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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35. -5 -9 BOX 16 01799 I �T �64 ' I• �JL I T ' . , E=l MTN 01799 !D liiiAB[ COUPW DIWAIfflNM OF HEALTH i DhrMiitW'Hetlm,See�s.ansal.:N:Y IS61?`.`�. 014. PUMM WON SKWAGa DMOSAL SYS18M A Owe /A ,a t sew y 2 i" �S /[/Lot, r rant C- ow• or V ®IIEe Reoewd —Q AkarWen ❑ Date of Peevlopa Apptoy�l ,,. �` v . A, Fm secdo. 0* Ntobw d Heti� Design Flow G P D Led U PCHD Nod&." o)aRepnb+ed Wbm Pm b cimpletett. 006 9a� S Sepafde Sy� M comma 1 Q�eptic Tack ..d Te M:e�ead.h7 TR 17 Add,to Water Sop*, Pdit Sop* horn Ad6me erg-- FsLPdta/e•SWi4 DAW by. Otbae Rognb�e • 1 represent .Mat I am wholly and eornpletoty responsible for. the design and location of the Proposed System($). 1) that the separate sew di sal stem avow dasxi0id will to Constructed as shown on tnj'appr",amendment there to and in accordance with the standards, rules a requ of o nom County Department of peelth, and that on completion thereof a "Cwtificate. of Construct ton Compiianp"+fatisfactory to the Commissioner of Naalthwin a submitted to the DepartIMent, and a written 'guarantee will be. furnished the owner. his suceasaors. heirs or assigns by the bulkier, that said builder will play. in good OONatinj condition airy part. of p10' sewage ;disposal systeie..durino the period of two (2) years kninedletely following the date Of the isau- once of the Soprar I of the Cortifkati "of ConR►uctfon Coinwiencie of the original system or any repHrs thereto; 2) that the drilled well deawON ai6ow will a kle�ted eS rleww on the aYp!oved Dian aM_tnai said well will be Instal . in accordance with the std rd rules and ►puTaifo of the Putnam county Dapastmarlt of Hm#th n /nl Date 1 � `s/ - [ � e v' � e t 'Sign �t v v G kense P.E.— RA. A ddr No — APPROVED — APPROVED FOR CONSTRUCTION: This approval expires two.yearf from the gate issued unless construction of he building has been undertaken and is rviocable for cause or may be an►endad or eiodifie0 when considered necessary by the Commissioner of 14"Ah. Any change or alteration of construction n0uhefi a new permm Appro"d for dispout of domestic sanitery� sewage dy6r private, water supply only. Rev. 0/88 pne "./z / . /�� � Bye' Title e1,MpNItI Date fit "'. 11 and . .. I - 'i", Will "�Ote,.'q!ho ,t low. ;o►tNkate' of Cow well if ii milhou IPpoved plan and' that said 'well will Instal - in ran 4 �'AkA. ION :. Al T "ction 'of,thwt u Win- Tmials co -,b. 1 99 s. on and is *04.ippr 114i irdi to I •ik. woe� li, rogn,t a do , s . finite y rid/o-r* supply only miliwlrii� mw�pirmlt Ap,pro4lw f6i 41""i oftion""'d,le 0. a a Rev. By .10/88 Gate TitN l � 1 ' '' DNIM� d Ssivloaa.'C�tal. Pi.Y 1RSl?„ :a®CB�T� � M'� �t _I � � Y'8' IWAIM DErOSAL:STSZM.. liaaltl pt OL V A" r r-:0 Y)&_I Aj , 0--d e1,MpNItI Date fit "'. 11 and . .. I - 'i", Will "�Ote,.'q!ho ,t low. ;o►tNkate' of Cow well if ii milhou IPpoved plan and' that said 'well will Instal - in ran 4 �'AkA. ION :. Al T "ction 'of,thwt u Win- Tmials co -,b. 1 99 s. on and is *04.ippr 114i irdi to I •ik. woe� li, rogn,t a do , s . finite y rid/o-r* supply only miliwlrii� mw�pirmlt Ap,pro4lw f6i 41""i oftion""'d,le 0. a a Rev. By .10/88 Gate TitN LAURENT ENGINEERING ASSOCIATES, P.C. Route 22 & Milltown Road Brewster, New York 10 509 (914)278-6108 - (FAX) 278-2658 HARRY W. NICHOLS JR., P.E. CONSULTING .SITE ENGINEERS April 4, 1997 Robert Morris, P.E. Pu tnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Renewal Lot #1 Old Wall Estates Hayt Road Town of Patterson, New York Dear Robert: Enclosed are the following: 1. Four (4) prints of SS -1 "Proposed SSDS - Lot #1 ", revised 4-4-97. 2. "Application For Approval of Plans For a Wastewater Disposal System". 3. "Construction Permit For Sewage Disposal System", dated 44-97. 4. - "Application to Construct a Water Well" .dated 4-4-97. 5. "Letter of Authorization", dated 4-4-97. We would appreciate your review, approval and issuance of the Renewal Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nic ols, Jr.*, P.E. H)VN:RL:bd y W. NTicols- 92073 cc: Mr. J. Marrone w/enc. 4 Lb j -d DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 ;OI' `-WATER PCHD PERMIT 23 - 92 WELL LOCATION Street Address A/a -7�- Aoc, d Town/Village/City tea. ors Tax Grid Number 35._5_9 WELL OWNER J Nam Mailing e s a rrawe 127 Address `" Ac. re Private O Public USE OF WELL - primary 2 - secondary RESIDENTIAL 0 PUBLIC SUPPLY 0 AIR /COND /HEAT PUMP ® ABANDONED D BUSINESS 0 FARM 0 TEST /OBSERVATION 0 OTHER (specify ® INDUSTRIAL U INSTITUTIONAL 0 STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING 0 REPLACE EXISTING SUPPLY 19 NEW SUPPLY NEW DWELLING 0 TEST /OBSERVATION ® DEEPEN EXISTING WELL L1 ADDITIONAL SUPPLY DETAILED REASON FOR DRILLING c WELL TYPE DRILLED ®DRIVEN ®DUG GRAVEL. OTHER IS WELL SITE SUBJECT TO FLOODING? YES _/X _NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Q /a( Lot No. 1 WATER WELL CONTRACTOR: Name �% •8,D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: NIA TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:.-,- - - - LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE ON SEPARATE SHEET 4 -4 -97 L /)LO (date) (signature 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 thirt;• (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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: Date of Expiration Permit is Non - Transferrable 3/89 19 19 Permit Issuing Official White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller 44, APPLICATION FOR APPROVAL.:OF -PLANS FQR'A'-,'. VAST EWAT E R DISPOSAL.SYSTEX 1. Name and Address Mr ' . .bf. Appl icant::--' r Aa J,/^'O' nle .../27 A/ X ��5�9 2. - -H an, e of ProJect: 3. Lo'cation(!)N/C* '50 il 6 Ad'd'ress: Millbrooke Office Cent: n' ' :_ ) 4. Project Engi eer '-'---Br 'wstef '.NY '10509 e 0 V. License HuMber: Phone: (914).%278-6103_ a Tyoe of Project...' q, ..X Privlate/Residen'ial Food .Service' --nercial Apa rtri-ten ts I ns t itutional .' H6b,i,l e Home Park Office Buflding. Realty .:Subdivision:, -Other.(specify) Is this'project subject' t o State Environmental -Quality Review (SEQR)? TYDe Status (Check One) Type 1. ExeMDt Type II. UnlAste.d, X S. Is a Draft Environimental impact'- Statement (DE required? ............. L 9.- Has DEIS been completed 'and found acceptable by Lead Agency?, AIIA e.ncy i. is this project in an area under•'the control of -local planning., zoning, or other- of-I icials, ordinances? ......................................... 2. If so, have. plans been suL-mitted to such.'author.i ties?... l-'as prel in. inary approval beep* 'granted by '.such -authorities? F A Date Granted: ... Type of Sewage Disposal, System Discharge...... Surface Water X Ground �,at-ers If surface water discharge, what is the stream class designation ?......... ........ Waters index number (surface) ............... ........................ .... . TS project located ............... ca'ed nea L L .(: a public water supply system? Distance to xater supply 1\11A.. `F "'es, nar,-,e of water supply A10 TS near a public sewage collect-ion or disposal OT sewage systen, Distance to sewage Syster. Ilea -o[-: ob S e r ve JJ: 5 9Z_ 21:1. Na( 13 o: r-, , I t i 1 n s Pe c`L fl�,." (gallons pal- day) ...... : .......... 1 0 � 0 }25_ �TIs;Srate�.Q l ?�ut>a'r;t �D °f° c'h rge"El-in, ination System Pern, it required ?. 26. Has SPDES Application been.submiated to .local DEC Office? .............. 27. Is any portion of this project located within'a des ignated 'Town ,or'State wetland? .............. �� �23. Wetland ID Number ......:.......:.'.: ........ ............... ........ A 29. -is Wetland Permit required? ............. ... ............. NO Nas zppl icAt.ion been made to Town or Locale DEC Office ?' ......... . . . 3o. Does project require a DEC - Stream Disturbance Peri n? . .... .. NO 31. Is or was project site used for - agricultural activity iny'olvi'ng %application OT pesticide$_ to orchards- or other crops, solid or hazardous waste disposal,-.;. land-Filling, sludge application or industrial activity? YES"or:h0 % 6 . 32. Is project Iocated•w.i thin 1;000-feet of existence.of abandoned . landfill hazardous waste site, salt:stockpile,' andfill; sludge:d sposal. site or, any other potential known source of cont�nination? ...............YES or NO NO DESCRIBE: -: 33. Is there a local master plan or file with the Town or village? ...... S 3;. Are co.-, :-ii unIty water, sewer facilities planned to be developed within 15 years? A/0 - 5 .- Ar- e- -any'- sEUaS.e: dispo -s -al areas 'an "e'xcess o. i5"` slope? ....................... /V 0 S. Tax Nap ID huciber ....... ............................... ;f. Approved Plans are to'be returned to:' ................ . Appiicant _ Engineer" the application',is signed by a person ocher than the applicant shown in Item .1, the. pplication must be•accempanied by y-a Letter of Authorization: Failure to comply with this Covision may be grounds for the rejection; of any sub.-iiission. hereby affirm, under pena7ty' of perjury; that information provided on this on is true to the best -of Gy know7e -Hre end b--7 ier. Fa Ise stat &7�nts 'n, zde herein are punishable as a Class k Hisde;. .eanor pursuant to Section 210.45 of the Penal Law. j n U C S ` Cz 0 i r �. C ! . L ( L E S : 1 �/W y'�l J' • / /w'J�!%!�• �I --- - -.... iill'(vEoo!:e Office. Cui�tse LN� ' Rre� aster, 1' 1050, "' �,DDr,ESS: • PUTN__LjUNTY DEPARTMENT OF HEA'i DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date.,:* - Re: Property of /Lip, ; %,� t r-5 A4 g V'1r-O', f Located at 7 J (T) �c��, �Gti Section �5�, Block Lot Subdivision of Subdv. Lot # j Filed Map Date 3 /y. Gentlemen: l This letter is to authorize A0, V- r «�, a duly licensed professional engineer [__�or regist.ered architect (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 th'e 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 sy "stem "dr syst -ems -in - conformity" with the provisibns of Article 145 or 147, Education L� the Public Health Law, and the Putnam County Sani- ,,iQr. tar' Cqde . w� NIC ��" i� h Very tru y urs , + 2' a� •� �s, ,�..:.��, �, ��1 u ^rte= Signed ne '�:? �a``r / - Coun ersi g =SSi�'j ne �l �i P.E. R.A. , # ��� 2Z./ Addr_ ss Address To-+An j 5�� -C� o Telephone Telephone r n, . t ecl TTi ®F ®O�UANi$ r®e�r Foe sawwGE Dli� i e 3 4 _a Owalo/ AppWmit i/ "� YfY/"tC1' eao9_ l�ovl®8� ❑ / Nena Adiliew TOM ubdivsion . Fee 'Enclosed ljpe�C Lot AeaO �r C��o Se2tlea pad alt+ Vala®e• ned9oa Ilow c P D es m w n,Pm m lea — 1 Dt3d seea sy� to Gaut d . Took mo 31 IN easmalkliled by --� ®vainer $fib' piihib Slt`Fti� Atidieeis _h) err 1/ odite S ao9y, Dsffimd by 1 rapreant'that'l em wholly a'" completely rospo not a for the design and location of the proposed system(s); l) that the soparato saw di sal stem . ab0lie ddpipo0 will,bo,constructed as shown on.Me approved amendment there to and in accordance with file ftarida►ds, rules a requ ns -o : nam Cquf:Y Deportment .;of bfeetih; a�lA flail on cofnpgtion thereof a'nertificato of Construction Compliance" m, actory.'to the ConlmissbnN;of MMlthwili IM Rfbniill"' to tho._ 0,6' rlment and a wrltten?iguaranteo will `, fumish®d tM ovrner ills ti+ccessors. heirs or" Designs by tho builder. that sell builder will .in good operating "condition any ?part of 'told savq qe dilposH System during the period of live 12) years'hnmedistely following.thedate, of the issu- ante Of the appr"'ml � the'.CertifWAte of Construction Compliance of the origUnal system_ or any repaint t ' eto; 2) that the drilled well described above wlol be located as alw6r n on the sppvoved a" and that said well will be.lnstal ie accordeno0 with the stands s. r and ►egu ha of the Putnam CeuntY Oepartniam of Meetth; Date P E P.A. t?y Addle At i I b�eolk _ - (�t'i f.0 License No APPROVED FOR CONSTRUCTION ,T1i;s approval expira{tiao Peak from'the data.., issued unless constructio . of file building has been undertaken and i4 IeY04ble for teens 01 may W,anNnOeO or mod Nhid. when con sidaree notes Rev. O 'o�wr of Health. Any change or alteration of construction "s ires a now pMn Approwfed Yor' disposal of domestic sanitary ago at supply - only. Oo4o f� . r. 7 . gy T �. 10/88 Title DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 r �..- > 'APPhI` CATION �� '.: w. t..�:"TO CON STRUCT-�A;:.WATER-_•WE,Lt _ _ _- . .., PCHD PERMIT P -Z3`9Z, WELL LOCATION Street A dre s a o 1/,Village Cit Tax Grid Number WELL OWNER ame Mailing Address 01""^ '/✓it s, irrat4 , 6% w ff rivate ublic 6 SE OF WELL - primary 2- secondary RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION 0 INDUSTRIAL b INSTITUTIONAL O STAND -BY MA D O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /16 ❑ REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLING PEOPLE SERVED S` /EST. OF DAILY USAGE (L gal ❑ TEST /OBSERVATION GL ADDITIONAL SUPPLY 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE VkRILLED DRIVEN []DUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: A taa Lot No. % --r WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 4,1- NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER_MAIN: ..... W� bf _ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET 9 R- 94 date) (si ture) 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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a m ner as not to degrade or otherwise conta ce or groundwater. Date of Issue: 19� Date of Expiration 19T Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller i6 PUTh -_.L COUNTY DEPARTMENT OF HEA.L_rI DIVISION OF.ENVIRONMENTAL HEALTH SERVICES - Date Re: Property of /Lip- /`t 4 V -O� P . Located at 1 (T)� Section Block 5' Lot Subdivision of Subdv. Lot # % Filed Map ; )1.3 Date 3 /y Gentlemen.: W This letter is to authorize )4cayrrn 141, 'v"k, /f Z' a duly licensed professional engineer [_�or registered architect . 9 (Indicate) . to apply for a Construction Permit for a separate selvage system, to serve the above noted property in accordance with the standards, rules or regulations. as promulagate.d.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 provisions of Article 145 or 147, 'Education Law, the Public Health Law, and the Putnam County Sani- tart' Cgde. / ' Coun ersigne� P.E. , R.A. , . # �3 Address PQ_ t�)5 611 �Y a-� 0 __ &,10 0 Telephone Very tru1 y purs , Signed t&v' (1 1,/('/)�"/1� Oz e% of P]q' e� 01 Add. ss Town' 21' -7 � Telephane D t; a LAURENT ENGINEERING T 5 ,.:. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278-6108 - (FAX) 278-2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS September 30, 1994 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Renewal Lot #1 Old Wall Estates Hayt Road Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -1 "Proposed SSDS - Lot #111,. revised 9- 30 -94. 2. "Application For Approval of Plans For A Wastewater Disposal System ". 3. "Construction Permit For Sewage Disposal System ", dated 9- 30 -94. 4. "Application to Construct .a Water Well" dated-9-30-94. 5. "Letter of Authorization ", dated 9- 30 -94. We would appreciate your review, approval and issuance of the renewal Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Ha y W ls, Jr., P.E. HWN:bd 92073 cc: Mr. J. Marrone w /enc. • b • pUTNAN.� COUNTX DEPARTMENT OF 1`iEALTH APPLICATION . FOR APPROVAL OF PLANS._ FOR..A- WASTEWATER ...DISPOSAL SYST :EM,_:, ... m.i .v.- •-r,r .:.a::._. _.e . . - s a.,t =•... _.s...:.. ..r,._ _ .. .-.v ,. -�ti _ +x..a. a._ 1 . Name and Address of Applicant: __��( v, �J�,r,•, ,�/�� r!-��, �� i 2. Name of Project: %0 i 3.._, Location/TyV /C: ���w✓sa ti Aja 4. Project Engineer: to r c' r, 5. Address: .License Number: Phone:2:7 9 �4 «� 6. Type of Pro•iect: !/ Private /Residential Food-Service ...Commercial , Apartments Institutional Mobile Home*Park Office Building; Realty Subdivision Other (specify) 7. Is thi; project subject' to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? vd 9. Has- DEIS been completed and found acceptable by Lead Agency? 410. Name of Lead Agency 11. Is this project in an area under the control of local planning.,_ zoning,.......__ .or.other officials, ordinancesT . ......:.. .....................:....:.... /�%U' " 2. If so, have plans been.submitted,to such.authoriiies? .................... ��_ 1• 13. Has* pre] iminary approval* been granted by such authorities? Date Granted: i4. Type of Sewage Disposal_ System Discharge..,... Surface Water mound Waters 5. If surface water discharge, what is the stream class designation ?........ 6. Waders index number (surface) ... /✓ 7. Is project located near a public .water supply system? .................. 3. If yes, name of water supply —'--i Distance to water supply, . f 9. Is'project site near a public sewage collection or disposal system ?..... V o _ 3. Name of sewage system Distance to sewage system 1. Date observed: to ti /9—) 23. Name of Health Inspector: (l , rJ 5In'' Project design flow (gallons per day) ...... ............................... oa e" ` . 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. U 26. 'VHas' SPDES Application been submitted to local 'DEC Office? ............. 27. Is any portion of this project located within a designated Town or State wetland ? ............. - ..I...... ..... ............................... 28. Wetland ID Number ........................ ............................... ✓/ 29. -Is. Wetland Permit.-required? ............... ............................. ... /✓ d Has application been made to Town or Local DEC Office? ..............:.... 30. Does - project require a DEC Stream Disturbance Permit ?, ................... 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards 'or other crops, solid or hazardous waste disposal;``'`' landfilling, sludge application or industrial activity? .... :.YES or N0 32. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of irontamination? ...............YEAS or NO.— DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........:. :__ 34. Are community water, sewer facilities' planned to be developed within 15 years? ✓d 35. Are any sewage. disposal. areas..in excess of 15% slope? ..............:..:...... A0-- 36. Tax Hap ID Number ... 37. Approved Plans are to be; returned to: Applicant l/ Engineer 'f the application is signed by a'person other than the applicant shown in Item.1, the. application must be-accompanied. by - a Letter of Authorization.' Failure to comply with this )rovision may be grounds for the rejection of any submission. I hereby affirm, under- penalty of pej-jury,- that information provided on this , form is true to the best of my knowTedge and be7 ief. False stater,}ents made herein are punishable as a Class A Hisdemeanor pursuant to Section -210.45 of the Pena 7 Law. ,I A , ;IGNATURES & OFFICIAL TITLES :_ :AILING ADDRESS: DESIGN DATA SHEET-SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner V Address Ci, Located at (Street) Sec. 33 S'. Block Lot. (indicate nearest cross street) Municipality Watershed kv a2:!4 Date of Pre-Soaking 16 jq2- Date of Percolation Test 14 Iq 2-., ROLE KVBm CI= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start-Stop Min. Start stop Drop In Min/In Drop Inches Inches Inches 1 g '4 3 q — I d! o (g- 2-7 2:a 11 ";� 'A *3 1, 9 pT -1 2 0: 'o t, - 10 ' 3 30 d —3 M-3a- /I �d(. 3o 4 5 -10 2f 2-"e' L, 211 Q :7- 9 T-2- 2 W:04 -16',31 -7 :Z77 3 10:3 10!5-9 :2 4 5 2 3 4 Nom: 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 revie"w.* 2. Depth aeasureTents to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. / HOLE NO. ? HOLE NO. G.L.. . ... . . _. 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 1.2' 13' 14' INDICATE LEVEL AT WHICH GROUND IMM IS ENCOUNTERED . INDICKE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE:. DESIGN Soil Rate Used -tU Min/1" Drop: S. D. Usable Area Provided No. of Bedrooms 3 Septic Tank Capacity 16 00 gals. Type Cz,,,c Absorption Area Provided By 333 L.F. x 24" width trench Other Name yr AleLL r, Signature 1� Address '73 y I"�?. t r e v ° F r v e,, SEAL � � g Au n THIS SPACE FOR USE BY -HEALTH DEPARZMENT ONLY: s No. 56124 �O'00OFESS%o Soil Rate Approved sq.ft /gal, Checked by Date APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: , � - V, Lo i-o J 2. Name of Project: 0 re- 120 — I.. _. TIV/C: _Locatiok�, 4. Project Engineer: r CT 5. Address: License Number: Phone:2:7_9� - 6. Type pf Project: Le" Private/Residential Food .Service .•..Commercial Apartments Institutional Mobile Home Park Office Building, Realty Subdivision other (specify) 7. Is this project subject:to� State l' :Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name.of Lead Agency -p-roject -fn_ -an --area---unde r- -the - control- -of-Ioca-l- pl dnnifng-i- zon i n-9 i or other officials, ordinances? ........................................ 12. If so, have plans been.. submitted to such..authorities? ..................... 13. Has preliminary approval been* granted by such authorities?— Date Granted:—/V/ A 14. Type of Sewage Disposal. System' Discharge ...... Surface Water mound waters 15. If surface water discharge, what is the stream class designation ?........ '6. Waters index number (surface) ............. ............................. 17. Is project located near a public water supply system? .................. i8. If yes, name of water supply Distance to water supply ;9. Is project site near a public sewage collection or disposal system ?..... N/J 'O. Name of sewage system Distance to sewage system 11. Date observed: 10 /11�- /97— 23. Name of Health Inspector: 4. Project design flow (gallons per day) ..................................... Le OCI E 25e I "s State Po3l�rtsni Dischai-ga Cl °isnination -Systun (SPDES) Permit required?. ' 26. Has SPDES Application been submitted to local DEC Office? ............... _ 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... Xc 28. Wetland ID Number ............ ......... .............................. 29. Is Wetland Permit• required ?', ............................................. d Has application been made to Town or Local DEC Office? /U a� 30. Does project require a DEC Stream Disturbance Permit? ✓ V a 31. Is or was project site used for agricultural activity involving application of pesticide$_ to orchards or other crops, solid or hazardous waste disposal',," landfilling, sludge application or industrial activity? ........ YES or NO 32. Is project located within 1;000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of. contamination? ..... ".........YES or NO DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ............ _ 34. Are community water, sewer facilities planned to be developed within 15 years ?. /" d - 35: Are any sewage -dispose' -- areas: In . excess - of J5 %- -slope? 36. Tax Map ID Number .......................................................... 35"'11, "— S- 37. Approved Plans 'are to be: returned to: ................ Applicant C�-� Engineer :f the application is signed by a person other than the applicant shown in Item.1, the. application must be: accompanied by y-a Letter of Authorization.' Failure to comply with this )rovision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Hisdemeanor pursuant to Section 210.45 of the Pena 1 Law. ;IGNATURES & OFFICIAL TITLES: (AILING ADDRESS: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 _ APPLICATLON -TO. CONSTRUCT A WATER WELL - /1 PCHD PERMIT #�� WELL LOCATION Str � A dr70 ` �ll�age C Grid Num�ber WELL OWNER -Name Mailing ✓av-,v Aweal' lZ Address Private d 8i_c� Y, r i � Public 7 SE OF WELL 1 - primary - secondary RESIDENTIAL BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT J gpm /# PEOPLE SERVED �_ /EST. OF DAILY USAGE gal REASON FOR DRILLING O REPLACE EXISTING SUPPLY dNEW SUPPLY NEW DWELLING O TEST/ OBSERVATION Q ADDITIONAL SUPPLY U DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING z t WELL TYPE I OPRILLED DRIVEN ODUG EIGRAVEL C1 OTHER IS WELL SITE SUBJECT TO FLOODING? YES 1--'NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Old w..' j. Lot No. WATER WELL CONTRACTOR: Name 7_80 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES [/ NO NAME OF PUBLIC WATER SUPPLY: -R Z/A-- TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH.& SOURCES OF CONTAMINATION PROVIDED 151,ON SEPARATE SHEET (d e) ignature) 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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: 095r 19�-- Date of Expiration 19, Permit Issuing Of icial Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 16' X 40' Unfinished Second Floor ® 640 Sq. Second Floor First Floor rpa,, , PUT,I414 C .. 40, _ 1 DIHIx6 ROOW I l TH 0 `- TE�R BED 'MASS 4 0' — KITCHEN I E'- E'X 1 S' -O' LIVIH6_:ROOM 7411. a, X..i s,: O,._. MEN JJJ 27'8" t�.' �► ` Cn r ra � STANDARD NEWFOUNDLAND FEATURES • Luxurious First Floor Master Suite o Fireplace Options Available • Compartmentalized First Floor Bath with o Consult an Authorized Westchester Builder Two Separate Vanities for a Complete List of Options • Formal Entry Foyer 0 Artist's renderinos and Floor Plan Dimensions are • Formal Dining Room approximate. Allwspecilcations must t;e Written in the Contract. No oral conditions. • Formal Living Room • Spacious Eat -in Kitchen 11 :: _ES TCHESTER ODULAR OMES, INC. Reagan's Mill Road o Wingdale, NY 12594 (914) 832 -9400 • (800) 832 -3888 v 0 E: -, G '4 I X,, ` l JJJ 27'8" t�.' �► ` Cn r ra � STANDARD NEWFOUNDLAND FEATURES • Luxurious First Floor Master Suite o Fireplace Options Available • Compartmentalized First Floor Bath with o Consult an Authorized Westchester Builder Two Separate Vanities for a Complete List of Options • Formal Entry Foyer 0 Artist's renderinos and Floor Plan Dimensions are • Formal Dining Room approximate. Allwspecilcations must t;e Written in the Contract. No oral conditions. • Formal Living Room • Spacious Eat -in Kitchen 11 :: _ES TCHESTER ODULAR OMES, INC. Reagan's Mill Road o Wingdale, NY 12594 (914) 832 -9400 • (800) 832 -3888 v LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE _.._.._ __. _a ._ -. _ _..__._.. _, �..,:a..P�i�Ef.�S.C3Al;»=t CIE. W.. YARlE�i2563:4 ;_ „- �_�.__- ,..,�. ;� r�.:.�.- :�.�:,• :-:� ;:.���,�..= .,.o.,;- e.,....., (914) 278.6108 -(FAX) 278.2658 RANDOLPH W. LAURENT, PE. HARRY W.NICHOLS, JR., PE. CONSULTING SITE ENGINEERS November 4, 1992 Mr. William Hedges Putnam County Health Department Route 312, Geneva Road Brewster, NY 10509 Re: Individual SSDS Lot 1, Old Wall Estates Hayt Road Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of drawing SS -1 "Proposed SSDS"., dated 11 -4 -92. 2. "Application For Approval of-Plans For A Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 11 -4 -92. 4. "Application to Construct a Water Well ", dated 11 -4 -92. :....__._,. .5:; "Design -Data''Sheet" . _ 6. "Letter of Authorization ", dated 11 -4 -92. 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 8. Money order in the amount of $300.00, review fee. We would appreciate your. review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely, LAURENT ENGINEERING ASSOCIATES, P.C. H drry 7 W. 'chols, Jr., P.E. HWN:bd 92073 cc: Mr. K. Dumont w /enc. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of /Li ter, ;)r- A4q I-t-O� P. Located at 1 5 R/I42) Section Block 5' Lot Subdivision of od Subdv. Lot # % Filed Map # lbI3 Date 3 )jb Gentlemen: This letter is to authorize Aa V r JI FY, a duly licensed professional engineer c %r registered architect (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 provisions of.Article +145 or 147, Educa tary C the Public Health Law, i Coun P.E. , R.A. d Address Telephone and the Putnam County Sani- Very truly y`purs , Signe O-YV -- 4e 0of P ert � �J Addr ss Town ,!!� '4s--3 Telephbne F PUTNAM COUNTY DEPARTMENT OF HEALTH �._.�:,. �;. �.: ��.: �:_. �DLV��I�► �:- OF: EI�JVIR. O. ��. �__ ��: H��A_►.- L-_ ��- I.. ���. t .VIC�S.:.:.:;_.���_..__.....�:_ CERTIFICATE OF CONSTRUCTION COMPLIANCK 1 0 , ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P 312 i Z IFIZ LE. 11Vz 0509 Located at U / }eo J Town or Village A ors d Owner /Applicant Name Ja—L -, r s 1144 j_ y_ai, Tax Map '3!;"' . Block 5� Lot _ Formerly Mailing Address 1 Z7 Subdivision Name Subd. Lot # Zip -10 S`a `%' Date Construction Permit Issued by PCHD dj - 2.3 9 7 Separate Sewerage System built by Address "� 7Q�►, e_rF -� Consisting of 10 U dl Gallon Septic Tank and '/335 U, 4, A Y, Other Requirements: Water Supply: Public Supply From Address or: %/ Private Supply Drilled by ��. �c jt/ei� �G Address J& ra. Ca- ,JJ _..._ ...BuildingType / 5 P.k f t u Has erosion control-been completed`.- ..__....._. y - a Number of Bedrooms Has garbage grinder been installed? ' U d 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 Countypep"ent of Health. Date: 12 -2A -99 Certified by Address ME P.E. `--"' R.A. License # 'S'6- l 12— 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 apesubject to modification or change when, in the judgment of the Public Health Director, such revocation; m dificati A r change is necessary. By: Title White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY (DEPARTMENT OF HEALTH (DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT del) )Coca iom "'`° Sfr-&t G Tess: -` - /- - " - "-' - �cQ 120 0.o/ Town/Village: Cc,�i�PilS a-d1 Tax ,�Grid # MA "5 jslock Lot(s) Well Owner: Name: i Q Address: Z 7. - �Q e ro n � � a W V 0 & "2e-' %'ot Use of Well: 1- primary 2- secondary V, Residential Public Supply Air cond/heat pump rrigation Business Farm . Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion __X Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Casing Details Total length _ft. Length below grade a-j ft. Diameter , (I in. Weight per foot _L9 lb/ft. Materials: Steel _ Plastic _ Other Joints: —Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner Yes V No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test Bailed Pumped –1 Compressed Air Hours Yield I O gpm Depth Data Measure from Ian surface- static (specify ft) (� During yield test(ft) !S'S— Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface W !SS'" `r _ If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type4 � Capacity Depth Model 4 g _ jD C7 �l Volta e Tank Type �,�lxa,,,��Volume Date Well Completed 10 -13 -fig Putnam County Certification No. 00S Date of Report Well Driller (signature) 4, NOTk': Exact location of well with distances to at least two permanent landmarks to be provon a separate sheet/plan. Well Driller's Name Address: %ZD �5' �Sa- ��l 6 Signature: Date: it (,p 9-tx White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 NORTHEAST LABORATORY OF DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06$11 - CT Cert: PH -0404 r , (203) 748 -7903 -FAX (203) 748 -0651 NY �Cerf: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: HAROLD HAVILAND DATE SAMPLE COLLECTED: 12/17/99 27 KENWOOD RD TIME COLLECTED: IO:OOAM PATTERSON, NY 12563 COLLECTED BY: HAVILAND DATE RECEIVED @ LAB: 12/17/99 TESTED BY: LAB #11471 REPORT DATE: 12 /20/99 SAMPLE SITE: OLD RD. PATTERSON, NY 12563 SAMPLING POINT: KITCHEN FAUCET SOURCE: WELL TREATMENT: NOT STATED TEST PERFORMED RESULT: MAXIMUM CONTAMINANT LEVEL BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml PHYSICALS: Color 0 15 Odor ND 3 Units pH 5.95 no designated limit Turbidity, 1.7 NTUs 5 NTUs CHEMISTRY: Nitrite N <0.005 mg/L as N 1 mg/L as N Nitrate N 2.24 mg/L as N 10 mg/L as N Alkalinity : 32 mg/L no designated limits _Hard_ ness _.__ „w -68 _. mom._ :.:._ nmg/L -.__. no designated limits Iron 0.081 _ 0.30 mg/L z Manganese <0.01 mg/L 0.30 mg/L [Note: Combined. Limit for Iron plus Manganese = 0.50 mg/L1 Sodium 24.9 ** mg/L 20 mg/L ** Lead 0.006 mg/L 0.015*** m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units "Notification Level * **Action Level RESULTS BASED ON SAMPLES SUBMITTED: SAMPLE, AS TESTED ABOVE: AM POTABLE or OkOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) a I'll Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY (DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT....- _. WelrLocation Street Address: 0 t /,;?(9 TownNillage: a*- ,4S a I 1M50:!5_y1ock Tax grid # Lot(s) Well Owner: Name: Address: j2, j) /LL 7-a tea.mes Marron 'w'S7X70-L /— Use of Well: 1- primary 2- secondary _ K. Residential Public Supply Air cond/heat pump frrigation . Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion __K_ Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length �_ft. Length below grade av ft. Diameter _�in. Weight per foot _lb/ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: KYes No Liner _ Yes _1 No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) - Developed? First Yes—No Hours Second Well Yield Test _ Bailed Pumped A Compressed Air Hours:? Yield I a gpm Depth Data Measure from land surface-static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses .... are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface % i(,/ _t If yield was tested at different depths during drilling, list: Feet Gallons Per Minute . Pump /Storage Tank Information Pump TypegU raj Capacity 7G'� Depth Model d �� Voltage 0© Tank TypeQ YX,—' Volume Date Well Completed 10 -13 49 Putnam County Certification No. 00S Date of Report Well D`rillller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provi n a separate sheet/plan. Y� 4'41UtaM bJt Q (% Well Driller's Name Address: Signature: 4 Date: LO S White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 N NORTHEAST LABORATORY OF DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT.Cert: PH- 0404 -- :: _"-_'1.-'(203).748 - 7903: - FAX�'(203)- 748-0652: -- _ ` . _ , ._ N1' Cerf: 11471 , LABORATORY REPORT -,- WATER SUPPLY TESTING REPORT TO: HAROLD HAVILAND 27 KENWOOD RD PATTERSON, NY 12563 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) PHYSICALS: Color Odor pH Turbidity CHEMISTRY: Nitrite N Nitrate N Alkalinity Hardness .... - .. iron Manganese DATE SAMPLE COLLECTED: 12/17/99 TIME COLLECTED:10:00AM COLLECTED BY: HAVILAND DATE RECEIVED @ LAB: 12/17/99 TESTED BY: LAB# 11471 REPORT DATE: 12 /20/99 OLD RD. PATTERSON, NY 12563 KITCHEN FAUCET WELL NOT STATED RESULT: N 0 ND 5.95 1.7 <0.005 2.24 32 68 _ 0:081 - <0.01 MAXIMUM CONTAMINANT LEVEL per 100 ml 0 per 100 ml 15 3 Units no designated limit NTUs 5 NTUs mg/L as N 1 mg/L as N mg/L as N 10 mg/L as N mg/L no designated limits mg/L no- designated limits mom, .....: _- - U.J0 mglL•.. ...... _ ... mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 24.9 ** mg/L 20 mg/L ** Lead 0.006 mg/L 0.015 * ** ml = milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTED: SAMPLE, AS TESTED ABOVE: AMPOTABLE or aOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) « ! Y'ftiq Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 ptynu%M co_mrvy r;�',A a1r�;.:.nr or �; Ar..;rTl DIVISION .' OF LWjRC)NL mF rfd, HEAL'r �' SL;RVICES Owner °or.Purchaser bE`Bu 'l :ins Sec�ion Block Lot Building. Conof r�u'rt+ 4 tai - '1� Location, - S tree L - - -- Suixa ivision� '. M nicipality ' I devt-tc t�_ Building Type -- - -- ;,ILkdivision Lot # GUARANI' AI AN'CI" .� ;ri Ir l c, . , 1.., , I? I 1121�'A I' •;[;Ihf'71 � `(1; ;1\ ;Yr, . � ' �. �.....- _.......�J.... _ .... . _.- rte_....__- r...._- .._.. -_ 'II• , • ' ' '•I •..AI/' Ir1 ti•' y rc' �p for • tiha location, t wra rt ]l f �u workmanship, mkiter`lal, constturti.c�n ;'n:l clrni.n.7190.of: tho sowage disposal system serving the above' desczibO. prolx_rty, and that it ,has been constructed as shown on the approved plan or app'roved awun dmunL Lhefe-Lo, ana In accordance with the standards;' rules: and :regulations of the Putnam County Department of Health, and hereby guarantee to thie 'owner'; his successors, heirs or assigns, to place in good operating'condition any part of said system constructed by'me which fails to operate' for .a period, of two: -years .iirmecli ately i:r.',1', wing the date of approval of the "Certificate of ConstrPction Compliance'' A i:ha sewage disposal system, or any repairs made_by ms t''o :;uch nystrin, whor,' '..`;r• i,- •a.i.l.urn to oper.-4_te properly is ,. caused -b, the' ctii3 -f1- or- -nE 1'i cnt L of , , •. :1:::' y g - uparrt of --the•• buildin ' ut•il -izin the system. The undersigned further :.Il�rl �. i ,c:::. �,t a; :OIIC.I.u_:.ive Lhe detetm.ination of the' Director of the Division of Envirnnirrntal ;iealti Services of the Putnam County. Department of Health as to wheUier oc noL Lhe LaiL.,ire of the systen to operate'was cauaed, by, tho willful or nhgli1Jr l,r. :,L:1 ,�f. I.lu� Ix:cu;:, :tnL oC Lho building utilizing the system. Dated this day, of o✓ 19 9 ��i� riaLur'� 1.'1. LIE! ', �zSd �,.st /lam General Contractor (Ownu )' - SiYrraturo e!5 ,v; /,ti 41t L �?Orporz ion Name- (if 'Corp.) Corporation Name (if Corp.) 1�7 4 z,, " j " v_d A•- l v Addr7s mk � ' _3 7 Address / -,thdt represent— am.! Wholly 4111d; Coii'1j')1,,L,.�L61y rdsoonaiblo for the location, workmanship, material, c6b'gttucti,or) �-nd d r.-,- i i n., i rj 6 , of the sewage disposal system , esq" sending - the ab ov ,d ri property, and that it::has been constructed as shown on tha approved plan or at)pr6Ve-d wnundmc nL and In accordance With the standards;' rule, s.: and,. re1gul Ati on s of the Put66in, County Department. of Health, and hereby' the &wm6 guarantee to tj`his successors;' heirs or assignst to place in good operating "condition, any part of said sy��Lpm constructed by me' which fails to operate' :for .a .period. of. two. -.years i-irtnediatel Y fn]', wing the date of approval of the ."Certificate of Constrgcti6n Compliancb" it th'a sewage disposal system, or any repairs made. by-ma.. to:.�u6h nystem, oxropF vhpr,-� 'Ix- -failurp. to operate- properly is caused by: the Wilifill or neigliqeh �1 'I of the utilizing nt act, o th building u i izing the system. The undersigned further a:; xxiclusive the actetmination of be. Director of the Division of Envirorare'rital 11-lealt-i Services of the Putnam County. Department of Health . as to whether or 'n'OWLhe iaiL-Lce of the system to operate''was cauned by, t: j willful, or.- nbc1licje nt- ricl. of Elio of Lho building utilizing the system. Dated-this day, of General Contractor (Ownex-) "1 Sic. I—rl P. -orporaelon Nam- (if *Corp.)' Addr7s I: irpv. 49/05. Al. Address PUTNAM COWI[Y OF i"PAUMI DMSION.'OF ENVIRC)NMRrpi, BEAL.r.p SM.VICF S 4 Owrlb or •Purchas ei� of g. Block Lot j, Building cbnotrt I!"::. Location Street :q. '51A division Lot # Building Type -,thdt represent— am.! Wholly 4111d; Coii'1j')1,,L,.�L61y rdsoonaiblo for the location, workmanship, material, c6b'gttucti,or) �-nd d r.-,- i i n., i rj 6 , of the sewage disposal system , esq" sending - the ab ov ,d ri property, and that it::has been constructed as shown on tha approved plan or at)pr6Ve-d wnundmc nL and In accordance With the standards;' rule, s.: and,. re1gul Ati on s of the Put66in, County Department. of Health, and hereby' the &wm6 guarantee to tj`his successors;' heirs or assignst to place in good operating "condition, any part of said sy��Lpm constructed by me' which fails to operate' :for .a .period. of. two. -.years i-irtnediatel Y fn]', wing the date of approval of the ."Certificate of Constrgcti6n Compliancb" it th'a sewage disposal system, or any repairs made. by-ma.. to:.�u6h nystem, oxropF vhpr,-� 'Ix- -failurp. to operate- properly is caused by: the Wilifill or neigliqeh �1 'I of the utilizing nt act, o th building u i izing the system. The undersigned further a:; xxiclusive the actetmination of be. Director of the Division of Envirorare'rital 11-lealt-i Services of the Putnam County. Department of Health . as to whether or 'n'OWLhe iaiL-Lce of the system to operate''was cauned by, t: j willful, or.- nbc1licje nt- ricl. of Elio of Lho building utilizing the system. Dated-this day, of General Contractor (Ownex-) "1 Sic. I—rl P. -orporaelon Nam- (if *Corp.)' Addr7s I: irpv. 49/05. Al. Address PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES o FINAL SITE INSPECTION Date: I/ Z Inspected by.` 4,►� __ ....a StceA.atao - ... _ :Y, T, �t�.!:., Town Permit # �1_ TM #. Subdivision Lot # / 7' ' 1. SewaLye Svstem Area a. STS area located as per approved plans ........................... b., Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil riot stripped............ ............................ d. Stone, brush, etc., greater th 5' from STS area.......... e. 100' from water course / wetlands ...... ............................... H. Sewage System a. Septic tank size 4 1; 00 ......... 1, 250 ......... other ................ b. Septic tank instal e evel ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... f. -trenches 1. 1-en—gth required 3 3 3 Length installed 305- 2. Distance to watercourse measured -�- /oO Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 1 %" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10: -Pipe ends.capped...................................................... . -- _. -_ g. Pum or Dose stems , r 1. Size o pump cT amTe ................ ............................... 2. Overflow tank .............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Building a. House located per approved plans ... ..............:................ b. Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans . ............................... b. Distance. from STS area measured + I o D ft........... c. Casing 18" above grade ........................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercours g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 6/97 N i i1 -01 -1999 e2:19PM FROM TO 92787921 P.01 PUTNAM COUNTY DEPARTMENT OF HEALTH ^q. DIVISION OF ENVIRONMENTAL HEALTH SERVICES UQMI EQLE2 L D4SPPE^CTION l°g For :^ Fill Trencbes PCHD Construction Located -72-W 2 (T) ) Sat. Owner /Applicant Name TNi ,1 ock Lot Formerly Subdivision Name Is system fill completed? Date�� Is system complete? �, Date Z •-- is system constructed as per lens? �ek Is well drilled? Date Is well located as gar plfns7 ✓f Are erosion control measures in place? Y certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordanpe -% th fide issued PCHD Construction Permi: and approved plans :rid tae Standards, Rules anu,I$ttloz��.o,iPutraam County Department of Health. --- ....__ Certif ed by Date: ? $E - _ 1tE1. ,P Comments, Q c. l�C 0_ 1 z�,2��T # 9073 Dorm FIR-99 TOTAL P.01 Y d I 1 4 is I, ' S t 1114 -'/. 7--- -?A 17 %rf 4 r- - . ,1I} i � U J" ........................ A 8 o v � 770�k ivo - -e(/ Aba�vt� ©�t 12uv1 o�lonJr,. �i`GQe 6A S hocv� a� DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Date: To: _A /Vi D l2 r From: Gene D. Reed Putnam County Department of Health BRUCE R. FOLEY PuNic Health` °Dir'ecior Fax #: o7- 7 6 2 6 5-8 No. Pages L (Including cover sheet) t.. c►rwpiifillformation . '- :.... I'lease_responr For your review Attached as requested As discussed Please call Notes/Messages In the event of transmission /reception difficulties, please contact this office at (914) 278 -6130 ext. 157. DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 -� APPLICATION TW`CONSTktJft - WATER'Wkf PCHD PERMIT # 2�3 WELL LOCATION Street Address Town/Village/City Tax Grid Number WELL OWNER Name Mailing Address j C ' ¢-Private .._O Public USE OF WELL 1 - primary - secondary (& RESIDENTIAL ® BUSINESS ® INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION 0 INSTITUTIONAL O STAND -BY ® ABANDONED O OTHER (specify AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING ® REPLACE EXISTING SUPPLY 2 . NEW SUPPLY NEW DWELLING O TEST/ OBSERVATION CIADDITIONAL SUPPLY ® DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE j DRILLED ®DRIVEN ®DUG ®GRAVEL. ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name [Dr- Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __K_NO NAME OF PUBLIC WATER SUPPLY: L4/A TOWN /VIL /CITY r DISTANCE TO_ PROPERTY .'FROM „ NEAREST, WATER 'MAIN :. - LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (date) s 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. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: 19 Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller . PUTh:_ &UNTY DEPARTMENT OF HEAL DIVISION..OF ENVIRONMENTAL HEALTH SERVICES Re. Date /© �� -C�rO Property of /L11 Jr �S �`� � ��U� P. Located at L -1 I /l,�)o,- (T) g',�,.� ^G� Section ?jS�, Block �' Lot Subdivision of od 1/J" !i ��ct1Jc/ Subdv. Lot # Filed Map , /14J 13 Date Gentlemen: w This letter is to authorize )40'VKZj 16- a duly licensed professional engineer L--�or registered architect 9 (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 provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Cqde. Coun ersigne�Y: P.E. , R.A. Address fc Telephone Very tru Signed urs , rl l Telephone Oi4ne of Pr e�t Addr_ ss MY .2 ; -397 Telephone - )�iCJ'2'N�A.N� COUN'Y''Y DEP,A.RTME�IT OF HE..A.Y,,'�'� • - r A-.PPLIEATION- -•FOR- A- PPROVAL OF PLANS FOR -A - WASTEWATER'S DISPO.SAL' 8Y8T'EH —' 1. Name and Address of Applis ant: _ At v, J t^. -g,� ,�dc:., - I e,- 2. Name of Project: 3.._.- LocationeT.YV /C: ��� /1 Asa ti• 4. Project Engineer: /�,c, 5. Address: License Number: `� � �t Phone: 27O�LIUB1 6. Type of Project: l/ Private /Residential Food .Service ....Commercial , ` Apartments Institutional Mobile Home Park Office Building; Realty Subdivision Other (specify) 7. Is 'this project subject' to State Environmental Quality Review (SEAR)? Tvoe Status (Check One). Type I.. Exempt Type II. Unlisted =L,� 8. Is a Draft Environmental Impact Statement (DEIS) required? VC/ 9. Has: DEIS been completed and found acceptable by Lead Agency? ........... _ 0. Name of Lead Agency Z11A _11,.._ -.s this-project in an area under the - control of -lo_ cal_ - p.l'ann ng., ._.z9.n.i ng., _ _ - •• -- -- or other 'of ficial's;_ordinances? ......... ............................... �0 12. If so, have plans been .submitted .to such. authori ties? ..................... 13. Has preliminary approval been granted by such authorities? Date Granted: �4. Type of Sewage Disposal, System Discharge.....'.^ Surface Water- mound Waters ;5. I,f surface water discharge, what is the stream class designation ?........ 5. .Waters index number (surface) .......,,. /✓ /� 7. Is project located near a public water supply system? .................. 3. If yes, name of water.•.,supply Distance to water supply �. Is'project site near a public sewage collection or disposal system ?...., v0 ). Name of sewage system ,Distance to sewage system 1. Date observed: 10 �1 9 7 23. Name of Health Inspector: w , acrd r S Project`• design flow (gallons per day)....... ............................oC� f' 2 . 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?..ter,, �.: . 26. Has SPDES Application been submitted to local DEC Office? ............... '27. Is any portion of this project located within a designated Town or State wetland ?. .. .... ....... ............... ..... / C 28. Wetland ID Number ......:........... ............................... t/l, 29. Is Wetland Permit required? .............. %d Has application been made to Town or. Local .DEC..Office? .................. /v 14- 30. Does project require a DEC Stream Disturbance Permit ') . ................... / V d 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal; landfilling, sludge application. or industrial activity? ........ YES or NO 32. Is project located within 1;000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or �J any other potential known - source of contamination? ...............YES or N0 DESCRIBE: 33. Is there a local master plan or file with the Town or Village? 34. Are community water, sewer facilities planned to be developed within 15 years? *6 35. Are any sewage disposal areas. in excess of 15,-v slope ?__.. "._... ........._.... w - 36. Tax Hap ID Number ..... ....3 37. Approved Plans are to 'be returned to: Applicant l/ Engineer :f the application isisigned by a'person other, than the applicant shown in Item .1, the. application must be-accompanied by. a Letter of Authorization.' Failure to comply with this )rovision'may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury's: that inform» tion provided on this form is true to the best of my knowledge and belief. False- sr:ataaents made herein are pun ishab 1e as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Latf. IGNATURES & OFFICIAL TITLES: AILING ADDRESS: XL,• y D"%p Flow .G . P D PCHD Nedhosdon Is Raqvired WIsm FM:b onq*lIed, To* s - h0e,0 4aw q* ow :ZQ 9J � Seporaft a 1p Sware Syiden to eudd au Ube, Adlinses Waim 340ts P Addreft evi 09 Plf t* Sop* M116d 096 I too sent-that.1 am who , lly and compietely, resvisible for the design and location of. the proposed systern(ii); 1) that the Sop I @rate disposal '"I'll, - construited'is i 'n MM above described will be show on the approved amendment there to and in accordance with the standards. rgies arm regulations of- ins 'Futnarn County Department of Posillith. and that on cornplatiOn-th6r,0011 a "Certificate of Construction Complianewl:satisfactorif to the 4tornmijajdhai of Has lih will "niltlid to the, Depakn�,844wrlitin guarantee will be furnished the.owner, his succeftors. heirs or Millions by the builder that. said b411dM will Part' of 'Syd during the PWiod of two (2) "WS lately follow ine'theelate of'the Issu- W M — ance 40 the a - Do M , of the .CertWlcate Of Construction .. Con e Original system an . y'ralam, ato; that at the drilled "I described Aftin s shaii i on'i6i a006vail plan that aid will In &cc* the a S. F t ww'be 'Ilocited a' will it rae-ULTIM-01, the':PU "Am Counili:04ioikinim of l0k "ft.' Date nod 1 V. _: =n*10 Address-M, t h mke License No APPROVED FOR CONSTRUCTION- thil,apprbiAll expires t" years from the '44/inued' unless Construction of the building bas been undertaken and is revocaile for cause or may pi.arnended or',modifled when considered name fy by ;the' , Commisgoner -of Multh. Any change or illieritkin of construction re'lluk" a r Approved for disposal of domestic unitary sawage, or.. a to supply only. Rev. rr *7 �t S I A � 97-P —Title 10/88 - �, Z 9 % F, !' } I Y , � ue �• . a ' s i *$ p Y 8 s 3 . T 'e - ; s ° / d ` l , , < . S t i C J , s 1 a t S[ x -. 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