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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -4 -127 BOX 16 ., '. `I. : 1 �• Ad .��� . T vt ' �s gL , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well 1566if%11 - Street'Address: " ° ` " r'_' ° _ " ' Town/Village`' , 9 1 �lv a e, - &. z 2 & & & Tak Grid # ' Map'I S, Block 4- Lot(s) (21 Well Owner: Name: Address: Use of Well: 1- primary 2- secondary Re Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _,X- Compressed air percussion Other (specify) Well Type Screened Open end casi >C Open hole in bedrock Other Casing Details Total length _OR/ ft. Length below grade _ft. Diameter _in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ WeldedX Threaded _ Other Seal: Cement grout , Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _Bailed _Pumped Compressed Air Hours_& Yield J& gpm Depth Data Measure from lad surface - static (specify R) ,7 During yield test(ft) Depth of completed well in feet are, 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 - If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume 6�jjlyze n Date Well Complied �p� 4 d3 Putnam County Certification No. jVr Date of Report Well Driller (s' ature) NOTE: 'Exact location of well with distances to at least two permanent landmarks to be provided;& a separate sheet/plan. Well Driller's Name Address: F27 ijV lnG, Signature: Date: fie White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # =jgze Located at 2-1 COW -A H w bOD D P E Town Owner /Applicant Name W Y OM At 1-0 MA ' Tax Map es Block 4 Lot I2.1 Formerly 63-J. DeN�L jv m Subdivision Name Subd. Lot # Mailing Address 4b cowto -J p 019--1'4� 6j - et'16T O- Date Construction Permit Issued by PCHD 0 T `06 9 0 �- Separate Sewerage System built by WOOMM -MMO Consisting of I' 60 Gallon Septic Tank and Other Requirements: Water Supply: Public Supply From or: Private Supply Drilled by O�D AKF6 IAH WELL Address W N K 52 e Nl 1611 Building Type -� d� Has erosion controlbeen completed. ` ° ` i O T Zip 107-01 Address I COLLlovJ000 Of- �'6 ► IKU I 5 a0 L'fF J Address Number of Bedrooms �- Has garbage grinder been installed? 00 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 regulatiops, of the Putnam County Dpp"ent of Health. Date: Address U50 9T Certified by 14- f ul'x / --- P.E. X R.A. 10'Wk icense # 5 6i 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 74s bject to odification or change when, in the judgment of the Public Health Director, such revocatio , o icatio change is necessary. By: M'' Title: Date: +� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 ,.ate PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT N TE: 'Exact location of well with distances to at least two permanent landmarks to be provid _ a separate sheet/pl Driller's Name Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 `Town/Village'- T°ax- rid. #_ �_....,N......... �_ .. _ Map Block 4- Lot(s) 121 Well 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 C Compressed air percussion Other (specify) Well Type Screened Open end casing - Open hole in bedrock _ Other Casing Details Total length _421 ft. Length below grade z;20 ft. Diameter _ , in. Weight per foot lb /ft. Materials: k Steel _ Plastic _ Other - Joints: . _ WeldedZC 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 JZL 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 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Compleled Putnam County Certification No. Date of Report Well Driller (s'gnature) N TE: 'Exact location of well with distances to at least two permanent landmarks to be provid _ a separate sheet/pl Driller's Name Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 BRUCE R. FOLEY LORMA MOLINAR! M.S.N. Public Health DtreclaJ _ _.�.4. t. � �Pa� . Nralt� uoc �,, Dlrtc • Q% Patlrnr Sarvkcr OF • HEALTH ...... 1 Geneva Road - - _ Brewster, New York 10509 Earircumcatal HWtb (914)271.6130 Fact(914) 271.7921 Kurcia;. Scrvlca (914) 271.6558 — Yf IC (914)271.6671 .Fi5g9tO 271.6911 _..... __.x .._ .: .. Errfy'Tctcrvic�oa (914) I7f •6014 Trac600l (914) 21E-60E2 Fix (914) 27f• 665E E911 ADDRESS-VERIFICATION FORM owrlERS rtAmE: �1Qi pfd'+ M ts�i-...._... in .n .... .. .. ...... -�_.�.__.......- • -- -• E911 ADDRESS;,.. f l�G fly' AUTHORIZED TQw1Y.QFRICIAL: - (Signature) DATE: _ .. _.. The Putnam C ounty Department.• of Health will not -issue a- Certificate of -- - Gonsfructioh Compliance. unless the above form is. completed, i.e., a Iegal E911 address _is_assigned by an authorized town official. This form -is to be submitted---`--------- with the application for q Certificate of Construction Compliance. (E91 I YERFR1vn.. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SU13SURFACE SEWAGE TREATMENT SYSTEM /+ 12� Owner or Purchaser of Building Tax Map Block Lot ..W . �a. t = PA P -for► - Building Constructed by TownNillage �.1 C,ou.1 H�oap p�►�� - ��� --w'� Location - Street Subdivision Name 45; Building Type. Subdivision Lot # I represent that I am wholly" and completely responsible for the location, workmanship, material, construction and'draina'ge of the sewage Ire atment 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 coris'iructed by me which fails-to operate for `a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system,..except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system.. � ....- - -- - _ I-- - .__. 7 ._ .. _ _.. 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__ M ✓ Dated: M t �1AJ Day2� Year 2� ©�' Signature. 'oy,t, Co Title: I L-, I/. P - ene al Contractor (Owner) = signature WND kPm �U l'wS Corporation Name (if corporation) Address: A C4V. WDOP 0�- WViTE �- State 1" J Zip 105-01 Corporation Name (if corporation) Address: Cfi woAy b(L Stm J State �1 Zip DS� Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES i' FINAL SITE INSPECTION l Date: Z Z 2 ZLO-0 specte n._- treet Loeafii©n _ r A.I ..... Permit m eirt " # ¢ TM # 3t;7- - i z Subdivision Lot # f -57 1. Sewage System 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 r,..<" 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. renc es . 1. Length required 5'c-© Length installed 57,o 2. Distance to watercourse measured oo Ft.......... j- ✓ >�� . 5. 10 ft. from property he - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ..................... S. Size of gravel 3/4 - 11/2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... - .._g..., . -. ipe.en. s.. a :....:.:..::. .:..::::.:.:.�... ...:::........= Pump or Dose vstems 1. Size of pump chamber ................. ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/audio. * ...... ......... 4. Pump easily accessible, mo grade ................. 5. First box baffled .....:.................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildihe a. House located per approved plans .............. :.................... b.. Number of bedrooms ....................... ...... .......................... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured / / 3 ft........... c. Casing 18'_' above ade ..�-... 1* 11 !-- - ...... V. a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contams..stones <4" diamete�_ r___. e. =C drain & s #andp es- installed aesordng�to pla f. Curtain drain outfall protected & dir.to exist waterco g. Footing drains discharge away from STS area ............... h. Surface water protection adequate. :.......................... i. Erosion control provided ................. ............................... Rev. 12/02 NO C0M[MENTS s Z .� i d , 72-1 orm JAN -08 -2004 11:'17 AM HARRY W NICHOLS 914 279 4567 P.01 YUT'NAPI COUNTY DEPARTMENT OF HEALTH DIVISION.OF ENVIRONMENTAL HEALTH SERVICES RFQTjEST FQJ& E NAL INSPECIM For: Fill Date: TAj3 • o lad ,. Trenches PCHD Construction Permit # 2-12-04 Located: !b..cGL Off„ ja; -„ , (T) M PwCY' s2 S Owner /Applicant Name: W3gbjj,Atrl Atagg "Qh A TM, 3S. _Block �_. Lot 127 Formerly: Subdivision Name: 'blcg- mob Subdivision Lot # 45 , is'systeaftll completedT bate: T I's systexa complete? vc Date: .1 Q e2 lad Is system constructed as per plans? Y is Is well drilled? Aft. bate: h1AL% 01/0 .Is well located as per plans? yxs Are erosion Control measures In place? I certify that the systern(s), as listed, at the above premises has been constructed and I have inspected and :verified their completion in accordance with the issued PCTM Construction Permit and approved plans and' the Standards, Rules and Regulations of the Putnam County Department of _ Health, ' Date: 4 Certified b ✓ R.A Design.' ofessional Address: —go-so gt-��rr z?. 6au., sSm '0 10501 Lic, # 56124 Comments:. FOR: IJ ADAM GENE 0 ..... ...... (NAME) ..... Form FIR -99 TnAI n "7ParwA TLJI1 44.7A TCI - 0.dc�- P7Q_7Qa1 K10MC•01 ITKIGM (-rll IAITV MC'0n0TMCIJT nE' 0 4 .g ...a +m _ o .�. -. .: _ . - � n _- c...s.. asr... x .- 1sP..+.w•d -.�.. �..�.....ec- .n..,... 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 January .12, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 .Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — G.J. Development Corp. Deerwood Lane, (T) Patterson Lot # 45, TM# 35.4-127 The above referenced separate sewage treatment system can be backfilled. The following comments must be addressed. _ ..... -- -. 1. Cast-irdit- -pipe. needs to be _installed..s ._....... '..... . _ -_ . _..._ :. _ -_ _ :.... _.,... 2. Curtain drain stand pipes must be correctly installed. 3. Grading around the well needs to be completed. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, 4-�' V9. law Gene D. Reed. Sr. Environmental Health Engineering Aide GDR: cj - " May 28, 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 -4003 Fax: (845) 279 -4567 Email: hnengineer@aol.com Re: Individual SSTS Compliance — Lot # 45 27 Collinwood Drive Deerwood (Windsor Woods) Subdivision Town of Patterson, NY T. M. # 35.4-127 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing 5 -45, "As -Built SSTS", dated 04/01/04. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 05/21/04. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 05/21/04. - - 4. Laboratory Report, dated 05/06/04. 5. "Well Completion Report", dated 10/28/03. 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, Harry W. Nic ols Jr., P.E. HWN:gav 03- 056.45 YML ENVIRONMENTAL SERVICES 321 Kear Street yorktown Heights, N.\i,j059B' (914) 245-2800 Albert H. Padovani, Director � LAB #: 93.400888 CLIENT #: 57197 NON STAT PROC PAGE: 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ WYNDHAM HOMES 8 COLLINWOOD DRIVE BREWSTER, NY 10509 DATE/TIME TAKEN: 04/09/04 10:14A DATE/TIME REC'D: 04/29/04 1100A REPORT DATE: 05/06/04 PHONEt (845)-279-2022 SAMPLING SITE: 27 COLLINWOOD DR SAMPLE TYPE..: POTABLE : BREWSTER NY PRESERVATIVES: NONE COL'D BY: TEMPERATURE..! < 4C NOTES...: KITCHEN TAP COLIFORM METH: MF ~~~~~~~~~~~~~~~~~ —mm ~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE PUTNAM CNTY PROFILE 04/29/04 MF T. COLIFORM ABSENT /100 ML ABSENT 04/29/04 LEAD (INS) 4.1 ppb 0-15 ppb 04/29/04 NITRATE NITRDG 1.95 MG/L 0 - 10 04/29/04 NITRITE NITROG 0.018 MG/L N/A 04/29/04 IRON (Fe) <0.060 MG/L 0-0.3 mg/l 04/29/04 MANGANESE (Mn) 0.033 MG/L 0-0.3 Mg/1 04/29/04 SODIUM (Na) 29.3 MG/L N/A O4/29/04 pH 5.6 UNITS 6.5-8.5 04/29/04 HARDNESS,TOTAL 190 MG/L N/A 04/29/04 ALKALINITY (AS 48.0 MG/L N/A ' 04/29/04 TURBIDITY (TUF} ~-, f1 NTU ` ' 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN�-�f�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. 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 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. METHOD 1008 9101 9139 9146 2037 2037 9O43 _ ' '^' -� .-t. , YML ENVIRONMENTAL SERVICES 321 Kear Street � � Yorktown Heights, N.Y. 10598 ` -_- �2 �' (�14> 24�;8(�) Albeet H. Padoyani, Director LAB #: 93.400888 CLIENT #, 57197 NON STAT PROC PAGE: 2 WYNDHAM HOMES DATE/TIME TAKEN: 04/09/04 10:14A 8 COLLINWOOD DRIVE DATE/TIME REC'D: 04/29/04 11:00A BREWSTER, NY 10509 REPORT DATE: 05/06/04 PHONE: (845)-279-2022 SAMPLING SITE: 27 COLLINWOOD DR SAMPLE TYPE..: POTABLE : BREWSTER NY PRESERVATIVES: NONE 'OL'D BY: TEMPERATURE..: < 4C NOTES...: KITCHEN TAP COLIFORM METH: MI:-_ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAB 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 .- MODERATELY HARD WATER: 70-14O,M64L _ __MG/L.,_MILLIGRAM PER LITER SUBMITTED BY: Albert H. PadovanK M.T.(ASCP) Director ELAP# 10323 \' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM e PERMIT # 0 Located at D-e-,or WOO) La-le— Town or ViOITge ip��lelrsGL) Subdivision name D =tea, b1lor,J Subd. Lot # 5—' Tax Map 3 Sj Block + Lot 1.7-7 Date Subdivision Approved Renewal Revision Owner /Applicant Name (,- , �, 1%�,.vjd p d►, �► v p Date of Previous Approval Mailing Address !l iU ►��� j2�� 1 oe�h,,� Jei�C Zip l �S-7 Amount of Fee Enclosed 360 Building Type ke-s) J " � Lot Area M40 No. of Bedrooms _ Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of i 7-'�70 gallon septic tank and Other Requirements: To be constructed by ` Te 0 ) j7 Address Water Supply: Public Supply From Address or. t/ . Rrivate'Supply Drilled-by / ► �5'� Address I X, V 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,, stem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: h1 g� �V, jjA , -, , P.E. R.A. Date 4 -f -0 Z Address 51 License # 21 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 whe c sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit A roved discharge 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 FOR APPROVAL.OF PLANS FOR A.WASTEWATER TREATMENT SYSTEM` 1. Name and address of applicant: ` r 1 2. Name of project: 5 3. Location T 4. Design Professional: ,,,,. /U c- f, %F5. Address: 2:) 6. Drainage Basin: a ; N- 7. Type of Project: Private/Residential Food Service Commercial Apartments . Institutional - Mobile i"Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject.to State Environmental Quality Review Type Status check one .. �.-. %Type I' ' _ Exem t Type. II Unlisted ` l/ 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Has DEIS 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::,: officials; ordinances? . 13. If so,.have plans' been submitted to such authorities? .......... ............................... d.: y 14: Has preliminary, approval. been granted by such authorities? Date granted 15. Type of Sewage Treatment System Discharge ................. . surface water i/ groundwater 16. If surface water discharge; what is the stream class designations .` . .. 17. ' Waters index number (surface) ......... .......... ............................... ...... . 18. Is project located near a public water supply system? - — 19: If yes, name of water supply /U Distance.to water: supply 20. Is project site near .a public sewage collection'or treatment system? ::::'.::: " :':.:: 21. Name of sewage system /'t� , - Distance to "sewage system' �'t : . 22. Date test holes observed 23. Name of Health Inspector A J 4J )3uvL 24. Project design flow (gallons per day) ............................................... ...... :.c'o`•. ! ,' ...... . 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... orm PC -97 z 27. Is any portion of this project located within a designated Town or State wetland ?. yuo 28. Wetlands ID Number ................... ............................... _. 29. Is Wetlands Permit required? ............................................. ............................... . . Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? NO 31. Is or was project site used for agricultural. activity involving application o.f 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 lbd DESCIUBE: 33. Is there: a local master plan on file with the Town or Village? ......................... �I 34. Are communitywater and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... Ur,Iow� 35. Are any sewage treatment areas in excess of 15 %slope9 . ............................... 36. Tax Map ID Number .......................... ............................... Map 3S' Block -f Lot /' 37. Approved plans are to be returned to ..... Applicant Z/ 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, a'- nd 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 Sectipn 210.45 of the Peng f Law. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... _v5t7 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL Well Location: Street Address:) Town/v' age Tax Grid # D2eir tucoo e- ) Map 7jsN Block 4 Lot(s) ,, Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Pump J Irrigation 1- primary Business . Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Q Est. of Daily Usage O 6Ci gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling !/ New Supply new dwelling) Deepen Existing Well Detailed Reason Avoacj ktXJP,-,Ce-, for Drilling Well Type _ j� Drilled Driven Gravel Other Is well site subject to flooding? .................................................. ............................... Yes No Is well located in a realty subdivision? ...................f ................. ............................... Yes y No Name of subdivision no Lot No._ Water Well Contractor: I 7-1191D Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: AI A Town/Village Distance to property from nearest water main: Proposed well location & sources of contaminatio to be provided on se at sheet/plan. Date: Z Applicant Signature: 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. evision or alteration of the approved plan requires a new permit. Well to be constructed by a water wi drill ler certified by Putnam County. Date of Issue 'Permit Issui ial: 1 Date of Expiration a Title: Permit is Non- Transfe ra e 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 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 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 Officers-Are: President - Name: Gilbert Johnson Address: 11 White Birch Road, Pound Ridge, New York 10576 Vice President -Name: Address: Secretarj` -Name: - Eleanor Johnson " Addi 11•14h to Birch Road, Pound Ridge, New York 10576 Treasurer - Name: Gilbert Johnson Address: 11 White Birch Road, Pound Ridge,-New York 1 0.57.6 - and that I am and will be individually responsible for any and all ac of the corporation with respect to the approval requested and all subsequent acts relating they . t f Signed/.0 Titl Presiden Sworn to before me this.-7 day.of VA,i (month) ;)-c)6 (year)" 7.9i( �A Jw`l NotaryyTublic Q A190NO Cor orate Seal �OTARIt STATE of ZW YORK Corp rate N A�50�2117 El( S WINE 15 _:3�PP6 Form CA -97 e' Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 April 25, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 RE: G. J. Development Deerwood Lane, Lot #45 (T)Patterson, TM# 35 -4 -127 Reservoir Basin Bog Brook Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application,_ including fee, and received by.this..Department on- April - -11, 2002 is co_ mplete. The Department will notify you by May 20, 2002 of its determination. . ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (�) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the .NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a proj ect, such as stormwater plans 4 Letter to: Harry Nichols,-P.E. - -April 25.,2002- - -2- - or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call meat (845) 278 -6130 ext. 2166. 1-15INTU�1 Very truly yours, Robert Morris, PE Senior Public Health Engineer n- _..... -� BRUCE R. �FOLEY Public Health Director wv rLORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT -OF HEALTH 1 Geneva Road Brewster, New York- 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 April 25, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: G. J. Development Deerwood Lane, Lot #45 (T) Patterson, TM# 35 -4 -127 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above- regarded proi ect has, been com leted.. Comments are offered as - follows: 1. Erosion control measures for the house, well and SSTS has not been shown. 2. Stand pipes and stand pipe detail 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. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve y yours, AIIJ/4U0 Robert Morris, P.E. Senior Public Health Engineer RM:tn PUTNAM COUNTY DEPARTMENT OF HEALTH �5 DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM. Owner ,% Di yCL_ypAAcni7- GdRP Address /l bJ4JTC' 8t1Z +2D _ POUND AIDcp— Located at (Street) ra- t: tZ, bud o D L6;&j )z-_ Tax Map 35 Block �_ Lot (indicate nearest cross street) - - Municipality pT Drainage Basin D� p1 - SOIL PERCOLATION TEST DATA - Date of Pre - soaking to . 2? -4j C�o Date of Percolation Test. Hole No. Run No. Time Start - Stop Ela se Time �1VIin.) Depth to Water rom Ground Surface (Inches) Start Stop Water Level Drop in Inches Percolation Rate Min/Inch -, 1 1 I '. 12 - lr2 95 I C4 2 2l0 3 J. 3 1 2 11; 3 0 11'. �56. 2 22'A 16, 9J �lz 1 3. 12'. 5 I' 44- :50 29 25 3 2 2�2 / ' 25 2 3 12'. I b - 121. SO 22 4 5 2 3 NOTES: A. Tests 10 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 _ .. ;..� C TEST PIT DATA;- DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES t • DEPTH HOLE NO: w MOLE 1`10. 2 HOLE NO._ ,t.. 'J - . G.L. 0.5 S Gi L u ' 2.0' ' 2.5' 'rll t� Is I LZ N t--I N 5- `SC1.N i'J 3.0' - 4.0' 10.0' . Indicate level at which groundwater is encountered Indicate level at which mottling is observed 4 Indicate level to which water level rises after being encountered Deep' hole observations made' by: M ,Bor7z i N SKI (412) � Date1,2-12-44- Design Professional Name: Address: AST T Lr2Sa,j PIM,K - S U 1T 1.64,_ - _ as to R 7r-- 22. -. _ • • - �h 1N T ..M?. � :. 1,05 ®� • Signature: Design Professional's Seal w 58124 _ v AqO ' ESS14�� 14 -16-4 WS} --Tul 12 . • .. •. .... 81T:Z0 .SEC -R PROJECT L0. NUM6FJi y. State EnvWnmsntai Quality. Re`v(iw — -- ' SHORT ENVIRONMENTAL. ASSESSMENT ' For UNUSit;Q �1t3T10N8 Ont�c -� - ' PART I— PROJECT INFORMATION (To be completed by Applloant or Project ap011400• i . APPLICANT BPON80R 2. PROJECT NAME--' J. PROJECT LOCATK)_0 . NP+IhY firs a y Clou nty �. PRECISE LOCATION MVsat godm %" )ard r`"d Intwwtlam, prminont landnwk% W4 or provide map) 5. I3 PROP06ED AGTM'... . s+r . _._G &Wa w G Modlllaa"altaratbn 6':-' DESCRIBE PROJECT MUM. Yo+GS�t�' 5 Is- TS G� lv el l S'�rvE✓ S t 4� _. V -C"� 14 C t_" 7. AJAOJJHT OF LAND AFFECTED; wuty 0 7 ions Ul UW+WY -6-4 9 sons 6. WILL PROPOSED ACTION OOUKY.WITH EXISTING ZONING OR-oTHEA EXERTING LAND U$I 1114TRTR1CTION81. . . RY44 O No .1114% dsso u Fiddly ` v. "T 18 PREBr;NT LAldO U8I IFj VKxNRY Oi< PROJEOTT — - _ - RassdariUal ❑ Indwtrw ' O Coriunirola! - G Aprbultun" . ^ G ParWFw@4UOpsn apace G ovw 10..DOE8 ACTION INVOLVE A PVWff APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM My OTHER 00YKANMt'.tRAL AGENCY (MERAL. STATE. OR LOCALP �Ysa ' ❑ No Ursa, Ilat spsnoy(i) and pannitlapprovala - - f d O Q �rscti got ldr d"�► ti,� 11. DOES ANY M. P.6sOT OF THO ACTIO WW1; A WNW MY VAUD PE MIT OR APPROVALI'. r _. _....... _.......:: ❑ Y44. q " U N, Ila1AGwy MW utd wallUgwwal • 'ice. . •J '3., ..y'• .. • _.. � • .. .. .. . .. .. 12. AS A RESULT OP PFi0Pt38ED ACTION WILL t7USTINO PIJWRIAPPHOVAL REQUIRE MOOIF'iCATIONf ❑ Yes I CUii1FY THAT THI INF.OWTION PROVIDED MOVE 13 TAUI TO THI BUT OF YYVaffi = AcvUWUS nam« 71 Dat« ^0 2. Slynaturs L/ It the action Is In tha.Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment ^% 09.0% PART 11— ENVIRONMENTAL ASSESSMENT (To be completed by.Agency) - -= A. DOES ACTION EXCEED ANY TYPE I THRE$HOW IN b NYOPIN PART 017,47' If ye&, 000rdlnGIV Cie revlaw Pro"" and use�he FULL EAt% B. WILL ACTION RECEIVE CO MNATE®REVtt:W As pR4VIDFA t :OR VNU@TED ACTIONS IN 8 NYCRR, PART 817-67 11 No, a n�aitvo doclargllon may co svporsood by another lnvplved so!+�Yi 0 Yea ONO Couuo ACTION RESULT IN ANY ADVERSE EFFECT$ AS$MATED WITH THE FOLLOWING; (Mfwero may be hwWw(llten,,II 101019) cI. Esiattn9. air quality; mart or eroundwet}r Quailty or Quantity, noloe lave$&, axl &ling lralfig payernta,.ea!d weal® p!oduoNcn -vr dtspos8l,: p9tont1w for ero&lon, drainage or flooding problem &7 Explain briefly: cz. aestnoiic, a9ricullural, arch40010gloal, hlotodo, or other natural or cultural rosources; or community or nolghtwrhood character? Explain briolly: CJ. V0941411on or fauna, 116h, sheUtlm of 0141llo &pecleo, olgnllloani hobltato, or threatened or endangered spoole &7 Explain Wally; Cl. A community's existing Plana or 90816 as ofiklaliy adopted, or a chango In use or Intensity of use of Wid of other n8twal.rowuroes7 Exploln briefly CS. Orowtn, 6V0"gVenu development, of related sotfvitise IWAly to bo induood by the propoaod 001190 Explain tuletey. C4. Long torm, Nw loan, curtwialtvo, of outer oiled: not "filwo in clo? Explain briefly. — - C7. Oihw Impacts (Including changes In use of either Quantity or type'ol onwgy)? Explain briefly, q. WILL THE PROJECT HAVE AN IMPACT ON THE t:NVIRONM;WAL CHAMCTERI,$TIC$ THAT CAUSED THE _EBTA�ti$MEPJT OF A.CEAt oY No IS THERE, OR IS THERE LIKELY TO SE, CONTROVERSY. R9LAT9b TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Yes ❑ No II Yea, explain- briefly -- PART III— DETERMINATION OF SIGNIFICANCE (To be completed by'Agency) INSTRUCTIONS; For each advers© effect Wontifled above, determino whother It Is substantial, large, Important . or otherwise significant. EAcn ellect should be-&$*$"ad In oonneotion with Its (a) settlno 0.e, urban or rvralk .�b�prvbaWlity.oi.00aaatng (cj•du tlgn; (d) ,rrevorslblllty; (e) go"'raphlo scope; and (q maorlftuds, If necessary, add attaWynento or reference supporting. materlslo, Ensure that explanation& contain sufficient detail to show• thal all relevant adverse impact$ have been Identified and adequately addressed. 11 quostlon 0 of Part 11 was checked yes, the determination and WortillAance must evaluate the potentlal Impact of the proposed action on the snylronmental 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. O check this box if yov�•hav®. determined, aced on tbo Informatlon and catalysis •above and any supporting documentation, that the proposed action Wilt. NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasono supporting this determination; Arta 61 1,94d Doty ru,t a yp9 N#nw 6r.. W43 AvIKy Two R KOVM440 r $insigne o ResponsibW ,. .. CM Wy . , 1111e 91 Prows( e<ent Imm laspolulwe 911290 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of _ GJ Development Corp. Located at B E E P -WOOD i- 14-Nr T,N Patterson Tax Map # 35 Block 4 Lot Subdivision of Deer Wood Subdivision (AKA Windsor Woods) Subdivision Lot # -457 Filed Map # 9,6q 113 Date Filed Gzndemen: -- 3 -1-' -�6 Z_ This leaer -is to authorize Harry Nichols a duly licensed Professional Engineer or Registered Architect to apply for the required ,xastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance 'Xitr: the standards, rules or regulations as promulgated by the Public Health Director of the Putnan. County Health Department, and to sign all necessary papers on my behalf in connection with this :natter and to supervise the construction of said wastewater tretment and/or water supply systems in.. _..u_�._._... _.�o �. ►a, iry -with the provisions of Article 1.45 and/-or - 1-4.7-6f tlie'Bducati6h*Law,the Public }-Heal`: and the Putnam Coyju X§,aanitary Code. NIC11 ' f oumtersigne P.F., R. A., # P No. 56124 'Mailing Address 2-6 a, Very truly yours, -� lGJ Devel men Co p. Signed: (OwncrorProperry) esident State Zip j 0s-vq Telephone: X09 - 400 -� Mailing Address: 11 White Birch Road Pound Ridge State New York Telephone: Zip 10576 (914-) 764 -4080 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 _ . _.._ .. $rewstenj -NY 10309-; Telephone (845) 2794003 Fax (845) 2794567 April 5; 2002 Putnam County Health Department One 'Geneva Road Brewster; New York 10509 Att: Robert Morris; P.E. Re: Individual SSTS Lot # 45; Deerwood Subdivision Deerwood Lane Town of Patterson; T.M: # 35: -4 -127 Dear Mr. Morris: Enclosed are the following: 1. -Five (5) prints of SS-45; `Proposed SSTS," dated 3 /29/02. 2. "Short EAF," dated 4/4/02: 3. "Application for Approval -of -Plans -for a .Wastewater - Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 4/4/02. 5. "Application to Construct a Water Well;" dated 2/19/02. 6:. `Design Data Sheet:" `.`T,etter of Authorization &-Corporate-Resol"utibh " di te`d' 1 /SOt0 : 8. Two (2} copies of Residence Floor Plan(s }, for `Bi�droom Count Only." 9. Review Fee in the amount of $300.00. We would appreciate your review; approval and issuance of the Construction Permit at your earliest convenience: Very truly yours, Harry W. Nic ols Jr., P.E. HWN:JM:jmm 02- 006.45 X Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 B�ewster,-NY 10509- Telephone (845) 279 -4003 Fax (845) 2794567 April 29, 2002 Department of Health One Geneva Road D Brewster, New York 10509 j= a- Att: Robert Morris, P.E. Senior Public Health Engineer Re: Proposed SSTS: G.J. Development Deerwood Lane, Lot # 45 (T) Patterson, TM# 35 -4 -127 Dear Mr. Morris: In response to your letter dated April 25, 2002, we offer the following: 1. Erosion Control Measures are now shown on the Plan. 2. Standpipes and Standpipe Detail is now shown on the Plan. If you have any further questions, please call. Very truly yours, Harry W. Ni ols Jr., P.E. HWN: JM.- j 02- 006.00a 9,38 EA!STIMC% 4 BA. w. 1. 1250 GAL. SEMC TANK I> FJr- sDCL ZS C.O. F Box 0' LP '5 17 4 A AS TAE 16 -4"(� eVC. (r,/P) (-ry P) 1(5 3 5 14- o 1��4' lis z 21, la r130 8 it 14` 23 19 10 —4- 56, AREA a 5Z' 4'7' 43' M76°23144' am am ' at ISO 2. Soll! L 50-c�2.50.04D W009 DIMENSION CHART (in feet) Number A 8 i A2 19 z 60 3z 3 12 47 4 75 52 5 78 57 6 82 63 86 69 $ 91 74 9 95 8o 1 0 1 27 103 I I 1 24 98 12 120 94 13 117 90 14 115 86 15 113 83 1 6 110 79 17 41 40 i 8 47 46 1 9 53 51 20 59 S7 21 65 62 '68 _.. _._.e... 23 85 i5