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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -5 -5 BOX 16 �t7,' ti � - I �� lie - e' rti� , . 'rep .� el 01795 PUTNAM COUNTY DEPARTMENT OF HEA ®,, DIVISION OF ENVIRONMENTAL HEALTH SERVICES-" v CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at OLP R-0,Al2 Town or Village FArTEY -60� —P Owner /Applicant Name ��T'e� L�' Q� t-' M-A Tax Map 474 f Block r7 Lot Formerly Subdivision Name O%-D Subd. Lot # Mailing Address i'� ►1� -1=i ICI) VF- PA-rT EF41) �6 1J`� Zip 1246 -?p Date Construction Permit Issued by PCHD 1 0 I k / io Separate Sewerage System built by 1A�T2-tcfl-_ _0 FA Address Z 15%*ZAAA2 Consisting of to Gallon Septic Tank and .00 i.l+ A0y, rVr-HG.W Other Requirements: Water Supply: Public Supply From Address or: X Private Supply Drilled by `�' -PL � 6OH6) iK, Address 4 �r� A4' 8PW6tdL t� 10 SO Building Type 4'.1 p N G Has erosion control been completed?. Number of Bedrooms Has garbage grinder been installed? N I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam ounty Department of Health. Date: L3 1 5 Certified by P.E. x R.A. Design Professional Address P,0, 0,9* �1 0 "W5ir , AY 10 o License# Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply. becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocati n, modification o change is necessary. By; y Title: Date: —Z3 White copy - HD FilerYello co y - Building Inspector; Pink copy - wne , O ange copy - Design Professional / Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WFI I rOMPI FTION REPORT Well Location Street Address: 42 Old Road Town/Village: Patterson Tax Map # Map 35 Block -5 Lot(s) -5 GPS 410 27120" N 730 34151" W Well Owner: Name: Address: Patrick 0lYbra, 73 Fairfield Drive, Patterson, NY 12563 Use of Well: 1- Primary 2- Secondary X Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment _XRotary _Cable percussion Compressed air percussion _Other(specify) Well Type _Screened _Open end casing X Open hole in bedrock _Other Casing Details Total Length 31 ft. Length below grade 3Qft. Diameter 6 in. Weight per foot 1glb /ft Materials: X Steel Plastic Other Joints: Welded X Threaded Other Seal: X Cement grout Bentonite Other Drive shoe: _ X Yes _ No Liner: _Yes xNo Screen Details Diameter (in) Slot Size Length (ft) Dept to Screen (ft) Develo ed? First I _Yes _No Hours Second Well Yield Test Bailed _Pumped X Compressed Air Hours 6 Yield 6 gpm Depth Date Measure from land surface - static (specify ft 10' Dur ng yie test (ft) 240' Dept o compete we n ft. 280' 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 - 15 Drilling in ov rburd_en cliv, and boulders Hit rock at 15 - 15 31 Drillino in ro k set casi o routed 31 280 Drillin i If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity Depth Model lVoltage HP Tank Type Volume Date Welf, Completed 1`2/26/12 Well Driller MTs zu PC Certificate # 1301`9 NY State # NYRD10105 Date of Report" Well D'rlller Name &,Address , R�& � �s= f k }I: FY '� gyp'" P F Beal &Sons, Itic 4 PutnamAvenue „Prwster, NkY ]0509 > Tr. .s 5.• .; .'E...th •t :L .S.k.a..Ju A�.. �: ..� A,; �Y Pum Installer Nam &Adtlress 4 y e •a a >' a ,r.v -'` c `"L rip��o-1',xt•:. 1�Uell Dr111 atur 3� P ',' -:. —'sE NOTE: Exact Location of well with distances to at least two permanent IandmarKs to be provided on a separate sneevpian. White copy: HD File; Yellow copy -Building Inspector; Pink copy -Owner; Orange copy -Well driller Form WC -97 Rev. 3/06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 42 Old Road Town/Village: Patterson Tax Map # Map 35 Block –5 Lot(s) –5 41° 27'20`', N 73° 34151" W Well Owner: Name: Address: Patrick O'Yom, 73 Fairfield Drive, Patterson, NY 12563 Use of Well: 1- Primary 2- Secondary X Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment _XRotary _Cable percussion Compressed air percussion Other(specify)' Well Type _Screened _Open end casing X Open hole in bedrock _Other Casing Details Total Length 31 ft. Length below grade Mft. Diameter 6 in. Weight per foot _MIb /ft Materials: X Steel Plastic Other Joints: Welded X Threaded Other Seal: __L Cement grout Bentonite Other Drive shoe: _X Yes _ No Liner: _Yes xNo Screen Details Diameter (in) Slot Size Length ft Dept to Screen ft Developed? First _Yes No Hours Second Well Yield Test _Bailed _Pumped X Compressed Air Hours 6 Yield 6 gpm Depth Date Measure from land surface-static (specify ftj 10' 1juring yield test (ft) 240' D ept o f completed well in ft. 280' Well Log If more detailed information descriptions or- Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land Surface 15 Drilling in ov rburden clay, and boulders Hit rock at 1.5 sieve analyses are available, please attach. _ 15 ' 31 R _ Drilling in ro k set casine. 2routed 31 280 Drillin i I- arqni to 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 DafeawedCOmPleted� Well I3flll r f�rCerkicate x kIYS a e "�y @a1; nfRepori Well Dlrher Na a 8�Adtress 4 tl s,.q. a -0x`K �xx a u s5 "a fi R a:'x N ,S4"•':$' +s9k F{Sl.naa� , a � �, ��N �x F':r'�� - $.ax:h?x..'�,•><a ..4j.�5:., �x�_.x..e ... �'�`+�..�xmr ,�. :s�e.�4�F, .. r� xJi; a � � -xk f� - gT�e`.d"Yx ._ _ �9-e . • _._a'i .x C }�Yx suii��.'x'_liFi.. �_'.H�.... . �F x ...§. ..�fe!x� _. s _ w a.. '�" 3 `. f s',as,' d'.tY Pum 'AhI d1h N'- ""ek &i9ddr�ess " vri � - „� ">a,Sa� d✓,: s -`i� a /, x 'i a x#,e xv.m .ri",y. _:�,:.Bv ..J. ttt�,. el f atur X.t .�i °�; : . � �F �} .:, s Fr � �: . - :-C . .. M ... xk% ✓...... ' �` " ;- - : . i i i:ay"ti NU i t: txact Location of well witn distances to at least two permanent landmarks to be provided-on a separate sheet/plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION Of ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SU$SURFA.CE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Building Constructed by 47 014 1&p Location - Street F-t� -9 19 f, F4 Tax Map Block Town/Village OLD - W4L-L 516frAI-9�� Subdivision Name V2 Building Type.." Subdivision Lot # Lot .I represent that I.. am wholly- and completely responsible for the location, workmanship, material, con$trnrCtiori and dtaina`ge of the sewage reatment system serving the above - described property, and that is has been constructed as shown ort 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 guar tutee to the owner, his successors, heirs or assigns, to place in good operating condition.. -- - -- any parr-of said ' *stem constructed by' me which fails to operate "fora period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system,.. except where the failure to operate properly is caused by the willful or negligent act of the occupant 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: onth Day -,2,c) Year 1 Signature: Title:- ©W Ng� General Corrtractor'(Owner) - signature y . Corporation Name,(if porporation) Corporation Name (if corporation) Address: 107 F-A l f 100 OF-NO FIVE 0 Address: I'- PAEF�r1" 0915 Per CH State Zip State Zip Form GS -97 Name: Sample Date: Receipt Date: Report Date: Sample Site: L AQUAINVIR NM NTAFEA- -_ - 56 Church Hill Road • Newtown, CT 06470 * (203) 270 -9973 Patrick O'Mara 73 Fairfield Dr. Patterson, NY 12563 10/9/2013 9:00 AM 10/9/2013 10:04 AM 10/11/2013 42 Old Road, Patterson, NY Report of Analysis Sample ID #:. 148982 Sample Type: Drinking Water Sample Source: Kitchen Sampler: PM Parameter Sample Result Units Limits Method MDL Analysis Date Biological Coliform Bacteria absent none 0 SM9223B 0 10/9/2013 e Coli Bacteria absent none 0 SM9223B 0 10/9/2013 Inorganic Compounds Chlorine, residual ND mg/L 4 4500CLG 0.05 10/9/2013 Metals Iron 0.03 mg/L 0.3 EPA 200.5 0.01 10/10/2013 Lead <0.001 mg/L 0.015 EPA 200.5 0.001 10/10/2013 Manganese 0.02 mg/L 0.05 EPA 200.5 0.01 10/10/2013 Minerals Alkalinity 68 mg/L No Limit Set 310.1 5 10/9/2013 Hardness 174 mg/L No Limit Set EPA 200.5 5 10/10/2013 Sodium,.... _ ... ;. _ _.._... _ . ; 60.2 * -. _. ---mg/L --28 _.. EPA 200.-5 - ----- -•. _ -- 1-0 /-10/20.13 -= Nutrient Nitrate as N 5.4 mg/L 10 EPA 300.0 1 10/10/2013 Nitrite as N ND mg/L i EPA 300.0 0.1 10/10/2013 Physical PH 6.3 * SU 6.4-10 4500HB 0 10/9/2013 Turbidity 0.5 NTU 5 180.1 0.05 10/9/2013 Comments: Based on the bacteriological examination, according to the Federal Safe Drinking Water Act ND =Not Detected (SDWA), this water was safe for drinking purposes at the time the sample was collected. * =Above Specified Limit Report Approved by: t*Ot CT Lic PH -0787 NY Lic 11706 Lab Director Analytical results relate to the samples as received at the laboratory. Report shall not be reproduced except in its entirety without written approval from the laboratory. Page 1 of 1 Sherlita Amler, MD, MS, FAAP Commissioner of Health Robert Morris, PE Director of- - OWNER'S NAME: Department of Health 1 Geneva Road, Brewster, NY 10509 E911 ADDRESS VERIFICATION FORM ?A,tP-1Cjd- 0' HA r-A TAX MAP NUMBER: lb 1�? E r e E911 ADDRESS: TOWN: 60H AUTHORIZED TOWN OFFICIAL: l (Signature) DATE:. 1e11 / 3 Robert J. Bondi County Executive 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 with the application for a Certificate of Construction Compliance. Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845.).225 -5418 Nursing Services (845) 278 -6558 Fax (845) 178 -6026 Nursing / Home Care Agency (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 o Harry W. Nichols Jr., P.E. P.O. Box 252 Brewster, W 10509. Tel. (845) 2794727 Fax (845) 279 -4728 4, September 30, 2013 Michael J. Budzinski, P.E. Director of Engineering Putnam County - Health Department 1 Geneva Road Brewster, New York 10509 RE: Individual SSTS Compliance — Patrick O'Mara 42 Old Road Patterson, NY T. M. # 35. -5 -5 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of Drawing S -5, "As -Built SSTS ", dated 09/30/13. 2. "Certificate of Construction Compliance for Sewage Treatment ....System", dated. 09 /30/13. _ 3.---,- Three (3) copies -of "Guarantee of Subsurface Sewage Treatment " System" Dated 09/30/13. 4. Laboratory Report, dated xxyyzz 5. "Well Completion Report', dated 09/06/13 6. Application Fee in the amount of $300.00 payable to Putnam County Health Dept. 7. "E -911 Address Verification Form ", dated xxyyzz. If there are any questions concerning the enclosed, please call. Very truly yours, Har ry . W ichols Jr., P.E. HWN:jdm 07 -019 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E., "1VIPft" 1 Director ofEnvironmental Health September 4, 2013 Harry Nichols, P.E. PO Box 252 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York, 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Executive Re: Field Inspection — O'Mara Old Road (T) Patterson, TM 35. -5 -5 A re- inspection at the above referenced lot has been completed. There are no further comments to be addressed at this time in reference to this Department's open work inspection. „ If vou_have any_further questions, please. Contact ine at _(845) .80$ =1.340 Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:cw REBECCA W &NBERG, RN, BSN Public Health Director ,-- ROBERT'-�I�HORRIS, PE Director ofEnviromneWal Health February 13, 2012 Harry Nichols, P.E. P.O. Box 252 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Re: Field Inspection — O'Mara Old Road (T) Patterson, T.M. 35. -5 -5 MARYELLEN ODELL Courtly Executive The above referenced separate sewage treatment system can be backfilled. - The following comments need to be addressed: 1. The silt fence needs to be installed in the ground. 2. Pipe from the house to the septic tank needs to be installed and inspected by this _ . _..._._ .._.. I?epartment..r. 3. The well needs to be installed and inspected by this Department. 4. A bedroom count needs to be performed by this Department. If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw PUTNAM COUNTY DEPARTT4ENT*.OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH -SERVICES FINAL SITE INSPECTION 9/.7 3 OZ Date: Inspected by: 6,A� Gum 22 er -- Town V; M Fah 4e e v I Permit # -P - oz -,o TM # 3 6' �5 —!5 Su!bdMsion. Lot 1. Sewage System Area a. STS area located as per 4pproived plans .......................... b. Fill section - date of placement .3: 1. ba m-er Lgth. Width _Avg.Dpth___�_ c. Natural soil not stripped....._. ...:........ .............I ................. d. Stone, brush, etc., greater than 15' from STS area.......... e. -400'from water course/wetlands ...................................... IL Sewage System .000 -tank siz 1, 250 ......... other .......... eptic b.Septic'tankls�ie&lKe�l . c. 10' mi-nimi im from foundation ......................................... d. Distribution Box 1. All outlets at same eldvation-water tested .................. 2. Protected below frost .............. ; .................. k ................ 3. .. 1Vfiftimurn 2 ft. Original soil between box & trenches e. Junction Box properly set ........................................... 6. 'Trienches, f. Length required Length installed .2_oC 2. Distance to watercourse measured Ft .......... 3. Installed accordirig to plan .......................................... 4. Slope of trench acceptable 11.16 -1/32" /foot ..... I ....... 5. 10 ft. from property line - 20 ft.- foundations......... " 6, Depth of trench <30 inches from suffice ................... 7. Room allowed for expansion, 10.0 %.... .................. 8.. Size of gravel 3/4 - I'A".diameter clean ................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends ..capped .. ................... g.- 'PUMD-or- Dose T Size of pump chamber ................................................ 2. Overilow tank.... ............................................................ 3 Ah=4 wsuaVaudio .......... * ..................................... 4. P easily accessible, manhole to ....... UMP .......... S. 'First box baffled.: .......................................................... 6. CIF Y e witnessed by H-D. estimated flow/cycle ............. DI House/Buildhig! a. House located per approved plans ............. j b Number.of bediroods ........................... .......... IV. WeIl 6�K t_ rIp 0t1V%X__ Well located as per approved plans ................................. b. Distance from STS area measured le90 ft ........... C. Casing. 18" above grade ........... d. Surface drainage around well . acceptable ........................ V. Over" Workmanship . a.. Boxes properly grouted .................................................. b. All pipes partially backfi.1led .......................................... c. All pipes flush with inside of box .................................. d. Backfilt 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. 12/02 NO CONMNTS .' Ale. e45- ,a � a? Aw. X.4- 1K orm FEB -09 -2012 02:41 PM HARRY W NICHOLS 914 279 4567 P.02 07-01 C j . o-0 2�- DIVISION OF EN'VMONMENTA,L HEALTH SERVICES gE IT FAT FOR IN I. INSPECTION For: Fill Date: z- Trenches PCHD Construction Permit # Q d Located: 20 m,J (T) 1a'�rro 2=i�_ Owner /Applicant Name; ,84,4 rtc- G,M &OM TM Fj Block W S' Lot Formerly: SubdivisionNatne; O.W W"I Etfcj,4r Subdivision Lot # T_ Is system fill completed? Is system complete? Is system constructed as per plans? Is well drilled? %Ila Is well located as per plans? Are erosion Control measures in place? _ �C Date. Date; '.. d t Date: _ I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Mte: -f - -1 - . Certified hy: jDi'ga profession Address: # �e Continents: FOR: 0 ADAM GENE 0.^,.,, (NAME) Form FIR-99 Located at 0110 IORYT FOR SEWAGE T ATMENT SYST'EN fLoAl p Town or Village fA:fT 0 LID L04 Subdivision name ES7.4. iF-17 Su jbd. Lot # Tax Mapi Date Subdivision. Approved 04 ®10 ! �i I Renewal Block �5 Lot 15� Revision Owner /Applicant: Name P A-r z i zi� & P t o-A Date of Previous Approval Mailing Address 7'i D9lN4j0,r" %A77r5F-�Iji 10` Zip i2 b-) Amount of Fee Enclosed i S ao Building Type 416 1 V 1F)4 GF- Lot Area 1.6-M No. of Bedrooms 2 Design Flow GPD 400 Fill Section Only Depth Volume PCIID NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1000 gallon septic tank and I-Od LF- 06y I �N lid Other Requirements: To be constructed by Water Supply: T, i�' P, Public Supply From Address Address ors .... priwate Supply- Drilled -by l .fir ..%+ Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: T�), P.E. X R.A. Date ° Address d. g, �ti� w��CL, °`��9 License # 12-d- 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 when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe4nit. ApprovedfAischarge of domestic sanitary sewhe only. By: It,/ White copy - HD Title: A,` a i5�c Dater /0 -z2 - > Yellovk*y - Building Inspector; Pink copy - - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES •____.._ ._. __t a.�. __ x ._- .r.,__= _ .., y- APPLICA TION 'TO'CONSTRUCTXWA'TEItWELL-. please print or type Weil Location Street Address: Town/Village: Tax Map # O L-C) 9-0 AL p � n`T� ��Oi-� Map SA), Block 5 Lot(s) Well Owner: Name: P���- ' Address. 1'b �� i6W DAI ` pl M 4 �;6� Phone #: )'l"11 -low Use of Well: I 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 05,r gpm # People Served 1--K Est. of Daily usage 40 gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling K New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type_ iC Drilled Driven Gravel Other Is well site subject to flooding? ....................................................... ............................... Yes —No Is well located in a realty subdivision? ........................................... ............................... Yes X No Name of subdivision 90 Lot No. 15 Water Well Contractor: Address: Is Public Water Supply available on site? ....................................... ............................... Yes —No 'A Name of Public Water Supply: — Town/Village ^' Distance to property from nearest water main: Proposed well location & sources of contamination to be provid9d on s/par o sheet/plan. Date: QB ` l) ' -�-QOA 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 Healthy Department. 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 Commissioner of Health. Any revision or al eration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam Bounty. A Date of Issue /o Permit Iss 'ng Official: Date of Expiration Or l2. Title: Permit is Non - Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Ownv; Orange copy - Well driller Form WP -97 Rev. 3/06 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health Associate Commissioner of Health NAME: ADDRESS: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAIVER /0 1 11A A - ROBERT I BONDI County Executive ROBERfi- lV[ORRIS, PE { Director of Environmental Health -7,3 ,r,,,4i( A- , AlL% SITE LOCATION: OzA R,q AA DATE: '6— .3- /O STAFF PRESENT: Michael Budzinski P.E. Robert Morris P.E. Gene Reed Joe Paravati SPECIFIC WAIVER REQUEST: DOES THE PROPOSED VARIANCE REQUEST POSE A HEALTH HAZARD OR ENVIRONMENTAL CONTAiMINATION PROBLEM? YES ❑ NO 11 WILL DISAPPROVAL RESULT IN A SIGNIFICANT—HARDSHIP) YES t1;Y NO . ❑ DISCUSSION REQUEST APPROVAL OR DENIED APPROVED V DENIED ❑ REASON FOR DENIAL DIRECTOR OF ENVIRONMENTAL HEALTH DATE &-e"l "'v o DATE � 1)14 i /0: COMMISSIONER OF HEALTH Environmental Health (845) 278 -6130 Fax (845) 278 -7921 (SPECWAIVER) Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 NEW YORK SI'A'1'N: ©�j SYN(lN1( WAIVER APPLIC ATION �� r Request for Approval of Noncompliance with DEPAtTMEN T OF HEALTH Bureau of Water Supply Protection the Standards of IONYCRR Appendix 75 -A Wastewater Treatment Standards - Individual Household Systems GENERAL O• a t t Name of Applicant Lul / G�� — - Address K - -- - " FT�p t W —,� %014 V aa cFI i tyt / rown "Street .? 1 State ZIP Contact Information �p phone:C�y M y 1 0 d0 FAX: t% 21 1 kl emaU: Site Location I Street•O': --0 F•0AP I cityrrown PArrr 60H �z county i V -i_HA VN z;P � The following information is being submitted in support of my application for a specific waiver from compliance with one or more standards of 10NYCRR Appendix 75 -A, "Wastewater Treatment Standards Individual Household Systems': 1. The wastewater treatment system cannot meet the following standards of l ONYCRR Appendix 75 -A: 'd Separation distances cannot be achieved (75- A.4(b), Table 2, Separation Requirements) ❑ Excessive Slope (75- A.4(1), Soil and Site Appraisal) ❑ Design is not addressed in Appendix 75 -A ❑ Technology is not addressed in Appendix 75 -A ❑ Other: Explain: Sa 'Je i2 *AVN iiQH $ 1, bf- Mi( QMOtan WV� V5 WiayFlk i)y! ` f To ''ai fty We l A1Na 2. The following design is proposed to it' ate noncompliance with Appendix 75 -A (brief description): IM51 -Ll1-i (a l� ' W iH l i M e e TWO P4C9= ye$516j -8 � ! -El�G1 t 9 r+?a �'l r � pp�t,�410� ! H MFNtCJ :? Supporting information provided: V Detailed Site Plan Cr Detailed Design V Soil and Site Evaluation 61/ Neighboring conditions of concern (e.g., wells,. waterbodies, wetlands, etc.) ❑ Other: Explain: I, (applicant) �" � PAr 0' MOA (type or print) acknowledge that this waiver request is necessary because it is not practical-for an onsite wastewater treatment system to mee erence ands of IONYCRR, Appendix 75 -A on .._ this property.. ....: ., J Signature Nate I, (engineer) Iy�LJ� U6 $_ (type or print) acknowledge that th' ° .vez� request is necessary because it is not practical for an onsite wastewater treatment system to meet the referenced RR Appendix 75-A on this property. In my P rofessional opinion, the proposed design described in this a degree of protection equivalent to the onsite wastewater treatment standard(s) that will nol be mej forC s 1 of create an increased risk to public health or the environment. 0 Signat re License # No 56124 ° *For Health Department use only * Ore s" ? 5111 Based upon the information provided in this application to waive the referenced standards ppendix 75 -A and in acSprdance with IONYCRR §§ 75.3 and 75.6 (b), the waiver requested is hereby: Approved as proposed. ❑ Approved, with following conditions: ❑ Not acted on, because additional information is required: ❑ Denied, because: Note: This waiver may be revoked should any approving this waiver change after approval, Health Department Representative S gnature Date Harry W. Nichols Jr., P.E. P.O. Box 252 EM Brewster, NY 10509 Fax (845) 279-4728 October 12, 2010 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Att: Michael J. Budzinski, P.E. - . Director of Engineering Proposed SSTS (O'Mara) Old Wall Estates Lot 5 42 Old Road Patterson, NY T.M. #35.-5-5 Dear Mr. Budzinski: In response to your October 6, 2010 review letter, we note the following: 1. Reference to the drywell has been removed from the plan. 2. A copy of the Individual Residential Stormwater permit issued by the NYCDEP on September 21, 2010 is enclosed. In addition, a copy of the final Wetland/Watercourse Permit from the Town of Patterson issued on September 24, 2010 is enclosed.: 3. As -built f6c ... aflo'n*'-of the 'loth -,gS,T,8- i's--,n-o'-w-"s*,h -"o,-w,n-'-o on -th", e-, - plan. . ....... Reflecting the above, enclosed are five (5) prints of the following: SS-5 "Proposed SSTS", rev. 10/12/10. Kindly continue with your review of this Application. Very truly yours, Harry W. ichols.Jr., P.E. HWN:jdm 07-019 f INOMDUAL RESIDENTU AL STORMWATER PLAN DETERMINATION Pin'simt to the axii1mrity granted under: Article 11 ' of the Now York State Public I calth Law; RxAos and Regulations For The Protection From Contamination, DcSra htian and Pollution Of The New -,Yo, City Water Supply and Its Sources, 15 RCSY Chapter 18, 10 INTYCRR Part 128, IN Taw York City Department of EnviroDmenul Proteotion makes the felloviin determinat.io-as with. respect to the stomiwaterpollution pr"entioix plan described below: Name of Project: O'Mara Property Location: Tax Map No. 35-5-5 Old Road at intersection with Collinwood Drive Town of Patterson, Putnam County, State of Now York Oymer: Patrick O'Mara Addiess: Drainage Basin: General Description: 73.Fairfield Drive Patterson-,-New .Y6rk 1250 East Branch Reservoir Basin Proposed construction of a two (2) bedroom, single family residence on a 1.67-a� re 16t. The- prop'O's.eia" house, and driveway are vnffii:u WO feet of New York State regulated wetlands BR-9. The iinperviow areas will be captared and treatod using, a rain garden Whi "M-6 Leaf- of ffi- e- proposed house. Consiuimction shall be compictcd in a-mordarmc -wiCh the PI-qn entifi ed 'Proposed SS —1 S' prep&--ed for 01d Wail EsLatcs.' 1-16f NO. 5,01d R-64 Patterson, New York, dated August 10, 200, last revised A-dgust 10, 1010. The plaini -was prepared byliarry Nichols, P.E. (see Appendix A). Date(s) of site inspection: August 2010 a —7-114.101VIPUAL RESIDENTIAL STORMWATER PLAN DETERMINATION O'Mara Property September 21,2010 (T) Patterson Page 2 of 4 ( XX) Approved ( ) Denied Conditions of Approval- This approval is granted with the following conditions: The regulated activity must be conducted in compliance with the plans as approved, hs#ed..in :.. _... . Appendix A, all applicable accepted standards, and all applicable laws, rules and rcpUtaons. Any alteration of the plans must be approved by NYCDEP prior to construction. Alteration or modification of any activity in a manner will rcquirc i'tiT'Y L uEP review anal .approval az" an amdudcdd IRSP. • All .erosion and sediment controls must be .Properly installed and maintained until the site has been _ stabilized and the risk of erasion eliminated. FfiW stabilization is defined in New York.State.General _ Permit for Construction Activities (GP 010 -001) as all soil disturbing acti'trities at the ' site Me ... . completed,. arid. a uniform perennial vegetative cover with a density of 80% cover for the Area en has be,•.._ ,_ ... established or equivalent stabilization measures (such as the use of mulches or geotextiles) b4ve bvM' .:.:. . employed, • Th0 applicant must schedule a pre - construction conference prior to the start of construction. Present at the meeting should be the applicant, the engineer, the contractor, and NYCDP.P staff. m The -applicant-must notify 1v'YC17FP at least fxirty- exgtxt (4) hours prior to the commencement of conknwtion activity so that inspections can be scheduled by NYCDEP. • This alyproval. shall expire and thereafter be. null and void unless construction is completed within taro.. (2) years of the date of issuance or within any Wended period of time approved by N V"CDEP upon good cause shown. • 7n the event that the mg1mia) submitted is inaccurate or misleading, this approval is not valid and construction of this project is in violation of NYC1)EP Regulations • Failure 'to 6oxhply with any of the conditions of this approval is a violation of this alr'i al and *6 Rules and Regulations for the Protection from Contamination, Degradation and Pollution Of The New Fork City Water Supply and Its Sources. • The storinwater management facilities must be maintained is accordance with the maintenance• schedule included in the IRSP and approved by NYCDEP, • The applicant is required to submit as -built plans for all stornawater management and water duality facilities. en 'a ti_ : r 1 n n7 17 nac• e ' INDI VIDUA ..RESIDE TIAL 3 T OMPAWATER. PLAN DETERMINATION .. ... O'Mara Property September 21,2010 (T) Patterson Page 3 of 4 I. This approval 0.4 all conditions of the approval are binding on ties owner of the property where the O'Mara. Property, on Old Road is located. Anj references to the "applicant" in this approval ' in any co dWans T thus approval shall be deemed to refer to the owner of suer property. 2. If the applicant sells or otherwise transfers title to the O'Mara Property on Old Road, the applicant . AW require the nmv o-mer ( "Buyer ") to comply with the indk dlaal residential stormwatcr plan approved by :the 'New York City Department of Environmental Protection on September 21.,. 201.0.. _ C'MF) including, brat not limited to, all provisions relating to erosion and sediment control during...... cons'--uct :on and to maintenance of the storm-water naariagement Lazilitics once construction is completit. Tr: particular, +dle applicant shall provide the Buyer with a copy of the IPSP and shall caase the following real covenants and restrictions to be recorded with the deed for the &Mara Property on Old ftad with the follo" g provisions: a) Bu'y?Z h&elby aclouawledg s �nM and n e, ha/ah ��ii inst, 1 A .. CS, G(}'VC'.fE'ii2it5, wa.�..�.,�, 3.x`l. � j,T.°.S� "ie tr�� a1G.'! E ouau u.a�u.0 tutu maintaill any and all erosion conuols and stormwater management facilities on the premises in accordance with the .IRSP, soh MSP being attached hereto as Exhibit A. 1) Euyw's 1-1 I tallatic nr and maintenance of the erosion control and st^rmwater =,anagemew facilities . "shall. bid • f6r the benefit of the consumers of the Neva Ybik City drinking water suPP1Y r ystem as well as for the owners of O'Mara property on Old Road. cj Buyer's ot�li$atiout to. install and maintain any and all erosion con&ols and stormwater . manager eat facilities on the premises in. accordance with the. attached. MSP -ball be peipetual, shall run with the land, and shall be binding on Buyer's heirs, successors, and assigns. hereby covenants,; warrants .attc .rcpresetuts_ that ,aany__le� ; riiortgage;: srsbgty lion, or other = : _....- ..._.: transfer of the individual residence and driveway, or any intereat therein, shall be subject to the iestrictiv8 Cov"enints contained herein pertiinins tb the installation and maintenance of erosion _ _... control seal" stormwater management facilities, anal any deed, mort age, or ofliez ins mneul of conveyance shall specifically refer to the attached 1RSP and snail specincaI state that ire the thereby conveyed. is s-vbject to co'v'enants and restrictions coniaineci nerein. PnoL TS! cQIIYyJFt lithe to i]'l1�Iara Property on Old mad,? applicant Sh811 sul3mit r rnatri York r'+ r .. .:.. .. uepa mFmn% of Envizonmental Protection a proposed deed containing the aforementioned real covenpntS and restrictions. Date: September 21, 2010 DeterminattiollAlftade by: Maur P. Ga o Supervisor Stormwater :Program, East of Hudson This determination letter must be maintained by the applicant and be readily available for inspection at the construction site. . a QUAL. 13� i[3 iiT �iL i{n� TE i.4,9e1 D'ET � TiC i ... .. O'Mara Property (T) Patterson Appendix A September 21,2010 Page 4 of 4 =rsz°usy iti% iivi8, r. 1;. przpslzd tic ionow ng dvuumcno For me G-Mara Propeny 9E. Old Road, Patterson, NY: 1. "Proposed SSTS" dated August 10, 2009, last revised. August 20, 1010; 2. 'T- iu Gardeu Sizing" dated July 19, 2010 cil1.4 CC I; 1 0 ir.7 17 nZn a > `.' t . TPLANNING DEPARTMENT P.O. Box 470 1142 Route 311 Patterson, NY 12563 Michelle Russo Sarah Wagar Secretary Richard Williams Town Planner Telephone (845) 878 -6500 FAX (845) 878 -2019 Date: September 24, 2010 TOWN OF PATTERSON PLANNING & ZONING OFFICE ZONING BOARD OF APPEALS Howard Buzzutto, Chairman Mary Bodor, Vice Chairwoman Marianne Burdick _ .... ... _ ., .. .r- Lary Olenius . Gerald Herbst WETLANDS/WATERCOURSE PERMIT Permit # 090901 Permit is hereby issued to: Patrick O'Mara 73 Fairfield Drive Patterson, NY 12563 Location of work: 42 Old Road Tax Map No.: 35. -5 -5 PLANNING BOARD Shawn Rogan, Chairman Charles Cook, Vice Chairman Michael Montesano Thomas E. McNulty Ron Taylor To conduct work as follows: Construction of a Single - Family Dwelling and all components associated with construction, as shown on the plans last revised July 1 GENERAL CONDITIONS 1. No activity shall be permitted within controlled areas except as identified in the approved application and plans. 2. All work shall be performed in accordance with the New York Guidelines for Urban Erosion and Sediment Control. 3. The Permit Holder shall notify the Environmental Conservation Inspector (E.C.I.) in writing, at least five business days in advance of the Date on which project construction is to begin. 4. The Permit shall be prominently displayed at the project site during the undertaking WETLAND/WATERCOURSE PERMIT September 24, 2010 Patrick O'Mara - 42 Old Road 4 of the activities authorized by the permit. 5. The boundaries of the project shall be clearly staked or marked and maintained. In addition, any wetlands contained within the boundaries of the project shall also be staked or marked. 6. The Environmental Conservation Inspector (E.C.I.) or his designated representative shall have the right to inspect the project. 7. The Permit shall expire on completion of the acts specified and unless otherwise indicated shall be valid for a period of one year. 8. As a condition of the issuance of this permit, the applicant has accepted expressly by the execution of the application,.the full legal responsibility for all damages, direct or indirect, of whatever nature, and by whomever suffered arising out of the project described herein and has agreed to indemnify and save harmless the town from Suits, Actions, Damages, and costs of every Name and description resulting from the said . project. ISSUED BY: .SPECIAL CONDITIONS N/A 4163 PATTERSON PLAIMG —BOARD ,._. . cc: Environmental Conservation Inspector Town Engineer Codes Enforcement Officer WETLAND/WATERCOURSE PERMIT September 24, 2010 Patrick O'Mara - 42 Old Road Page 2 of 2 Sberlita Amler, MD, MS, FAAP Commissioner of Health Robert Morris, PE -• - � , 'Director of Environmeiztal =Health= �����yw ;�=� -- - Harry Nichols, PE P.O. Box 252 Brewster, NY 10509 Dear Mr. Nichols: ]Department ®f Health 1 Geneva Road, Brewster, NY 10509 Office (845) 808 -1390 Fax (845) 808 -1937 October 6, 2010 Re: Proposed SSTS for Patrick O'Mara at Lot # 5 — Old Wall Estates (T) Patterson, T.M. # 35. -5 -5 Robert J. Bondi County Executive This Department, in conjunction with the NYCDEP, has received and reviewed the revised plans for the above referenced project-and the following comments are offered for your consideration. The :reference to the 50 feet separation distance from the well to the drywell is to be deleted in the site plan. A2.1 Please provide this office with a copy of Individual Residential Stormwater Permit approval issued by the NYSDEP•. •.. - .....__......_ ... _.. .......... t. _ ......._..._..._ . ,..._ . 3. The as -built location of the lot # 6 SSTS is to be shown on the plan. Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. MJB:kly Respectfully; 3 tV VY i ViV.1 J 1 Ilk 1L' EPARTM ENT 0"F 11 ALTH �il'1:C: YIC WAIVER APPLICATION Reque r Approval of Noncompliance with ai.- o.. .a__�_ _r nwrz rr,rT • _ _�__ n beau of Water Supply rrotecnon LIM t.411u41 Ub ui 1UI. xk-"A' t-ypCitu,x /Z)-H Wastewater Treatment Standards — Individual Household Systems me of Appli;.ant r �� a •tt .t tttt• `First dress Street � /�6� ^ �VV F/ � City/rrrrown FAN l FP- -4e* i� State 1`� zip ntact Information /�-� Phone: d��±' U �r% FAX :'17 1. J - �+ Vey! email: e.Location Street: `01"'0 F—oAr' Citvrrown FATi -r fisH 1 County F0I.MAF! Zip the following information is being submitted in support of my application for a specific waiver from compliance with one or more ,tandards of IONYCRR Appendix 75 -A, "Wastewater Treatment Standards Individual Household Systems': The wastewater treatment system cannot meet the following standards of 1ONYCRR Appendix 75 -A: Separation distances cannot be achieved (75- A.4(b), Table 2, Separation Requirements) ❑ Excessive Slope (75- A.4(1), Soil and Site Appraisal) O Design is not addressed in Appendix 75 -A ❑ Technology is not addressed in Appendix 75 -A ❑ Other: Explain: Sr,'A- A0-I- l'1W'H 4 v N- CZAILA � 0z' tIrr, Tt 1, it 4\44 -)-js r�4 pi Gai ftw 1F1C 11-ANe The follov l.4'1'4 l 3. Supporting information provided: l( Detailed Site Plan le Detailed Design V Soil and Site Evaluation F/ Neighboring conditions of concern (e.g., wells, waterbodies, wetlands, etc.) ❑ Other: Explain: 1, (applicant) p MW (type or print) acknowledge that this waiver request is necessary because it is not practicaf °for an onsite wastewater treatment system to mee erence anda _of lONYCRR, Appendix 75 -A on . this ZLI Signature ate [, (engineer) i`'�� �' iyl�('�0 (type or print) acknowledge that not practical for an onsite wastewater treatment system to meet the referenced Ott property. In my professional opinion, the proposed design described in this aol'ic equivalent to the onsite wastewater treatment standard(s) that will no be mef for! increased risk to public health or the environment. 1 'j ` 4 ~, rty *For Health Department use only * Based upon the information provided in this application to waive the referenced stan accordance with 1ONYCRR §§ 75.3 and 75.6 (b), the waiver requested is hereby: ❑ Approved as proposed. ❑ Approved, with following conditions: ❑ Not acted on, because additional information is required: ❑ Denied, because: is necessary because it is Z Appendix 75 -A on this degree of protection 'ril not create an r7 1 pendix 75 -A and in Note. This waiver may be, revoked shoutd'any conditions considered'6efore approving this waiver change after approval. Health Department Representative Signature Date SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH - I Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health 61w6'. ht,�EZ'1:51E> TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM )a-� ,- /3/FKJ JOIN' REVIEW PROJECT: TOWN: _ SUB'D APP DATE DATE: 7-2 .3 -/0 ❑ Within the drainage basins of West Branch, Boyds Comer Reservoirs or Croton Falls. ❑ Within 500 feet of a reservoir, reservoir stem or control lake. Within 200 feet of a watercourse or a DEC wetland and appearing on a subdivision map approved after December 31, 1992. ❑ Design flow greater than 1000 gallons /day. ❑ Commercial SSTS. itreview Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 Harry W. Nichols Jr., P.E. P.O. Box 252 Tel. (845) 279 -4727 Fax (845) 279 -4728 July 21, 2010 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Aft: Michael J. Budzinski, P.E. Director of Engineering Re: Proposed SSTS (O'Mara) Old Wall Estates Lot 5 Old Road Patterson, NY .T.M. #35. -5 -5 Dear Mr. Qudzinski: In response to your September 29, 2009 review letter, we note the following: - b. Comment noted. c. Ten feet of separation distance is now provided on the plan, eliminating the need for a waiver for this condition. 2. A completed NYSDEC wetland validation block has been added to the plan. 3. Copy of approved NYSDEC Wetland Permit is enclosed. 4. The minimum dimension of 50 feet from the well to the septic tank is now shown on the plan. 5. The numbering sequence of the perc tests has been corrected. 6. Response to the NYCDEP memo of 09129/09 are as follows; a. Plans were forwarded to Mary Galasso. A site inspection with Ms. Galasso and this office was conducted on July 16, 2010. from information gathered at this site meeting, the seepage pit previously proposed has been removed and a rain garden has been added to the design. This information was forwarded to NYCDEP on July 21, 2010. b. A completed NYSDEC wetland validation block has been added to the plan. r c. i'lie Subdivision consists of 9 lots iii&Was approved by=th&To�ifiwr, of Patterson Planning Board on May 14, 1981 and filed on June 12, 1981 at the Putnam County Clerks Office as Filed Map 1813. Reflecting the above, enclosed are five (5) prints of the following: SS -5 "Proposed SSTS ", rev. 07/21/10. Copy of "Specific Waiver Application" dated 11/05/09. "NYSDEC Wetland Permit" dated 03/23/10. Town of Patterson "Resolution for a Wetland/ Watercourse Permit' Dated 05/06/10. Kindly continue with your review of this Application. Very truly yours, Harry W. Nic Jr., P.E. HWN:jdm 07 -019 ANEW YORK STATE DEPARTMi OF ENVIRONMENTAL CONSERVATI Facility DEC ID 3- 3724 -00234 Under the Environmental Conservation Law (ECL) Permittee and Facility Information Permit Issued To: Facility: PATRICK OMARA OMARA PROPERTY 73 FAIRFIELD DR OLD RD OPPOSITE COLLINWOOD DR PATTERSON, NY 12563 BREWSTER, NY (845) 279 -1000 Facility Location: in PATTERSON in PUTNAM COUNTY Facility Principal Reference Point: NYTM -E: 618 NYTM -N: 4590 Latitude: 41'27'10.5" Longitude: 74'35'14.1" Authorized Activity: This permit authorizes the construction of a single - family dwelling with a portion of the dwelling and associated driveway in the 100 -foot Adjacent Area of NYS -regulated Freshwater Wetland BR -9 (Class 1) in accordance with the plans referenced under Natural Resource Permit Condition #1. Permit Authorizations Freshwater Wetlands - Under Article 24 Permit ID 3- 3724 - 00234100001 New Permit Effective Date: 3/23/2010 Expiration Date: 12/31/2013 Approval: _.._:. - ...- - -.._. By acceptance of this permit, the Permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, and all conditions included as part of this permit. Permit Administrator: ALEXANDER F CIESLUK, JR, Regional Permit Administrator Address: N.YSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS RD NEW PALTZ, NY 12561 -1620 Authorized Signature: Date 3 1 e-3 120,10 Distribution List B. DRUMM - DEC H. NICHOLS, JR., PE NYC DEP - EOH PUTNAM COUNTY DEPT. OF HEALTH Page 1 of 6 (TA a) NEW YORK STATE DEPARTIt Facility DEC ID 3 -3724 -00234 4T OF ENVIRONMENTAL CONSERVA'. iN Permit Components NATURAL RESOURCE PERMIT CONDITIONS GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Permit Attachments Miscellaneous Attachments - Not Otherwise Specified NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following Permits: FRESHWATER WETLANDS 1. Conformance With Plans All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or applicant's agent as part of the permit application. Such approved plans were prepared by Harry W. Nichols, Jr., PE, and consist of a site plan dated August 10, 2009, with the newest revision date of November 16, 2009, titled "Proposed SSTS Lot 5" which is hereby made part of this permit. 2. Notice of Intent to Commence Work The permittee shall submit a Notice of Intent to Commence - - - - -- -- Work-to-Brian,Drummn, DEC-Bureau -of Habitat; -at brdrumm gxAr.dec:state:ny:us ' at least 48 hours:in... -_ advance of the time of commencement. 3. Post Permit Sign The permit sign enclosed with this permit shall be posted in a conspicuous location on the worksite and adequately protected from the weather. 4. Work Within Area Depicted on Plans All construction activity, including operation of machinery, excavation, filling, grading, clearing of vegetation, disposal of waste, street paving and stockpiling of material must take place within the project site as depicted on the project plans referenced by this permit. Construction activity is prohibited within areas to be left in a natural condition or areas not designated by the subject permit. 5. Install Controls as Shown on Plans Prior to commencement of the activities authorized herein, the permittee shall install securely anchored silt fencing and /or continuous staked straw bales as shown on the plans or drawings referenced in this permit. 6. Maintain Undisturbed Wetland Buffer A 60 foot buffer of undisturbed natural vegetation shall be maintained landward of the wetland boundary at all times. No Wetland Disturbance No disturbance to.the wetland is authorized. .Page 2 of 6 Am aftme NEW YORK STATE DEPARTM& OF ENVIRONMENTAL CONSERVATIC Facility DEC ID 3- 3724 -00234 s. Storage of Materials Excavated materials and or fill materials shall be stockpiled more than 100 ._ feet landward of the wetland or water body and shall be contained by straw bales or silt fencing to prevent erosion. 9. Permanent Barrier A permanent barrier such as a post and rail fence, stone wall, or equivalent approved by NYS DEC shall be installed along the area of disturbance as shown on the plans referenced in Natural Resource Permit Condition #1. In addition, three (3) 100- foot Adjacent Area markers as illustrated on Attachment 91 to this permit shall be installed on the east -side of the permanent barrier. Markers shall be installed at the northern and southern property lines and in the center of the parcel. running parallel to the Limit of Disturbance and barrie. A notice of completion of this work with photographic documentation must be submitted to the NYS Department of Environmental Conservation's Regional Permit Administrator by the expiration date of this permit. 10. Deed Covenant for Individual Lot This property contains portions of New York State regulated Freshwater Wetland BR -9 and /or its regulated 100 foot adjacent area. Accordingly, the deed for this property shall be amended to contain the following notice: "This property contains New York State regulated freshwater wetlands and /or regulated 100 foot adjacent area. For as long as any portion of the property described in this deed is subject to regulation under Article 24 (the Freshwater Wetlands Act) of the Environmental Conservation Law (ECL) of the State of New York, there shall be no construction, grading, filling, excavating, clearing or other. regulated activity as defined by Article 24 of the ECL on this property within the wetland area or its 100 foot adjacent areas at any time without having first secured the necessary permission and permit required pursuant ' to the above noted Article 24 from the NYS Department of Environmental Conservation " EC ` .his'restficfion'shall"Vi*ftdt the Gfantees, and- sh'aff-be-e Tess' set forth in all subsequent deeds to this property." By January 1, 2011, the permittee shall file with the real property records of the County Clerk's Office this deed notice revision. The permittee shall, within two weeks following the filing of the deed notice revision, submit proof of filing from the County Office showing the Liber and page number at which the deed notice revision was filed and the date of filing to Regional Permit Administrator NYSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS- RD NEW PALTZ, NY12561 -1620 to document compliance with this condition. M Precautions Against Contamination of Waters All. necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended. solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. Page 3 of 6 O 'NEW YORK STATE DEPARTN. ,T OF ENVIRONMENTAL CONSERVA', N Mod Facility DEC ID 3- 3724 -00234 Il , Stake- Ka,y.,-, Cquire ;Site. R s.toration If upon, th"xpiration,er revocation of -dais permit; the - project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. 13. State Not Liable for Damage The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which maybe caused by or result from .future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. 14. State May Order Removal or Alteration of Work If future operations by the State of New York. require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the, structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, full, excavation, or other modification of the watercourse hereby authorized shall not be completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. GENERAL CONDITIONS - Apply to ALL Authorized ]Permits: 1. Facility Inspection by The Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and 'intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this. permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301 and SAPA 401(3). The permittee shall provide a person to accompany the Department's representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. 2. Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. Page 4 of 6 Am INEW YORK STATE DEPARTME, OF ENVIRONMENTAL CONSERVATI( softne Facility DEC 1D 3- 3724 -00234 lic tioris For Permit`l enewal's, 1VIodifications be-T •ansfers Tlie'permittee must sii init a" y r separate written application to the Department for permit renewal, modification or transfer of this permit. Such application must include any forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. Submission of applications for permit renewal, modification or transfer are to'be submitted to: Regional Permit Administrator NYSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS RD NEW PALTZ, NY12561 -1620 4. Submission of Renewal Application The permittee must submit a renewal application at least 30 days before permit expiration for the following permit authorizations: Freshwater Wetlands. 5. Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate statements in the permit application or supporting papers; b. failure by the permittee to comply with any terms or conditions of the permit; c. exceeding the scope of the project as described in the permit'application; d. newly discovered material information or a material change in environmental conditions, relevant technology or applicable law or regulations since the issuance of the existing permit; - - -e..- noncompliance -with previ ously issued ernit- conditions --orders of the comp- nissioner an y ..., -..... provisions of the Environmental Conservation, Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or another permit condition. Applications for permit transfer should be submitted prior to actual transfer of ownership. Page 5 of 6 14 NEW YORK STATE DEPARTI'v, T OF ENVIRONMENTAL CONSERVAI N Facility DEC tD 3- 3724 -00234 NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, and agents ( ":DEC ") for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, or actions naming the DEC and. under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item 'B: Permittee's Contractors to Comply with Permit The permittee; is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee .is responsible for obtaining any other permits, approvals, lands, easements and rights -of- way that may be required to carry out the activities that are authorized by this permit. 1tdM D::.NoRight to Trespass -or Interfere .with- Riparia -n:- Rights.: :. -- .....:_ ...... This permit does not convey to the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. Item E:. SEAR Type II Action Under the State Environmental Quality Review Act (SEQR); this project has been determined to be a Type II Action and therefore is not subject to further procedures under this law. Page 6 of 6 PLANNING DEPARTMENT P.O. Box 470 1142 Route 311 Patterson, NY 12563 Michelle Russo Sarah Wagar Secretary Richard Williams Town Planner Telephone (845) 878 -6500 FAX (845 ).,878 -2019 TOWN OF PAXURSW PLANNING & ZONING OFFICE PLANNING BOARD OF THE TOWN OF PATTERSON, NEW YORK ZONING BOARD OF APPEALS Howard Buzzutto, Chairman Mary Bodor, Vice Chairwoman Marianne. Burdick ;.Lars Olenius Gerald Herbst Resolution for a Wetland/Watercourse Permit Patrick O'Mara Motion introduced by Member; Charles Cook Motion seconded by Member Michael Montesano;:. 2010; >. PLANNING BOARD Shawn Rogan; Chairman Charles Cook, Vice Chairman Michael Montesano Maria Di Salvo Thomas E. McNulty AT a duly noticed meeting of the Planning Board of the Town of Patterson, held on May 6, WHEREAS, a Wetlands and Watercourse permit application No. WW0909 -01 has been submitted by Patrick Omara, which proposes activities occurring within a wetland controlled area as shown on a Plan entitled Proposed SSTS and Site Development Plan Lot 5 prepared by Harry. W. Nichols, Jr. P.E., dated August 10, 2009, and last revised on November. 16, 2009, and ,VHEREAS,..the Applicant proposed to construct a she family, home within the 100' regulated buffer area, and WHEREAS,.the Planning Board has complied with the requirements of Article 8 of the Environmental Conservation Law ( "SEQRA ") and 6 NYCRR Part 617, and has duly filed all appropriate SEQRA determinations in accordance with 6 NYCRR Part 617.10;. WHEREAS, a public hearing was held on the application on May 6, 20.10, and WHEREAS, the Planning:Board, pursuant to Chapter 154 of the Town Code has considered the application of Patrick O'Mara for approval of a Wetlands and Watercourse permit No. WW0909- 01,,and WTI+ REAS; pursuaiiti to Section 154- 18:E(2) the-Plannmi g-'Board finds that the activities - proposed by the application, as modified by any applicable conditions contained herein, will not have a substantial effect on the wetlands or any surroundingTroperly;. NOW THEREFORE BE IT RESOLVE THAT in the application of Patrick O'Mara for approval of Wetland and Watercourse Permit Application No. WW0909 -01, pursuant to Chapter 154 of the Town Code,.the Planning Board finds that the subject application and plans, as modified in accordance with any applicable conditions set forth in this resolution, complies with all requirements of the Town Law and Chapter 154 of the Town Code, and hereby grants approval to said wetland and watercourse permit application,.subjectto the applicant's compliance with thefollowingggneral and special conditions ;. GENERAL, CONDITIONS: 1. No activity,, shall be permitted within controlled areas except as identified in the approved application and plans. 2. All work shall be performed in accordance with the New York Standards and Specifications for Erosion and Sediment Control. 3. The Permit Holder shall notify the Planning-Department in writing,, at least five business days in advance of the Date on which project construction is to begin. 4. The Permit shall be prominently displayed at the project site dunng.the undertaking, of the activities authorized by the permit. 5. The boundaries of the project shall be clearly. staked or marked and maintained. In addition, any wetlands contained within the boundaries of the project shall also be staked or marked. 6. The Environmental Conservation Inspector (E.C1.). or his designated representative shall have the right to inspect the project. ..7. The Permit shall expire on either the completion of the acts specified,, or unless otherwise indicated shall be valid for a period of one year from the date of issuance. 8_ As a condition of the issuance of this permit,.zhe applicant has accepted expressly by the execution of the application, the full legal responsibility for all damages, direct or indirect, of whatever nature, and by whomever suffered arising out of the project described herein and has agreed to indemnify and save harmless the town from Suits,Actions,.Damages,.and costs of every. Name and description resultingfrom the said project. Resolution of Wetland/watercourse Permit May 6, 2010 Patrick O'Mara Page 2 of 4 `� = 9: In fife °c erifi -that any -.of the, material -sub mitted- relation to: this application is:. inaccurate or misleading, or the owners of the project do not have the legal right to develop or use the property. where and as shown on the material submitted to this Board, then any. approvals herein granted are deemed null and void. BE IT FURTHER RESOLVED that this wetland and watercourse permit approval shall be deemed null and void if the applicant fails to comply with all conditions stated above and/or construction is not completed within one year of the issuance of this permit,. and any.. extension thereto granted by. the Plannin&Board, A copy of this Resolution shall be filed with the Town Clerk and the applicant upon adoption. VOTE: Shawn Rogan: Yes Michael Montesano: Yes Charlos,- Cqqk:_ - Yes.. DATED: May_6,.2010 Thomas McNulty: Yes Maria DiSalvo: Absent Resolution of Wetland/watercourse Permit May 6, 2010 Patrick O'Mara Page 3 of 4 L STATE OF NEW YORK} :SS} COUNTY OF PUTNAM) I, MICHELLE RUSSO, Secretary of the Planning Department of the Town of Patterson, do hereby certify that the foregoing is a true and exact copy of a Resolution adopted by the Planning Board of the Town of Patterson at a meeting of said Board of the Town of Patterson held on May 6, 2010 e Zt� MICHELLE RUSSO I, ANTOINETTE KOPECK, Town Clerk of the Town of Patterson, do hereby I certify that the foregoing Resolution was filed in the Town Clerk's Office on May 7, 2010. WFA .10 011 111 Resolution of Wetland/watercourse Permit May 6, 2010 Patrick O'Mara Page 4 of 4 c NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 3- 3724 -00234 Under the Environmental Conservation Law (ECL) Permittee and Facility Information Permit Issued To: PATRICK OMARA 73 FAIRFIELD DR PATTERSON, NY 12563 (845) 279 -1000 Facility: OMARA PROPERTY OLD RD OPPOSITE COLLINWOOD DR BREWSTER, NY ` Facility Location: in PATTERSON in PUTNAM COUNTY Facility Principal Reference Point: NYTM -E: 618 NYTM -N: 4590 Latitude: 41'27'10.5" Longitude: 74'35'14.1" Authorized Activity: This permit authorizes the construction of a single - family dwelling with a portion of the dwelling and associated driveway in the 100 -foot Adjacent Area of NYS- regulated Freshwater Wetland BR -9 (Class 1) in accordance with the plans referenced under Natural Resource Permit Condition #l. Permit Authorizations Freshwater Wetlands - Under Article 24 Permit ID 3- 3724 - 00234/00001 New Permit Effective Date: 3/23/2010 Expiration Date: 12/31/2013 NYSDEC• Approval - ww._..,:...._.._..:. _.._.... _ _....... _ -.. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable Kegulations, and all conditions included as part of this permit. Permit Administrator: ALEXANDER F CIESLUK, JR, Regional Permit Administrator Address: NYSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS RD NEW PALTZ, NY 12561 -1620 Authorized Signature: ,�, ,�, Date 3 / e.3 /10 �o Distribution List B. DRUMM - DEC H. NICHOLS, JR., PE NYC DEP - EOH ,.DU* AM COUNTY DEPT O.,F3H �1L`THE Page 1 of 6 (TA 8) NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 3- 3724 -00234 Permit Components NATURAL RESOURCE PERMIT CONDITIONS GENERAL CONDITIONS, APPLY TO ALL AUTHORIZED PERMITS NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Permit Attachments Miscellaneous Attachments - Not Otherwise Specified NATURAL RESOURCE PERMIT CONDITIONS - Apply to the Following Permits: FRESHWATER WETLANDS 1. Conformance With Plans All activities.authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or applicant's agent as part of the permit application. Such approved plans were prepared by Harry W. Nichols, Jr., PE, and consist of a site plan dated August 10, 2009, with the newest revision date of November 16, 2009, titled "Proposed SSTS Lot 5" which is hereby made part of this permit. 2. Notice of :Intent to Commence Work The permittee shall submit a Notice of Intent to Commence to- Brim°Drumm, -DEC• Bureau of Habitat, at brdrumtn @gw.dec.state.ny -.us apt leasV48 hours in advance of the time of commencement. 3. Post Permit Sign The permit sign enclosed with this permit shall be posted in a conspicuous location on the worksite and adequately protected from the weather. 4. Work Within Area Depicted on .Plans All construction activity, including operation of machinery, excavation, filling, grading, clearing of vegetation; disposal of waste, street paving and stockpiling of material must take place within the project site as depicted on the project plans referenced by this permit. Construction activity is prohibited within areas to be left in a natural condition or areas not designated by the subject permit. 5. Install Controls as Shown on Plans Prior to commencement of the activities authorized herein, the permittee shall install securely anchored silt fencing and /or continuous staked straw bales as shown on the plans or drawings referenced in this permit. 6. Maintain Undisturbed Wetland Buffer A 60 foot buffer of undisturbed natural vegetation shall be maintained landward of the wetland boundary at all times. 7. No Wetland Disturbance No disturbance to the wetland is authorized. Page 2 of 6 4e NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION r Facility DEC ID 3- 3724 -00234 - s. -:Storage of :Materials 'Excavated materials and or fill materials shall be stockpiled more than 100 feet landward of the wetland or water body and shall be contained by straw bales or silt fencing to prevent erosion. 9. Permanent Barrier A permanent barrier such as a post. and rail fence, stonewall, or equivalent approved by NYS DEC shall be installed along the area of disturbance as shown on the plans referenced in Natural Resource Permit Condition #1: In addition, three (3) 100- foot Adjacent Area markers as illustrated on Attachment #I to this permit shall be installed on the east side of the permanent barrier. Markers shall be installed at the northern and southern property lines and in the center of the parcel. running parallel to the Limit of Disturbance and barrier. . A notice of completion of this work with photographic documentation must be submitted to the NYS Department of Environmental Conservation's Regional Permit Administrator by the expiration date of this .permit. lo. Deed Covenant for Individual Lot This property contains portions of New York State regulated Freshwater Wetland BR -9 and/or its regulated 100 foot adjacent area. Accordingly, the deed for this property shall be amended to contain the following notice: "This property contains New York State regulated freshwater wetlands and /or regulated 100 foot adjacent area. For as long as any portion of the property described in this deed is subject to regulation under Article 24 (the Freshwater Wetlands Act) of the Environmental. Conservation Law (ECL) of the State of New York, there shall be no construction, grading, filling, excavating, clearing or other. regulated activity as defined by Article 24 of the ECL on this property within the wetland area or its 100 foot adjacent areas at any time without having first secured the necessary permission and permit required pursuant to the above noted Article 24 from the NYS Department of Environmental Conservation '-( shall bind the Grantees; their sa&e� -gor's and'assigiis aiid`slia� be expressly set forth in all subsequent deeds to this property." .By January 1, 2011, the permittee shall file with the real property records of the County Clerk's Office this deed notice revision. The permittee shall, within two weeks following the filing of the deed notice revision, submit proof of filing from the County Office showing the Liber and page number at which . the deed notice revision was filed and the date of filing to. Regional Permit Administrator NYSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS RD .NEW PALTZ, NY12561 -1620 to document compliance with this condition. 11. Precautions Against Contamination ofWaters All. necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. Page 3 of 6 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 3- 3724 -00234 _ State . May. Require._Site:Restoration.�-If upon.the:eXpiration or. revocation of,this.permit,, .the project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require; remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. 13. State Not Liable for Damage The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by or result from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right: to compensation shall accrue from any such damage. 14. State May Order Removal or Alteration of Work If future operations by the State of New York. require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse_hereby authorized shall not be completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. GENERAL CONDITIONS -Apply to ALL, Authorized Permits: 1. Facility Inspection by The Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the permittee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71- 0301 and SAPA 401(3). The permittee shall provide a person to accompany the Departments representative during an inspection to the permit area when requested by the Department. A copy of this permit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. 2. Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination previously issued by the Department or any of the terms, conditions or requirements contained in such order or determination. Page 4 of 6 v AIM NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Facility DEC ID 3- 3724 -06234 3-. Applications For- Permit Remewals; Modifications or 'frafi rs The permittee must submit a separate written application to the Department for permit renewal, modification or transfer of this permit. Such application must include any..forms or supplemental information the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. Submission of applications for permit renewal, modification or transfer are to be submitted to: Regional Permit Administrator NYSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS RD NEW PALTZ, NY12561 -1620 4. Submission of Renewal Application The permittee must submit a renewal application at least 30 days before permit expiration. for the following permit authorizations: Freshwater Wetlands.. 5. Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this permit. The grounds for modification, suspension or revocation include: a. materially false or inaccurate statements in the permit application or supporting papers; b., failure by the permittee to comply with any terms or conditions of the permit; C. exceeding the scope of the project as described in the. permit application; d. newly discovered material information or a material change in environmental conditions, relevant . technology or applicable law or regulations since the issuance of the existing permit; _e.. _ -n oncompliaii�,e- witli..prevtousl-y- issued permit. conditfions; orders-of the commissioner; -any provisions of the Environmental Conservation. Law or regulations of the Department related to the permitted activity. 6. Permit Transfer Permits are transferrable unless specifically prohibited by statute, regulation or another permit condition. Applications for permit transfer should be submitted prior to actual transfer of ownership. Page 5 of 6 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION FaH t' DEC ID 3- 3724 -00234 NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the Department of Environmental Conservation of the State of New York, its representatives, employees, and agents ( "DEC ") for all claims, suits, actions, and damages, to the extent attributable to the permittee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terms and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to the extent attributable to DEC's own negligent or intentional acts or omissions, or to any claims, suits, or actions naming the DEC and arising under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The permittee; is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the permittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the permittee. Item C: Permittee Responsible for Obtaining Other. Required Permits The permittee: is responsible for obtaining any other permits, approvals, lands, easements and rights -of- way that may be required to carry out the activities that are authorized by-this permit. ___.... _:._:........tem,D.:No..Rightto Trespass or. Inter-fere-with Riparian Ri�hts This permit does not convey to.the permittee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. Item E: SEQR Type'II Action Under the State Environmental Quality Review Act (SEQR), this project has been determined to be 'a Type IT Action and therefore is not subject to further procedures under this law. Page 6 of 6 ArrACHnieMT #'l -ro ,DeC M, - .#V 3- 3.72`f- 0023LJ 00001 New York State Department Of Environmental Conservation Division of Environmental Permits,_ Region 3 South Putt Corners Road, New Pa1z; `few'ork f 12561 -16Z0� ""` --��` Phone: (845) 256 -3054 ' FAX: (845) 255 -4659 Website: www.d6c.ny.gov Example — Survey Marker for NYS Freshwater Wetland Adjacent Area Alexander B. Grannis Commissioner June 2008 S:\PERMITS\Programs \Freshwater Wetland \Example FW Survey Markers.doc Decal /Marker Language WETLAND ADJACENT AREA SURVEY MARKER LANGUAGE C Flexible Fiberglass These markers must contain the following Boundary Post "� or language: C Equivalent � "STATE WETLAND ADJACENT AREA" Existing Grade "SURVEY MARKER NOT TO BE REMOVED" • "CONTACT NYS DEC" �r cv C, CO June 2008 S:\PERMITS\Programs \Freshwater Wetland \Example FW Survey Markers.doc New .York State Department of Environmental Conservation JT. S e The Department of Environmental Conservation (DEC) has issued permit(s) pursuant to the Environmental Conservation t=aw for work being conducted at th.is site. For further information regarding the nature and extent of work approved and any Department conditions on it; contact the DEC at ,845/256 -3054. Please refer to the permit number shown when contacting the DEC. Perrnittee: Eck In am, Permit No 3- Effective Date: Expiration date: M-31-Z0,13 ® Applicable if checked. No instream work allowed between October .1 & April 0 r NOTE: This notice is NOT,a permit.. i BRUCE R. FOLEY Public Healthy Djrector,•,,, , ,�, _ _ _.: _ . LORETTA MOLINARI R.N., M.S.N. -• � -� -- -°v �-•° ��tssociate '•Public�`Health'?�ir'ector" " ' ` Director of .Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6I30 Fax (914) 278 - 7921 Nursing Services (914)278-6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW PROJECT: TOWN: (JTREV2) DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAIM JOINT RE VIE F VISIO DATE: �/ --C �. Harry W. Nichols Jr., P.E.- P.O. Box 252 Brewster, NY 10509 1'A (845) 279 -4727' Fax (845) 279-4728 November 9, 2009 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Att: Michael J. Budzinski, P.E. Director of Engineering Re: Proposed SSTS (O'Mara) Old Wall Estates Lot 5 Old Road Patterson, NY T.M. #35.-5-5 Dear Mr. Budzinski: In response to your September 29, 2009 review letter, we note the following: 1. a. Comment noted. b. Comment noted. Ten feet of separation distance is now provided on the plan, eliminating the need for a waiver for this condition. 2. A completed NYSDEC wetland validation block has been added to the plan. 3. An application package has been sent to the NYSDEC and was received by DEC on 09/17/09.(see attached notice of receipt). 4. The minimum dimension of 50 feet from the well to the septic tank is now shown on the plan. 5. The numbering sequence of the perc tests has been corrected. 6. Response to the NYCDEP memo of 09/29/09 are as follows; a. Comment noted. This office will contact DEP with regards to , the Individual Residential Storm Water Permit. b. A completed NYSDEC wetland validation block has been added to the plan. c. The Subdivision consists of 9 lots and was approved by the Town of Patterson Planning Board on May 14, 1981 and filed on June 12, 1981 at the Putnam County Clerks Office as Filed Map 1813., A copy of this map is enclosed for review. A Reflecting the'above, enclosed are five (5) prints o4`fhe following: ` y SS -5 "Proposed SSTS ", rev. 11 /09/09. Specific Waiver Application dated 11 /05/09. Kindly continue with your review of this Application. Very truly yours, Hairy W. Nic s Jr., P.E. HWN:jdm 07 -019 (fold #2) NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DIVISION OF ENVIRONMENTAL PERMITS NYSDEC REGION 3 HEADQUARTERS 21 SOUTH PUTT CORNERS RD NEW PALTZ NY 12561 HARRY W NICHOLS, JR —:_—_ PO.:BOX 252. _.�__.: .......... >. _ . .� BREWSTER, NY 10509 (fold # 1) -- staple here NOTICE OF RECEIPT OF APPLICATION The Division of Environmental Permits has received the application referenced below. The material submitted is being reviewed by staff, and you will be advised in writing regarding the department's findings. In all future communications, please refer to the Application ID number. Application ID: 3- 3730 - 00335/00001 Date Received: September 17, 2009 Applicant: PATRICK OMARA Facility: OMARA PROPERTY Description: portion of dwelling and driveway in adj. area FW #BR -9 DEC Contact: REBECCA S CRIST New York City Department of Environmental Protection www.nyc.gov /dep 59-17 Junction Boulevard Flushing, NY 11373 465 Columbus Avenue Valhalla, New York 10595 -1336 Steven W. Lawitts Acting Commissioner Tel. (718) 595-6565 Fax (718) 595 -3557 Bureau of Water Supply Paul V. Rush, P.E. , Deputy Commissioner Tel (914) 742 -2001 Fax (914) 741 -0348 September 29, 2009 Michael Budzinski, P.E. Putnam County Department of Health 1 Geneva Road Brewster, New York 10509 Re: O'Mara Residence — SSTS Old Road, (T) Patterson TM # 35 -5 -5 East Branch Reservoir Drainage Basin DEP Log # 2009 -EB -0622- DJS.1 Dear Mr. Budzinski: The New York City Department of , Environmental Protection (DEP) has determined that the above - referenced application received by the DEP on September 17, 2009, is incomplete. The following information is required before the DEP may commence its review: • It appears that the house'and driveway are within 100 feet of a NYSDEC wetlands as such an Individual Residential'Storinwater Permit is required to be submitted to DEP for review and' approval. Please contact Mary Galasso at (914) 773 -4440. • Provide a completed NY-SDEC Wetlands Validation Stamp on the site plan. • Provide verification of the 1981 subdivision status.- In addition, include the total number of lots in the subdivision. If you have any questions regarding this matter, please contact the undersigned at (914) 742 -2010. Sincerely, . A av-�� 6��, David Alderisio Associate Project Manager Wastewater DesignReview xc: Roger Sokol, PhD., NYSDOH Patterson Planning Board Mary Galasso, NYCDEP SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, PE P.O. Box 252 - Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva.Road. Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health September 29, 2009. Re: Proposed SSTS for Patrick O'Mara at Lot # 5 — Old Wall Estates (T) Patterson, T.M. # 35. -5 -5 This Department, in conjunction with the NYCDEP, has received and reviewed the submitted application - - - -- - - - - - -- -- and - -plans for -the- above - referenced- project -and- the - following comments -are- offered for- -your- consideration. -- - L The submitted application is denied since the following items do not comply with current code requirements. t4 SSTS reserve area of 50 % provided, whereby 100% is required. ✓Ei. Minimum three - bedroom SSTS design is required whereby only a two- bedroom SSTS is provided. `/c. Minimum 10 feet separation distance between septic tank and water line is required, whereby only 7 feet is provided. + The NYSDEC wetland validation block is to be completed. �3. A NYSDEC freshwater wetlands permit is required due to disturbance within the 100 feet /wetland buffer. 4. The; plan is to label the minimum separation distance of 50 feet from the well to the septic tank and drryywell. v It appears that there are two (2) percolation tests labeled "PT -1 ". 6. Please refer to the NYCDEP letter, dated September 29, 2009, for additional comments. Upon completion of the above, this Department will continue its review. Kindly advise us if there are any questions. Respectfully, Michael J. Budz ski, Y.E. Director of EnefneerinL MJB:kly Enc. cc: D. Alderisio, DEPEnvironmental Health (845)278-61'30 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 Nursing Home Care Fax (845) 278 -6085 WIC (845) 278 -6678 Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580 Oka. New Yark'City Department of - Emrlroomental Protection www.nyc.gov /dep :59Z1Z.)uncti9n, Boulevard Flushing, IVY 11373 465 Coiumbus Avenue Valhalla, [`taw Yor c . Steven W. Lawitts Acting. Commissioner Tel. (7 i 8) 5954556+5 Fax (713) 595 -3557 Bureau of Waiter Supply Paul V. Rush, P.E. Depyty Commisslanar Tel (J14) 742 -2001 Fax (914) 741 -0348 Michael Budzinski; P.E. Putnam County Department of Health I Geneva Road Brewster, New York 10509 Re: O'Mara Residence — SSTS Old Road, (T) Patterson TIM # 35 -5 =5 East Branch Reservoir Drainage Basin DEP Log # 2009 -EB- 0622 - DJS.l ' Dearl\/fr. Budzinski: The New York . City Department of . Enviror mental Protection (DEP)' has determzned_ that _ the above-referenced a-mlication receiited.- l_X._. September 17, 2009, is incomplete. The following information is required before the DEP may commence its review: • It appears that -the house and driveway are within 100 feet of a ;`1YSDEC wetlands'as such an. Individual Residential Stormwater Perrnit is reguized to be submitted to DEP .for review and approval. Please contact Mazy Galasso at (914) 773 -4440. • Provide a cornpleted Iv`Y SDEC Wetlands Validation. Stamp on the site plan.. • Provide verification -of the 1981 subdiivzsion. status. In addition, include the total number of lots in the subdivision. If you have any questions regarding this matter, please contact the undersigned at (914) 742 -2010. Sincerely, 1 (David Alderisio !Associate Project Manager. Waste1zrater 17esip'Review Ixc: Roger Sokol, PhD.,,NWSDQH - Patterson Planning Board Mary Galasso, NYCDEP NEW YORK STATE SPECIFIC WAIVER APPLICATION DEPART NiEN T OF HEALTH" Request for Approval of Noncompliance with Bureau of Water Supply Protection the Standards of IONYCRR Appendix.75 -A Wastewater Treatment Standards — Individual Household Svstems IGENERAL • • (Applicant Name of Applicant Last First ' - — MI Address Street City/rowa State Zip Contact Information Phone: FAX: email: 'City/Town Site Location Street: County Zip The following information is being submitted in support of my application for a specific waiver from compliance with one or more standards of IONYCRR , 4ppendix 75 -A, "Wastewater Treatment Standards Individual Household Systems'. 1. The wastewater treatment system cannot meet the following standards of IONYCRR Appendix 75 -A: ❑ Separation distances cannot be achieved (75- A..4(b), Table 2, Separation Requirements) ❑ . Excessive Slope (75- A.4(1), Soil and Site Appraisal) ❑ Design is not addressed in Appendix 75 -A ❑ Technology is not addressed in Appendix 75 -A ❑ Other: Explain: 2. The following design is proposed to mitigate noncompliance with Appendix 75-A (brief description): .. -1 Supporting information- provided: — --------------.__-- ❑ Detailed Site Plan ❑ Detailed Design ❑ Soil and Site Evaluation ❑ Neighboring conditions of concern (e.g., wells, waterbodies, wetlands, etc.) ❑ Other: Explain: I, (applicant) (type or print) acknowledge that this waiver request is necessary because it is not practical for an onsite wastewater treatment system to meet the referenced standards of IONYCRR, Appendix 75 -A on this property. Signature Date I, (engineer) (type or print) acknowledge that this waiver request is necessary because it is not practical for an onsite wastewater treatment system to meet the referenced standards of IONYCRR Appendix 75 -A on this property. In my professional opinion, the proposed design described in this application will provide a degree of protection equivalent to the onsite wastewater treatment standard(s) that will not be met for this property and will not create an increased risk to public health or the environment. Signature PE License # *For Health Department use Based upon the information provided in this application to waive the referenced standards of Appendix 75 -A and in accordance with lONYCRR §§ 75.3 and 75.6 (b), the waiver requested is hereby: ❑ Approved as proposed. ❑ Approved, with following conditions: ❑ Not acted on, because additional information is required: ❑ Denied, because: Note: This waiver may be revoked should any conditions considered before approving this waiver change after approval, Health Department Representative Signature Date instructions for Completing the Specific Waiver Application: Wastewater Treatment Standards - Individual Household Svstems Applicability: This Specific Waiver application form is intended for use by the applicant (property owner) or the applicant's representative (e.g., PE) to present information for consideration by the Health Department having jurisdiction to approve a new onsite wastewater treatment system (OWTSI,on previous[ undevelopgCLproperty-that does not comply with one#sr- amore- stamcl'ards of`,Appendir75' A;" " .,.:.- .o..... `Wastewater Treatment Standards - Individual Household Systems ". A specific waiver shall be obtained before construction of the onsite wastewater treatment system. Background: The responsible city, county, or district health office may grant a 10NYCRR Part 75 Specific Waiver from a provision(s) of 1ONYCRR Part 75, Appendix 75 -A, only under the following circumstances: 1. Conditions at the particular site make it impractical to comply with these standards; 2. Appropriate protective measures to mitigate noncompliance are applied; 3. The design is not likely to pose a health hazard or create environmental contamination; and 4. Disapproval will result in a significant hardship. A Specific Waiver IS NOT intended as a device for routinely approving individual residential wastewater treatment systems that do not meet design standards. It is intended to provide administrative flexibility to resolve rare cases when hardships exist and /or other circumstances that make it impractical to meet Appendix 75 -A standards The Specific Waiver application shall provide information and background about the site conditions and detail the proposal so that the Health Department is able to determine whether to approve or deny the application. The Health Department representative may ask for additional information to be submitted to make that determination General Information - - -- -- - - - -- ..... - ... -_ .- _.....p _...- - .............. _. -- p - Provide the a `- [icanf'`s current mailin - address and contac�nformation. Also provide the address of the property the specific waiver is being applied for, even if it is the same as the mailing address. Reasons for Noncompliance Check the applicable reason(s) for which the waiver is requested. If not already listed, include the specific standard(s) in the space provided and provide a brief explanation. More detailed information can be attached as needed or as appropriate. Proposed Mitigative Design Provide a brief description of.the site characteristics and OWTS design in the space provided. Detailed information and plans ' can be attached to the application. Supporting Information - . % ----.Check any.information provided. - Any additional information caii be listed at`ter other in the space provided. Any or all of the information listed may be required by the Health Department representative depending on the complexity of the site conditions. To obtain a waiver, the applicant must demonstrate that the onsite wastewater treatment system design proposal is acceptable and is not likely to pose a health or environmental hazard. Detailed Site Plan contents may include some or all of the following: surveyed plat, accurate location of onsite and neighboring offsite (if applicable) drinking water sources or water courses, site topography, drainage features and any pertinent physical features. Appendix 75-A, Table 2, lists required separation distances. Detailed Design shall be submitted by a NYS licensed P.E. and will clearly identify the OWTS components and locations. Soil and Site Evaluation shall incorporate the characterization of the existing soils through, at a minimum: percolation tests and test pit evaluation, which identifies soil types and geologic limiting conditions (e.g., groundwater, rock or clay). Neighboring conditions of concern (if applicable) shall include at a minimum, onsite or nearby: drinking water sources, watercourses and wetlands. Other identified possible areas of concern that could be impacted by the OWTS shall also be identified. Acknowledgement of Risks The applicant (property owner) is required to sign the Specific Waiver application and acknowledge the risks that may be associated with the OWTS serving their property. A NYS Professional Engineer (P.E.) is required to provide his or her name and license number on the form and submit the supporting information and stamped design plans on behalf of the applicant. Health Department Representative Response The Health Department representative will approve; approve with conditions; not act and request additional supporting documentation; or deny the Specific Waiver application. The determination will be sent to the applicant and a copy of the determination and all information submitted with the application will be retained. P:\SectionAResidential Sanitation \OWTS \GLIDANCE\Specific WaiverOWTS- Legal.doc Sep 29 2009 10:29 P.02 PRW iotember 29,.2009 No* York -City Department of -• EnVIrOBmetMhl! Protectlort .. Michael Budzinski f F.E. - P . . w w w. ,, y c. g o v/ d e p Putnam County Department of Health 1 Geneve, Road ,,,S9;Ji.Jun_tiort Bvulewd Brewster, New York 10509 Flushing, NY 11373 465 r-ofumbus Avenue Valhalla, NBwYork y Re: 0 Mara Residence — SSTS "Y069- s3s Old Road, (T) Patterson ' TM # 35 -5 -3 EastBranch Reservoir Drainage Basin PEP Log # 2009 -EB- 0622 - DIS. I Steven w. Lawitta Acting. Commissioner Dear Mr. Budzinski: ' Tel. (718) 595 -6565 - Pax (718) 595-3557 The New York, City Department of . Environmental Protection (DEP) has deiermimed -that the above - referenced' application received by the DEP on September 17, 2009, is incomplete. The following information is required before the DEP may commence its review: Bureau of Water Supply It appears that the house and driveway are within 100 feet of a N Sl SbEC V.' wetlands 'as' such an Individual Residential Stormwater Permit is required Paul RU9h, P.E. Deputy commissioner to be submitted to DEP for review and approval. Please contact Mary *742-2001 Galasso at (914) 773 -4440. Tel - J$i4j Fax (914) 741 -0348 ® Provide a completed NYSDEC Wetlands Validation Stamp on the site plan.. _ _ e Provide verification of the 1981 subdivision status. In addition, include the total number of lots in the subdivision. If you have any questions regarding this matter, please contact the undersigned ,.�.. _._.:....._ .. at.(914) 742 -2010. Sincerely,. _ ...._... David Alderisio Associate Pxoject Manager M Wastewater DesigdReview :.. xc: Roger Sokol, PhD.,�NYSDOH ::.: Patterson Plamling Board 4. Mary Galasso, NYCDEP SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN x Associate Commissioner of Health DEPARTMENT OF HEALTH I Geneva Road, Brewster; New York 105.09 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health At-6 z-rsic,) TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM JOINT REVIEW PROTECT: O 14 TC�' c--;)GA 2-6;4A TOWN: LG�S�� SUB'D APP DATE NOTICE OF COMPLETE APPLICATION: DATE: ❑ Within the drainage basins of West Branch, Boyds Corner Reservoirs or Croton Falls. ❑ Within 500 feet of a reservoir, reservoir stem or control lake. Within 200 feet of a watercourse or a DEC wetland and appearing on a subdivision map approved after December 31, 1992. ❑ Design flow greater than 1000 gallons /day. ❑ Commercial SSTS, i trevtew Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (815) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 -Early Intervention /Preschool(845)278 -6014 Fax(845)278 -6648 PUTNAM COUNTY .DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of Located at LETTER OF AUTHORIZATION 4L'(� �-0 T/V PAr_r5P -f2©H Tax Map # ?d'rJ 4 Block C. Lot C7 Subdivision of Subdivision Lot # Gentlemen: 00,9 . WAW_ . �_ 16TA _rJ5 91-1:) 15 Filed Map # 1$112 Date Filed 06 / 1 -161 1 This letter is to authorize 14 A W - �A I G �4 0 irh A- Fr a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health. Law; and the Putna` ''county Sanitary Code. Mailing Address State P� Zip (06 04 Telephone: (0q0 s 211- 4121 Very truly yours, Signed: (Owner of Property) Mailing Address: 102 P/-4i(L ELL 94e State W .Zip Telephone: 04 ,5) 2I I — 10 0 0 Form LA -97 To: 1-1 Attention: AW &OU4 Harry W. Nichols Jr., P.E. P.O. Box 252 `"Brewster, NY"105Tel. (845) 2794727 Fax (845) 2794728 Date: Job No.: D Project 0119 mv>� o- -IA475'b - "'T" ;;5 'bpi �4 Ge tlemen: We enclose copies of CZ/W. Prints 0 Reproducibles 0 Reports 0 Tracings 0 Specifications 0 Memorandum 0 Copy of letter 0 Description: (I ) 6ADK gAr- -Hrr 64 16H A Sent Via: Q) AR6.16WOH F-5r q— E;( Our Messenger 0 Blueprinter 0 First Class Mail 0 Your Messenger 0 Hand Delivery Copy- to Revision/Date No. \k V 0 Special Delivery Very truly yours, 34f I o , ijw4 Harry W. Nichols Jr., P.E. F UTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT :S;Y &TEM..- 1. Namef and address of applicant: PA-PA 64--. Q PK -f r-- yJ off. 2. Name of project: i_< 3. Location TN: PArrf �D w 4. Design Professional: IPA k Mu,NO �45 5. Address:. f IB0X 1-151 6. Drainage Basin: 7. Tape 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) ....................................................... Type I Exempt Type.Il Unlisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? ............................. i-14 10. Has' DEIS been completed and found acceptable by Lead* Agency? ............... NA 11. Name. of Lead Agency MA 12. Is this project in. an area under the control of local planning, zoning,- or other_ officials, ordinances? ... ...............:....... i.........:.................... .... .............:.::.::..::.:.. 13.-. If so, have plans been submitted-to such authorities? ...:.....::... �1Q 14. Has preliminary approval been granted by such authorities? MO. Date granted: N A 15. Type of Sewage Treatment System Discharge ................. surface water .x groundwater 16. If surface water discharge; what. is the stream class designation? .................. ... .. 17. Waters index'riumber (surface) ..................................................... �. ................ _ ... 18-. Is project located near a public water supply system? ....... .I. .................:........... 19. If yes, name .of water. supply N A Distance to water supply 20. Is project-site-hear a public sewage collection or treatment system? ......:::::..:.: p 21. Name of sewage. system _ l`ti Distance to sewage system � A 22. Date test holes observed 011 4 2009 23.. Name of Health Inspector MiGHW, 5oyo4pi f e - 24. Project-,design flow (gallons per day).............................. ..: ................................... 4.4. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?:.. I�10 26. Has SPDES Application been submitted to local DEC office? ......................... BHA Form PC -97 Pa -27. Is any portion of this project located within a designated Town or State wetland? YF� 28. Wetlands ID Number .:.....:...::... ........... :................................................... ........... 29. Is Wetlands Permit-required. `.: .................:......:..:.:........ ..............:..............Eh Has application been made to Town.or Local DEC office? .:.............. . PEHol NIA 30. 31. Does project require a DEC Stream Disturbance Permit? ...................................... 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? ......... 32. Is project located within 1,000 feet .of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or an other potentially known source of contamination? ................ ...:. DESCRIBE: . No NO Yes/No 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? ....... 1 ......................................................... 140 35. Are any sewage treatment areas in.excess.of 15% slope? . ............:.................. wo 36. Tax Map ID Number ....... ................ :... :.............................. Map Block- 42- Lot 37. Approved plans are to be. returned to...... Applicant X Desigii.Professional NOTE:.Afl applications -for review and. approval of a new SSTS to be located. withintheWC:Watershed shall ..be sent to the-Department; and need not be sent in duplicate to the DtP, 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 ofa project, such as stormwater plans or. the creation of .impervious surfaces; and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item I Jhe application must be accompanied by a Fetter of Authorization (Form LA -97). Failure to comply.with this provision may be grounds for the rejection of any submission. ��hereby affirm, under penalty of perjury, that information provided on this form-is true - toffie best of my knowledge and belief. False statements made herein are punishable as. a eassrA misdemeanor pursuant to Secti n 210:45 of the'. en Law. SIGNATURES & OFFIML TITLES: �.L Mailing Address : .............................. j L o� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner FXr9--1C9-- .()'�AS-A.. Address It rAl 9-HOW DFA'4e PATf, 0? C2,50i Located at (street) C�,OWJ4WOOV Tax Map Block L;p Lot (indicate nearest cross street) Municipality PA'-rf � � %-A Watershed �A6T �P-W 6 14 SOIL PERCOLATION TEST DATA Date of Pre-soaking 011 IA Date of Percolation Test 01 PID I U01 From Ground vi ..... .... ... .. :z .............. 2 1A 9-6. 3 101T t)7 4 5 91)0 1A 2k I 2 9 94%- 14 1A 26 /h 4,111 3 110 iol"A I /A 4,111 4 5 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 I 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 Indicate level at which groundwater is encountered �40Hr" - Indicate level at which mottling is observed Np�� Indicate level to which water level rises after being encountered a Deep hole observations made by: M1G4AE1. Jp tj02iH,6V i1 px Date 01 ItO ( ®q ► j4i&kD ., JP-, P.Z. Design Professional Name: HAfq. W- J41 C/(+01 -6 JQ-FE Address: P, o f V)4 Signature: Design Professional's Seal Nil, �o� i � t1J j C' W !I 110 56124 C� mow: TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. G.L. 0:5' .0 -!o "�QP�o�L Q - b" °fioI 6M� 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 5 R N 4.0' 4.5' 5.0' 5.5' 6.0'. . 6.5' 7.0' 7.5' 8.0' 8.5' 9.0` 10.0' Indicate level at which groundwater is encountered �40Hr" - Indicate level at which mottling is observed Np�� Indicate level to which water level rises after being encountered a Deep hole observations made by: M1G4AE1. Jp tj02iH,6V i1 px Date 01 ItO ( ®q ► j4i&kD ., JP-, P.Z. Design Professional Name: HAfq. W- J41 C/(+01 -6 JQ-FE Address: P, o f V)4 Signature: Design Professional's Seal Nil, �o� i � t1J j C' W !I 110 56124 C� mow: PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT'SYSTEM Owner PAcTP -IGj4_ . 04 M-A Address'14J FAIWW 04�j PAIT, 1�6� Located at (Street) ©iIP IOk9l C0WAtJW M0 01'4�i� Tax Map K, Block Lot (indicate nearest cross street) Municipality PMT! ; 0_4 Watershed Chi NY" UH SOIL PERCOLATION TEST DATA Date of Pre - soaking Q) I I-A Date of Percolation Test 0-7 0)O M 5 1- iutiti 1013 2 1 �1 1 049 41 3 jQv II°, 4/1 4 E I.1 I 15 1 1 1 1 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 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES . � DEPTH • �= - � � � • �� I�GLE NO. .... _ _.. HOL-•E NO � _ ., .. - _- ..:.:. I�O)JE NO'. G.L. 0.5' 0 —�" �'o�� -�" ToMm. 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' �jl'kND SAND 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered HOHt Indicate level at which mottling is observed HoNrl Indicate level to which water level rises after being encountered NA, Deep hole observations made by: H)U-�ho— J, 603WA6 =1; p,E Design Professional Name: _) +AW. W, WWOL6 J'He Address: P , Cs i ROY- Signature: Design Professional's Seal Date 01N6101 � � 'z 14 -16-4 (9/95) —Text 12 _ PROJECT I.D. NUMBER : ?`'t "d*l .617.20 Appendix C State Environmental Quality Review eu n *' Et itir)n iRnor r i A ASSEbolyl N I FORM ..•_ 3. For UNLISTED ACTIONS Only PART I— PROJECT INFORMq`1I6k (To be completed by Applicant or Project sponsor) SEAR 1. APPLICANT /SPONSOR D�T�1C.0 �r `^AILA . 2. PROJECT NAME 3. PROJECT LOCATION: 'f " � p \ T _ o h �,J{ Municipality I + County t� 1 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 04 �OK, C-vWV�) NOf% UP (,DW4\.10C1'D Pk\1 5. IS PROPOSED ACTION: &OW ❑ Expansion ❑ Modltication/alteratlon S. DESCRIBE PROJECT BRIEFLY: 1J-'�at� I fj�A'1• �,��?, `v�G�l �- �.d?1'��1-'1{�� � ijivl�� 7. AMOUNT OF LAND AFFECTED: I` CIS Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? ❑ Yes ® No If No, describe briefly VwP -AO�eh L rl 51L6 iW O -1i AOO r-P-WiA6t� ' 9. WHAT IS PRESENT LAND USE IN -VICINITY OF PROJECT? 26e3ldenllal 0•Indu3lfiai ❑ Commercial ❑ Aprlculture ❑ ParWForesUOpen space ❑ Other Describe: 6iW644- i"-1�t11 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCALJ? OYes ❑ No If yes, list agency(s) and permlUapprovals Ws71.AttD �(T- TQ�tJ �� pail �.�jor►1 J-rth1��L DP�� "sW� 4Q�N \tom ��� - ��fis� HIU►�t''� �E1��' �jdiv91� 5���" TOir►t' CY ��ISS£4h0� �1.Ot�� p�QT 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMrr OR APPROVAL? • &o ❑.Yes It yes,° 11st agency name and permlUapproval 12. AS A RESULT OF PROPOSEQ ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ONO ❑ Yes I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE H1GI44i / ��..FE /�� Pc!nE}A� °�" 10—O CI x AppJlcanUsponsor name: Date: Signature:' V if the' action Is in the Coastal Area, and you are a. state agency, complete the . ;lop,, - AVAssessmen t• Form before proceeding with. this assessment OVER PART II— ENVIRONMENTAL ASSESSMENT (To -be completed by Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate, the review process -and use the FULL EAF. ❑ Yes ❑ No B. -WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be- superseded by another involved agency.: ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers maybe handwritten, if legible) C7. Existing air quality, surface or groundwater quality or quantity, noise. levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character'? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species; significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. 06. Long term, short term, cumulative, or other effects not Identified in C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE.-CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? Dyes 0-No If Yes,- expWn- briefly-.. - . PART III— DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is- substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a).setting (i.e. urban or rural);'(b) probability of occurrir" f k- (c) duration; (d) irreversibility; (e ) geographic scope; and () ma nitude'. If necessary, attachments or reference su pport ing marials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ 'Check this box if you have Identified one or more potentially large or-significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a. positive declaration. . ❑ Check this -box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND. provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print.or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsi •e OfficeC in Lead Agency Signature of. Ptepa!er (I if erent from responsible officer) Date K PUTNAM COUNTY DEPARTMENT OF HEALTH _ u DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A.. GENERAL INFORMATION Lp7` Name of Project P4711NCAk Ci 7 County _ Site Location Building construction begun Extent Is property within NYC Watershed ?. .. ................ 1XI Yes No SECTION .B..TOPOGRAPHY (Please check all appropriate. boxes) 1. T 7 Hilly F--] Rolling [:R Steep slope dGentle slope 0 Fiat 2. Evidence of wetlands Low area subject to flooding Bodies of water 0 Drainage ditches_ F7. Rock outcrops 3. Property lines or corners evident ................ ....... ...........:................... d Yes F No 4. Do water courses exist'on or'adjoin the property? Yes No 5. Will. these affect the design of the sewage system facilities ?............ P71 Yes a No 6. Do watershed regulations apply in this development ? ................. ...... Yes F__] No 7 Will extensive grading be necessary? ......:.......... ............................... Yes No 8. Will extensive fill be necessary for SSTS ? ............:..... _Yes.. ��r .9. Do filled areas exist within the SSTS area? ........ Yes No If yes, what is the condition of the fill? SECTION C., SOIL OBSERVATIONS 10. Appearance of soil: M Sand 0 0 � 0 Gravel Loam Clay Hardpan Mixture 1=1: Observed from: Borings Bank cut �'Backhoe excavations l . 'Soil borings /excavations observed by 3 a on c .13. Depth to groundwater 7 t on 14. Depth to mottling —7 on 15. Are test holes representative of prim ry & reserve areas ....... ...................... .I........ Yes No AJ�SAStc� X11, Ai 5- 16. Soil percolation tests made by 9" 1 1 on 7 17. Soil percolation tests witnessed by �� on SECTION D (on back). Form ST -1 2 SECTION b. , DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes �No 19. Will groundwater or surface drainage require special consideration? ..................... Yes No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... 0 Yes No SECTION E. REMARKS 21. If a common water supply is proposed, has an inspection been made of existing or proposed source and facilities? ... Yes No . � :..................... o 0 Inspection data 22. Do adjacent wells and/or.sewage systems exist ?... .. .:................ ...... Yes --].No 23. Additional comments 24. Site observer /inspector and title V JU . ' I 1a 25. Date(s) of observation(s)inspection(s) . ®' :TEST PIT PROFILES Hole # Lot # Hole # 62 Lot # Hole # Lot # . Depth to water Depth to water Depth, to water Depth to mottling Depth to mottling . Depth-to mottling Depth to rock/imp, Depth to rock/imp. 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 A 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6 :0 6.0 6.0 7.0 _ .: 7.0 7.0 / 8.0 i, 8.0 .8.0 9.0 9.0 9.0 10.0 i 10.0 10.0 15. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT - SYSTEM Owner: J.. t1�al! lS Address: i Located at (street): /(� TM # Section: , Block ` Lot Municipality: Pro-- Watershed: _ SOIL. PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: 2 © Date of Percolation Test: (� • • • Time Stop Ela (min.) Depth water from ground surface Wate drop in inches Percolation Rate • �j=001 �L�AM, I�i�1_��i� 7■ WNIiIIN =1110410111M, =111 Notes: - l: Tests to be repeated at same depth until approximately equal percolation rates are obtained at, each percolation test hole. (i.e., < 1 min for 1 -30 min; inch, < 2 min for 31 -60 .miniinch). All data to be submitted for review, 2. Depth measurements to be made from top of hole. Form DD -47, p; t of { TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE # HOLE # HOLE # HOLE -# HOLE # G. L.. '. 0.5' 1.0' 1.5' 2.0' 2.5' - .3.0' 3:5' 4.0' _ < : 5.5' 6.0' 6.5' - '. 7.0' T5' 8.0 8.5' 9.0' 9:51 - t, 10.0' -t 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: Date Design Professional Name: Design Professional = Seal NOV -26 -2008 03:49 PM HARRY W NICHOLS 914 279 4567 Ik Po v � � :f•"'n.wn�' 'nip• —rn'e- A,.a :�.'„e.a. •'y'nw..�� ,ra,...'r } •N,.i�Mh •: +!,wt,!.t �� •yN+.kC :t��a � <:. i• • w MTt., ....�, -ate •- ;yk., ,,.rrr ' .�.rd'� •a`J � ;q ,. ,�i.• �c `h .':,r% •:: �ra,�"k�gao,�'° ,T.�•., i"'' Y��it> y d 'lli'KF�L�RY'?SMV •iF'�^; ... •MGS•'�'. y !. may ro✓ .�-StC' � 9M�•.n '!.tip: •� ,vjM1. ryi� • �:1r �> r.•V�ArA •, M' �i "C" T.n'1M.M.:IIh M:V1/N, PL 'Y•.. ♦ vn.. , - . .. .. ... .. ___ .. .- . .. . 7 - .. . -.... T.._.+ .. _ ,:,.',._.•..r.... ,.,,.,_,,,n,,,., � `� c''�' =.ate � . ,�. 6. 1�yeC•�'• a?w" t r• rf'• 1 �? /M�. ew•yWkP Hlat::mv,•;a , 'M cwsnMbN•1� -.r•r. r. . _ ..,•mow :d-" �f` �; •�.,F�. 4 _w.,� �.. i - Cam' -7'� ' 67411 JUL =1.3 -2009 04:23 PM .HARRY W NICHOLS :.,SHZRLITA AMLEI I-MD; MS, FAAF Commissioner of Health 914 279 4567 - ROBERT J._ R.ONDI Counry Exeemilve . P.01 0'7 -01 c LORETTA MOLINA►RI, RN, MSN "`"fit►° Q� j Associate Commissioner of Health DEPARTMENT OF HEALTH Sade.d 14 ri 1 Geneva Road, Brewster, New York 10509 REQUEST FOR FIBLD TESTING d�.daof All information below must be fully completed prior to any scheduling. : . ENGINEERING FIRM: r r, p$ONEt.#: x.71. w PERSON TO CONTACT: NEW CONSTRUCTION 0 REPAIR PROGRAM 17 ADDITION PROGRAM REASON: DEEPS: PERCS: PUMP TEST: 0 . 11 ROAD /STREET: TOWN:_ ,- 1r _ - TAX MAP #:, 3S_, 5-_ ,�..._ t SUDDIVISION: F LOT. #: OWNER:. star l �/±1�Ct lun NYCDEP CRITIE;RIA FOR JOINT REVIEW AND WITNESSING'OF SOH, TESTING YES N11 = ❑ Proposed SSTS within the drainage basin of West .Branch, or Boyds Corner & Croton Falls Reservoirs. ❑ .9k Proposed SSTS within 500 feet of a reservoir, reservoir stem or control `lake. o Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ �, Proposed SSTS design flow greater than 1000 gallons /day or SPDE, S Permit required. ❑ [ Proposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYC.DER project status (Joint or Delegated) based on the response. If you answered yes to any of the questions, NYCDFP must witness the soil. tests. This Departmdut will coordinate a mutually suitable time for field testing with the Design Professional andNYDC)EP. if a project has been.determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility-of the design professional to schedule re- witnessing of the soil testing with NYCDEP.* FOR COUNTY USE ONLY DATE:_„ TIME: CQIVIMFNTS: {fEQ. FOA FIELD T]l4CIN04CLY Environmental Ilealth (845) 278 -613o Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (843) 278.6026 WIC (845) 278 -6678 Nursing Nome Care Fax (845) 278 -6085 �•._._�_.... -. -. sa....�ty.e-- >.....r /QAC� 770.,CnIA Tr— MA @1 '170 X4A0 MAY -22 -2009 02:54 PM HARRY W NICHOL.S SHM01TA AMLEitT; Commissioner ofXealrh LORETTA. MOLINARI, RN, MSN Associate Commissioner of Health 914,279 4567 P,02 ROBERT J. BONDI DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 h EOU .,.EST FOR FYELD TESTING r All itaformation below must be fully completed prior to any scheduling. DATE: ~C ENGINEERING FIRM: �"`, PHONE #: PERSON TO CONTACT:_ rr V,NE CONST.RUCTION CI REP . R PROGItAIYI 0 ADDITION PROGRAM REASON: DEEPS- U, PERCS: W PUMP TEST: 0 -ROAD/STREET; TOWN: SUBDIVISION: 1 TAX MAP #: LOT #: UCDEP CRITERIA FOR JOINT RF-VMW AND WITNESSING OF SOM TESTING w - � . Y" E S . NO _ p Proposed SSTS witliir•,th�,, dr- inage .basl_n _of 'Vest Branch er Boyds Corner - &. _ .... _ _:... Croton Falls Reservoirs. ❑ Proposed SSTS within 500 feet of a reservoir, reservoir stem or control ts'ke. ❑ Proposed SSTS within 200 feet of a watercourse or a DEC wetlhnd, Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required, ❑ * rroposed SSTS for a Commercial Project. It is the responsibility of the design professional to provide the above l aformadoit prior to soil testing. The Department Will determine the NYCDEP,projcct status (Joint or Delegatod) based nn'the response. If you answered yes to any of the question's, N''Y.CDEP must witness the soil tests. This Department will coordinate a mutually suitable time for field testing with the :Design Professional and N'YDC P. If a• project has been.determined to be Delegated based on the above response and then subsequent inforination indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOIE COUNTY USE ONLY DATE• 'LIME- - _ -- -- k2Q. MK KeLfl TC21M* "Y Environmental Ilealth (843) 278 -6130 fax (843) 218 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278.6558 Fax (843) 278.6026 WIC (845) 278.6678 Nursing Home Care Fax (84$) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 MAY-22-2009 02:53 PM HARRY W NICHOLS 11arry W. Nichols Jr., F.E. r.0. Box 252 B•rewster,.N"'�C 10509 (845) 855-9275 TOS S Cl) worn: Z7 �Q. Pas1w, Imt RA9: CC; '11 616t 13' Urgent- rar'Rev" '13 Pleass Cbw1WCM lease Ke0y keo)ftl4p • Comments; kit ufsTzd_ r x* a . r7 o _ a° I VOC)J l0ao P Putnam County Department of Real= Avision of Environmentaf Health Services approved as noted for conformance with applicable Rules and Regulations of the Putnam County Health Department.. L 9 1 0 � n , o w Q1 �Q 41 �u t a e •\ ' n q n �•� A N h a - n � Putnam County Department of Healtil )ivision of Environmental Health Services approved as noted for conformance with applicable Rules and Regulations of the Putnam County Health Department... I ;tanature Title to THIS IS TO .,i'RTi; l' T;,: \'i l l;i lrii \i'; \: ".I' t ?i;i ...,.11. Sl S ?'T A! WAS to Q IITTR_Y"IED AS iNDICATfD i ?`+ i'iilti PI.AN SYSTEtf VVA.`i '111E SYSTEM WAS ::ONSlRi.'i i'Fi.% ;., ?,i(.i kihi' -..c CJIT'Ff A'_L T}IE RULES AND REGUiJ1TIG�Nt; O THE PU'tiNA,,i CO-UNTY OP HEAL'CH. i t g3.6 5;, I =� I ve 2.? F-v kA �OISy� �� ='�'a� �.:.; Ate:, r; � ✓i%� I'P:�rJa.:,�. r _ ` l.Ci � I�iO 4'Jl O4•" �aei�.l,..: �� �+ t M 1G'7 ,• ° NF � 1. , I° T�- e I x -elk SST 3�-�'• ��'-•� j (02' i 4 tT ve 2.? F-v kA �OISy� �� ='�'a� �.:.; Ate:, r; � ✓i%� I'P:�rJa.:,�. r _ ` l.Ci � I�iO 4'Jl O4•" �aei�.l,..: �� �+ t M 1G'7 ,• ° NF � 1. , I° ROB n OLLJ. op SO CL4 :vw .+u+w+ m AMU -. .vary: -�'!+a -m. . •. -.. � .. !. I �.'�° . � - � Op �oa� g � A 4 �-` -�- : Z.Ttos A Ytffgo LI c' iyt �..�a'a - - �� --•" q -1t r v 0 G.r -4 NOSE -26 -2008 03:48 PM HARRY W NICHOLS 914 279 4567 P.01 Harry 'W. Nichols Jr., r.E. P.O. Box 252 Brewster, NY 10509 (845) 855 -"75 e, From r1 phoned Dula• Res M. [� Urger! • E3 For Review [)[Please Cotr wmA © Please It" (3 plies 1teQyole, NOV -26 -2008 03:49 PM HARRY W NICHOLS SHERLITA AMI.,F:>EL, MD, MIS, FAAP' LORETTA MOLINA,RI, RN, MSN Associate Commissioner of Health 914 279 4567 DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 REQUEST YFIEJL]D TESTING P. 02 07.__0 ` cl ROBERT J. B.ONDI All information below mast be f. uily completed prior to any scheduling. DATE: 1 —LSD ENGINEERING FIRM: P PHONE #:, _ - PERSON TO CONTACT:, _ f Pk,NEW CONSTRUCTION ❑ REPA,XR PROGRAM Q ADDITIO PROGRAM REASON: DEEPS: ]PERCS: PUMP TEST: ❑ ROAD /STREET:,,Q TOWN:_ TAX MAX' #• srDIVISION: �',, t8 LOT #: ..._. OWNER:. r NYCDEP RI ERIA FOR- JOD T REVIEW AND WITNESSING OF iOlL TESTING _. S .._..NO. __..._• ....._ K . _ . . O ` Proposed SSTS within the drainage basin of West Branch or Boyds corner & Crotbn Falls Reservoirs. ❑ "" Proposed SSTS within 500 feet of a reservoir, reservoir stem or conttol lake; r3 Proposed SSTS within 200 feet of a watercourse or a DEC wetland. Proposed SSTS design flow greater than 1000 gallons /day or SPI)ESTermit required. ❑ Proposed SSTS for a Commerciai Project. It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the NYC))EP-project status (Joint or Delegated) based on the response. If you answered ygs to any of the questions, NYCDEP must witness the soil tests. This Department will eoordinsite it mutually suitable time for field testing with the Design Professional and NYIYCEP. If a. project has been.determined to be Delegated based on the above response and then subsequent -Information indicates NYCDEP is required to witness the soil tests, it will be the sole responsibility of -the design professional to sehedule re-witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY DATE: — Tim. COMMEI'iI's:• • q.gonms� »vesraaaxry ' Environmental Health (845)27&6130 Fax(845)278-7921 Water Supply Section (845) 225 -5186 Fax (845) 225.5418 Nursing Services (845) 278-6558 Fax (843) 278 -6026 WIC (845) 279.6678 Nursing Home Care Fax (845) 278-6085 Early Intervention/Preschool (845) 278 -6014 r4x (845) 278.6648 V1 ` poTted 'ZOwhiWAppReiWUN y.,xiiiiibei: Be" m \ / k�� \\ �,T o jWconst :#thi rSe ma: % .d :6 2kha - 2 : Ve : i <£ c in t ■#f,_k, ®.R :t a L Wwm Af»owv &9 +_ of / DAVID D. 'BRUEN County Executive DEPARTMENT OF HEALTH Division Of Environmental Health Services Decehiber 15, 1986 Robert Benedict 7 Lakeview North Salerm, New York 10560 RE: Proposed SSDS Constance Ciava Hyat Road Patterson, NY 80-3-4.5 Lot 5 JOHN SIMMONS, M.D. Deputy Commissioner ..Dear Mr. Benedict: Review of plans and other supporting documents submitted at this time relative to the above-captioned project has been completed. Comments are offered as follows:, 1. The proposed house is located within 100 feet of the designated wetland. According to General Note #1 of the Approved Subdivision, all structures, must be locatbd more than 100 feet from the-wetland.area. Upon-receipt.of a submission revised to reflect the above comments, this wilil be considered further. Very truly yours, William Hedges, Jr. Public Health Technician WH:rrk TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) -225-3641 , - 1151V__ � -1 iL ', _. , Zj-- 7 7777-17-, 77-F7, , -77, p, z .,Z�A % permit +f .COU NT DEPARTMENT 'HEALTH Re 7� Sdi' 'ai b&Wdn of 4, 05 2 'TION-PERMIT ..'FOR - SEWAGE .'DISPOSAL SYSTEM 4- jToWn or Village, 2V = Tax _�Mi 'Sub& ,000 171 % ' 0 1 Revision ell) Ak ib. 0wrier*/Addie- x.,�Aq; ".Da Date A tion' _Onl�E Npfiqap�on Require Number of �poro6!ps- Design Few C Notification -;Separaib :S`6 Werige' System , I -to consist of `Gal Septic .Tank n Sm Water : m0p.ly: Pdbljp. supPly. From S Supply to,:be drilled !rppresent t - Ka t-1 am' . wholly antl 6 m 4i6f ",above described will be con'striicted,a I s iKb4n -on' the',-a j County. D epart rn`eni, of `.Adalth_an6 thatlon c6rnplel be submitted td ' tSI - e , b`e' a : " Men a,nd ,a written In �pRe r atnj co#4kidA -any of said ance,Of At po iovil,dr"thi Cer i ca e,'&I, Construi wAll be located as shown , on the ap-iirovid-piari and !that County" Dapartment �of H ealth. _0 A. iV 7 Ad-dress -APPROVED iFOR CONSTRUCTION:.,This,approval., r'evocaDle -,IF. or cause 4;nended dr,oltfflei.' 'A -.new ermi r Approv d, for drspoial 0 G , � :Date - Rev.. 9-8i k W5 23 ir,the design and location o, he proposed - j th J 4 S60 ritoC46,Aiage�,disposal :SYsiin`4sjI -' atth ' a I _ ys'om 'an*regulat ions. of --tpe iin4ndrnent,tliereio and- iri accordance *lth"thi itin6ards,�ru_lei ATRIM 66m,riiissiotier'.6f Healthwill ;ee:wJl `bes, :furnished ;the owner his sueeessors,•heirs or;.sss�gns'by the builder that said builder. W iii4"o.- " f ' two , - j j- j 1�,yeja! s immediately Jol( 6'w in o t�h_ 4 _d, .i-� ts of, tqI i S4 Compliance -oreanyrepairs�ttj!'et q 2)1 that.the drilled'vell 89scr ibed above: - WOW-Wili beiniiallid' in.,accordance - , the standards. -ru6lei�j ar�d :i6iZ-IWIqns of.- th.i Putnam. V. I License. . No. 4"4. bg� ,es on I p �y r , 'e� I -from the date. ' ) i 4e d- ni e ,coq�tru c !on of b'een un - d er . t ke n a_ nd is c niid6ed:ne66ssj -I the;` change qrat i op I iconstruction st�cY it sew n orV r supply Y. Title •Z - . J 7 Owinei ovalA v� on equired = - ro 4� F � = ti 5 tl)� that 'the separate sewage:dlsposal "system indard6 rUle9an '.Cegu a IOftS "O 8; U name 1 sfactory to the C ati ommissioner of Healthwfll,. massigns'by� the builtler tha4 Said builder wrill aryl %immediately following 4hetlateA4the Issli a ere4o 2) °ttist the ddllled well described above rtls, ",rules and [egu NMI <of the °Putnam. c i Fv N Z 29 I °License'No i Iof the buildinghas been undertaken and is h ny " ;, ange.or.' alteration Of..COnftrUction'- Title ;, C. M I L T 0 N W-I1 S0N LICENSED PROFESSIONAL ENGINEER deq' Glia.e� C��'►�y w. '20 C/ loves -J 42 LAKESHORE DRIVE R2 BREWSTER NEW YORK 10509 TEL: (914)669 -5290 COMMERCIAL REFRIGERATION AND AIRCONDITIONING SEPTIC AND WATER SYSTEMS HEAT AND POWER CONSERVATION i L P Li • PUTNAM COUNTY DEPARTMENT. OF HEALTH R 7".07, E.I 4 - DIVISION OF ENVIRONMENTAL HEALTH SERVICES 3-1982 ;:..COUNTY "OFFICE' BUILDING; CARDM' �N Y 10512 ... PUi 'NAM COUNTY. .._ _.....,,,.. DEPT;. OF .HEALTH DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. ��, Ownerr � Jw d Located at (Street Sec. Block Lot , s street). Municipality Watershed .SOIL:PERCOLATION TEST DATA.REQUIRED TO BE SUBMITTED. WITH,,APPLICATIONS e Number CLOCK.:..TIME PERCOLATION PERCOLATION Elapse Depth to Water VaEer Ve . No >....._....... Time - From Ground Surface. in Inches' - Soil. Rate Start Stop Min. Start Stop .Drop in Min. /iri drop Inches Inches_,. Inche4 3D 6-5? 2..:_ _...:..._..._..- 3 �o 1A 30. 3 0. _.__.._....___.. _.._ ✓ el .� %- • � � � � a 5� .3 fa Notes, 1): Te' is to.be repeated at same depth until approximately equal soil rates are obtained -et lei ✓ .� %- • � � � � a 5� .3 fa Notes, 1): Te' is to.be repeated at same depth until approximately equal soil rates are obtained -et each percolation test hole.. All data to Tae submitted for . review..: ::,:,`2) Depth measurements, to be made from top of hole. 48„ 5 it 60" 6611 7211 7$'► 84" INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED INDICATE LEVEL-TO WHICH WATER LEVEL RISES AFTER BEING ENCOUN' TESTS MADE BYE Date •� r 20TAWMAYW&M 1Jr;51li1V , Soil Rate Used j Min,/l "Drop: S.D..Usable Area Provided _±Lj p00 No. of Bedrooms Septic Tank Capacity. 1 ?Gals �y Absorption Area Provided ByJ L- F. x24." ti/ P�ame rJ TA��i ARAv,4 Signature., Address U V—,P— . v0` . 2 SEAL THIS SPACE FOR USE BY -HEALTH DEPARTPMT ONLY: Q Checked by TNr. Date . • PUTNAM COUNTY DEPARTI11NT OF HEALTH DIVISION OF ENVIRO.NISNTAL HEALTH SERVICES Date�f I92 • Re: Property of \f d. Located at 04 Section Block Lot Gentlgmen: This letter is to authorize a duly licensed professional engineer or registered architect (Indicate) • __.___._ to apply for a Construction Permit for a separate sewerage system; to serve the above noted.property in accordance with the standards, rules on regulations as promulgated by the Commissioner of the Putnam County Department of Health,-and to sign all necessary papers on my behalf in* connection with this matter and to supervise the construction of said system or systems -ii - conformity with the provisions of Article 145 or 3.47, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. • � j R. 7,C41 Fp Ceuntersi F r4 TNF STAlt .( Seal ) ress �T7 'el.ephono Very truly vu,7s Signed_ - - - Owner of Propty X10 , (-'D E Address Tel ®p E ne • SEC 3 1962 . PU'f -NAM CUUNTY DEPT. OF HEALTH PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date __.. /Y c11i j 1.8 C> Re: Property of '� Located at 45 H�A-T (T) L3 Section Block Lot Subdivision of C_)t_D Subdv. Lot # r) Filed Map # Date Gentlemen: This letter is to authorize] . a duly licensed professional engineer or registered architect V ( Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection -with this matter and to supervise ,the.construction of said system or systems in conformity with " the " "provisiaris of"Art"icle -145 or 147, Education. Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned P.E. , R..A. , # Address �, ng �6 / I 75 WA n / 5' 6 elephone ery truly yours, i gn e d \' A A,C1lt1�.t'JZ. L�GL�CJI Owner of Property Address Town Telephone Division Of Environmental H%a,4h Services TWO COUNTY CENTER - CARMEL, N.Y.. 10512 (914) 225 -3641 -- • -. APPLICATION TO CONSTRUCT A- WATER_ WELL, C S WELL SITE SUBJECT TO FLOODING? _ YES .tg, NO F WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_6/,p.tgg"L, ESvA•T-e LOT NO-: 1=1V ATER WELL CONTRACTOR: Name / N%iQLA/%A5t4JA/--Address: •S PUBLIC WATER SUPPLY AVAILABLE TO SITE: _ YES �( NO - AME OF PUBLIC -WATER SUPPLY: -'-- - TO LC ISTANCE TO PROPERTY FROM NEAREST WATER•.MAIN I" y _ - OCATION SKETCH &'SOURCES "OF_' CONTAMINATION • `u `tom h'o h (d tie) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well 'as •set forth above is granted under the provisions of 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 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 attached to this .permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. ; Date of Issue: 19 • Permit Issuing Official Permit.is.Non- Transferrable STRkil A00HESS. • SUViNIVILLAGEICIFT lax GAW NUbibEA. :U. LOCATION 14 y 4-r' p P/-X'-IT F_ 86y 'IEEE OWNER NAME. • 11,E e AooaESS: 105 �u GIIA 4-22- I\?,-5-AiqA,\. .�SIVATI: ❑ 2U80 UC ISE OF WELL O'RESIOENTIAL ❑ PUBLI SUPPLY ❑ AIR/COND./HEAT PUMP ❑ ABANOONEO primary ❑ BUSINESS ❑ FARM ❑ TEST /OBSERVATION ❑OTHER (specify) • secondary ❑ INDUSTRIAL ❑ INSTITUTIONAL ❑ STAND -BY ❑ IOUNT OF USE YIELD SOUGHT —42— gpm. /N0. PEOPLE SERVED 4- -�/ EST. OF DAILY USAGE gal. 1EASON FOR ANEW SUPPLY ❑ PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION DRILLING ❑ flEPLACE EXISTING SUPPLY. ❑ DEEPEN EXISTING WELL WELL TYPE ❑ DRILLED F__j DRIVEN DUG GRAVEL OT?i 3. S WELL SITE SUBJECT TO FLOODING? _ YES .tg, NO F WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:_6/,p.tgg"L, ESvA•T-e LOT NO-: 1=1V ATER WELL CONTRACTOR: Name / N%iQLA/%A5t4JA/--Address: •S PUBLIC WATER SUPPLY AVAILABLE TO SITE: _ YES �( NO - AME OF PUBLIC -WATER SUPPLY: -'-- - TO LC ISTANCE TO PROPERTY FROM NEAREST WATER•.MAIN I" y _ - OCATION SKETCH &'SOURCES "OF_' CONTAMINATION • `u `tom h'o h (d tie) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well 'as •set forth above is granted under the provisions of 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 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 attached to this .permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. ; Date of Issue: 19 • Permit Issuing Official Permit.is.Non- Transferrable POTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF RVIRONMENIAL HEALTH SERVICES DESIGN DATA SHEET-SUBSUFACE SEWAGE DISPOSAL SYSTEM, FILE NO. I i ..Address'. ij, S4 t� , Located at (Street) �S HYAT T pp Sec. Block lot 5 nearest cross street) municipa.Lity Watershed KTIMZ SOIL PERCOLATION TEST DATA, PSQUI11ED TO BE SUBMITTED WITH APPLICVrW(#NS Date of Pre-Soaking 4 (,6 2 lqf6 Date of Percolation Test A ij(, 14 Igg HOLE KEBER CL= TIME PERCOLATION PERCOLATION Flom Elapse Depth to Water Fraa Water Level 90. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches ZeS 2 ao a5 0 a -3 3 4 5 2. C9 06 3 (9 a I Co c�5 5,3 4 315 3,3;Z 94 2 c�q 5(0 2 as, 1-7 it 3 0Y Q1 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to'be submitted for review. 2. Depth measurements to be made fray top of hole. rev. 9/85 I00i4v;i 1' 2' 3' TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION " DESCRIPTION OF SOILS ENOOIJUERFD IN TEST HOLES HOLE NO. JW HOLE NO. 4- HOLE NO. &fJDY 617a, j 5' 6' 7' 8a;ZJ 9° ST 10' % / :;:SV F5Q t 31 G c'� r� 11' ( ��t` ='1 ✓ c7 r 12' 13' M ' " 14' �0V2 190E ,! INDICATE LEVEL AT WHICH GROUNDWATER IS ENOOUNTERED PU TNA M nc pop Av y INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENODUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided 6-0 04 . No. of Bedr Septic Tank Capacity gals. Type D RC Abs ti y L.F. x 24" width tra' Other;r a- 0 1/�^' _z. V V • �.J�/ ' ,SfiV�s FS�i�'�D /n' 7 /�t�'�. Name I 0 Signa SEAL LOW, O.Y. (0(-09 �Co30 s OF NO THIS SPACE FOR USE BY HEALTH DEPAR'IlU ONLY: Soil Rate Approved sq.ft /gal. Checked by Date EDGE OF Mre7DF-e- wEr►..�,,ro pc� a of w,uar Lam►. W�fI.A►+D wE'rLA+•+� � ' o , _ OAPopH I Y g l LtYP) CIS 'ME -E OF ZK i { 1-1r �Q JE06 a. OF Ai-4r) NY-51 W aTI -AM D r -n 7