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PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Streef Address:
Town/Village:
Tax Grid #
Map_? , Block` r Lot(s)/M
Well Owner:
Name:
Address: '04 Mlpo'q
PA :3
Use of Well:
1- primary
2- secondary
Residential
Business
Industrial
Pdblic Supply Air con eat pump gation
Farm Test/monitoring Other(specify)
Institutional Standby
Drilling Equipment
Rotary
Cable percussion _X Compressed air percussion Other (specify)
Well Type
Screened
Open end casing Open hole in bedrock Other
Casing Details
Total length _WV ft.
Length below grade (,�ft.
Diameter _in.
Weight per foot lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded ZC Threaded _ Other
Seal: X Cement grout _ Bentonite Other
Drive shoe: X Yes No
Liner: Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Wx
-Yes-No
Hours
Second
Well Yield Test
_ Bailed _
Pumped Compressed Air
Hours
Yield gpm
Depth Data.
Measure from land surface- static specify R)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve amilyses_ . -....
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
t✓ B S
....
_
:.
-- ..
_ _ .... _ -.... ..... .. ... .. ::.... .:.�
Al .11
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
S'
3
Pump Type u Capacity
Depth 12-5' Mode17620041 Z
Voltage 23 0 HP 210
Tank Type M -302 Volume
7 YL7A
GFV
Date Well Comple d
fo �� 3
Putnam County Certification No..
Date of a
c
Weil Driller (signature)
/--'107060'
fm3 i m rxact iocarion or wen with atstances�to_ at least two permanent landmarks to be provt n a separ4/,te sneevpian.
Well Driller's Name z1jKfkLZ ,f , J02 Address: iL V//0 Y-1Y lid 05
Signature:
White copy: HD
Date:
r f B,
Yellow copy - Building Inspector; Pink copy - Owner;
�copy Well driller
Form WC -97
TNAM COUNTY DEPARTMENT OF HEALTH
r IV--.OF E �gRONMENTAL HEALTH SERN710ES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # °
Located at t A �_. A da
Owner/Applicant Name N 11 CLIVL
Formerly,
Town or V MA0,-1WL
Tax Map Block Lot
Subdivision Name & e r W011 d
Subd. Lot #
Mailing Address Cd 8t " W00 41 Ar- r ee, /�a1f7ir ak Zip /
Date Construction Permit Issued by PCHD /1-7 O 2– n j
Separate Sewerage System built by ,% ' o ddress d �-O! �a wc�� Q—
Consisting of J 6 d G Gallon Septic Tank and G C r�
Other Requirements: ev Aalt-, �` 1
Water Supply: _ Public Supply From q ) Address
or: Private Supply Drilled by RaQ n Address G SZ
! _
Building Type ! L5Te Has erosion control been completed?
ff.?
Number of Bedrooms :j Has garbage grinder been installed?
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 regulatigr*.of the Putnam County Dfpartment of Health.
Date: S -19 –0:1 Certified by
Address
P.E. R.A.
License # SLc 1
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 ubject to modification or change when, in the judgment of the Public Health Director, such
revocatio , m ificatio r change is 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
Vi ll'>0 oc ff in ,
Sfreei Ad&egs:- -
/
]Map
Grid #
Block Lot(s)
Well Owner:
Name: Address: 0 /
Use of Well:
1- primary
2- secondary
Residential Pu tc Supply Air`condllieat pump Irpr ation
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 -X Open hole in bedrock _ Other
Casing Details
Total length _z�Lft.
Length below grade a ft.
Diameter in.
Weight per foot lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded 25� Threaded _ Other
Seal: X 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
Yield 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
e S
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
y5`
Pump Type v Capacity )'Z
Depth 3 3-S Model 7620-11 Z
Voltage 2-3 0 HP Z, 0
Tank Type ty)(- 302, Volume
ory
Date Well Comple d
!��
Putnam County Certification No.
D0 3
Date of Rep rt
Well Driller (signature)
NOTE: Exact location of well with distances to at least two permanent lAndmarks to be provi n a sepai*6 sheet/plan.
Well Drille.
Signature:
White copy:
Address:
Date:
Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
-
�: J
BRUCE. R. FOLEY ua ; RETTA MOLINARI• RN., M.S.N.
Public Health Dlrtuor
Grclor - Qf P tru Sarvlcu
_.._. - - - DEPARTMENT OF HEALTH
__ _ ....
'I Geneva -Road _.
Browster, New York 10509
Ea*ccmcAUI HWtk (914)211.6130 Fuc(914) 211.7921
Nur&Lq.Scrrica (914)271.65n --- WIC (914)-27F=6671 .Fik(91,0271.60 :S ..
- E&r1y'751cr i0oo (914)11f• 6014 Fradool (914) I71-6M Fix (914)17x• 6641
E911 ADDRESS -YERIFICAITON FORM
OWNERS NAME: W l NDOM- �- 0M56 i� Ate.___...
'T'A.X• MAP NUMBER -- ' _ ... S o .4 ° IAP. _...:_' ........ -
E911 ADDRESS;
TOWN:
A, 2
AUTHORIZED TOWN_9.MCIA -,:.
(Signature)
PATE:
The Putnam County Department of Health = will not issue a - Certificate of
Construction Compliance- unless the above form is. completed; i.e., a legal E911
address is assigned by an authorized town official. This form-is to be submitted" -
Nxith the application for q Certificate of Construction Compliance.
(E,911 WRFI" __ ......
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
4
Owner or Purchaser of Building Tax Map Block Lot
I . J+Q _T
PP(
Building Constructed by TownNillage
24
Location - Street Subdivision Name
Building Type. Subdivision Lot. #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction an'd"drain *age of the sewage -treatment system serving th"e"abovi;e-desc'riL)ed'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.
-y any `Farr -of said-system constructed 6y'me which fails-to operate for-a period' of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system,except where the failure to
operate properly is caused by the willful .or negligent j4ct.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 Day Year
Ge4dfral'Co n-tractoor'(Owner.) - signature
W WD �4114 //Pl &
Corporation Name (if corporation)
Address: g C01-WkjVqdD ff illt
State eg —ti t eCoLl A1,Y, Zip / (�C,
Signature: io owfil
Title:-- VP ew,1;TyV(-T141
Corporation Name (if corporation)
Address: _$ COWA)4�06)2 Aetilf
State APrtgj "&V kl-( Zip
Form GS-97
EM
LORETTA MOLINARI
Public Health Director
ROBERT J. BONDI
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
Harry Nichols, P.E.
Patterson Park
Suite 106
2050 Route 22
Brewster, NY 10509
Dear Mr. Nichols:
May 24, 2004
Re: Proposed Compliance: Wyndham Homes, Inc.
118 Apple Hill Road, Lot 44
(T) Patterson, TM #35.4-126
Review of plans and other supporting documents submitted at this time relative to the above -
regarded project has been completed. Comments are offered as follows:
1. The SSTS has not been constructed as per approved design.
2._ _ _. Trench length exceeds 60' feet.. The. maximum -trench -length allowed utilizi, a_
gravity system is 60' -feet.
3. Curtain drain location has not been shown.
The construction of this sewage disposal system may be subject to local wetlands regulations.
You should contact local wetlands officials in this regard.
If percolation tests were not witnessed by a representative of the New York City Department
Environmental Protection on this lot, percolation tests must be witnessed by a representative of
this Department.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Ve ly yours,
RM: hm Robert Morris
Senior Public Health Engineer
,
YML ENVIRONMENTAL SERVICES �
321 Kear Street
_
10598
800 ' - -----
Albert H. Padovani, Director
LAB #: 93.400826 CLIENT #x 57197 NON STAT PROC PAGE: 1
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
WYNDHAM HOMES
8 COLLINWOOD DRIVE
BREWSTER, NY 10509
DATE/TIME TAKEN: 04/20/04
DATE/TIME REC'D: 04/20/04 11:35A
REPORT DATE: 04/28/04
PHONE: (845)-279-2022
SAMPLING SITE: 118 APPLEHILL RD SAMPLE TYPE..: POTABLE
: BREWSTER NY PRESERVATIVES: NONE
COL'D BY: KAREN SAMPERI TEMPERATURE..: < 41''
NOTES...: KITCHEN TAP COLIFORM METH: MF
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
PUTNAM CNTY PROFILE
04/20/04 MF T. COLIFORM ABSENT /100 ML ABSENT 1008
04/20/04 LEAD (IMS) 2.8 ppb 0-15 ppb 9101
04/20/04 NITRATE NITROG 2.99 MG/L 0 - 10 9139
04/20/04 NITRITE NITROG <0.01 MG/L N/A 9146
04/20/04 IRON (Fe) <0.060 MG/L 0-0.3 mg/1 2037
04/20/04 MANGANESE (Mn) 0.045 MG /L 0-0.3 Mg/1 2037
04/20/04 SODIUM (Na) 30.2 MG/L N/A
04/20/04 pH 5.7 UNITS 6.5-8.5 9043
04/20/04 HARDNESS,TOTAL E04 MG/L N/A
04/20/04 ALKALINITY (AS 42.0 MG/L N/A
04120/04 TURBIDITY (TUR '<1 NTU 0-5 NTLj- -.
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A
SATISFACTORY SANITARY QUALITY ;3 THE 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.
ihlic 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.
February 24, 2004
Robert Morris, P.E.
Putnam County Health Department
One Geneva Road
Brewster, New York 10509
4-
Harry W. Nichols Jr., P.E.
Patterson Park - Suite 106
2050 Route 22
Brewster, NY 10509
-i'e1 (i45) 279 -0003....,
Fax: (845) 279 -4567
Email: imengineer@aol.com
Re: Individual SSTS Compliance — Wyndham Homes, Inc.
111 Apple Hill Road - Lot # 44
Deerwood (Windsor Woods) Subdivision
Town of Patterson, NY
T. M. # 35.4-126
Dear Robert:
Enclosed are the following:
1. Five (5) prints of Drawing 5-44, "As -Built SSTS ", dated 04/19/04.
2. "Certificate of Construction Compliance for Sewage Treatment System": -
3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment- System",
dated 01/09/04.
4. Laboratory Report, dated 04/28/04.
5. "Well Completion Report", dated 05/03/04.
6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept.
7. "E -911 Address Verification Form ", dated 05/07/04.
.If there are any questions concerning the enclosed, please call.
Very truly yours,
PW. Tio Jr., P.E.
HWN:gav
03 -056.44
YML ENVIRONMENTAL SERVICES
321 hear Street
`Yorktown Heights, N Y 5
Albert H. Padovani, Director
~
LAB #: 93.400826 CLIENT #: 57197 NOW STAT PROC PAGE: 2
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~^~
WYNDHAM HOMES
8 COLLINWOOD DRIVE
BREWSTER, NY 10509
SAMPLING SITE: 118 APPLEHILL RD
: BREWSTER NY
COL'D BY: KAREN SAMPERI
NOTES...: KITCHEN TAP
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
DATE/TIME TAKEN: 04/20/04
DATE/TIME REC'D: 04/20/04 11:35A-
REPORT DATE: 04/28/04
PHONE: (845)-279-2022
SAMPLE TYPE..: POTABLE
PRESERVATIVES: NONE
TEMPERATURE..: < 4C
COLlFORM METH: Ml--'
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
RESULT NORMAL - RANGE METHOD
pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH lS ' E 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 & MAGNEAUM
CONCENTRATIONv 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
MODERATELY HARD WATER: 70-140 MG/L !.MG/L.* MILLIGRAM PER LITER
.
SUBMITTED BY: ' 0 fitclv
Director
ELAP# 10323
PUTNAM COUNTY DEPARTMENT OF HEALTH
.`.r: DIVISION OF ENVIRONMENTAL HEALTH SERVICES
FINAL SITE INSPECTION 7112 -lo y -Qk
r:
Date: � � o
Inspected by: C, KOe O
Street._Locat' ,: :fit 4 &�& 4, Zo,a Owner
Town G�,�r7�TCsoit/ Permit # - �Z � - o;L
TM # 3 Subdivision Lot # �f
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. 100' from water course/wetlands.. : ...................................
II. Sewage System
a. Septic tank size - 1,000 ........ .1, 250 .. ....... other ........:.......
b. ' Septic 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. rent' cF es
1. Length required 4 i� % Length installed l/ %
2. Distance to watercourse measured -} i o 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... Pumi) 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 baffled .......................... ...............................
6. Cycle witnessed by H.D.estimated flow /cycle...........
M. 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 / j, ,I_ ' - ft...........
c. Casing 18" above grade .................. I ........... , .......... I......
d. Surface drainage around well acceptable .......................
V. Overall Worlananshiv .
a. Boxes properly grouted :.................. ...............................
b. All pipes partially backfilled ........... ...............................
c. All pipes flush with inside of box . ...............................
d. Backfill material contains stones <4" diameter ..............
e. Curtain drain &.standpipes installed according to plan..
f. Curtain drain outfall protected & dinto exist watercourse
g. Footing drains discharge away from STS area ........ h. Surface water protection adequate .:.i. Erosion control provided ................ ......................
Rev. ?2/02
APR -19 -2004 10:16 AM HARRY W NICHOLS 914 279 4567 P.01
i'
01
1
Pi1TNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
&F, MMS.T. DE MIA :ibi2E TiON For:. Fill
Date: .Saa L /su Trenches
PCHD Construction Permit #
Located: 62f LS N11>I (T) M fA1j &-%aj
Owner /Applicant Name: KRAL TM Slack 4 Lot 12
Formerly_
_ Subdivision Name :�eeb
Subdivision Lot # M
Is ' systelm" fill completed ? ". Date: ea - t6-
Is 'system complete? Ves Date: eu- i if - oy
Is system constructed' as per plans? yes
Is well drilled? Date: __ ey- [d• 0
M
Is well located as per plans ?�
Are erosion control measures in place? Yst . ,.....,,;,.
I cettit?y 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 isue_d PCHD Construction Permit and
approved plans and the Standards, Rules and Re gui Nadi nam County Department of
Health.A *�,
y
Date: Ada 1 O4 Certified,by: / R * ps RA
esi si
ti
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
April. 21, 2004
ROBERT J. BONDI
County Executive
Harry Nichols, PE
Patterson Park,'Suite 106
2050 Route 22
Brewster, New York 10509
Re: Field Inspection — Wyndham Homes
Formerly G.J. Development Corp.
Apple Hill. Road, (T) Patterson
Lot # 44, TM# 35.4-126
Dear Mr. Nichols:
The above referenced separate sewage treatment system can be backfilled. The following
comments must be corrected in the field.
1. Additional silt fence needs to be installed per the approved plan.
If you have any further questions, please contact me at 845- 278 -6130, ext. 2261.
Sincerely,
Gene D. Reed
Sr. Environmental Health Engineering Aide
GDR:cj
O
rl
- L~ 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
July 12, 2004
Harry Nichols, PE
Patterson Park, Suite 106
2050 Route 22
Brewster, NY 10509
Dear Mr. Nichols:
ROBERT J. BONDI
County Executive
Re: Field Inspection — Wyndham Homes
Formerly G.J Development Corp.
Apple Hill Road, (T) Patterson
Lot #44, TM# 35.4-126
..... ....... .
The above referenced separate sewage treatment system can be backfilled.
- Thore
are, no-,open, comments _to,be,addressed at_this time.
If you have any further questions, please contact me at (845) 278 -6130, ext. 2261.
GDR:km
Sincerely,
xo� -6. -F(-e-j
Gene D. Reed
SR. Environmental Health Engineering Aide
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
-
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # a _
oL
Located at P P L�-- 41 u- P-0 6 Town or Village
Subdivision name VX'CQA� 00b Subd. Lot # Tax Map Block Lot 12 �P
Date Subdivision Approved 1 2 — ,, Renewal Revision
Owner /Applicant Name G �� . �F U E LOP Iii E 10'� C W, Date of Previous Approval —
Mailing Address l\ vi ���_ W �(:)At� yNT) RV�)GE, bN Zip I V 7(�
Amount of Fee Enclosed]
Building Type ] \\�E�JC,E Lot Area 1,0AAoEof Bedrooms Design Flow GPD So 0
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of \ b0 n gallon septic tank and-
bu-� Ov: --V�N C,\\
Other Requirements: 1' 01, (Q` 01' Cue-IN %\ N �W—N\ N
To be constructed by 1- �J Address
Water Sup"I Public Supply From Address
PP y - .. y _... _ :..
or: Private'Su'� "1` D'riTl'ed b'` �� Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewagg treatment Ustem 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 # 5 6 � 2
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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
anew permit. App rov or discharge of domestic sanitary sewage only.
By: !,H Title:(( A-- Date :�-, 1 j--
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
Harry W. Nichols Jr., P.E...
Patterson Park, Suite 106
2050 Route 22
'Brewster, NY::105d1t3L,
Telephone (845) 2794003
Fax (845) 279 -4567 .
June 24, 2002
Putnam County Health Department
One Geneva Road
Brewster, New York 10509
Att: Robert Morris, P.E.
Re: Individual SSTS
Lot # 44, Deerwood Subdivision
Apple Kill Lane
Town of Patterson, T.M. # 35.4-126
Dear Mr. Morris:
Enclosed are the following:
1. Five (5) prints of SS-44, `Troposed SSTS," dated 6/24/02.
2. "Short EAF," dated 6/24/02.
3: "Application for Approval of Plans for a Wastewater Disposal System."
4. "Construction Permit for Sewage Disposal System," dated 6/24/02.
5. "Application to Construct a Water Well," dated 6/24/02.
.6. "Design Data Sheet."
7. "Letter of Autliorization`$c- Coipohi 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 WnNic is Jr., P.E.
HWN:JM:jmm
02- 006.44
PUTNAM COUNTY DEPARTMENT OF HEALTH....
DIVISION OF ENVIRONMENTAL HEALTH SERVICES.
DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM
J1
Owner C00. Address Pit► ND.._210GC� 1Vy
Located at (Street) p ,\ "'M Kos _ Tax Map 3 Block Lot
(indicate nearest cross street)
Municipality &c-Q' N Watershed
.... SOIL PERCOLATION TEST DATA
Date of Pre - soaking �(�� — 2n —'-I (o Date of Percolation Test
Hole No. ,
Ruh No
T..me ::
Start .Sitop
El lD�In
(ni
D_e�pth to Water
From. Ground
SStarte (Incheps)
Sto
Water
Level
Drop:In
Inches
Percolation
Rate
1VIio/Inch -
2-T
2 `2
2
3
���23 -�i,50
21`12
4
--
-io,3 ,6- 11,010
3 0
21 21 1.12
�j2 -
C9 0
.2.
�1`,0 -1�;��
20`/2 21
'12
2C� -
3
11;0 -2:10
_S0
20 )I2- 21
'lam
20
4
5
1
2
- -...
3
-
4
5
NOTES: 1. Tests to'be.repeated at same depth until approximately equal percolation rates are obtained at each
percolation: test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
VV I
Address
Nicly �s
W
Signature:
No.58924
O
Design Professional's Seal ''EsS O .
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 " - )Vo
Subdivision of Deer Wood Subdivision (AKA Windsor Woods)
Subdivision Lot # Filed Map #91 Date Filed
Gentlemen:
This lever -is to authorize Harry Nichols
:. duly licensed Professional Engineer or Registered Architect to apply for the required
,,�'astewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
.,rich the standards, rules or regulations as promulgated by the Public Health Directbr of the Putnan.
County Health Department, and to sign all necessary papers on my behalf in connection with this
maRer and to supervise the.construction of said wastewater tretment and/or.wat.er supply systems.!!..
�o� ?ormity °with the "provisions of "Article `i45 "and/oi 147'of fh•e Educai►on Law;+[he Public Hzal!,
and the Putnam Co5ar Code.
\_ .Nteho
�
tQ QQ` `9
Countersigned: yj
R.A., # rn J
No. 56124
O
'Mailing Address OFFS
State, Zip SQ)1
Telephone: 6 ��� r ° pO j
Very truly yours --
GJ Develo ent -49or
Signed:
,46wncr orPropcm) p sident
Mailing Address: 11 White Birch Road
State
Pound Ridge
New York
Zip 10576
Telephone: (914-) 764 -4080
__ ... F,, -,., I %.:,
PUI'NAM COUN'T'Y DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT
To: Public Health Director
In the matter of application for:
I, Gilbert. Johns.on..... .
represent that I am an offteer 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 Officers-Are:
President - Name: Gilbert Johnson
Address: 11 White Birch Road, Pound Ridge, New York 10576
Vice President - Name:
Address:
Secretir -Name: Eleanor Johnson
as 11 White Birch Road, Pound Ridge, New York 10576
Treasurer - Name: Gilbert Johnson
Address: 11 White Birch Road, Pound Ridge, New York' 10,576—
and that I am and will be individually responsible for any and all acts of the corporation with respect
to the approval requested and all subsequent acts relating theret
�� A
Signed:
Title:
Sworn to before me this I day -of
a-( c,K( (year)
Notary Public
tsoso- G. AWTONQ
NOTARY PNo COIAN5012117 YORK Corporate Seal
P IALIFlED IN - WESTCHESTER COU P" �
Form CA -97
Presiden
PUTNAM COUNTY DEPART LN iE \T OF HEALTH ..
DIVISION
OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION PERMIT
r NAl,4E OF OWNER:
STREET LOCATION:
REVIEWED BY: RM, GR, AS, SRDATE:
TXX M4P =: (CONFUt�%1ED)
1� .N DOCUMENTS
Y (REQUIRED DETAILS ON PLANS CO\ I''D) - -
�(__) PERMIT APPLICATION ' ; :
U HOUSE SE«'ER -' /�" FT. 4 "0'; TI:PE PIPE CAST IRON
1VELL PERMIT OR PWS LETTER
.
�NO BENDS; MAX BENDS 450 W /CLEANOUT
(,4(__)PC -97
RENEWALS
LETTER OF AUTHORIZATION
)SITE NOTE (\0 CHANGE)
4Ugf
DESIGN DATA SHEET (DDS)
FILL SYSTEMS
CORP ORATE RESOLUTION
10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
(JSHORT EAF
FILL SPECS.' FILL NOTES 1 -5
(__)UPLAIVS -THREE SETS
U(�HOUSE PLANS -TWO SETS
FILL PROFILE R DIMENSIONS
Lti EX- PAINSIOs`1 AREA
U VARLkNCE REQUEST
(�lJFILL
FILL GREATER THAN 2 FEET
% SiJBDMSTON
CLAY BARRIER
C�6/ LEGAL SUBDMSION
,'PSUBDMSION APPROVAL CHECKED
' PERC RATE
FILL CERTIFICATION NOTE. '
TDEPTH GAUGES
VOL ON PLAN FOR RO.B., UNCL�.SSIFIED & Ib1PERVIO
FILL REQUIRED DEPTH
JS
DRAIN REQUIRED
SEPARATIO ' DISTANCE FROM TOE OF SLOPE
——CURTAIN
WATERSHED GENERAL
'LOCATEII IN NYC ATERSHED
'
TRE\CR
( ZPARkLLELTOCON&TOURS LF TRENCH PROVIDED GOFT MAX.
°
(___) .. PLANS SUBMITTED TO DEP -
DELEGATED TO PCHD
-
/ '10� %OEXP,S.NSIOtiPROVIDED
DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL.
(� DEP APPROVAL, IF ItEQ'D
"OBSERVED
vUGEOTEXTILE COVER
( DEEP TEST HOLES
SEPARk:TIO`( DISTANCES ON PLAN: FRO11 SSTS -
�PERCS TO BE WITNESSED ( X10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL .
EX-APPROVAL SSDS AD7, LOTS. �2p' TO EOU \DTION WALLS
U �VExLANDS - TOW,N/DEC.PERMTf•REQ'D ?) Cis 100' TO WELL 200' I`ii.DLOD 150' TO PITS
(� , ,
(� DATA 0;`i DD&PLANS. &:PERVIYT SA1vfE L%) 100' TO STREAM. WATERCOURSE, LAKE (iuc. espaa)
PRE 1969 NEIGHBORNOTIFICATION (.-6UJ50' TO CATCHBASIN,35' STOR:tiIDRALN, PIPED WATER
LETTER BI/ZBA
�- --)�. - - C.
�
(10' TO WATER LINE (pits - 20')
(, 100 YR. FLOOD ELEVATION W/I200' , J50'. ,TER >IITTENT..ARALN�.G,E- COURSE _: -- • • = -= .: - =- _ .,,.,._�, .w-
' ( =_) SDII; TESTLNG LOTS >10 YEARS OLD " `7
(��}300'/500' RESERVOIR, ETC. 150' GALLEY SYSTEMS.
$EOUTRED DETAILS ON PLANS (j(__)10'.bILN TO LEDGE OUTCROP
• -.
SEWAGE SYSTEM PLAN - (NORTH ARROW), SEPTICTANK
SSDS HYDRAULIC PROFILE
GRAVITY FLOW (��10' FROM FOUNDATION; ; 50' TO WELL
� WELL .. .
COYST_ RUC' II9Y.NOTES_1- 15.._— .- ��-- ..._ -- _ ..
— — - / DIZIENSIO:cST0PR0PERTYLI`(ES _._...__
( DESIGN DATA: PERC & DEEP RESULTS �LOCATIO;i OF SERVICE COIECTI0. _
(2' CONTOURS EXISTING &PROPOSED (�UIII`i 15' TO PROPERTY LINE
DRIVEWAY & SLOPES;, CUT SL_ OPE
FOOTING /GUTTERICURTAIN DRAINS UU$I.OPE �jt SSTS AREA (520 °!0) �.
USDA SOIL TYPE BOUNDARIES
TITLE BLOCK; OWNERS NAME ADDRESS UUREGRADED TO 15 %, IF REQUIRED
) DOSE/PUMP SYSTEMS
TMR, PE/RA; NAME, ADDRESS, PHONES PUMP NOTES
( _)DATE OF DRAWING/REVISION FERENC U DOSE 75% OF PIPE VOLUhIE/DOS-E VOLUME NOT
'DATUM REFERENCE DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
U(�LOCATION OF WATERCOURSES, PONDS U PIT AND D -BOX SHOWN & DETAILED
/ LAKES,WETLANDS WITHIN 200' OF P.L. 1 DAY STORAGE ABOVE ALARti1
(�` UPROPOSED FINISH FLQOR AND
BASEMENT ELEVATIONS CURTAP(DRATN
WL—JEROSIOiN,CONTROL � WELLS & SSDS'S WAN 200' OF SSTS STANDPIPES, S' BOTH SIDES, DETAIL
PROPERTY METES & BOUNDS la' MI:`! to CDS = >S %, 20'4 %; -25' -3°!0, 35' -1 % 1bo %-<i%
FOR HOUSE WELL & 20' MIN to CD DISCHARGE /100' with 182 cons day discharge
SSTS, ERSION CONTROL NOTE IlJLJ10' blhN to NON- PERFORATED PIPE
COMMENTS:
(REVSHEET)09101 /00
TEST PIT PROFILES
Hole #_ Lot # el V
Hole # Lot #
Hole # G_ Lot #_.
:: -.... Depth-to water , j,
Depth to `rater 1®��
Depth to water
Depth to mottling IJoAj F
Depth to mottling. AID N i.
Depth to mottling - Q&9
Depth to rock/imp. AjQAj9
Depth to rock/imp.
Depth to rock/imp. ---"
G.L. 1CCAc -in Nld'4
G.L. o�'� "y�Pf�ui� 'Q*vr t
G.L. .
0.5 i+` ���
0.5
�v 75,
0.5
ill S
1.0
1.0
"7 13 r,
1.0
2.0 - S
2.0
2.0
3.0
3.0
3.0
i
4.0
4.0
4.0
5.0
5.0
5.0
6.0
6.0
6.0
r
7.0
7.0
TO .�
. , 8.0 s
8.0
8.0
9.0 Mve
9.0
9.0
10.0
10.0
10.0
Hole # Lot #
Hole #_ Lot #_
Dole # Lot #
...., Depth - to. water, • -lr�x3 - ':
. Depth to water
Depth to mottling AJJ) 9
Depth to mottling ,OoAVZ
Depth to mottling
Depth to rock/imp.
Depth to rock/imp.. r
Depth to rock/imp:
G.L.
G.L.
G.L.
0.5
0.5
0.5
1.0
�'
1.0
1.0
2.0
2.0
2.0
3.0
3.0
3.0
4.0
ill /a ,
4.0
4.0
5.0
5.
.5.0
6.0
6.0
6.0
7.0
7.0
7.0
8.0
8.0
8.0
9.0
9.0
9.0
10.0
10.0
10.0
14.16.4 (9195) —Text 12
PROJECT I.D. NUMBER 617.20 SEAR
Appendix C
State Envi�onme��al_,Quality::Reviaw
ENVIRONMENTAL ASSESSMENT FORAAJ..._,x., °._...,....,._,
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR((''`` 11 {{^^
cap.]
2. PROJECT NAME
3. PROJECT LOCATION: n ^ r
Municipality 1 p^ * � `� f �d County P LAN
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map)
v 1
t � 1�'_ ['K �4 i�.Ja\
5. IS PROPOSED ACTION:
New ❑ Expansion ❑ Modiflcatlon /alteration
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED: t
Initially i.C3,� acres Ultimately `1Q acres
8. WIL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
2Yes ❑ No If No, describe briefly
9. WH/yT IS PRESENT LAND USE IN VICINITY OF PROJECT?
�J 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 CJ No If yes, list agency(s) and permit /approvals
11. DOES ANY ASP CT 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/OROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes No
I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THEE BEST MY KNOWLEDGE—
jOF
V ` Wo-� " � ` `�' `- " T
Applicant/sponsor name: ' `DLS) „8 Date:
Signature: h�3 1411
L/ V
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 OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
Well Location:
Street Add dress: Town/Village Tax Grid #
APP L� �1 ,L PJ, T VEP,'SQ -U Map S Block Lots)
Well Owner:
Name:
Address: 1 1 W q \-VZ t312C1a e--DAD
G,J,DFVF�L'q[K Fv
P000 R-Xt )G [-iIVY
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 5+ gpm # People Served T -b Est. of Daily Usage _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 T-) F �- ±'-W O O) Lot No.
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 separ a sh d Ian.
Date:.- Applicant Signature: )�AAA-L
PERMIT TO CONSTR CT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED -FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. y revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water well revision
certified by Putnam
County. /' A
Date of Issue °i' ry 9 2- Permit Issu'
Date of Expiration �Vll v Title:
Permit is Non- Transfertable '
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 SER' I ESs
- .APPLICATION FOR APPROVAL OF I'L;1S FAR r
A, WASTEWATER. TREATMENT SYSTEM'
1. Name and- address.of.applicant:'' 8 -bV_:V� —_'Q9 +11
,V
2. Name of project:"'�5
Location TN�TI TIT F.SO,
4. Design ProfessionalA ,Ni=t0 ,JZ,U.5. Address: 201;0
6. Drainage Basin: 1 '_ 6 D ?�E W ST 1:Nf %. . 35 01
7. Type of Project;
Private/Residential Food Service Commercial- ,
..Institutional MobikRome Park_.
Office Building Realty Subdivision (specify)
„.
8. Is this project subject•to.State Environmental Quality Review'(SEQO ' * -
Type Status :(check one). .,, ....................... Type'i a. Exempt
Type-II : Unlisted ��
9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... D
10. Has DE IS been
completed and found acceptable by Lead Agency? ....
11.- Name of Lead Agency'-
12 Is this project in -an area under the control of local planning, zoning,.or other
...._ _ .a.._ _ . _. __
oicials ordmances�
13. If so, -have plans been submitted to such authorities ,,...,
-
-Y4, Has. relimin :a royal been anted.b . such authorities? Date ' :anted
P ,Y .PP. g? Y g
15. Type of Sewage Treatment System Discharge e ........ surface water groundwater
16.. If surface. water :discharge; what is the streamzclass' designation? :.: ':.;'', `
17. Waters `index number (surface) ....:.........
18. Is project located near a public water supply system? .:.... .............................t,
19. If yes name of water su P P1 . y ; Distance to watertsu PP 1 ;T
20. Is project site near ublic'sewa a collection or treatment s' stein.':;...::. ;...::.
P J P g y �...: ,�
21. Name of sewage system g ,y:
g Y Distance'to sewa e s stem >.
22. Date test holes observed 6* 23. Name of Health Inspector
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? ......................... 1\ f PA
Form PC -97
2-
27. Is any, portion of this. project located within a designated Town or State-wetland? A/0
28. Wetlands ID Number... ......... ............................... ............ w
29. Is Wetlands Permit required? ....................................... ............................... ... NO
Has application been made to Town or Local DEC office? ...............................
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 )v D
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination? ............................... Yes/No
DESCRIBE:
33. Is there a local master plan on. file with the Town or Village? ......................... .
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to- project site ? ......... ..... I ............................
35. Are an;y sewage treatment areas in excess of 15% slope? .. ...................:...........
36. Tax Map ID'Number .......................... ............................... Map S Block_L Lot Z�
37. Approved plans are to be returned to ..... Applicant Design Professional
. G _ _;. NOTE;- Alhaplications for review and approvahof a- rlewSSTS "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, 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 PenalAaw l
SIGNATU ;S & OFFICIAL TITLES: --i
'd Z':r, r Z 0
Mailing Address (� �W' —ANY
�t�
r
,.4
DIMENSION CHART (in feet)
Number
A
g
C
p
1 20
I S
2
58
54
3
.60
54
4
62
53
5
65
53
6
68
53
7
7z
56
8
77
60
9
61
63
10
86
66
1
69
62
17-
64
56
13
62
52
14
50
43
IS
42
37
16
32
.34
17
28
36
IS
43
31.
19
43
32
20
78
77
22
82
78
23
84
`►8
24
86
'78
25
89
So
26
93
83
27
98
81
28
104
9 1
V �
oo
f o
A 2 105 °4358'
L- 25.0o'
R. 4 6.13`
2iI.Sp�
�=4oer��16" `� N°
L = 175.7g' e,, N
4"d SOLID PVC i
1p
i
Uk B
- s
0
011
105043158'
R = 46.13' . ; mom am 20I.2
-
R oo'
X11 L� ROAD
APP► -E ,