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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -121 BOX 16 me AM A •I � i' T r ' 16 .'L I �, - � , 01782 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT „ Well Location _ ,... r_. ,.... Street Address: . 0 - 2� t i* j� �M T n/Village� .nw Tax Grid Map �?5. Block �- Lot(s) LLI Well Owner: Name: Address: / 09`j A Use of Well: 1- primary 2- secondary -,�/ Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion k 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 1p in. Weight per foot lb /ft. Materials: XC Steel _ Plastic _ Other Joints: _ Welded __X Threaded _ Other Seal: Cement grout_ Bentonite Other Drive shoe: Yes No Liner _ Yes -C No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test Bailed _ Pumped —X Compressed Air Hours Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) 6 ,� 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 rn Description % n ft. ft. Land Surface �a� -- ee t r1 i� If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type $o Capacity l o Depth 1-16 Model t: u Edo S` -4t Z- Voltage 9--30 HP Tank TypelyX-30 2 Volume{ 00 ha s / i!� rrvl V11 Date Well Completed Putnam County Certification No. Date of Rep rt Well D .iller signature) r4vir,:/rxact iocatton of welt wttn atstances to at least two permanenriancmiarks to be A/ r/,4/ W. �o>' Well Drille Signature: White copy: HD File;-Yellow copy - Building Inspector; Pink copy - Address: Date: A a sh eet/ptan. Orange copy Well driller Form WC -97 %9`lw rn CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P- M D4 y Located at a87 -M J---A<Pi / Owner /Applicant Name MOD ftM55 i M/ I Formerly Town or Village pl�'M�0H Tax Map- Block 4' Lot Subdivision Name 50.woop 114 Subd. Lot # Mailing Address t� i Zip 4 A Date Construction Permit Issued by PCHD P''s'r 0 1 Separate Sewerage System built by W?*fM 140MY) Addressl Q1-1 owmv PQ-NF. Consisting of Gallon Septic Tank and +00 L F- j'R)5'e H Other Requirements: Water Supply: Public Supply From. Address or: Private Supply Drilled by SCY0 A PP Address Building "Type �? 1 tom' Has erosion control been completed7" Number of Bedrooms 4 Has garbage grinder been installed? Ho I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations) of the Putnam County D9partment of Health. Date: 67 - P3" 6 5— Certified by Address License # P.E. A R.A. 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 uNect to modification or change when, in the judgment of the Public Health Director, such revocation, mo 'ficatigp or change is necessary. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT rWell 11 Location ...: - . Street Address: (J ' y-$ P ��CLM T' si iliage: Tax Grid # Map i1,�6, Block �- Lot(s) 1L) Owner: Name: Address: /� Use of Well: 1- primary 2- secondary Residential Public Supply Air cond/heat pump Irrigation . Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion 3t 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: Xl Steel _Plastic _ Other Joints: _Welded _CThreaded _ 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 e!� Compressed Air Hours Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) e A19 Depth of completed well in feet /l U 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 6G/ _ _ If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity 10 Depth Ho Model i U E- J0 S- -1t Z- Voltage "MO HP Tank TypelyX 3G Z Volume ,-t! AU/ .,07 ! 7d �y/ -'" Date Well Completed Putnam County Certification No. .7-3 Date of Rep A /�, A-JZ2 1,41— Well D 'ller signature) F N V rE:/Exact location of well with distances to at least two permanentliandrharks to be AY4,- / /�AOo11-2 . Well Drille Signature: White copy: HD File;-Yellow copy - Building Inspector; Pink copy - Address: Date: 14 i �� a�eeet/ptan. Orange copy Well driller Form WC -97 Jun 16 05 11:46a TOWN OF PRTTERSO 845- 878-2019 P -2 @1 CpG e. ! -C _ <. B2CCc R FOLcY ... "L.G�Z"ETI`A MOf,.[1vA..'tI• R.N., BLS Piib7�' "Xealth J'te�et . associate Prbtre Y.ea!ela Dlraeter D!rattar of Pattsnt Servtcts DEPARTN ENT OF HEALTH I Creneva. Road Srew3t:r, Now York 10509 " Earitoacaeatat Ft:�lth (9ii)27B -6U0 Fmc(41 <) 278 -7922 rsttilaq 4•evlea j9:at 27i -6ss8 R':C (4L6; 2Ti • Sd'8 Put j414} 278 . 6Q@3 En:fy iatene¢�aa t?14).,8 -6Qli Praeflaal (9I4)2Ti<�6a� Fsr(SIl� }378••6648 _i✓1: ik " OWNERS vAi1'1.E: E911 ADDRESS: _ �i! L jp TOWN. fi �%�f�•�c 3" ®t1 /��,� ✓f21/lliZ�'� AQTHORIZ:.b I'C?1YN OFFICL-kL: (Sign 8t it rE) f DOTE: The Putuam, County Departmeat of Health will not issue a Certificate of Coastruction Compliance unless the above form is completed, i.e., a legal E911 address ..is assi ted by an iufhoi zed town official, This form is to be submitted -0ith the applicatoa for a. Cer dficate of Constrcciion Compliance. (E9! 1 V'ERtaMM) -PUTNAM COUNTY DEPARTMENT OF. HEALTH DIVISION OF. ENVIRONMENTAL HEALTH' SERVICES GUARANTEE OF SUDSURFACE SEWAGE TREATMENT SYSTEM _. . Im .. a ..:.i .. . .... I IHL ° Owner or Purchaser of Building Tax Map Block Lot W'4j0 "6-,- -Wo ; tei ltl Building Constructed by Location - Street Building Type.' TownNillage 4)a1?_ v ova Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construz<tiorl and "draina'ge of the sewageIreatment system se' erving the 'above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in ,good operating condition.. any part-nf said 18�stem coffs1ructed by ` me which fails to operate'for la 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 . ._...- 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 systems ._. Lel: M Day .1 Year y eneral Contractor (Owner) = signature_ y Wow\ HOMF�2_1* f)-4L-. Corporation Name (if corporation) Signature: 9t' Title: VP` (1opi 5r, W eAjV RA #1 f am&,, f He— Corporation Name (if corporation) Address: I C&c(.vwyr .09-1-16- R- Address: Cot �i- ttyv�w Pit, Me- ��w5 State gtw —i 0fZk, zip 18 40 ( State !'w YON( zip�S(�°I, Form GS -97 June 22, 2005 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003. _ ... ., ._ ... . Fax:- (845) 279 - 4567" Email: hnengineer@aol.com Re: Individual SSTS Compliance — Wyndham Homes, Inc. 28 Teal Lane - Lot # 39 Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-121 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -39, "As -Built SSTS ", dated 06/14/05. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 06/15/05. 3......_ - Three.(3) copies of "Guarantee.of.S,ubsurface Sewage Treatment_ System ", dated 06/15/05. 4. Laboratory Report, dated 04/26/05. 5. "Well Completion Report", dated 06/22/05. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated 06/16/05. If there are any questions concerning the enclosed, please call. Very truly yours, O(b Harry Wt Jr., P.E. HWN:gav w . 03- 056.39 C`? ° ' --x - ^~ ^ YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. l0598 (914) 245-28O0 Albert H. Padovani, Director LAB #: 9.500748 CLIENT 0: 57197 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 DATE/TIME TAKEN: 04/15/05 11:30 DATE/TIME REC'D: 04/15/05 0l:00 REPORT DATE: 04/26/05 PHONE: (845)-279-2022 SAMPLING SITE: 28 TEAL LANE, PATTERSON SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COL'D BYs JOSE W. QUICENO TEMPERATURE..: NOTES... COLlFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY PROFILE 04/15/05 MF T. COLIFORM 04/18/05 LEAD (INS) 04/18/05 NITRATE NlTROG 04/15/05 NITRITE NITROG 04/20/05 IRON (Fe) 04/25/05 MANGANESE (Mn) 04/25/05 SODIUM (Na) 04/18/05 pH 04/19/05 HARDNESS,TOTAL 04/19/05 ALKALINITY (AS 04/19/05 TURBIDITY (TUR RESULl ABSENT /100 ML 5.5 ppb 2.65 MG/1 <0.01 MG /L {0.060 MG /I.,. 0.O81 MG/L 6.79 MG /L 6.5 UNITS 54.0 MG /I 62.0 NO /I... 1.2 NTU _ NORMAL - RANGE METHOD ABSENT 1008 0-15 ppb 9003 0 - 10 9052 N/A 9162 0-0,3 mg/l 9002 0-0,3 mg/1 9002 N/A 9002 6,5-8,5 9043 N/A N/A 9001 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TINE OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. mblic 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 i.3 mg/L, else water undertaken to reduce the waters corrosive Oe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. �a No limits for Sodium are proscribed. Suggested guidelines state that for peop1e on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 . ' Albert H. Padovani, Director LAB #: 9.500748 CLIENT #: 57197 NON STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLlNWOOD DRIVE RALPH TEDESCO BREWSTER, NY 10509 DATE/TIME TAKEN: 04/15/05 1030 DATE/TIME REC'D: 04/15/05 01:00 REPORT DATE: 04/26/05 PHONE: (845)-279-2022 SAMPLING SITE: 28 TEAL LANE, PATTERSON SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: NONE COL'D BY: JOSE W. QUICENO TEMPERATURE..: NOTES...: COLlFORM MET*: N/A ------- -~--.m ---------------- m14, is suggested,, pH pH SCALE }N 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 & MAGNESJUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/1-, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATEBx ABOVE 3OO MG/L - `= MlLLIGRAM-PER'L]7ER --- HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) ` ` ^ ;UBMITTED BY: Albert H. radovani, M.|.(HScp) � Director ELAP# tO323 ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: 4 lo eo . Inspected by: ��. Street Location %� L�,1 �" Owner z✓sir��l�r1u1 �/� ►c�s Town Permit # ® - /3 - n y TM #— '31 , 4 IA-1 Subdivision Lot # 3- 1. Sewage Svstem Area a. STS area located as per approved plans .......... .. ................ b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped .................................................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 1 00' from water course / wetlands ...... ............................... IL Sewage System a. Septic tank size - 1,000 ...:....'1,25 .........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 ydo Length installed # ©v 2. Distance to watercourse measured 4- 1 v 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 capped ........................ ............................... g.. Pump or Dosed Systems _ 1. Size of pump chamber ................ ........................:...... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio ........:........:.. ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffied .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... D1 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 ley C') ft..Kzf' 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:: Backfillmaterial c6ntains=stones; <4" -d- to "r e Curtain drain & staiandpipes in stalled`according to plan:: f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ..... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 r� 0 VIA v� NIP= VAMM JUN -10 -2005 08:51 AN HARRY W NICHOLS 914 279 4567 P.01 a PUTNAM COUNTY DEPARTMENT OF HEAL'T'H DIVISION OF ENVIRONMENTAL HEALTH SERVICES For: Fill Trenches. // D3 -0 jr'1164 , 3 � PCHD Construction Permit # P u- o 4 Located: __- (T) 4. '0 Owner /Applicaat Name: Gca L= c TM U . Block --I .Lot Formerly: Subdivision Name: U� Subdivision t.ot # . _ 3 5 Is system fill completed? __. Date: Is system complete? Date: Is system constructed as per plans? T-, Is well drilled? u Date: r__... 9 - 0 Is well located as per plans? Are erosion control measures in place? 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 County Department of Health.. Date: Cr -G Certified by., _ -. _._...:.;...._...___. Desi Professional Address: _ d .A' !`cam ` eoc AL �,' � Lie. # FOR: ❑ ADAM GEM ❑ _. (NAME) TIN -10 -2005 FRI 09:08 TEL:845 -278 -7921 Dorm F'TR•99 (AME:PUTNAM COUNTY DEPARTMENT OF P. 1 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health ,- LORET.TA MOLINARI, RN, MSN Associate Commissioner of Health June 13, 2005 Mr. Harry Nichols P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, . Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Field Inspection — Wyndham Homes Teal Lane, (T) Patterson Lot #39, T.M. #35. -4 -121 The following comment must be corrected in the field. .• All rock greater than 4 inches in diameter must be removed from the SSTS backfill material. If you have any further questions, - please contact meat (845) 278 -6130, ext. 2261. GDR: cw Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 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 M1 • -SENDING CONFIRMATION . DATE JUN -13 -2005 M6N':16 :31 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH " TEL 845 -278 -7921 PHONE 92794567 PAGES START TIME JUN- 13 :16 :30 ELAPSED TIME : - 00 40' i MODE G3 RESULTS OK FIRST PAGE OF RECENT. DOCUMENT TRANSMITTED q. - .. SHEf(LfPA AMUR_ MD. M PAA, ROBER1'J. BONDI .. Cnm trlonar nfNmGh .... .. ., � Gtinry � •nuw< I ORErTTA MOLINA RI, RN, MSN. ' AscaUnf�fammius7�ner oJ'Hrnith DEPARTMENT OF t IEALTH I Genrva Road. Arewgter. New V -k 10509 Jude 13; 2005 . Mr. Harry Nichols P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, VY 1(1309. ... - y .. _ --`.... -.. ... ..Rt•- •tlield Inspection - Wvndhantklomas I . .. '. Tcal Lane. fT) Patterson rho following comment fuu. be rorrecte l'li th Ir.!d e All rock greater thiin 4'inchea in di>mm -wr 'n-t ho re.novcd from the SETS back6ll material. fl you have any further questions, please. contact i fit! n 18451 18 h130, oxi ?2,61`... Sr. lim•ironn��;:nal Health Fny-•ittccting Aide . GPR:cw .. . ., Wew!biblrskaiw (eu)2r3slx6 Arfµsl7tsfA11 ' Bnrlroemm/al, HexMM1'(ig5)TT &6Iw F'ex (8/5)2Ta -7921 .,:� ' Ntmltt:yMen (815)'276b55a WI('(g15)R74 -ba78 Rex (tW5)278�6013 " _. Eerly latnventln�r!¢axol ls:tl117xfut�e Pux'(s45),27RdR4s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # : 4 Well Location: Street Address: TownNilla a Tax Grid # TEAL LkH5 PAI Map 9JSa Block 4 Lot(s) Me- Well Owner: Name: mk w\ Address: , C'01'Lt W Oq45 Dmodtpj OKV Use of Well: 'C 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 5+ gpm # People Served Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling —5t, 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 X Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision D66 ?4 MQ Lot No. qA Water Well Contractor: 1-50 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 hee plan. r Date: ���1� 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 well driller certified by Putnam County. Date of Issue Date of Expiration Permit is Non - Transferrable Permit Issuing Official: Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP-97 . PUTNAM COUNTY DE?AR'Y'MENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH- SERVICES _CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at TF-AL- .- ,&H E Town or Village F�TTF,: - 50H Subdivision name DF-94-W" Subd. Lot # `� Tax Map ° 51 Block 4- Lot 1%4 Date Subdivision Approved 01 f P A A �- Renewal Revision Owner /Applicant Name X11 0 014A- H W IM E-4 1 H L' Date of Previous Approval Mailing Address -7 C6I�jpj W000 UP -l-,4a A�W'27Ef`/ N� zip JO C209- Amount of Fee Enclosed 4 400 Cc Building Type i06HL6 Lot Area 0,12 4 No. of Bedrooms 4 Design Flow GPD 100 Fill Section Only Depth Volume PCH D NOTIFICATION IS RE lUIRED WHEN FILL IS COMPLETED ---L Separate Sewerage System to consist.of 9 gallon septic tank and 400 Other Requirements: To be constructed by I? Address Water Supply: - Public Supply From Address or: Private Supply Drilled by TS P 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. Lj- Signed: i "�- P.E. X R.A. Date 0"110(.104 Address ji� O� 0 License # (o 11.4 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme tem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh co idered ne scary by the Public Health Director. Any revision or alteration of the approved plan requires anew perm' . roved fo schar of domestic sanitary sewage only. By: Title: (�/ Date. White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ please print or type PCHD Permit # 1 J 0�4 Well Location: Street Address: Town/Village Tax Grid # T�Al, LAN, PATT�s 14 Map Jf7< Block 4 Lot(s) Well Owner: Name: Address: Use of Well: jC 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 4- 6 Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type -A Drilled Driven Gravel Other Is well site subject to flooding? ................. Yes No X __X Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. _A Water Well Contractor: " 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: ~- Proposed well location & sources of contamination to be provided on separate sheet/ Ian. Date: D b 1 0Q' Applicant Signature: i 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. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ll 'ller certified by Putnam County. Alp Date of Issue d Permit Iss 7#1-2ff i al: Date of Expirati n 00 Title: Permit is Non-Transfibirable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of Located at LETTER OF AUTHORIZATION W HONcK TJ�A�- 1, ANC-- TN Tax Map # �S Block Lot Subdivision of Subdivision Lot # Filed Map # ��� Date Filed Gentlemen: 73- 1_+-+A 1[l +A mw W W 'HkCA+®� J"e-' P�' a duly licensed Professional Engineer ')( or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Counter; P.E., R.) Mailing State Zip Telephone: (S4;) Very truly yours, Signed: L4J (Owner of Prope Mailing Address: 1 CbWA0VJ0QD VJ44� State NY Zip_ Telephone: ( %44 2 .11— °P 10 �D q Form LA -97 PUTNAM,-.-: C.Q. DEPARTMENT ..HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN D"-A'--T4-'A-S-."-H'E'ET -8"UBStW'_ Owner: WYA'011: RDMfb 1Hf., ,Tax- 'Map' Block 4 Loft'-494 Located at (street) LAW A4f-'A0;L: (indicate nearest cross street) 4 Municipality. T Wate* rshed SOIL; PERCOLATION TEST DATA Date of-Pere o lationTest Date of Pid-soaking. 104% 14 4.11 1 -:2 3 14- 4 -2. 3- 4 5 2 3` t l-, .5 NOTES: J..'7, 'T ts"id"Wrepeated" at e depth until approximately equal percolation rates are obtained at each rc6latib'hiiest.h6le. '(he7 s 1 min for 1-30mWinch,& 2 min for 3l-60.min/in.ch) All-datato be Subriittid 6T re.yiew.: b d 2.' 15 ep me- asurements to be ma efrom top of hole. Form DD-97 Indicate level at which" groundwater *is encountered — -- Indicate level=.at which:mottling_is observed Indicate level to which water level rises after being.encountered Deep hole observations made by: � i-�°� p ( � ! • �V9°L►� 6M- MAP) Date. Design Professional Name:-. HAP-PI W ° Hiokk" J4- Address: Signature: Design Professional's Seal ...... TEST. PIT DATA _. 2 DESCRIPTION OF SOI- S-ENCOUWERED IN TEST .HOLES . _HOLF.,N0 _: -_..._ .. , . HOLE NO. �. a HOLE �10. 1.0' 8� $Q c�k u+W 2.0` 2.5' �1;D 3.0' 3.5' 4.0' _. 4.5' Oi.+vE 5.0' 5.5' MME SAM toA�'+. 6.0 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 7, _. 10.0' Indicate level at which" groundwater *is encountered — -- Indicate level=.at which:mottling_is observed Indicate level to which water level rises after being.encountered Deep hole observations made by: � i-�°� p ( � ! • �V9°L►� 6M- MAP) Date. Design Professional Name:-. HAP-PI W ° Hiokk" J4- Address: Signature: Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERNET APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: DEF-�W represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: S.1-L Having o f fi c e s a t: —\_v .. t Whose Officers Are: President - Nam�x'c_)rvoo�el Vice President - Name: Address: Secretdry -Nam Address.� Q c-, 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 ther o.,& Signed: A 1, JAJ;�. Cc� Title: \J, Swom to before me this day of (mon,lh (year) - ?�NN Q i, a ublic ROSADO state of Now Corporate Seal ""O.01F 10610= �a�iifl�c In r.utnam COWAY Form CA -97 03032100061 ARTICLES OF ORGAN9Aj QN OF WYNDHAM DEVELOPMENT AT WINDSOR WOODS, L.L.C. Under Section 203 of the, Limited Liability Company Law )(L STATE OF NEW YORK I�' T O ENF �T AT DEPART E MAR 2 1 260 Filer: Hankin, Hanig, Stall, Caplicki, Redl & Curtin LLP 319 Main Mall Poughkeepsie, NY 12602 APR 10 2003 REF. 07C 15620 DRAWDOWN E04 Rd Lo Z Il HVH NIS °27 03A l3 0032.x. e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, OR, AS, SRDATE: TAX MAP #: (CONFIRMED) Y DOCUMENTS Y (REQUIRED DETAILS ON PLANS CONT'D) /( _ � )PERMIT APPLICATION HOUSE SEWER -'/ FT. 4 "0'; TYPE PIPE CAST IRON /X� )WELL PERMIT OR PWS LETTER (= )(_,NO BENDS; MAX BENDS 450 W /CLEANOUT J PC -97 RENEWALS LETTER OF AUTHORIZATION (SITE NOTE (NO CHANGE) ICORPORATE DESIGN DATA SHEET (DDS) FILL SYSTE RESOLUTION 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE SHORT EAF FILL SPECS/ FILL NOTES 1 -5 (_))PLANS -THREE SETS FILL PROFILE & DIMENSIONS (_))HOUSE PLANS - TWO SETS ( _)FILL IN EXPANSION AREA UC�VARIANCE REQUEST FILL GREATER THAN2 FEET SUBDIVISION JL_)FILL LAY BARRIER *C--)PERC LEGAL SUBDIVISION CERTIFICATION NOTE SUBDIVISION A ROAL CHECKED EPTH GAUGES RATE _ OL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS ED DEPTH EPARATION DISTANCE FROM TOE OF SLOPE -4 RTAIN DRAIN REQUIRED E C GENERAL (_) LFTRENCHPROVIDED 60FTMAX. LOCATED IN NYC WATERSHED PARALLEL TO CONTOURS (PLANS SUBMITTED TO DEP 100 % EXPANSION PROVIDED, // DELEGATED TO PCHD �DETAIUDUST FREE CRUSHED STONE OR WASHED GRAVEL CZIC_JDEP APPROVAL, IF REQ'D (_)(_)GEOTEXTILE COVER DEEP TEST HOLES OBSERVED SEPARATION DISTANCES ON PLAN - FROM SSTS � PERCS TO BE WITNESSED ( 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL EX- APPROVAL SSDS ADJ, LOTS 20' TO FOUNDATION WALLS WETLANDS (TOWN/DEC PERMIT REQ'D ?) 0100' TO WELL, 200' IN DLOD,150' TO PITS L� _)DATA ON DDS PLANS & PERMIT SAME (---� ))l00' TO STREAM, WATERCOURSE, LAKE (Inc. espan) PRE 1969 NEIGHBOR NOTIFICATION 7�/ —�50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER LETTER BUZBA 10' TO WATER LINE (pits - 20') 100 YR. FLOOD ELEVATION W/I200' 50' INTFRMITTENT DRAINA,CTF COURSE - �l �(•_� -)SOIL TESTING' LOTS >10 YEARS OLD ETC. 150' GALLEY SYSTEMS REQUIRED DETAILS ON PLANS 10' MIN TO LEDGE OUTCROP C� SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK SSDS HYDRAULIC PROFILE (4010' FROM FOUNDATION; 50' TO WELL GRAVITY FLOW WELL CONSTRUCTION NOTES 1 -15 DIMENSIONS TO PROPERTY LINES DESIGN DATA: PERC & DEEP RESULTS E6LOCATION OF SERVICE CONNECTION 2' CONTOURS EXISTING & PROPOSED MIN 15' TO PROPERTY LINE DRIVEWAY & SLOPES, CUT SLOPE FOOTING /GUTTER/CURTAIN DRAINS SLOPE IN SSTS AREA 520 %) USDA SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME ADDRESS REGRADED TO 15 %, IF REQUIRED T1VI #, PE/RA; NAME, ADDRESS, PHONE# %PUMP NOTES DOSE/PUMP SYSTEMS DATE OF DRAWING/REVISION DATUM REFERENCE C_–)k..... OSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (__)LOCATION OF WATERCOURSES, PONDS U ETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) /LAKES,WETLANDS WITHIN 200' OF P.L. U IT AND D -BOX SHOWN & DETAILED (—A ROPOSED FINISH FLOOR AND C_) 1 DAY STORAGE ABOVE ALARM BASEMENT ELEVATIONS CURTAIN DRAIN *ELLS & SSDS'S WJN 200' OF SSTS STANDPIPES, 5' BOTH SIDES, DETAIL ROPERTY METES & BOUNDS 15' MIN to CDS = >5 %, , , 35' -1 %,100 % -<1% CIFROSION CONTROL; FOR HOUSE WELL & C—) 20' MIN to CD DISCHARGE /100' with 182 cons day discharge SSTS, EROSION CONTROL NOTE C_)10' MIN to NON - PERFORATED PIPE COMMENTS: (REVSIMT)09 /01 /00 August 31, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 -Tel: (845) 279" -4003 _ Fax: (845) 279 -4567 Email: hnengineer@aol.com RE: Proposed SSTS - Wyndham Homes, Inc. Deerwood Subdivision Teal Lane - Lot #39 (T) Patterson T.M. # 35.4-121 Dear Mr. Morris: Referencing your comment letter, dated August 11, 2004, we note the following: 1. Tax Map Number has been corrected on the enclosed documents. 2. New original corporate affidavit is enclosed. 3. Level"ipreader has been add&d.fo the plan. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, i Harry W. N chi ols Jr., P.E. HWN -gav 03- 056.39 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR 1 =...._A WASTEWATER, TREATMENT SYSTEM Y TM 1. Name and address of applicant:` Mid iN L 2. Name of project: L°'r 'bJ 02`57`5 3. 4. Design Professional: H'hW W° r' 5. 6. Drainage Basin: 7. Tvne of Proiect: Location TN: PATII-:F-6P� Address: 9-050 F-Ovri5 X Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park .Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted x 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... , t4 c) 10. Has DEIS been completed and found acceptable by Lead'Agency? ............... INP 11. Name of Lead' -Agency rl A 12. Is this project in an area under the control of local planning, zoning, or other, officials*, ordinances. 13. If so, have plans been submitted to such authorities? ... : ............... : No 14. Has preliminary approval been granted by such authorities? 00 Date granted: 14A 15: Type of Sewage Treatment System Discharge ................. surface water x groundwater 16. If surface water discharge; what is the stream class designation? .................... WA 17. Waters index number (surface) � . 18.. Is project located near a public water supply system? H n 19. If yes, name .of water. supply N Distance to water supply t4 ;k 20. Is project site near a public sewage collection or treatment system? ................ lip 21. Name of sewage system HA Distance to sewage system 4N 22. Date test holes observed 1�L, i'�0 `�� 23. Name of Health Inspector` b�fl2l�hi�l 24. Project design flow (gallons per day) ................................. ............................... do 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?...� 26. Has SPDES Application been submitted to local DEC office? ......................... NA. Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? NO 28. Wetlands ID Number ........................................................... ............................... NA 29. Is Wetlands Permit required? ... N 0 Has application been made to Town or Local DEC office? ............................... yel i� 30. Does project require'a DEC Stream Disturbance Permit? .. ..........................:.... 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling; sludge application or industrial activity? ...............::........... Yes/No 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 l DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ....................... ... 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? .............................................................. 35. Are any sewage treatment areas in excess of 15% slope? .. .......................... ....:. rID 36. Tax Map ID Number .......................... ............................... Map S, Block 4Lot 37. Approved plans are to be returned to :.... Applicant A Design. Professional NOTE:.All applications for review and .approval of a new SSTS to be loBated.wiftixthe NYC' ateished shall ' lie sent to t1ie.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 1.,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, underpenalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A.misdemeanor pursuant to Sectipn 210.45 of the Penal La )#. SIGNATURES & OFFICIAL TITLES. 4W WV HiCAAOO. *4 ft- &� A (3i kr. Mailing Address: .................................... 19 �29 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: represent that I am an officer or employee of.the corporation and am authorized to act for: Name of Corporation: 4DM07; S}-1Lr Having offices at:.. Gowoyb% �i�iy� fir•- -,'IMP lo? tnoo Whose Officers Are:' President - Name: Address: Vice President - Name: 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. NOWY hAAC, Wa of few yak. -worn to before me this �' . day of _(month) 2-M3 _ (year).. N ?9fy Public Form CA -97 Signed: I Corporate Seal Subdivision of Subdivision Lot # ' !_Filed Map #A Date Filed- — Gentlemen: This letter is to authorize RAW. W o 0 t U 40a JP FE a duly licensed Professional Engineer or Registered Architect to apply for the, required wastewater treatment and/or water supply permits) to serve the above-noted -property in :accordaiice with the standards, rules or regulations.as promulgated by the Public 14ealfh Director of.tho. PuthaM County Health Department; and to sign all necessary papers on my behalf in connection .with -this . . matter and to supervise the construction of saidwastewater tretment and/or water supply systems in conformity with the provisions. of Article 145 and/or. 147 of the Education..Law,4zhe Public_ Health: Law, and. the.Putnrn.ounty Sanitary Code:--- 4 _ . - q� ®f �9EB�l yo9 Very truly yours -- .. � n000r .0ountersigned: Cr Signed: P.E. R.A. # W (0 or of Property) Mailing Address State -zip. Telephone: Mailing Address: State Telephone:. ForaTLA -97 July 6, 2004 Putnam County Health Department 1 Geneva Road Brewster, New York 10509 ATT: Robert Morris, P.E. Re: Individual SSTS Deerwood Subdivision - Lot # 39 Teal Lane Town of Patterson T.M. # 35.4-119 Dear Mr. Morris: Enclosed are the following: Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 2791003 Fax: (845) 2794567 Email: hnengineer@aol.com 1. Five (5) prints of SS -39, "Proposed SSTS", dated 07/06/04. 2. "Short EAF", dated 07/06/04. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System, ", dated 07/06/04. -5. "Application to Construct a Water Well " -, dated 07/06/04. 6. "Design Data Sheet ". 7. "Letter of Authorization & Corporate Resolution ", dated 07/06/04. 8. Two (2) copies of Residence Y4wr Plan s), /for "Bedroom Count Only". 9. Review Fee in the amount o 400.00 We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Nic s Jr., P.E. HWN:gav 03- 056.39 9M PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH -SERVICES !..DESIGN-�ATA'SHEET-'= 'SU13SURFkCt SMAT TREATMENT SYSTEM Owner Address Located at (Street) 1'FA4, LPWQ 1, lim., Tax Maps Block Lot (indicate nearest crosq street) Municipality Watershed Ll SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test o1019%(1) NOTES: 1. Tests to repeated at same depth until ion rates are obtained at each percolation test hole. (i.e. - I min for 1-30 min/inch, -s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth-ipeasurements to be made from top of hole. Form DD-97 ......... 0 ........... . ......... - . . .... .. 14 2' 1 OqA 1�0 3 4 ..5 L 0- 6.7h 2 all, 115 3 4 5 2 3' 4 5 NOTES: 1. Tests to repeated at same depth until ion rates are obtained at each percolation test hole. (i.e. - I min for 1-30 min/inch, -s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth-ipeasurements to be made from top of hole. Form DD-97 TEST .PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. i G.L. - 0.5' TS >. 1.5' 2.0' 10.0' 2.5' LAM 3.0' 3.5' 4.0' 4.5' 5.011 N Sp� tqj 5.5' L R . 6.0' 7.0' 7.5' 8.0' 8 5' HOLE NO. HOLE NO. Indicate level at which groundwater is encountered ON Indicate level at which mottling is observed — Indicate level to which water level rises aft being encountered e observations made b : LA-4Y W� to t 1 a47_ ►sal U1�0 Date Dom} Deep hol ob y � � � � Design Professional Name: N 1Ult�Q�s J`� Address: U'0 PV� '�_t Signature Design Professional's Seal /�pF NEd{!�,�� ��; NICyO 9,f v p Cr. ?., LU W C� 4k No. 56124 \AROFrssloNP� 2 >. 10.0' Indicate level at which groundwater is encountered ON Indicate level at which mottling is observed — Indicate level to which water level rises aft being encountered e observations made b : LA-4Y W� to t 1 a47_ ►sal U1�0 Date Dom} Deep hol ob y � � � � Design Professional Name: N 1Ult�Q�s J`� Address: U'0 PV� '�_t Signature Design Professional's Seal /�pF NEd{!�,�� ��; NICyO 9,f v p Cr. ?., LU W C� 4k No. 56124 \AROFrssloNP� 2 ..1 V' • 11'1 t�.lYl l�•V V 1 Y 1 l� _L L` .0 tiles 11Y1:C'�l`I 1lJ.[ti •�1'L' L�:i:f :L'S']; � •- - -_• ... _. DIV-lSfON -OF: ENVIRONMENTAL= HEA:L,TR•SERVIOES'` -" :. , - - •'•APPLICATION FOR APPROVAL OF PLANS,'FOR - = • "A: WASTEWATER TREATMENT SYSTEM • � � =- • ::�- ��,��r- • � � r .'z • . �:. - _ _ T. Name`a id address of applicant: �- oC :.� _ h� _ L` ~4 • .. _.._:l : ! ���.�_.. _ ........... " - •� . tj"a7l,t- �'!�1`^t D1J0 �♦ \�r/ !••fi:. .: •��: j'i�: .+:::'�.: i.i .4'G tN 15- 2. Name of project: ��� �� 3. LocationT.V 4_ Design Professional: W�l IN loy-/ , J�rt; 5. • Address: _ SO r .. 6__ Drainage_ Basin: 7. Type of Project:: Private�Residential Food Service Commeieial Apartments -' - Institutional Mobile•Home- Park,. = Office Building Realty Subdivision _Other (specify) 8. fs this proj ect sub••ect.to State Environmental Quality Review SE . R•? ` Typt7-Status( check' one):..: :...:.............. .:............................. Type :Exempt. Type II ` - ' Unlisted 9. Is a Draft Environmental•Impact Statement (DEIS) required? ......................... Q 10. Has DEIS been completed and found acceptable. by Lead- A enc 11. Name of Lead Agency - - - -- - 12 :.Is this. project in an-area under the control of local planning, zoning, or other officials, ordinances? ...... :................................................. ............ .. 13.-.If so,'have plans.been submitted•to.such authorities? .......... .. _ - • 14. Has preliminary approval been - granted by such authorities? �JP .Date•gra_nted 15 Type o €Sewage''reatment System Discharge:..; ............. surface water -grouh4water 16. :If sur€ace-wafer disch-arge;. what is the stream class'-designation? ....::.::'::::.:::.:. 17. Waters- index number ( surface). ............................ .. ................... ............ . - :.. 1.8..Is project located near-a public water su PP I Y system? ....... ............:....:..:.......:.. 1�0 - .... - :t 19.• If yes, name -of Water- supply :Distance'to water: supply O, -2-A: Is.project site near a public sewage collection or tieatment.system? .......... ::: �I Q Name of sewage��system Distancefo sewage`sysf�m 22. Date test°hol-es•observed � � 114 21 Name of H•ealth.Inspectdr 84-AV4ki- �4 Fro_ject design flow (galtons.perday) ............................................. ...... -:... . 5• - 25. Is State Pollutant Discharge Elimination System. (SPDHS)• Permit required ?.: 26. Has SPDES Application been submitted to local DEC office? :.......... .. _ #.......... Form -PC -9� 2 Js: a�oq4 . pji.-of-Al-is pr . ept. State Wetland?.. No oJ .16catO.-W.j. hin:a- design. �-tpd Town*,or 28. Qands . Number ................ ............ : ........... .................. .......... ........ ......... 29. Is= a __CT Perrait required? -.......:......•... ....... .. ................ * ............. * .......... Has7appliettion been -madeto Town or LocMPEC office? ........... : .................... 30. project require a DEC Stream. Disturbance:-Permit? ..................... * ............... 31. Is or was project site used for agricultural activity involving application of pesticides to -orchards or other crops, solid or hazardous.waste disposal, landfillinz",'Sludge application-or industrial activity? ............................ Yes/No 332.' Is project located within 1,000 feet-.of existing or abandoned landfill-, ill., *slud.-e disposal- site or any hazard ous.1yaste site, salt stockpile, landfill, 0 other potentially known source-of contamination? ............................... Yes/No DESCRIBE: Is there a local master plan on.file with the Town or Village? ........ ' .................. 34. Are community 'water and/or sewer facilities.planned to be deve'l6p6d' 15 years in or adjacent to project site? .......................... ..................................... . 35. Are any sewage treatment areas in excess of 15% slope?.` ........................... C _3 6 Tax Map ID. Number ....... .. ........................................ Map Block Lo t II 37. Approved plans are to be returned to ..... Applicant Design Professional -L-NIOTE: All applications for review and approval of a new 8STS.-tb be located within the NYC Watershed shall he.senE to the Department,. and need not be sent in duplicate to the DEP, although the, project may require DEP• _•:pproval of the-1-SSTS'prriar* io final:approval by the Department. Projects WithiaAliq W_ atdrs.4ed.-_iDaX'al'so. require DEP *rie,*V*J*S"vti - - a* n d .A- pp_ro... val. of other aspects of a project, such as stornwater.plm-or the creation' of impervious.siurfaces, and. the project applicant should obtain the appropriate forms. for -such: activities from DEP and submit those forms to DEP fovrf--view and approval. If the application is signed by ap'erson other than the applicant shown-in Item L,the application must be accompanied by a Letter of Autbo, rization (Form LA-97): Failure-to compl y 'with this: provision. may be -grounds for. the rejection of any submission. 7 ifo oirpro.vided. i Ihere�y'.afjjrmi-iind�rpenallyofpe'rjiiry,tlia't-in. rtnafi* o H. ihis' fb'ftn. is trite to the best Oftny'knowledge andbel )cf. False itatemM',Istnade 'herein are panishabte-as, a Class A, misdemeator pursuant to SeWon 210.45 of the Penal' W.. S NA-TURES-& -OFFICIAL T1= IG Mailin',, Address: ................... I ................. K P-111 o M 1.4A6 -4 (9/95) -Text 12 PROJECT I.D. NUMBER 617.20 SEOR Appendix C ,..:. .. ,�._.. . _...r.......r_..... tats_ nmen pl.. . Qua .- ..::.:.....�. .:.......:.�..:._... .,....�...... �.. .. _4J! r9.._ t . 6[ty.:F3ev[ew-. SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Protect sDonsor) 1. APPLICANT /SPONSOR W"O RA A 4DME� IHL-` 2. PROJECT NAME 3. PROJECT LOCATION: P A TTIEP-6A County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) S. IS PR POSED ACTION: RNew ❑ Expansion ❑ Modlficatlon/alteratIon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AF CTED: �' ©° Initially acres Ultimately acres 8. WyI PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? &Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? %iftesidentlal ❑ Industrial ❑ commercial ❑ Agriculture ❑ ParklForest/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)? ❑ ICI Yes No If yes, list agency(s) and permitlapprovals Tow, br- PAIK60to eit1l1.0iw+ Pp4k4 T Q04r� It. DOES ANY ASPECT OF THE. ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? .91Yes ❑ No If yes, list agency name and permit/ . approval 12. As A RESULT ,O,��,,F((PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? C3 Yes 19no. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IIS� TRUE TO THE BEST OF MY KNOWLEDGE 1vt1 ` . " - W, !y�""'.,"' �R k— ftS c��t�"1 Q1 Applicant/sponsor a e: Date: 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 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, coordinate1he review process and use the FULL EAF. ❑ Yes ❑ No B::1(VIL1 AGTI, OfJ; REGELV�: GOORDI .NATED.REV.fEW,.AS:P >RO•VIDED FOR UNLIST-M.A IONS_IN =& NYC RR;.P.ART,fi1:7Z ?.: _IJ•Nor a negative &Iaralion 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 briefly: CC 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. r�05. Gr�th, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. Qi ..J;_.. C `y= .,106 '.Long t M, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. C7. ZSther 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 E.: IS THERE, OR -IS THERE LIKELY TO BE, CONTROVERSY RELATED T_ O POTENTIAL-"ADVERSE'ENVI RON M ENTAL IMPACTS ?, ❑ Yes _rte No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS:. For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed -in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II 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 significant 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 Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (If different from responsible officer) Date 2 A B n 4`� SciL ID / SbQ 3$ J. / r.. � N . Q A6g� / ��j ti Q= 50.00` L; 100.00' O :114° 35' 30" Ex 1517 WELL, .41 1 0 0 N r- �1250 GAL SEP{'1G TAN Box (Tyr) lop °� °� PgLc 6P W N B � O G5 E. • 10 N ..� _-R6 DIMENS�IO CHART (in feet) Number A I 1 3 I 27 2G 2 23 25 3 31 28 4 38 3_5 5 46 40 6 53 45 59 52 $ 6� SS 9 '13 64 10 79 -71 86 1 i �G 1 2 18 72 13 ,72 `p 14 GG G5 15 43 43 IG 58 62 111 55 61 Is 32 63 19 51 65 2 0 51. 4'1 21 3 am .00