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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -113 BOX 16 01774 A1 11 'm"d r N 16 , �,� a - Jr ` , F. 01774 Well Location -_ ' Street Address :. " ; - -' . Town/Village: wit Pt Tax Grid # Map." j. Block:': y Lots) Well Owner: Name:: <``:.: Address: Use of Well: 1- primary . ' 2- secondary Residential Business Industrial Public Supply : - Air cond/heat pump Iirtgation Farm.. Test/monitoring Other(specify) Institutional ' - .. Standby Drilling Equipment Rotary . Cable percussion . Compressed air percussion Other (specify) Well Type Screened Open end casing :. `' Open hole: in bedrock Other Casing Details Total length ft. Length below grade ,fib ft. Diameter {® in. Weight per foot 'ji—Ib /ft. Materials: 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 _jp Yield 5L 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. De thYroin•Surface Water: ' Bearing. Well Diameter(in) Formation Description 1t. ft. Land Surface t ei If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information ' l : ,,"D . Pump Type Capacity Depth Model Voltage BP Tank Type Volume Date Well Completed ID Putnam County Certification No. Date of Report Well Driller s\ign NOTE: Exact location of well with distances to at .least two permanent. laridmams to be.provlaea? oru+ ° a e v�plan. . Well Driller s`Name: �r� .. Address: itn •:, _ `'1 i J' Signature:. 1�O Date . r/ IL i!fp White copy:: File;' Yellpw copy Building Inspector;, :.Pink copy - Owner; Orange copy -Well driller Form WC -97 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Coleman 111 Apple Hill Rd. Brewster, NY 10509 Dear Mr. Coleman: DEPARTMENT OF HEALTH 1 Geneva Road, .Brewster, New York 10509 ROBERT J. BONDI County Executive January 24, 2005 Re: Addition — Coleman, Apple Hill Rd. No Increases in Number of Bedrooms (T)Patterson, TM #35.4 -113 I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated January 21, 2005. The addition is approved with the following conditions. 1. The total number of bedrooms'must remain at four without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing`fixtures must be updated with'water saving devices; Le.,'new low flush toilets, restrictors for shower heads and faucets, etc. Any permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Sincerely, Michael Luke ML: lm Public Health Sanitarian cc: BI (T)Patterson 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 MEPARTNENT OF I-MAL�3 v :on of Emtrenasental Ijealth aerates 4 Genava Road BTewster, New York JOSO9 Tel. .(914) 278.6130 Fax (914 278 - 7911 BRUCE K FOicY Publi.- Hecith Dir_vc-- STREET Wy. -� X Ni AY NAME oe" MA;ZNe ADDRESS �( � DESCRIPTION OF ADDITION � `L 13ER GF EXIST?�'VG BEU 00NI Ls , PROPOSED 4 GF BEnROOyLS� (FROM CERT. OF CC":UPANCY 0 CERTIFICATION FR01r1 S(;ILOINC INSPECTOR) *Ante addition v,-hich is cow tiered a be*oom requires formal approval of plans (Coamcdon Permit) prepared by a - refessior,al Engineer or Registered Arc'l tact in accordance with applicable sections of tht Puin3rn Cmmty Salita-*y Code. Please submit this fcrm and he 19'1otxing to Putnam Coua --v health Dc-pt., 4 Geneva Rd., Brcws =er, ANY 105 0 9, Phone ?'b -Fi 30. _.1. CeTtified-check.or mo, -.ey order for SI00.00 S�Setches of existing floor plan (drawnto scare,. all living area including basement) Non - professional sketch"-s axe acceptable 3. Two sets o: proposed floor plan (drawn to sca e, vNzth name, street, a :d ;a;: rap Y) * 1`'on- p :c.�ssiona's sketches are acceptable : 4. Copy of sarycy showing well and septic location, to the best of vour knowledge. Include date of insidUatica if known: Label all vieLs and septic systems within 200 feet of the property lire. Contact this office wi->1 any questions. 5. Copy of Cent. of Occupancy from Town or Certificatioa :57= Buildirg Dept. with legal. bedroom court of dwe?lir.,c,,: OFFICIE L�F . A, Commel7_s F:b 93 DEPARTMENT OF HEALTH Division . Of Environmental Health Services 4 Gene,4 Road, Brewster, New `'ork 10509 (914) 278 -6130 - Putntm County Dept. of Health 4 Geneva Road Brewster, NY I05C9 t RcsidencC Tax Map Gent -men: BRUCE R :_FOUE�. A g Aetlnp PUb11e Health Acco ► ding to records maintained by the Tovrn, the above noted dv elling iS `�'1 NOT i � T ' J - - in Con I :e %�41th ToN�-,. code attd the total number of bedrooms on record is This infb=, ,atien h-as been obtained from.: CERTIFICATE Or OCCLTFANCY: A. SESSORS RECORD: HF,R Building Inscector E PUTNAM COUNTY DEPARTMENT OF'HEALTH - •: DIVISION :OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATME ,SyYgEM PCHD CONSTRUCTION PERMIT # �� - Located at Owner /Applicant Name Lj )j. �j L, X.., $c Formerly w* Town orikla °ge Tax Map Block Lot J' Subdivision Name Ole Lti'ej 0 Subd. Lot # Mailing Address '{ + LY 1.1 -C,i,+ Zip Date Construction Permit Issued by PCHD I • Ce . Separate Sewerage System built by IV � , . e� � - Address ..1141 ,,, Ali ta l a V ",., 4'..: ti ' "Consisting of $�.; ,°` Gallon Septic Tank and", Via.. . Other Requirements: Water SURD 1V: Public Supply From. ME � Private Supply Drilled by ' ., � g ,,�� 6, ddress 1 d{w -.,, Building -Type �.� s r �." a = Has erosion -control -been completed? Ye r Address Number of Bedrooms ' Has garbage grinder been installed? .�`t✓r 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 regulatipo's of the Putnam County Pepaytment of Health. Date: , Address P.E.4,,,f R.A. ql& izlq 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 p modification or change when, in the judgment of the Public Health Director, such revocati � mgflific ti p or change s necessary. B .3P ..d, }'"..✓ Y {pl1�r�' �t j rye' + ✓j" LLII""" f 4' y' t � > Title: tom,.• =� Date: f�.. White copy - HD File-'Yellow copy - Building Inspector; Pink copy - Owner; Orange copy Design Professional Form CC -97 AM-ter 00 6, in ) /13 3 DO -wl 03 71 Fax tA(ze _____IIIiIIT[ CCI J3 Cli a- tA PM% sJ I - ,V01760- 1-9W 0 MIA I ope- I I � I --- ( 0 � - C�O je &j�j - 111 fib '// AWI Td-X "a p -it 3f-4i-1)2 I -6 k du.%7- � 9 W A rd 1 UT CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREA PCHD CONSTRUCTION PERMIT # P -3s'- 0 2- a Located at 120te 41d L-iJ Town or age L p Block_ Lot (� Owner /Applicant Name (,tj —T _;-� 4. �a a,., �S .�, Tax Ma '3�, Formerly 1 , „� �T - �- 110 Subdivision Name Subd. Lot # 2-c} Mailing Address r !%i zt✓ ��� i /U . 10 Zip s Date Construction Permit Issued by PCHD air Se arate Sewera e S stem built by u ` Address xAL. _ r w 1, Consisting of SC7 Gallon Septic Tank and Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by z 1 ��`� s � 4u d l G. 11,Address J U St 5'2— Building'Type rA`i Has erosion control -1 een cop Fet'e'd? " Cj ` V Number of Bedrooms Has garbage grinder been installed? IV 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 accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulatipis of the Putnam County Pep"ent of Health. Date: Certified by Address P.E. e:/ R.A. License # 12-4 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 ubjec o modification or change when, in the judgment of the Public Health Director, such revocati m 'fic 1 or chan necessary. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT 'Well -Locat on Street Address: 1 1\4& ToWin/VilW e:' _' ` Tax Grid # Map Block Lot(s) Well Owner: Name: Address: Use of Well: 1- primary 2- secondary Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion __A Compressed air percussion Other (specify) Well Type Screened Open end casing )( Open hole in bedrock Other Casing Details Total length ft. Length below grade eft. Diameter (0in. Weight per foot lb /ft. Materials: _ Steel _ Plastic _ Other Joints: _ Welded A 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 _)� Compressed Air Hours -t— Yield � gpm Depth Data Measure from land surface- static (specify ft) 19/ During yield test(ft) �1 al �r i1�1i�1J Depth of completed well in feet a 10 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 i Q pjG 5�` q _ t� If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 1 Pump Type Capacity Depth Model Voltage HP Tank Type Volume u - Date Well Completed o —ai —R3 Putnam County Certification No. 03 Date of Report Q io o Well Driller (si nature) NOTE: Exact location of well with distances to at least two permanent ldndmkks io be prov a separate she Vplan. `$a "554` 44i;4 GPeu CZ Well Drille Signature: White copy Address: Date: '9 It J; " t copy - Owner; Orange copy - Well driller Form WC -97 BRUCE R. FOLEY OLINARI•R.N. M.S.N. Public Health Dlrsctar• 4� R�r4ror.. xfare _: r_ _ . • .,;.....- .• :. Dtrrcrcv - q/ Patient Scrvlcer .. .. ._.. .. __ - -- DEPARTMENT OF HEALTH ..:... :.. _ _... . 1 Geneva Road..... ...... Brewster, New York 10509 EoviroamcnUI HWth (914)271.6130 Foc(914) 211.7921 Nuniaj•Scrvica ( 914)271.6558••• WIC (914)-271 6671 .Flx(9i 271.60:5 " -- Ecrty"fotervio76o -(914) 27f• 6014 Preschool (914)27:4M Far (9U) 27f• 6641 E911 ADDRESS- VERIFICATION FORM OWfiEPS NAIYM. L ' - TAX•11'1AP. NUMBER_.. • • '. ��. '°°� �•,jl � �j` ,(.�,. ...... .. .. ..... -;_- ....... .... - -- -• E911 ADDRESS; AUTHORIZED TQW- T 9 C (Signature) • ..:DATE: - .._ - _ _.. The Putnam County. Departmgnt..of Health -will not issue aCertificate -of - -V - 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 4 Certificate of Construction Compliance. PUT -NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location. =.. y Street Address._ , . - TownNillage: NOTE: Exact location oI well wltn distances to at.least two pertnannnL 011UHimnb w uc E,ivviucu:virs} 7 i A4 "t ^.. Well Drillees "Name <13r► >E�c� .: 1'Yi . ' ,r <�,,i1 Address. Signature: Date: _ >2 , v 7 =? White copy. File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller -97 Form WC Ea Grid # . Block.': Lots) Well Owner: Name. ' Address. i 1.'111:`5 +` `•�:�"�µ.•_., �:Gaa5��'r, ��.rJ�'' Use of Well. 1- primary 2- secondary ' Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) institutional' Standby Drilling Equipment Rotary Cable percussion" '`Compressed air percussion Other (specify) Well Type Screened Open end casing Open; hole'in bedrock Other Casing Details Total length ft. Length below grade .0 ft. Diameter _min. Weight per foot - 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 gpm Depth Data Measure from land surface - static. (specify ft) During yield test(ft) ."lr l+xw Depth of completed well in feet g% 1 Z), 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 Ll =, If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information '' ! 1.. jyy) Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Completed Putnam County Certification No. Date of Report Well Driller (sign4t u'e)f { yvC i NOTE: Exact location oI well wltn distances to at.least two pertnannnL 011UHimnb w uc E,ivviucu:virs} 7 i A4 "t ^.. Well Drillees "Name <13r► >E�c� .: 1'Yi . ' ,r <�,,i1 Address. Signature: Date: _ >2 , v 7 =? White copy. File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller -97 Form WC Harry W. Nichols Jr., .P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 February 24, 2004 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance — Wyndham Homes, Inc. 111 Apple Hill Road - Lot # 29 Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35. -4 -113 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -29, "As -Built SSTS ", dated 02/23/04. 2: "Certificate of Construction Compliance for Sewage Treatment System ". -_ 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 02/23/04. 4. Laboratory Report, dated 02/19/04. 5. "Well Completion Report", dated 02/10/04 (Original mailed to PCHD). 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. V/. 7. "E -911 Address Verification Form ", dated 02/24/04. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. chols Jr., P.E. HWN:gav 03- 056.29 PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVISION.OE ENVIRONMENTAL HEALT�-I�SER' ICE:S:; :.- -..._. GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM J I Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Location - Street �Y3"j t j e., J / " l Building Type TownIV Subdivision Name 2-A 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 `parr --of said I ystem co0ructed by me which fails ' to operate fora 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, ofthe- building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Date • Mont Day �,j Year �Lvv Ge ral ontractor'(0wner) - Signature Corporation Name (if corporation Address: - r < >r- iz _2r �, z State /V i Zip AM Signature: x Title: %/ P, 4.�c 5 rtl ,,I LCI! I & !L_ Corpo ation Name (if corporation) ) Address: ,- �� r e,! State Zip Form GS -97 YML ENVIRONMENTAL SERVICES ^ 321 Kear Street Yorktown` ghts"A~y. 10598+ (914) 245-2800 Albert H. Padovani, Director WYNDHAM HOMES DATE/TIME TAKEN: 02/12/04 10:30A 8 COLLINWOOD DRIVE DATE/TIME REC`D: 02/12/04 11:30A BREWSTER, NY 10509 / REPORT DATE: 02/19/04 PHONE: (845)-279-2022 SAMPLING SITE: 111 APPLE HILL RD SAMPLE TYPE..: POTA8LE : BREWSTER NY PRESERVATIVES: NONE COL'D BY: KAREN SAMPERI TEMPERATURE ..a < 4C NOTES...: KITCHEN TAP COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE PUTNAM CNTY P PROFILE 02/12/04 M MF T. COLIFORM A ABSENT / /100 ML A ABSENT 02/12/04 L LEAD (IMS) < <1 p ppb 0 0-15 ppb 02/12/04 N NITRATE NITROG 0 0.94 M MG/L 0 0 - 10 02/12/04 N NITRITE NITROG < <0.01 M MG/L N N/A 02/12/04 I IRON (Fe) < <0.060 M MG/L 0 0-0.3 mg/l 02/12/04 M MANGANESE (Mn) 0 0.033 M MG/L 0 0-0.3 mg/l � 02/12/04 S SODIUM (Na) 7 7.26 M MG/L N N/A 02/12/04 p pH 5 5.9 U UNITS 6 6.5-8.5 02/12/04 H HARDNESS,TOTAL 9 92.0 M MG/L N N/A 02/12/04 A ALKALINITY (AS 3 34.0 M MG/L N N/A 02/12/04 ( (TUR < <1 N NTU 0 0-5- NTU ' - 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 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 is suggested. METHOD 1008 9101 9139 9146 2037 2037 9042 , ` YML ENVIRONMENTAL SERVICES 321 Kear Street )/g�ktp�V h -M.Y"10598-.. - �� �' (4�4')�����-2�0b'^ ' Albert H. Padovani, Director LAB #: 93.400263 CLIENT #: 57197 NON STAT PROC PAGE: 2 of 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE BREWSTER, NY 10509 SAMPLING SITE: 111 APPLE HILL RD : BREWSTER NY COL'D BY: KAREN SAMPERI NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE DATE/TIME TAKEN: 02/12/04 10:30A DATE/TIME REC'D: 02/12/04 11:30A REPORT DATE: 02/19/04 PHONE: (845)-279-2022 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD 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 WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 M( /L . MODERATELYHARD WATER: 70-140 MG/L^ ' MG/L-= MILLIGRAM PER LITER SUBMITTED BY: Alb :rt7F—I.Padovani, M.T. (ASCP) Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: ,2-// 3/cq Inspected by: Zr Street. Location 4 Hale, 14,11 Town j?o__ters©►j Permit # P-- 3C -©2_ TM # 3 - `!/ 3 Subdivision Lot # ;L 17 1. Sewage System Area f a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................: .. ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System (1, � a. Septic tank size - 1,000 ...:...250 :../......other ................ b. 'S eptic'tank installed level ................ ............................... c. 10' minimum from foundation ........ ............................... d. Distribution Box 1. All outlets at same elevation -water tested ...............: . 2. Protected below frost .................. ............................... 3. Minimum 2 ft. Original soil between box & trenches e. Junction Box -properly set .......... ............................... 6. Trenches 1. Length required 5 7 �2_ Length installed _57 2. Distance to watercourse measured -}-1 U O Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ............ . ....... : 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends ca ed ........................ ............................... g. PUnrn or•Das-ecr Svstemr - - 1. Size of pump chamber ................. ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/audio.................:.. ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildhig a. House located per approved plans.........�.�..� .....,.... b. Number of bedrooms .............................r_ ... ............. IV. Well Well located as per approved plans .......................... b. Distance from STS area measured * t r, 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 YE NO,. - COMMENTS f X r` \ �r l i' ,J Form S M 6 SITE INSPECTION FOR FILL PAD- Date: 1 % CO 3 Inspected by: 5� , 2e {L . Fill pad located per the approved plan 141a et y Q (L Fill Pad Length Required Length Fill Pad Width g. Q G�.?� Required Width Fill Pad Depth 3 z o ! �� Required Depth Run -of -Bank Fill Quality Q, Slope from Top to Toe Impervious Layer Installed jAj a �' C Erosion Control Installed Sieve Test Results (if applicable) /V Additional Comments: rC yd.07` cevgi C_ , " , Reserved for Field Sketch if Applicable r JAN;09 -2004 12:41 PM HAWRY W NICHOLS 914 279 4567 P.01 f UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION -OF ENVIRONN NTAL HEALTH SERVICES RF IM I FOR FINAL INSPECTION For:. Fill Date: ��i,► >n� lh y' ,, Trenches PCHD Constructlotr Permit # Located: APPLE itLL ItaA& _ (T) (V)' F %Mho Owner /Applicant Naase: Oiilki�l ,, 06A TM 3? Block Lot 11 Formerly: Subdivision Name: `. Subdivision Lot # 2g , Is'system'fill completed ? s Date: XA61 01.01 .; is - system complete? ,; Date: Is system constructed' as per plans? Is well drilled? Date: .Is Well located as per'plana? Are erosion control measures m plain? I certify that the system(s), as listed, at the above premises, has been constructed and I have inspected. and verified thew completion in accordance with the issued PtHD Construction Permit anal approved plains azad• the Standards, Rules and Regulations of the Putnam County Departinerit of Health. ' Certified by:' _ - - - - - E RA - - -- Desi rofessional Address: ._ Z2_ bQS<,A -4V-- L 01, 100 Lic, # 5624 Comments:.= Y . PA :.gay FaR: a ADAM �CEx n (NAME) dif..t4y Form FM 99 TnK1_D_Ofilad TW11 17•Co TCI •0/IIZ_070_70a1 K10MC•DIITKIntA rniINTV r1CD00TMCtiIT nr7 D 1 4 d LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 3 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 January .13, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: G.J. Development Corp. Apple Hill Road, (T) Patterson Lot # 29, TM# 3 5.4-113 An inspection of the fill pad at the above referenced project has been completed. Comments are offered as follows. ...Fill _p44 Aqji4galled in accordance with the appzgved_plaiis. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. GDR:cj Sincerely, 4� *�.. ; 0. Gene D. Reed Sr. Environmental Health Engineering Aide SENDING CONFIRMATION 7. DATE JAN -13 -2004 TUE 12:49 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME JAN -13 12:48 ELAPSED TIME : 00'40" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED. J a 4 LORETTA MOLINARI ROBERT I. BONDI Public Hmhh Dlrcd- GnW O C ,y E� lw DEPARTMENT ON HEALTH 1 Qcnew Read, Browsler, New York 10509 Rwim-nm41 n-eh (945)178.6130 Pax(845)279 -7921 Bow l., ftrA - (945)}78.6559 WIC (94S)278.6678 Fu(845)278.6095 & ly Interv6ngenlPrercY- I,(I49)27B -6014 Fw(945)179.6642 January 13, 2004 Harry Nichols, PE . Patterson Park, Suite 106 2050 Route 22 Brewster, Now York 10509 Re: G.7. Development Corp. Apple Hill Road, M Patterson Lodi 29, TMd 35. -4 -1.13 .Dear Mr. Nichols: An inspection ofthe fill pad at the above referenced project has been completed. Comments are offered as follows. Fill pad not installed in accordance with the approved plans. Please note that field measurements by this Department in no way suggests the exact sire, depth and location of the fill pad. 1f you have any fluther questions, please contact me at 845- 278 -6130, ect 2261. Sincerely, �. Gene D. Rood Sr. Environmental Health Engiucering Aide GDR: cj LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 February 17, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — Wyndham Homes Apple Hill Road, (T) Patterson Lot # 29, TM# 35.4-113 The above referenced separate sewage treatment system can be backfilled. No further comments are offered at this time. Tfyou. have. any, further.questions,..please contadt'me -at 845- 27.8 -6130; ext. 2261.: Sincerely, Z *W VI f Gene D. Reed Sr. Environmental Health Engineering Aide. GDR: cj SENDING CONFIRMATION DATE • FEB -18 -2004 WED 10:09 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 2/2 START TIME : FEB -18 10:07 ELAPSED TIME 01'12" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a. t r.ORBTTA MOUNARI ,y ROBERT 1. BONDI Pahhe H V mhh bb ' � DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 9111 --W Bwhh (941) 278.6130 FU(A45)27$.M1 ..' s—U. m 279 -6558 WIC (845) 279 - 6679 F. (848) 379 - 6085 8tny BttffVWft.Mn=h.W (845)278.6014 Fix (945) 278.6648 February 17, 2004 .Harry Nichols, PE Patterson Park. Suite 106 2050 Route 22 Brewster, New York 10509 Ro: Field Inspection— Wyndham Homes Apple Hill Road, (T) Patterson Lot # 29, TMN 35,-4 -113 Dear Mr. Michels: The above refrrenced separate sewage treatment system can be bacldilled. No further comments are offered at this time If'you have any further questions, please contact meat 845- 278 -6130, evt. 2261. . Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj FEB-13-2004 09:49 AM' HARKY W NICHOLS 914 279 4567 P.02 .-j PUTNAM COUNTY DEPARTMENT OF HEALTH DPR SION OF ENVERONMENTAL HEALTH SERVICES YATAV T%VQh1%_Cj1QN For:. Fill Date: 3 Trenches PCEID Construction permit # P 3 Located:. J (T) -3 Block t JL3 Owner/Applicant Name. �)4 1, TM Lc Formerly: Subdivision Name: Subdivision Lotl Issystem fill completed? Vr_f, Date: 2 — 13 --Of� I's system complete? )ate: Is system constructed as per PIMS? Is well drilled? Is well located as per platy? Are erosion control measures W place? Date: 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, plahs and the Staadards, Rules and Regulations of the Putnam County- Department of Health, Lybate : Certified b 2, Address: �2&_',,o& 2—a # Comments: FOR 0 ADAM XGYENE El (NAME) Form FIR-99 NAME: P1 1TWQM rni INTY nF:P0PTM;:WT ng, P P PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # '� :.• -�'' Located at }��1`1 -� Hl�� Town or Village �A`��`i--1 Subdivision name Subd. Lot # 9 Tax Map Block -" Lot hl? Date Subdivision Approved Owner /Applicant Name Mailing Address Amount of Fee Enclosed I) +I oil. WHOH Aid, IRo mo r4 1{7 Building Type VLE6 196 -ig Renewal Revision Date of Previous Approval d9JomO'L A "I1� � Zip 10 ,511 Lot Area 1,K � i No. of Bedrooms 4 Design Flow GPD $00 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System tem to consist of d P15HIAA Other Requirements 9 `2f2a !� ` v o , b, F1 �-t, gallon septic tank and � �'� L� NM. To be constructed by I—bo Address Water Supply: Public Supply From Address or: Y-- Private Supply Drilled by 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: �, . L/___�P - E. R.A. Date ��- Address _ ,0. 9 �-�- � � �"J �5 c' License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment stem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified whe con idered ne ssary by the Public Health Director. Any revision or alteration of the approved plan requires anew permi± A roved f charge of domestic sanitary sewa y. By: Title: Date: a White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 i, , Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 _ 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 9=999�= . Fax(845)279-4567 January 27, 2004 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Robert Morris, P.E. Senior Public Health Engineer RE: Trench Permit - Lot # 29 Deerwood Subdivision Apple Hill Road Patterson, NY T.M. # 35.4-113 Dear Mr. Morris: The approved fill for the SSTS area has been installed and inspected by the PCHD. We are requesting issuance of the Trench Permit and enclosing the following: 1. "Trench Permit Application" 01/27/04. 2. Five (5) Prints SS -29 "Proposed SSTS, Lot # 29 ", rev. 01/27/04. 3. Design Data Sheet. Kindly issue the necessary permit at your earliest convenience. Very truly yours, Harry W. Nich s Jr., P.E. HWN:gav 03- 056.29 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner } AD {-1- tm N On`Cj Address 1-4 40 -nNieti Cis �V ZIS - Located at (Street) AY?L 4111 kAV Tax-Map `�'�• Block Lot . (indicate nearest cross street) Municipality .. P PT T1_PL60P Watershed R(A B�-oc�_ SOIL PERCOLATION TEST DATA Date of Pre - soaking O i / 14.1 04 Date of Percolation Test 01 65) Q 4 NOTES: 1. Tests to be repeated at same depth until approximately erlfion 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 2 (0-1 1C3'1� 1 - 4 5 3 ��s¢ i I 'l�jj�y ZV(( 1 4 5 1 2 1`oq NICH 3 a. Te _ W. z! i Lull 5 0.56 NOTES: 1. Tests to be repeated at same depth until approximately erlfion 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 m ;_BRUCE R - FOLEY. Public Health Director = LORETTA - MOLINARI RN., M.S.N.— ~ Associate Public Health Director 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 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085. Request for Status of Joint Review Project Date to /2,7,/o 2- On -412,51.02- Individual SSTS Construction for 4,.T. Da"LAPM1E, r CAP, } ���C �G� 14tit IAO tT) PA INAS p AJ was deemed to be complete. Plans were forwarded to the New York City Department of Environmental Protection' for review /comments /approval as required for joint review projects. Under the Watershed Agreement a determination must be made within 20 days after an applicants submission is deemed complete. At this time the 20 day period.is;. 1) ,r 2) Has past A determination has not been received by this Department. It is important that you notify. this Department as to the status of this project. Please respond by fax (914) 278 -7921, or call Robert Morris, P.E., Senior Public Health Engineer at (914) 278 -6130 ext 166, at your earliest convenience. Thank you, in advance, for your assistance in this matter. dep fax# 773 -0343 YAU VaA$C -.1 r M4. C4 dLD . r N.4"fi- (V" &'70 QM C-[r4W 4- TNA$Xs . SENDING CONFIRMATION DATE : OCT -22 -2002 TUE 10:57 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 919147730343 PAGES : 1/1 START TIME : OCT -22 10:56 ELAPSED TIME : 00'26" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED. BFJJ r R FOMY * LOtMA NOLWARI RN., M.O.N. PA* BaWI DOwdw AMA* P1-61k &dA D"" p7+ of Perlw &.A- . DEPARTNEENf OF HEALTH I Geneva Rand Bleays . Now Yost 10509 4rbe.emW 11uhn (P14)116.6130 Fn0M276.1911 NeMU &Men OMm -6776 hkOW)276.6017 Fa,ly 1. .4.014)270.6014 Fa0M276 -6646 WIC 614)2R-601 F.OM 2T -6067. Request for Status of Joint Review - Project Date to 122- /a on $ ��i o Z _ e �t Individual SSTS Construction ' for 4 S mtrxoA gwr ea, �,D� Liitt PAAD [) A aAJ was deemed W bd complete. Plans were forwerdcd to the New York City Department of Environmental Protection for miew /commcntslapproval as required for joint review projects. Under the Watershed Agreement a detcmliwAon mast be mode within 20 days after ark. applicants submission Is deemed complete. At this time the 20 day period is; 1) 2) Has past A determination has not been received by this AepsrhnenL It is imporutm, that you notify this Department as to the status of this project. Please respond by fax (914) 278 -7921, or call Robert Morrie, P.E„ Senlor Public Health . Sngineer at (914) 2786130 ext 166, at your earliest convenience. Thant you, in advance, for your assistance in this mattes. dep&O773.0343 t(p1: Q%E119� .P.fuifA%D'• lF liai GOJLD t 171�M�. loF.r So611Qrt6H1+�G. �{At,IL'S BRUCE`:`-R FOLEY-_.:. Public Health Director �- LORE-17A MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 July 24, 2002 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: G.J. Development Corp. Apple Hill Road, Lot # 29 (T) Patterson, TM# 35 -4 -113 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 July 9, 2002 is complete. The Department will notify you by August 15, 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 seferen. ced time frame, .you. may, notify the Department of its failure by Certified Mail, Return Receipt Requested. The notice would be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with Section 18 -23 (d) (6) of the New York City Department of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in, the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if DEP review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Ve yours, Robert Morris, PE Public Health Engineer RM:cj Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 July 2, 2002 Putnam County Health Department One Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Re:. Individual SSTS Lot #'29, Deerwood Subdivision Deerwood Lane Town of Patterson, T.M. # 35.4-113 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS-29, "Proposed SSTS," dated 7/2/02. 2. "Short EAF," dated 7/2/02. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 7/2/02. 5. "Application to Construct a Water Well," dated 7/2/02. 6. "Design Data Sheet." 7. '`Utfiri ofAuthorization &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. Ni ols Jr., P.E. HWNN: JM: jmm 02- 006.29 14.16 -4 (9/95) —Text 12 r OJECT I.D. NUMBER 617.20 SEQR Appendix C State Envi ran menfel_Quallty Review. ^ z SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT (SPONSOR 2. PROJECT NAME Lur 3. PROJECT LOCATION: '� 5 �� S(!� 1p NAM Municipality i I County v7 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) P cE w, R-0 5. IS POSED ACTION: NJ New ❑ Expansion ❑ Modlflcatlon /alteratlon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: _:I r,)q C) D Initially , acres Ultimately acres 8. WIL(�PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 2 Yes ❑ No If No, describe briefly 9. W,H T IS PRESENT LAND USE IN VICINITY OF PROJECT? lJ Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/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), ?�( ❑ Yes No If yes, list agency(s) and permit /approvals LJ 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes No If yes, list agency name and permit/approval 12. AS A RESULT O-�F(PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? El Yes O No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE MY KNOWLEDGE (BEST /�O/F "V ' ' 1 `�` v�` ' Date: Applicand sponsor ame:�� t 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION -OE, ENVIRONMENTAL-HEALTH'SERVI ES'1 "' - APPLICATION' FOR APPROVAL OF PLANS FOR ... ,A. WASTLWATER TREATMENT SYSTEM', 1 `'I �!. ,�> 1. Name and add ress.of. applicant'. C?;LQ � %'C( '> r; 2. Name of project: 5- O14, Location T%V�0�! 4. Design Professional: �� Q'-P�� N ��1�dLVp5. Address: 2OS0 2 2 P 6. Drainage Basin: 5��`��'i���o EUd��.1%`y.:...:�04 7. Type of Project; Private/Residential Food Service Commercial-,- Apartments...,-. T Apartments....- -.Institutional - MobileRome Park_.. Office Building Realty Subdivision,... Other (specify) 8. Is this project subject•to State Environmental Quality'R`eview (SEQR) ?'" Type 3tatus,(check_one)•. •,• . .:::.:..:.:......; Type I' Exempt ... .. :Type II Unlisted' 9. Is a Draft Environmental Impact Statement (DEIS) required? ........•..••••.....•.•.. A/0 10. Has DEIS been completed and found acceptable by Lead Agency? ....: , 11:- Name of Lead Agency.. JV 12. Is this project m an area under the control of local planning, zoning,,or other . -officials; ordinances w _ _ .'. 13. If so,,have plans! been submitted to such authorities 14" Has. relimm a royal, been anted. by such authorities? N 0 Date' granfed;` :P ..,. ��.PP, :. 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16.. If surface;water:discharge;.-what `is -the stream class designations ;� .` ,'3� + 17. Waters index n`umb'er (surface) ....................... ................. .......... ....•••.. •T. , < < 1 18. Is project located near a public water supply system? - . 19. If yes, 'name of water supply IV, A Distance;to water�supply, — 20. Is project site near ublic sewage collection or treatments' stem7�:...:..'.i..:.::: PJ P g Y 21. Name of sewage system g y N Distance t6'sewage sysfein-'- ' __ 22. Date test holes observed //)2/00 23. Name of Health Inspector M, E U b j 24. Project design flow (gallons per day) ............................................. ..................... . 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.,: ..... ......... . . 26. Has SPDES Application been submitted to local DEC office? ......................... NU A Form PC -97 27. Is any portion of this project located within a designated Town or Statewetland? 28. Wetlands ID Number............................................... ..... ,..............,...... _ JV1 A 29. Is Wetlands Permit required? ............ ..............................: ......... /Vo Has application been made to Town or Local DEC office? ............................... A/A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... i\j 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal; - IandfilIing, 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 /0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... y 34. Are community water and/or sewer facilities planned to be developed within 15. years in or adjacent to project site? .................................... ..............:..............,_ v� il�ilQ111//t/ 35. Are any sewage treatment areas in excess of 15% slope? ... ............................... 36. Tax Map ID'Number ..... ............................... p ..................... Ma �� Block Lot 37.. Approved plans are to be returned to ..... Applicant_ Design Professional ,._ NOTE: A11 applications for review and approval of anew SSTS'to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department; Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item I.,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.. firm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Pengl Law. SIGNATURES & OFFICIAL TITLES: 2©5�� 22 , ..� ,rtr�J Mailing Address: ................................... PUTNAM COUNTY DEPARTMENT OF. HEALTH ... .- .__......1 DIVISION OF ENVIRONMENTAL _HEALTH SERVICES.. DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM \I WA�T(� (SCR -CH 2b� Owner Co(Z -P, Address Located.at (Street) WLE 4ILL RQ W6 Tax Map 3 Block Lot ? .. (indicate nearest cross street) Municipality Watershed SO G (SCQ) 0 K SOIL PERCOLATION TEST DATA Date of Pre - soaking 6/2 o t o o Date of Percolation Test Hole No... No .;. Time :: Start S>`op ... ::........ Elapse Time ' Min.) D�e�p�th to Water From Ground Surface (Incbei Y Start Stop Rater Level Dro0n h Inc esIiiaYlocb Percolation Rate 11 1 9 's 10',O$ b 2 �o,� lo:�°, J 2 27 s. 3 4 - 5 2. 2� 2 2D - 3 �� ��; ��9� 2_3 2- 1:: 20 4 2 _.. 3 - 4 l. S I._ .__ I I NOTES: 1. 'Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percoiauon test nose. kt.e. s 1 min ror i -}v mini incn, s L min ror j i -ov mirvincn) An aata to oe submitted for review. 2. Depth measurements to be made from top of hole. FO. rm DD -97 _ TEST PIT DATA 2 IN EST Ii®LES 1) bk;mP'I'I ®N OF SOILS ENS ®UNTEItED T DEPTH HOLE NO. HOLE NO. 1 HOLE NO. G.L. Indicate level at which - groundwater is encountered W0 LR N 0, V3 ON LL 2-'A 0 Indicate level at which mottling is observed N C7 N E - - Indicate level to which water level rises after being encountered 21Q` Deep hole observations made by: M ?)Q'N N -Y,\ N,P,C, D aie �7l 12/� Design Professional Name:A�,�y W,11C�1pLS S�, P,F Address: 205(�) (CV 2? Signature Design Professional's Seal NEW }, NICHp� .f- w LU opgOFESSIfl�P 10'o--m A I 05 1.5' SANS Kowa'Sw 2.0' LCAM W 9-fl0r1s UD M 2.5' 3.0' .............. 3.5' .... 4. ... 4.5' : __.. 5.0' .. -- 5.5' 6.5' 7.0' . 7.5' 8.0' 8.5' _....... 9.5' 10.0' Indicate level at which - groundwater is encountered W0 LR N 0, V3 ON LL 2-'A 0 Indicate level at which mottling is observed N C7 N E - - Indicate level to which water level rises after being encountered 21Q` Deep hole observations made by: M ?)Q'N N -Y,\ N,P,C, D aie �7l 12/� Design Professional Name:A�,�y W,11C�1pLS S�, P,F Address: 205(�) (CV 2? Signature Design Professional's Seal NEW }, NICHp� .f- w LU opgOFESSIfl�P PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ .. .... please�irint or.tYpe =PCHD Permit Well Location: Street Address: TownNillage Tax Grid # 11'3 AK UP1 (� 1J ' �t 1 ��r,�3 Map Block t Lot(s) ag Well Owner: Name: Address: '11 GI Tc' v-)jW MIENT �'�� N � P'l 616- J N j 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 I , � gpm # People Served A — LD Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling J New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes= No Name of subdivision Lot No. 2-9— Water Well Contractor: Address: - ----� Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate eet/ an. Date:' �� �� °�–_ Applicant Signature: - V 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 wpK141ler certified by Putnam County. A A Date of Issue 2- f Permit Issu' cial: Date of Expiration j 2. Title: Permit is Non- Transierrible White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 ]PUTNAM COUNTY DEPARTMENT OV HEALTH H DIVISION OF ENVIRONMENTAL HEALTH SERYICES 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. Johnson....... XrEP-Wroo,D 1, 0.- �-1 represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: GJ Development Cgro. 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 Ridc[e. New York 10576 Vice President - Name: Ad ress: Secretat�' -Name: Eleanor Johnson "1'1' White Birch Road, JPound Ridge, New York 10576 Treasurer - Name: Gilbert Johnson Address: 11 White Birch Road, Pound Ridge, New York 1057'6 " 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 thereV. Sworn to before me this_ �_ day- of month (year) Nry o Public M Q Aff= NOTARY STATE Of Wd YORK fVO. 1AN012117 QUALFU RVESTCHWER COUNTY - ,DMPAISSON SMS JUNE 15. 8 2:22- 3 Form CA -97 Signed: Title: /. Corporate Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION .OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of _ GJ Development Corp. Located at 31 Old Road T,/V Patterson Tax Map # 35 Block 4 Lot II *" Subdivision of Deer Wood Subdivision (AKA Windsor Woods) Subdivision Lot #� Gzridemen: Filed Map # �Z 9 i Date Filed - This letter -is to authorize Harry Nichols duly licensed Professional Engineer _ C< or Registered Architect to apply for the required ,.Wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance -,� ith the standards, rules or regulations as promulgated by the Public Health Director of the Putnam :;ounry Health Department, and to sign all necessary papers on my behalf in connection with this Tarter and to supervise the construction of said wastewater tretment and/or water supply systems. ill. - -� or;�orrrii}--with-the, rovisions of Article 14 °5 and/or MTof the -EducaTion'Law; -the Public Heal!:: _a.�, and the Putnam County Sanitary Code. Co�.:ntrrsigrted: P.F. R..q., 'Mailing Address State Zip Telephone: ',7 Very truly yours -- GJ Develo ent eQr Signed: (Owncr or Properry) p s ident Mailing Address: 11 White Birch Road Pound Ridge State New York Zip 10576 Telephone: (914-) 764 -4080 ...a BRUCE 'R.,FOLEY— - Public Health Director LORET"TA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 FAX COVER SHEET Date: t � l 67- To: r{ - , .mot c : I`r From: Robert Morris, P.E. Senior Public Health Engineer Emergency Response Coordinator ._, For your information For your review As discussed No. Pages 3 (Including cover sheet) Please °respond -' - Attached as requested Please call Notes/Messages `p-0 y®y 4�pvg— 10UH&Sf- (> In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2166. d AU INAWIddalAU AINI IUD WUNII Id: 3WUN 22:8T nH1 2002-VT- : AON W, November. 14, -2002� .1 Robert Monis, RE Putnam Co. Health Dept, '. I 1 4 4 Geneva Road Brewster, NY 10509 -,J1;1,v.,:.*,::A.-. R , Deerwood Subd. Lot # 29/G.J,Development Apple Hill Road Patterson, Putnam Bag Brook Reservoir DEP Log # 12587(Joint Review) Dew Mr. Morris: Please note the following comments regarding the system design: 1. Profile shows less than 3' of fill, 2. Write on plan the total amount of fill proposed. If you have any qaestions regaiiding this matter, you may contact me at (914) 773-4416. Sincerely, N a T ...... . ... Sissy De La Ossa Assistant Civil Engineer Engineering Design & Review FRI' xc- James Covey, PM., NYSDOH iO'd TV:8T ZO, Vj AON 9-V20-S1Z-VT6:x23 9NDJ33NI9 3 d3l 3M 2 d 30 IN3WIdUd3G AINnoo WUNind:3WUN -November T26L-8L2-Gf78:131 T2:8T nH1 2002-tT-OON Robert Morris, P.E Putnam Co, Health Dept. 4 Geneva Road Brewster, NY 10509 Re: Deerwood Subd. Lot # 30/0 J.Development Apple Hill Road Patterson, Putnam Bog Brook Reservoir DEP Log# 12585(loint. Review) Dear Mr. Morris Please note the following comments regarding the system design: A 1. Identify location of T?#1 and any boundary condition in I W1 (soil data of 12/7/94)• 2. The toe of slope of fill must be at least 10' from property line. If you have any questions regarding this matter, you may contact me at (914) 773-4416- Sincerely, Sissy De La Ossa Assistant Civil Engineer Engin eering Design& Review ' S�:Y ZO"d xc: James Covey, PE, NYSDOH M ZO, t71 AON 2V7120-2 Z-PT6:xPJ 9NI2133NMN3 83a DAN DIMENSION CHART (in feet) N —be` A I 6 I C F D a I R =2250.. O� L= 99.43' _ A= 25'19'07" 508° I e 38 "E NOTES PA \ -?A N$ 0(N AJ- 1230 GAL. AREA SErIIG TANK 2Z z. to 14 A fi S /7\ THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME, BEFORE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES AND REGULATIONS OF THE DEPARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. SURVEY INFORMATION FROM SURVEY PREPARED BY TE0.cLY 6ERGEND02VF COLLINS, L.S. 10 40'LF 483 r#64cm TYp ) � Ex1yT1 9 I y 13 8 q••d eoLla VVC (TYr) 14 �• 6 16 5 J.BOX (ryr) 19 / 4 C-0- I / $71 10`7FREE 3 !/ ,DQ 35 PJ= l q' h / m ,w ELL O,q p : A ._._ T -. - 17. . . 27 r 2 I 22 83 3 82 25 4 40 21 5 43 26 6 46 31 7 49 36 8. 54 41 9 58 47 10 62 52 I I 67 58 12 100 64 13 97 58 14 93 53 IS 90 47 I6 98 42 17 85 37 18 84 33 19 29 67 20 35 69 21 41 "13 22 47 76 23 53 80 24 59 84 25 65 88 a I R =2250.. O� L= 99.43' _ A= 25'19'07" 508° I e 38 "E NOTES PA \ -?A N$ 0(N AJ- 1230 GAL. AREA SErIIG TANK 2Z z. to 14 A fi S /7\ THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME, BEFORE IT WAS COVERED OVER. THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE WITH ALL STANDARD RULES AND REGULATIONS OF THE DEPARTMENT OF HEALTH AND THE NEW YORK STATE DEPARTMENT OF HEALTH. SURVEY INFORMATION FROM SURVEY PREPARED BY TE0.cLY 6ERGEND02VF COLLINS, L.S. 10 40'LF 483 r#64cm TYp ) � Ex1yT1 9 I y 13 8 q••d eoLla VVC (TYr) 14 �• 6 16 5 J.BOX (ryr) 19 / 4 C-0- I / $71 10`7FREE 3 !/ ,DQ 35 PJ= l q' h / m ,w ELL O,q p SITE LOCATION PLAT SCALE: P'= 2000' PROPERTY SHOWN ON TOWN OF PATTE125ON TAX MAP: .35,-.4-113 iNO� 9 Putnam County Department of Healt,% Division of Environmental Health ServicbL' Appr as noted for conformance with pgp ca a .Ru s ,and; 7 bepaiii lationa of the - am y Heae' . 2 3 ignature & Title ate 0 PROJECT ROPOSED SSrS DE'9RW00D SUBDIVISION 1 -0TN °2 111 APPLE HILL ROAD PA7TERSON NE-W YOR CLIENT : WYAID14AM HOME5 24 AttBORVIEW CARMEL NEW YoF Harry W. Nichols Jr., I Suite 106, Patterson Pc 2050 Route 22 Brewster, NY 10509 (845) 279 -4003. Fax 279 -4 CONSULTING SITE ENGINE DRAWING, TITLE AG-BUILT- SSTS L07- No 2.g 1 °c 30' t�OF NEW. YO DATE : 02.23 -04 ,NIcHo� �CHECKED aRAWN BY: MC oc BY : H W N i W j 2 I JOB No.: 02.006 •\VA FF� W1 DRAWING No.: 4yvle, PlUITNAM COUNTY DEPARTMENT OF HEALTH HOUSIE' !"LANS APPRI FOR —FTf I TIM-fl- 1 Title Date ------------- - 'F SZ 1, 1- �eolp <Nc PUTNAM COUNTY DEPARTMENT OF HEALTH H()U�F: PLANS APPROVED FOR 8ELr'X00f!.4 COUNT ONLY, B 1,0A 0 1) I'M s Date rn C14 15 (n � O 11 C> C> C, c' JUN 12 2003 O-V E: 'D- T H-08 Lot 29 W&KOUT/ Lm I w• -0• 11 rn C14 15 (n � O 11 C> C> C, c' JUN 12 2003 O-V E: 'D- T H-08 Lot 29 W&KOUT/ Lm PUTNAM COUNTY DEPARTMENT OF HEALTH HOUSE PLANS APPROVED FOR BEOP00i'M COUNT 0:14-LY; Sipature & Tit e I Room ........... ............... Im m -s Juk 12 403:�:� L=— H-10 te, Z9 W&KOUT/ LW