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HomeMy WebLinkAbout1786DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -125 BOX 16 01786 I. L qmNr�'. I' F I 01786 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT We 1 ocation - Street Address: /? Town/Village: Tax Grid # Map ,7s, Blocky Lots) ZS Well Owner: Name: Ad ress: !� 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 V Compressed air percussion Other (specify) Well Type Screened Open end casing ­�L Open hole in bedrock _ Other Casing Details Total length ft. Length below grade,gft. Diameter in. Weight per foot lb /ft: Materials: )L Steel _ Plastic _ Other Joints: _Welded C Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: Yes No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test Bailed _Pumped -L Compressed Air Hours ' Yield Ugpm Depth Data Measure from land surface- static (specify ft) 1 During yield test(ft) Depth of completed well in feet Q� Well Log If more detailed information descriptions or sieve-analyses .. are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface F., ?A- :..._._:_ _.T ,�_,_ _ W _ .... _._ :� � ..... :. ... .... . _.._._. ,._ : .._ h - C If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information / Pump Type 44 Capacity Depth I go Model -/.CH 1 91 Z Voltage 2-3 © HP i Tank Type it) lC-30 -Z Volume 1,6125 j' r Date Well Completed -00k Putnam County Certification No. Q� 3 Date of R port :of /,�Fv Well Driller (signature) ` Exact location ot well with istances to at least two permanent lantimarks to be prov 6 a separates et/plan. Well Driller's Name Address: /4y1��_ 6�A , �L/Y Signature: _&Xaz Date: 7 .1—/� /I/ White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange co y - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH NISI -OY-OF' N t NTVIE TAL -HEAD -f 'SE _ IC y _ _ - :.. CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P 20 � )m /o y jUj Located at l *1447,g l e 1)11t y.a -aJ Town or e a Owner /Applicant Name h h��-,cs-r,,(JaxMap Block f— Lot i7-S Formerly (rv, Subdivision Name & er_ LJr)0 Subd. Lot # `f 3 Mailing Address 6 Co l! t +., woo ui t -o t e_, Zip Date Construction Permit Issued by PCHD '7 - 2_,73­6 2 Separate Sewerage System built by c Address S-¢ �, L Consisting of Gallon Septic Tank and C. a Other Requirements: C' A., 41 c., r 4'n Water Supply: _ Public Supply From, Address boll nn G � or: I/"- Private Supply Drilled by �il r A�1, boll ,.Address I j 54 Building Type -e-<t ,�Y,4 . Has erosion control been completed. Number of Bedrooms Has garbage grinder been installed? A/C) I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulatioNLslof the Putnam County IAp"ent of Health. Date: Z, 7 -01 Certified by Address P.E. R.A. License # 54,1 7-4 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 subject o modification or change when, in the judgment of the Public Health Director, such revocat' difica or ch7L_ 's necessary. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design rofessional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well I ocatio i ";- Street A dress" ` °`- TownM- 11 ge: " Tax Grid # -- - Map Block Lot(s) Well.Owner: Name: Ad ress: 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 � Compressed air percussion Other (specify) Well Type Screened Open end casing ­�L Open hole in bedrock Other Casing Details Total length ft. Length below grade Zq ft. Diameter _�in. Weight per foot lb /ft. Materials: )L Steel _ Plastic _--Other Joints: _ Welded .,K Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: )G 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 Compressed Air Hours , Yield .2& gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface AR , If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth p Model iEN1611Z Voltage '2-10 HP Tank Type w k • 30 Z Volume �J�! % ` Date Well Completed �` 0e� Putnam County Certification No. Date of Report 3 !y Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent lanflmarks to be provide ti a-sepi rate sbCet/plan. wygL'COQ� . Well Driller's Name W. Address :. 61 y Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange co y - Well driller Form WC -97 YML ENVIRONMENTAL SERV]CES 321 Kear Street (914) 245-2800 Albert H. Padovani, Director LAB #: 93.400873 CLIENT #: 57197 NON STAT PROC PAGE: 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE BREWSTER, NY 10509 DATE/TIME TAKEN: 04/27/04 09:00A DATE/TIME REC'D: 04/27/04 12�15P REPORT DATE: O5/06/O4 PHONE: (845)-279-2022 SAMPLING SITE: 124 APPLE HILL RD SAMPLE TYPE..: POTABLE - : BREWGTER NY PRESERVATIVES: NONE COL'D BY: KAREN SAMPERI TEMPERATURE..: < 4C NOTES."": KITCHEN TAP COLIFORM METHft MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE 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 MG/L - -MODER�TELY1HARD-�ATE[|�_�0���0-��/L-~ - .MG/L ��1M]�LLI�RAM1,ER.L.I F Z'�-,-'~'-_' HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Albert H! Padovani, M.T.(ASCP) Director ELAP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Nor ktw"Heights° NSS_10598.�_���=c' (914) 245-2800 Albert H. Padovani, Director LAB #: 93.400873 CLIENT #: 57197 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE BREWSTER, NY 10509 SAMPLING SITE: 124 APPLE HILL RD : BREWSTER NY COL'D 8Y: KAREN SAMPERI NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE PUTNAM CNTY 04/27/04 O4/27/04 04/27/04 04/27/O4 04/27/04 04/27/04 04/27/04 04/27/O4 04/27/04 04/27/04 04/27/04 PROFILE MF T. COLIFORM LEAD (INS) NITRATE NITROG NITRITE NITROG IRON (Fe) MANGANESE (Mn) SODIUM (Na) PH HARDNESS, TOTAL ALKALINITY (AS TURBIDITY (TUR DATE/TIME TAKEN: 04/27/04 09:00A DATE/TIME REC'D: 04/27/04 12:151--' REPORT DATE: 05/06/04 PHONE: (845)-279-2022 SAMPLE TYPE..: POTABLE PRESERVATIVE8: NONE TEMPERATURE..: < 4C COLlFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD ABSENT /100 ML 2.4 ppb 2.05 MG/L <0.01 MG /L <0.060 MG /L 0.033 MG/L 32"5 MG A... 5.8 UNITS 202 111G /L 42.0 NO /L <1 NTU ABSENT 1008 0-15 ppb 9101 0 - 10 9139 N/A 9146 0-0.3 mg/l 2037 0-0.3 mg/1 2037 N/A 6.5-8.5 9043 N/A N/A 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 TIME OF COLLECTION. Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. Ablic 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 ,the_ ter should contain no more than 20 mg/L of Sodium. For those!.pn a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. -11UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL, HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM IUM L4 ?jS !25 Owner or Purchaser of Building Tax Map Block Lot Building Constructed by TownNillage APY11" &II Rcj Ce, Location - Stre t Subdivision Name Nom! Building Type. ` Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and`drainage of the sewageIreatment system serving the 'above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition.. - - -- any part --of said "Kystem constructed ey,me which fails operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system,..except where the failure to operate properly is caused by the.willful or negligent .act- of the occupant of the building utilizing-the :.,._. _ system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system:. Dated: Month 57 _ Day Year 9W.4 Signature: d4 Title: U�? Coh��xtr�,%t�Q - Ge eral o:ntractor'(Owner) "Signature . fl U tA L. r lLw. 1'0 c, S , Is c- gkk G � Corporation Name (if corporation) Corporation Name (if corporation) Address: _ Cd Dr i v Address: 8 State _"�rs��, =�T Zip r'0 rl State P Zip 16 S -Q 5 Form GS -97 May 7, 2004 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 - Tel: , (845) 279-4fiG3 Fax: (845) 27913567 Email: hnengineer@aol.com Re: Individual SSTS Compliance — Wyndham Homes, Inc. 124 Apple Hill Road - Lot # 43 Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-125 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing 5 -43, "As -Built SSTS ", dated 05/07/04. - "Certificate of Construction Compliance for Sewage Treatment System "... - 2. .. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 05/05/04. 4. Laboratory Report, dated 05/05/04. 5. "Well Completion Report", dated 03/25/04 ginal mailed to PCHD). 6. Application Fee in the amount of 300.00 , ayable to Putnam County Health Dept. 7. "E-91 Address Verification Form ", ated 05/07/04. If there are any questions concerning the enclosed, please call. Very truly yours, H W. Nich s r., P.E. HWN:gav 03- 056.43 COUNTY PUTNAM DIVISION O §ENVIRONMENTAL HEALTH SERVICES ONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at *(U-! r wn or Village P A T T E 1V Subdivision nameV_�V_� 'P_K\ 1000 Subd. Lot # Tax Map ';_ Block Lot Date Subdivision Approved t —24 —0- Owner /Applicant Name Gx ,�E\iu_oway ccRP. Renewal — Revision Date of Previous Approval Mailing Address �\ W NA (3)9_Q) (�Q A11 (0 U M ('_% C,'P_ / At Y Zip 4'J 16 Amount of Fee Enclosed V_l o o. d Q) Building Type NCB Lot Area i�,o. of Bedrooms Design Flow GPD V V Fill Section Only Depth Volume PCH D NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage _System to consist of gallon septic tank and V-- -T q��_ N C V\ Other Requirements: 70" C u Q) y N be— J\W To be constructed by _r s Address Water Su ®®Iv: Public Supply From Address or: 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 s s= described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w n c nsidered ne ssary by the Public Health Director. Any revision or alteration of the approved plan requires a new permi proved fo charge of domestic sanitary sewage only. By: Title: 1 Date: 9-81,34– White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH ...: D1V,1S1ONJ.OE ENVIRONMENTAL- HEALTH'SER ES "t , „ 1 a ..__ - APPEICATION=FORRPPROVAL ORPLANS F-OR .. ::: A• WASTEWATER TREATMENT SYSTEM' 1. Name and address of applicant:`�F- 0�''P� i V-wA y7IL Poi I V \ %, /�l:.. ,j" Location T 2. Name of project:��tP�S /N: .P� T .d'P J ,. , r 4. Design 2D50 FT, 22. 6. Drainage Basin: D'CL�DOG�CZE1/w/ S 1 -.:1= 1.�J5� 7. Tvpe of Project: ... --_— 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) ....:.....:.....:......: .:...................... ype mpt ............ T I' ; a:Exe ' ':' n r V ype II• �. <; - °. .,U � listed a 9. Is a Draft Environmental Impact Statement (DEIS) required? .........•.. ......... D. 10. Has DEIS been completed and found acceptable by Lead Agency? %/ :N 11:' Name of Lead Agency 12: Is this project m an:area under the control of local planning, zoning; officials; ordinances? . 13. If so, have 'plans been submitfed to such authorities 1 ` •.� -t4;'Has relimin a roval,been, anted b such authorities? Date an fed;` P ..ya .. l Y �% gr �. 15. Type of Sewage Treatment System Discharge. : :::. :..::.. :. :. surface water groundwater 16..; Ifsurface:water:discharge what:is the stream lass designation? :.:::`; ::'.'''r;' ' ' Vl 17. Waters index number (surface) 18. Is project located near'a public water supply system? .: .,, _b If yes, .`. nam� e i o;f wLy ato t e.Vr � su .� .., ,D- istance;to,water�supplyk,, 19. , 20. Is project site near a.public'sewage collection or treatmentsystem? 21. Name of sewage system Distance- 's y sfem�` -� �'• 1. 22. Date test holes obsery ed 23. Name of Health Inspector 24. Project design flow (gallons per day) .......................... ............ _- _..... ,. ::..... . I. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?..: D 26, Has SPDES Application been submitted to local DEC office? ......• :................. Form PC -97 I 27. Is any portion of this project located within a designated Town or Statewetland ?1� _ 28. Wetlands_ID Number......,.......... ................. _ .,- . : ;r: ,, ... ............................... s 29. Is Wetlands Permit required? ..........................................:... ............................... AJO Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... /JO 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal; landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No N0 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? . ............................... — -... _ . 36. Tax Map ID'Number .......................... ...........................I... Map Block_A_ Lot 37.. Approved plans are to be returned to ..... Applicant �% Design Professional...__ -. — NOTE:: All ,applications' for review and approval of a new 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 l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. " -. I hereby affirm, ender 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 .4 misdemeanor pursuant to Section 210.45 of the Penal Lai SIGNATURES & OFFICIAL TITLES.. btv ,' 7 r 2 IGO . 2 2, Mailing Address: ................................... S�1 �3 1 PUTNAM COUNTY DEPARTMENT OF HEALTH,... DIVISION OF ENVIRONMENTAL HEALTH SERVICES_. DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM W w-i Co e-- OA 1� Owner &lDWFLOPPAFLJVT CCY-Pt Address Located at (Street) AKU � 41L. L- �OA Tax Map Block Lot 12 -'T (indicate nearest cross street) Municipality P A7� � (ZS &N Watershed ROG SRO N� SOIL PERCOLATIONTEST DATA Date of Pre-soaking j_ -4 Date of Percolation Test Hole No.. T Start .. ...... El apsq Time . p rth to W ate r . .. .... From ' Ground S.urface (Inches) Start :Stop 1 �2;�s- ; �-�- 2Z 2(-o 2 3 '-1 _3 23 4 5 1 6 22— 2,; 3 VA 07 21 22/ [;'L 4 5 2 3 11 : PercoIation Rate 7 —7 1 5__ 1 1 - I .I NOTES- 1. - 'Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. 15 1 min for 1-30 min/inch, s 2 min for'3 1-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from 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: M LLM Date _� 2 -�z g� Cwb) Design Professional Name: �4 -, Address: � 22_ Yom Signature Design Professional's Seal NICHOZ. !f"\ ........ m. l.. 2 w.: J' No.56124•-- Op'?O F ESS1,y��� TEST IPIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST - MOLES DEPTH L HOLE NO. i HOLE NO. - HOLE NO. - G.L. 0.5 p'p 01B'`TflP501L O`�"_O,3"7oPS�1L 1.0' , . -2'C'` F ow RED O' 1.5' �1N S py �oRM GRow A) IVA 2.0' 2.5' 3.5' 4.0'.::..:. 4.5' s A lo l-) 5.0' .. w POCK - _OAM� %W -- - ..... 5.5' 1n1) S 6.0' 6.5' _ 7.0' .. 7.5' 8.5' _.... 9.5' 10.0' Indicate level. at which - groundwater is encountered -- Indicate level at which mottling is observed - Indicate level to which water level rises after being encountered Deep hole observations made by: M LLM Date _� 2 -�z g� Cwb) Design Professional Name: �4 -, Address: � 22_ Yom Signature Design Professional's Seal NICHOZ. !f"\ ........ m. l.. 2 w.: J' No.56124•-- Op'?O F ESS1,y��� PUTNAM COUNTY DEPARTMENT OF IIEALTH _ ... DIVISION OF_ ENVIRONMENTAL HEALT_RISERVICES LETTER OF AUTHORIZATION RE: Property of _ GJ Development Corp. Located at 31 Old Road T/V Patterson Tax Map # 35 Block 4 Lot I�y�► Subdivision of Deer Wood Subdivision (AKA Windsor Woods) Subdivision Lot # Filed Map # `�`q Date Filed Gentlemen: This letter -is to authorize Harry Nichols duly licensed Professional Engineer K_ or Registered Architect to apply for the required %wastewater treatment and/or water supply permits) to serve the above -noted property in accordance .Yith the standards, rules or regulations as promulgated by the Public Health Direcibr of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this miner and to supervise the construction of said wastewater tretment and/or water supply systems ir. bn. ►ormlry with the provisions of Article 145 and/or 147 of the Education Law, the Public Heap:: and the Putnam Co _k itary Code. Co�.:ntersigrtc ?.E., R.A., # ':!ailing Addl 9 State / Zip to�Oq Telephone: (9 q�_ ) 2'7 1 - 1-0(-1 Very truly yours GJ Develo ent r Signed: /i(OwncrorPropcM) Vlesi de* nt Mailing Address: 11-White Birch Road Pound Ridge State New York Telephone: Zip 10576 (914) 764 -4080 PUTNL M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICP AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY.HEA.LTH DEPARTMENT To: Public Health Director In the matter of application for: �i%"�f ��� ��% I, Gilbert-. Johns- an..... represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: GJ Development Corp. Having offices at: 11 White Birch Road, Pound Ridge, New York 10576 Whose Officee: _..._.. . President - Name: Gilbert Johnson Address: 11 White Birch Road, Pound Ridge, New York 10576, Vice President - Name: Address: ecretar}' -. arne: Eleanor Johnson " Address: 11 White Birch Road, Pound Ridge, New York 10576 Treasurer - Name Gilbert Johnson Address: 11 White Birch Road, Pound Ridge, New York 10576 and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating theret9,9, worn to before me this ,1 day.of C' (month a c;�c- (year)-. No ary Public...'. ......, _:_.._.....:_ ,,_: MB& 0. AWON10 NOTARY PUBUC, STATE Of NEW YOFK N0. OIAN5012117 IN WESTCHESTER COUNTY t � QUi491SS�I0�N EXPIRES JUNE A. wave 3 Form CA -97 Signec Title: Corporate Seal � 3 I, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ „ PCID Permit # please print or type Well Location: Street Address: Town/Village Tax Grid # Pl " JJ�- �iLLP'Qtb F f,S Map Block Lot(s) Well Owner: Name: Address: 1J WMi E G l 2C 1A P rDA% MU9U , CQN�Er N11 Use of Well: V 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 __k—li Est. of Daily Usage $b 0 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling 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 lb EF "()01 j Lot No. � 1 Water Well Contractor: TC,,t 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 t be provided on separate heet/ lan. Date: 1 �'L. 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 a driller certified by Putnam County. Date of Issue la,. L Permit Iss g fficial: Date of Expiration Title: Permit is Non White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 ' Brewster, NY 10509 Telephone (845) 27911003 Fax (845) 279 -4567 July 1, 2002 Putnam County Health Department One Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Re: Individual SSTS Lot # 43, Deerwood Subdivision Deerwood Lane Town of Patterson, T.M. # 35.4-125 Dear Mr. Morris: Enclosed are the following: . 1. Five (5) prints of SS -43, "Proposed SSTS," dated 7/1/02. 2. "Short EAF," dated 7/1/02. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 7/1/02. 5. "Application to Construct a Water Well," dated 7 /1/02. .6. "Design Data Sheet." 7. "Letter of Authorization & Corporate Resolution," dated 1/30/02. 8. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." 9. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest conveniencqQ._ Very truly yours, Harry W. Ni ols Jr., P.E. HWN:JM:jmm 02-006.43 14.16 -4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 Appendix C — St -ate .Environmental- Quality Review - SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEAR 1. APPLICANT /SPONSOR �F_:�l��Pl'aP�i CAP. 2. PROJECT NAME �' oPpSE SS�� W3 3. PROJECT LOCATION: Municipality �'� �: jQV County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PRO OSED ACTION: 0 New ❑ Expansion ❑ Modification /alteratlon 6. DESCRIBE PROJECT BRIEFLY: —_ 7. AMOUNT OF LAND AFFECTED: i Initially 1 1 acres Ultimately ` 1 acres 8. W.,IILL1 PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? CJ Yes ❑ No If No, describe briefly 9. WH T IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential u 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 NJ No If yes, list agency(s) and permit/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes M No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? El Yes 9No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE n ( y� �\ � t ! v A ^ AQ�LS X_ V* N' Applicant/sponsor n me: V Dater Signature: // r 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 i q i t • fS X85 2 ��� ry /> T "y c J'80 k /�Y� 19 DIMENSION CHART (in eet)" Number A I 37 49 2 96 S2 3 101 88 4 106 94 5 iII 100 6 116 106 7' 121 I I Z g I26 1I$ 9 132 124 . 10 137 130 I 143 136 12 148 142 1 3 176 1 55 14 171 149 1 5 166 143 16 161 137 1 7 157 13 1' 1 g 1 52 125 t9 148 120 20 144 115 2) 140 1031. Z2 135 103 23 132- 97