fill completed? �J.,,�A Dater w Is system complete? -(M Date: Z - Zo ' Ulo Is system constructed as per plans? ?1 Is well drilled? 7f95 Is well located as per plans? YES Are erosion control measures in place? Y Date: Z - Z.D- CXo I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam Couuuty Department of Health. _ _.. ..... _ . Date: Z 2 D Certified by: PE RA Design Professional Address: E3 �a/��T. GRoi'o - �UQ N•Y Lic. # 2�4Na Io5Zo Continents Form FIR -99 AM COUNTY DEPARTMENT DE HEALTH CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P O 8 -015 Located at 6Z U.,1 L, LA � a Subdivision name PC- E g \^loo p Subd. Lot # I e 1 ,�L' Town or Village PATTER50� Tax Map Block -4-- Lot Date Subdivision Approved 3^1 O Z Renewal Revision Owner /Applicant Name�(1� cdm HOMe5 Date of Previous Approval 11+1 05 Mailing Address o e!5-01 I 1 f WDO p PO I\/ By wm ,.A--( Zip I pSO9 Amount of Fee Enclosed 2C)o Building Typ Lot Area. 2— No. of Bedrooms +_ Design Flow GPD Fill Section Only Depth Volume PCIID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage _S, stem to consist of 1 250 gallon Other Requirements: To be constructed by jj2 9K emew 1 Aw Address Water Supply: Public Supply From tank and Address _ ......:.._ . off. _ Private.. Supply- .Dril-led-by -o :IN ?F,, EA- 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 "Cert�icate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a wr' gum hill e furnished the owner, his successors, heirs or assigns by the builder, that said builder will place i 1 on any part of said sewage treatment system during the period of two (2) years immediately folio il'e dsof t ce of the approval of the Certificate of Construction Compliance of the original system or anylrVAF jjhej: o, -,.? i° _ * Signed: Address P.E. X R.A. Date 0 .:._ ice{ • APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme "ern has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh con idered essary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe t. oveed discharge of domestic sanitary sews a only. By: Title: ✓ Date: Q White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pr fessional Form CP -97 RALPH G. MASTROMONACO, P.E., P.C. Consulting Engineers 13 Dove Court, Croton -on- Hudson, New York 10520 (914) 271 -4762 (914) 271 -2820 Fax Mr. Robert Morris, P.E. Public Health Engineer Putnam County Dept. of Health 1 Geneva Road Brewster, NY 10509 Re: SSTS for Wyndham Homes, Inc. Quail Lane, Patterson, NY (Map 35 - Block 4 - Lot 106 - R.S. Lot 18) Dear Robert: Please find enclosed the following materials: August 3, 2005 Hand Delivery 1. Five (5) signed and sealed copies of the drawing entitled SSTS Plan R.S. Lot 18 of Deer Wood Subdivision (Map 35, Block 4, Lot 106) Prepared for Wyndham Homes Inc. Located at 50 Quail Lane, Town of Patterson, NY dated May 20, 2005, revised August 3, 2005. 2. Four (4) signed and sealed copies of the Construction Permit August 3, 2005 3. Check in the amount of $200. (revision) payable to the PCDH Based upon the Town planner's review, we have revised the swale located above the house site. 4 We are requesting your review and re- approval of the submitted materials. Please call me if you have any questions. ncerely, Ralph G. Mastromonaco RGM /jl Enclosures rION PERMIT FOR SEWAGE TREATMENT SYSTEM Located at L _ L A I \J F- Subdivision name I J CE R WW Subd. Lot # 9 Date Subdivision Approved 3 10 Owner /Applicant Name 1N -i� A M Mailing Address Town or Village A I I E Tax Map 3 Block 4- Lot ®� Renewal Revision Date of Previous Approval Zip ©5cq Amount of Fee Enclosed 4—ot) Building Type FAM I LY R P-5, Lot Area J "Z No. of Bedrooms 4- Design Flow GPD Boo Fill Section Only Depth Volume Separate Sewerage System to consist of 1 21SC) gallon septic tank and +44- L:F-, tip 24" W I D F A Ps --o1? orin.J ► 2Pi�i- Other Requirements: To be constructed byTp 8EE DE i ERWIi F-D Address Water Supply: Public Supply From Address orb X Private. Supply Drilled by-_-7Lo 9E� pe —I t=-.1 M it ep. 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 treatments stem 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 tas9i� f the approval of the Certificate of Construction Compliance of the original system or any fppairs thereto �,�`�� aGV M-43 :Y ®�� 1�i f M10 _ R.A. 1. r APPROVED FOR CONST �'proval expires two years from the date issued unless construction of the sewage trea system has been inspected by the PCHD and is revocable for cause or may be amended or modified en c nsidere cessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pp ov discharge of domestic sanitary se a only. By: Title: Date: % ® r White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design kfessional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL - ` please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # U I LA � E MATTE P-5C4J Map 35 Block 4— Lot(s) (7�0 Well Owner: Name: Address: n PdAM Ho aCoI hJ WOO p EDP, . EW5TEZ Y. ICs Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage E gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new Deepen Existing Well Detailed Reason D I vE i� Eb r, w E r J for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? �..... f ............................... ............................... Yes ?C No Name of subdivision W I � p50 P= W001 S Lot No. Water Well Contractor: -r'o f5F, t�,ETegmI r E-Q 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: OF NEW • ,. Proposed well location & sources of contaminatio o be provided on r Is . Date: 20 05 Signature: g ..Applicant ...pp o '- ' t'; •'y , r ,ri4r Pct. PERMIT TO CONSTRUCT A WA 41s age This permit to construct one water well as set forth above; is granted s `#- Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New Y " 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. An evision or alteration of the approved plan requires a new permit. Well to be constructed by a water w dr ller ce ed by Putnam County. Date of Issue Permit Issu' ffi ' Date of Expiration Title: Permit is Non -Trans rr le White copy - I-ID file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR Y A WASTEWATER TREATMENT SYSTEM 1. Name and address. of applicant: EER 2. Name of Vroiect:AKA,: W 4. Design Professional: 6. Type of Proiect: Private/Residential Apartments Office Building �IZ N. I. 1 0501 3. Location T/V: 6. Address: 13 Gave, C c ,�,��' Gr�ro� -I- �1- N� t��1, rlY. loses Food Service Commercial Institutional Mobile Home Park Realty Subidvision 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? ......................... 9. Has DEIS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency 341A 1 L. If this project is an area.-under the control of local planning,1zoning, or other . officials, ordinances? ......................................................... ............................... YG5 12. If so, have plans been submitted to such authorities? ........ ............................... 13. Has preliminary approval been granted by such authorities? 4A Date granted: tJ 14. Type of Sewage Treatment System Discharge ................. surface water groundwater 15. If surface water discharge, what is the stream'class designation? .................... r�/A 16. Waters index number (surface) ........................................... ............................... tJ A 17. Is project located near a public water supply system? ....... ...............:....:.......... d 18. If yes, name of water supply fJ %A Distance to water. sup ly 19. Is project site near a public sewage collection or treatment system? ................ D 20. Name of sewage system Distance to sewage system 21. Date test holes observed' Z .2 q 22. Name of Health Inspector IL)Pil j Form PC -97 2 23. Project design flow (gallons per day) ................................. ............................... aek-;> 24:: Ig State °Pollutant Discharge Elimination System (SPDES)'Perriiit required ?... to 25. Has SPDES Application been submitted to local DEC office? ......................... 26. Is any portion of this project located within a designated Town or State wetland? 1'J® 27. Wetlands ID Number ..:........::.`.. �..:....... .....:..:...................... ........................... 28. Is Wetlands Permit required ?' 0 Has application been made to Town of Local DEC office? . :.....:.........:..:.....,....: 29. Does project require `a DEC Stream Disturbance Permit? 30. 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 AO 31. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ... ...........................:... Yes/No 0 DESCRIBE: 32. Is there .a local master plan on file with the Town or Village? ......................... 33. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? .........:....................... ............................... 34. Are any sewage treatment areas in excess of TS %slope ?' .............................. .. 35. Tax Map ID Number .......................... ............................... Map2? Block Lot JQ� 36. Approved plans are to be returned to ..... Applicant Design Professional If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied,by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under. penalty of perjury, that information to the best of my knowledge and belief. False statements m a Class A misdemeanor pursuant to Section 210.45 of the n: SIGNATURES & OFFICIAL TITLES. Mailing Address: ................................... � ► , r_- true (e as 0 PUTNAM COUNTY DEPARTMENT OF HEALTH _. DI .0,NvOF- E VIRONME ITAL= EALT I SERVICES _ , : : AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To-:Public Health Director In the matter of application for: JO -* I a — PpgzP= woo represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: Li�vti��C1C;�Yr �1e�e 1N�. Having offices at: Whose Officers Are: President - Nam -e—R, Vice President - Name: Address: Treasurer - Name: Address: and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Signed: l Title: Swom to before me this . day of (month (year) Noe ,, blic --9VQ0q,��0rb* Corporate Seal oer°M Fnrn (-A Q7 PUTNAM COUNTY DEPARTMENT OF HEALTH: LETTER OF AUTHORIZATION RE: Property of Located at `� %il��Wo3b -bi(- I9E-wsi'97L- O 09 T/V p� ��� Tax Map # �cJ m Block _Lot 0(. Subdivision of Subdivision Lot # Filed Map # 7- S9 1 Date Filed.. �9° 14- -C)Z� Gentlemen: This letter is to authorize SAL? ki Nlv w�La Yom - a duly licensed Professional Engineer or Registered Architect to ply for the required wastewater treatment and/or water supply permit(s) to serve the above - noted - property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of.thePutnani County Health Department, and to sign all necessary papers on my behalf in connection. with-this matter and to supervise the construction of said wastewater tretment and/or water supply systems in - conformity with the "" r . ions: of Article r45 ar0or- Y47 -of the, Education.Law;.tlie Pu_blic_ - Healtlf Law, ano the Pu itary Code. C.ountersip P.E., R.A., # Mailing Address State Zip Telephone: (914) Z -7 1 ° ®i- Very truly Sighed: / C 3' Cam/ j✓ ( wn. of Property) Mailing Address: C.c :,\ Nwos (A State _ i��2 Zip Telephone: Form' LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH -- INDIVIDUAL- WATER,SUPPLY& SUBSURFACE:&BW. AGE:.TRTATMENISYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, GR, AS, =ATE: Y N DOCUMENTS �(-)PERMIT APPLICATION ( _- )WELL PERMIT OR PWS LETTER ER OF AUTHORIZATION Ti DATA SHEET (DDS) ORATE RESOLUTION T RAF TAX MAP #: (CONFIRMED) Y ".,N (REQUIRED DETAILS ON PLANS CONT'D) H OUSE SEWER -'/4" FT. 4 "0'; TYPE PIPE CAST IRON LINO BENDS; MAX BENDS 45° W /CLEANOUT RENEWALS E OTE (NO CHANGE) FILL SYSTEMS L�"' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE SPECS/ FILL NOTES 1 -5 LZ PLANS - THREE SETS ILL PROFILE & DIMENSIONS L –)HOUSE PLANS - TWO SETS ILL IN EXPANSION AREA (�L )VARIANCE REQUEST FILL GREATER TKAN2 SUBDIVISION LAY BARRIER P(,7-LEGAL SUBDIVISION ILL CERTIFICATION NOTE ::�,l UBDIVISION APPROVAL CHECKED LEPTH GAUGES PERC RATE OL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS ILL REQUIRED DEPTH EPARATION DISTANCE FROM TOE OF SLOPE URT AIN DRAIN REQUIRED TRENCH GENERAL LF TRENCH PROVIDED 60FT MAX. L� LOCATED IN NYC WATERSHED PARALLEL TO CONTOURS PLANS SUBMITTED TO DEP �) 100% EXPANSION PROVIDED DELEGATED TO PCHD �DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL bEP APPROVAL, IF REQ'D GEOTEXTILE COVER DEEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM SSTS ERCS TO BE WITNESSED Z410' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL X- APPROVAL SSDS ADJ, LOTS 20' TO FOUNDATION WALLS PWETLANDS (TOWN/DEC PERMIT REQ'D ?) 100' TO WELL, 2001N DLOD,150' TO PITS DATA ON DDS PLANS & PERMIT SAME 100' TO STREAM, WATERCOURSE, LAKE (inc. eepan) PRE 1969 NEIGHBORN.OTIFICATION . . _ . , 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER__ _ .. XC_)SOIL LETTER BI/ZBA 100 YR FLOOD ELEVATION W/I 200' C�50' INTERMITTENT DRAINAGE COURSE TESTING LOTS >10 YEARS OLD ( �200'/500' RESERVOIIt, ETC. _ 150' GALLEY SYSTEMS � REQUIRED DETAILS ON PLANS (_ _)10' MIN TO LEDGE OUTCROP SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK T�'�-21 )SSDS HYDRAULIC PROFILE C6L10' FROM FOUNDATION; 50' TO WELL GRAVITY FLOW WELL CONSTRUCTION NOTES 1 -15 ( DIMENSIONS TO OPERTY LINES DESIGN DATA: PERC & DEEP RESULTS LOCATION OF A CE CONNECTION CONTOURS EXISTING & PROPOSED P TY LINE DRIVEWAY & SLOPES, CUT SLOPE ( FOOTING /GUTTER/CURTAIN DRAINS (^SLOPE IN SSTS AREA (S20 %) L� USDA SOIL TYPE BOUNDARIES L _)TITLE BLOCK; OWNERS NAME ADDRESS ��(— )REGRADED TO 15 %, IF REQUIRED AX44 PE/RA; NAME, ADDRESS, PHONE# DOSETUMP SYSTEMS LD DATE OF DRAWING/REVISION . ATUM REFERENCE 2 LOCATION OF WATERCOURSES, PONDS AKES,WETLANDS WITHIN 200' OF P.L. L)PROPOSED FINISH FLOOR AND / BASEMENT ELEVATIONS 1 WELLS & SSDS'S W/IN 200' OF SSTS PROPERTY METES & BOUNDS (_)(__)EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: IT TTS)fRTTT4T�l1,1 Il11 /AA SUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PIT AND D -BOX SHOWN & DETAILED 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL 15' MIN to CDS =>5 %, 20'4 %, 25' -3 %, 35' -1 %; 100 % - <I% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge 10' MIN to NON - PERFORATED PIPE 14-1" (9195) —TW 12 PROJECT I.D. NUMBER 617.20 SEAR Appendix C ErivfionrttetrtaFa 'uafityiRevieMr -. SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (TO be comMeted by ADDiicant or Protect snonserl AP U NT PONSO 2. PROJECT NA E M E R=kvkoo AKAWI�QSiiva V==�s 3. PROJECT LOCATION, , A T Municipality E county► 4. PRECISE LOCATION. (Street address and road Intersections, prominent landmarks, etc., or provide map) 4f;?L)AIL LAME •' /Zr- ILEweSrof RTI- ZZ or-r- ArrLe- HILL 12c:)AC>. 5. IS kRqPOSED ACTION: ZVew ❑ Expansion ❑ ModlflcattorValterattan .6. DESCRIBE PROJECT BRIEFLY: PporoS,Ev ev,s,-Tp�ucj- )OJ of A 0 J FAMILY 945-5-P1 o8I1C W IT'j4 h pTIG,vVEL-L. Pal�EwAY'A9oA��IATE�G fz.Qt�1t•�G�. T. AMOUNT OF LAND AFFECTED 1 [nit" �• I �• ` acres Ulumat* acres 8. WI PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No If No, describe briefly S. WH T IS PRESENT LAND USE IN VICINITY OF PROJECT? idential ❑ Industrial gConunerclal ❑ Agriculture ❑ ParldForest/Open space ❑ Other Describe:- 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? &es ❑ No If yes, list agency(s) and permttlapprovals Pc.c> N - E3►o-, P A. 7&org 6F PATTew=J- Str66IVISicj QPPRc>,/AL, gU.iipirjG ®E F' 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT'OR APPROVAL? O Yes ❑ No If yes, list agency name and permlUapproval `Juf3DIJl -&ic) 1 A FTF•oJA�- 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes I CERTIFY THAT THE INFORMATI ON PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE RA H Applicantlsponsor name: 4 • , ` / �Q s1 Date: E 5 L2—c > Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 A. PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B�: WILL-. AG TI. ON;; ECEIVE_ a00RDINAT.ED,RE.VIEN:AS-PROVIDED FORUNLISTED ACTIONS-IN 6-NycAR, PAffrm7,in -;` if No, >a-negative•declaratidn •- may be superseded by another involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage.or flooding problems? Explain briefly. C2 Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain'brlefly C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely 4o be Induced, by the proposed action? Explain briefly., C6: Long tam, short terra, cumulative, or other effects not Identified in C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No p E. IS THERE. OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑Yes ❑ No If Yes, explain briefly - -_ C t PART III-- DETERMINATION OF SIGNIFICANCE (fo'be completed by Agency) - INSTRUCTIONS: For each adverse effect Identified above, determine whether it is substantial, large, Important or otherwLsignti%cant. Each effect should be assessed In` connection with Its (a) setting (i.e.'urban or rural); (b) probability 'of 'accurr(ng; (q"uratlbn (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure :th explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed.' f'' question D of Part If was checked yes, the determination and significance 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 signlf)cant adverse impacts which MAY ,occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this. box If you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this. determination: Name of Lead Agency Print or ype Name or Responsible Officer in Lead Agency Title of Responsible Otticer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from responsible officer) Date 2 N I r• o• • �• • •�� 10- • DESIGN; DATUM= - SUBSUFACE ,SEWAGE: DISPOSAL- SYSTIIrI Owner WWogAM How 55 1 Address �� 11r�W.W C) Dw, BP—F-WSTC -P- t4-.( Located at ( Street) QUA I L 4.� � Sec. � � Bloc)c 4' Lot (indicate nearest cross street) Municipality PITT- �,��.ap1�4 Watershed SOIL PERcOLATION TEST nuk 4 RF)QUM&" PTO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking - ��-� iv �,QIK t Date of Percolation Test I • Izo P M HOLE s NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth,to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 1 I o: 20 -10;45 Z! Zco Z 3'l?. 3' /z 71 210.4 -11 -15 Zt 21114 Z4 %4- 3 9.7 311:38-12:04, ZCv Z0 Iz Z 3 /z. 3 8.7 4 2 llo: 210:23- 11 Z , ;..310' 5, Zo 243 _ .33/8....._....... 3.`8 5 2 4-. 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2. Depth measurements to be made fran top of hole. rev. 9/85 TEST.PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION 9.3,0 4' ,5 1 . 6' 7' 8'a g' 10' . 11' 12' 13' i Z71e --(FL.LoW CD C_ Ate, 14' __._INDI TE LEVEL- AT- WHICH GROUNDWATER IS- ENCOUNTERED- INDICATE LEVEL TO WHICH WATER LEVEL RISES BEING ENMUNTERED -1j ®vjs .� 6®� peg: ® 12-9- � ®EP DEEP HOLE OBSERVATIONS MADE BY : 'o. St�Pz-wS*K! L_P�®P DATE: !Z° IZ° Soil Rate Used m� ® Min /1" No. of Bedrocros Fcu a Area Provided .B Other DESIGN Drop: S.D. Usable Area Provided GiC005F Septic Tank Capacity �- gals. Type d®ky,-< L.F. x 24" width trgnch WEREOtJ � MA,5nn dmg:�o Signature /II /Icr =:< *'fir\ • • - ss THIS SPACE FOR USE•BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date wynund111 noines, Inc. I- J PUTNA►.M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRO I�IT HEALTH' SERVICES A ; N DATA SHEE:T:: -- SUBSCTRFACE SEVVA E TREATIVzE . TSYSTEM' Owner m j e, 4 r _ M Amp Address Located. at (Street) Eby �� Qgp :. Tax Map 3� Block _Lot _ (indicate nearest cross street), Municipality 1'A�e<„5o� Drainage Basin lx,Y� P CB SOIL PERCOL' ATTON TEST DATA Date of Pre- soaking t 1- P° •61 to .iarA Date of Percolation Test' i i -1 61 .16o lo = H61c.No... Run,No.;... Time Start-Stop.- El i se Time Min.} De ti►: to Water rom Ground Surface ffaches) Staff Stop Water Level Dr "o In Ines. Percolatiozi Rate Minlinch " 20- 10, Arl; /2- oil) -7.1 1 z ♦ '. 1174 -1 .1. • 2l 2 2 ;t, esu to oe repeatea at same cepm unt►t apprgxppatety equal percolation, rates;are obtained at eacn percolation test hole. (i.e. s 1. min for I -30 "min/inch, s 2 min for 3I -60 min/inch) AJl data to be submitted for review. 2..::be�th measurements to be made from top of Bole: Form DD -97 1.5' 2.0' 2.5' 3.0' P u,uwate ievei at which groundwater•is encountered Indicate Ievel at which mo tiling is observed — - iidicateLevel -to which water Level rises after being encountered -- Deep hole observations made by: ' 1 n I N LL—P-- 4 i Date Design professioriaI Name':' Address:.. tr r J12. -1�.>✓ . AILLT OK Signature: Design professional's Seal OF NEVIN, . •.�P ��,Tii "Cyr 9,f, i W F� No, 561.24" p9oFESS101, PROPOSED plI PROPOSED 1 50 WELL SSTA ko 6 AI 1p 1 61 $ LOTj 17 PROPOSED S 5 5 7.5J6 E RIPIRAP S)VAUE 'A N 89'11' 7' E 3. GO kjE R-S E12 0 TYP 0. V/ FIRST 0 121 FEET INV. )377 ;,. 'Aiz S RIM 68 J.8 TO L 0, SO �Al� N�, BE ,SOLID 0' /PR.PgsgO .5L, To %�/�/OCATED 12 DUAL CO-'Aj;rE Z, \V AS, SHOWN ON THE A SL�EIOIVISIQN/ 71 CONSTRY71 ON P S. SEPTIC TAN % 3 KA GRAVEL BED/ 600 GE .71 T ,I-/, E ND' TO TANK -2-2 PROPOSED CB E 2a' ,, ' ' ' " " , , / PAXTON rE NON CAM RIM 880.90 MIN 6 0' 682 INV. 677.40 T FIE A, 713.25 )A- 42./ SS T5 XTO FINE S NDY YOAM tx A�EA I SC 01, TS f6A .0 ,A r—y PRO S T'l/ IN. IN A D IN A D �Op STA / 1� 118 OR ILli6l) P N ROOF OR PRAI OSED/S PVC DOTING 71 4 PVC TO 0 C • 7 DISCHARGE I ROAD ioe MIN. ILL LIN- A AMC L;FENE (,C PR S /SILT FENC 16T 28 L —M 86 TEmpo rly - 7 WE FUMP DEEP 4 qG S 08*53?4" 5?6.43' N % 19 L by ol 4oposeri DPIVEWAY/ A WE PROPOSED 100' MIN. SETBACK "Y 1,b 'i 20()* MIN. SETBACK IN ;D H.P. + 9.14