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01817
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
7 WELL COMPLETION REPORT
Well Location
Street Address: ' '
"if
Town/Village:
I /ae
Tax Grid #
Map S6 Block r,> Lot(s) -7
Well Owner:
Name: CJ Address:
±n' �D r C �STPdA,� p ud b� l� IT� ?0 �4 !�� I 0 � 0
Use of Well:
1- primary
2- secondary
Residential Public Supply Air cond /heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length / ft.
Length below grade Q ft.
Diameter _-7in.
Weight per foot / lb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded Threaded _ Other
Seal: Cement grout _ Bentonite Other
Drive shoe: Yes No
Liner: Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
_ Bailed _ Pumped _ Compressed Air
Hours
Yield gpm
Depth Data
Measure from land surfaa e- static ((s specify ft)
During yieelld- test(ft)
Depth of completed wellll in feet
On
Tee
Well Log
If more detailed
information
descriptions or
sieve analyses
are available,
please attach._,
De th From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
('- E)' S
_w
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Stora a Tank Information
Pump Type OU Capacity
Depth Z6 Model 7 SOS
Voltage ;-330 1 Z
r-
Tank Type Well- �'� olume
Date We /ll Completed.
C5 ��
Putnam County Certification No.
00 7
Date of R port
7 W
Well Driller (signature)
NOTF: Yxact location of well with distances to at least two permanerft laddmarks to be provided on a separate sVet/plan.
Well Driller's Name IV/ a Address: . v/f RA 3l/ A e rs-om, N
Signature: Date: 15- 0
White copy: HD File; Yellow 0'opy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
ET t1 ,` t, ', .,.. 1. 1
3 6
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # P 14 ' ®� �'�
Located at Town or Try flN
Owner /Applicant Name i4� BAkVO COO' Tax Map G , Block rD Lot
Formerly Subdivision Name F49
Subd. Lot # I
Mailing Address Jo C.o r l l�qe F LA LF AFT-, 4E \9U k (re f LA)H6 lei Zip 1 0C O
Date Construction Permit Issued by PCHD 0&:)l f ot
Separate Sewerage System built by 'ME BAfUW Address 0aRAE P Lmz Ar y qF
-WTI loco)
Consisting of _ �' A 0 Gallon Septic Tank and 400 V�E H& A
Other Requirements:
Water Sup"I :
Public Supply From.
Address
or: Private Supply Drilled by L'1 0 VY�Vr Address
Building-Type`--. . -- �. L�. ..- - Has erosion control-been completed? �L7
Number of Bedrooms Has garbage grinder been installed?
00
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
`plans and the standards, rules and regulations of the Putnam Co D artment of Health. J
Date: I G ( Certified by un P.E. R.A.
Address 1- p K M f)-E�J
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 a subject to modification or change when, in the judgment of the Public Health Director, such
revoca - n, odifi capi On or char is necessary. ;
By: Title: - Date: /
White copy - HD File, Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
Harry W. Nichols Jr., P.E.
Patterson Park, Suite 106
2050 Route 22
Brewster, NY 10509
:Telephpne. 279-4AU.,�,
Fax(845)279 -4567
November 6, 2003
Putnam County Health Department
I Geneva Road
Brewster, NY 10509
ATT: Mr. Robert Morris, P.E.
RE: Individual SSTS Compliance
The Barlow Corp. - Lot # 7
Sylvia Barlow Way
Patterson, NY
T.M. # 35.-5-38.7
Dear Mr. Morris:
Enclosed are the following:
1. Five (5) prints of S-7, "As-Built Plan", dated 09/25/03.
2. "Certificate of Construction Compliance for Sewage Disposal System"
dated 11/06/03.
3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System",
dated. 10/03/03.
4. Well Completion Report., dated 06/07/00..
. ........ . .. ... ..
5. Laboratory Report, dated 10/02/03.
6. Application Fee in the amount of $200.00 payk-l-e to Putnam County Health
Department.
7. 911 Address Verification Form.
"If there are any questions concerning the enclosed, please call.
Thank you.
Very truly yours,
Harry W. Nichols Jr., P.E.
HVvN:gav
00-096.07
e
PUTNAM COUNTY DEPARTMENT OF H
DIVISION OF ENVIRONMENTAL HEALTH.
GUARANTEE OF SUBSURFACE SEWAGE TREA
Owner or Purchaser ofBiuilding .
Tie_ - 2�1 ouz\ c t_a C
Building Constructed by
�4 6�(LN . IP\ �)N�LUW WP��
Location - Street
�cHc
Building Type
TH
VICES
'.NT SYSTEM
r All
Tax Map - Block °" Lot
TownNillage
r-Af-E2,-E
Subdivision Name
Subdivision Lot
I represent that I am wholly and completely responsible for the location, Workmanship, material,
construction and drainage of the sewage treatment system serving the above-described property, and
that is has been constructed as shown on the approved plan or approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County .Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition
any part of said system constructed by me which fails to operate for period -of two years
immediate) following the date of approval of the- "Certificate of Constructi Compliance" for the
Y g PP 4, P
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 tli 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 th4 building utilizing *the
system.
Dated: Month - l D .r Day F3'� Year �oo�J Signatu` —`
- � t
Signature
C o ation Name (if corporation)
Addre
State �� �'V�� Zip C)&D
tQ
®[l7
State ' W VM
(if corporation)
Zip `oUj
Form GS -97
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Heiohts, N.Y. 10598
(914) 245-2800 ^
Albert H. Padovani, Director
LAB #: 32.307779 CLIENT #: 54805 NON STAT PROC PAGE
THE BARLOW CORP DATE/TIME TAKEN: 09/23/03 10:00A
10 COTTAGE PLACE DATE/TIME REC^D: 09/23/03 02:O0P
APT BE REPORT DATE: 10/02/03
WHITE PLAINS NY 10601 PHONE: (914)-659-1266
SAMPLING SITE: 24 SYLVIA BARLOW WAY BREWSTER, NY SAMPLE TYPE..: POTABLE
: KITCHEN TAP PRESERVATIVES: NONE
COL`D BY: JOHN FARESE TEMPERATURE..: < 4C
NOTES...: COLIFORM METH: MF
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
RESULT
NORMAL - RANGE METHOD
PUTNAM CNTY
PROFILE
09/23/03
MF T. COLIFORM
ABSENT
/100 ML
ABSENT
09/23/03
LEAD (INS)
<1
ppb
0-15 ppb
09/23/03
NITRATE NITROG
<0.2
MG/L
0 - 10
09/23/03
NITRITE NITROG
<0.010
MG/L
N/A
09/23/03
IRON (Fe)
<0.060
MG/L
0-0.3 mg/l
09/23/03
MANGANESE (Mn)
<0.010
MG/L
0-0.3 mg/l
09/23/03
SODIUM (Na)
3.64
MG/L
N/A
09/23/03
pH
7.2
UNITS
6.5-8.5
09/23/03
HARDNESG,TOTAL
129
MG/L
N/A
09/23/03
ALKALINITY (AS
118
MG/L
N/A
- 09/23/03
-
TURBIDITY (TUR
� <1
NTil�
COMMENTS:
BACT THESE RESULTS
INDICATE THAT THE
WATER
(WAS NOT) OF A
SATISFACTORY SANITARY QUALITY
ACCORDIRIEVSHE NEW
YORK STATE
AND EPA FEDERAL DRINKING WATER
STANDARDS, FOR THE
PARAMETERS
TESTED, AT
THE TIME OF COLLECTION.
Pb/Cu LEAD limits for public schools are set at 15 ppb.
EPA Lead & Copper Rule for Public Systems requires that no more
than 10% of their distribution points have a LEAD value of more
than 15 ppb and a COPPER value of 1.3 mg/L, else water
treatment must be undertaken to reduce the waters corrosive
potential.
Fe/Mn If both iron and manganese are present, their total value
combined shall not exceed 0.5 mg/L.
Na No limits for Sodium are proscribed. Suggested guidelines state
that for people on a sodium restricted diet,the water should
contain no more than 20 mg/L of Sodium. For those on a
moderately restricted diet, a maximum of 270 mg/L of Sodium
is suggested.
1008
9101
9139
9146
2037
2037
YML ENVIRONMENTAL SERVICES
321 Kear Street
Yo H0,Uhts°-_W '0�^"1, 8�^��'�
(914) 245-2800
Albert H. Padovani, Director
`
THE BARLOW CORP DATE/TIME TAKEN: 09/23/03 10:00A
10 COTTAGE PLACE DATE/TIME REC'D: 09/23/03 O2:00P
APT 8E ' REPORT DATE: 10/02/03
'
WHITE PLAINS, NY 10601 PHONE: (914)-659-1266
-
SAMPLING SITE: 24 SYLVIA 8ARLOW WAY BREWSTER, NY SAMPLE TYPE..: POTABLE
: KITCHEN TAP PRESERVATIVES: NONE
COL'D 8Y: JOHN FARESE TEMPERATURE..: < 4C
NOTES...: � COLlFORM METH: MF
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5.
Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM
CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE
HARDNESS MAY RANGE FROM O TO HUNDREDS OF MG/L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L
---__'_--1i Y' 1HARD'- WATER: -7014L0.. MG/L MG/|=-=_M --Ll'TEfi'''�-_-_.-�---_
HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L)
SUBMITTED BY: 6 ao e
Director
ELAP# 10323
Oct 14 03 07:10a TOWN OF PRTTERSO 845 - 878 -2019 P•1
vo -canes n4:62 PM HARRY W. NICHOLS 914 279 4567 P -82
•BRUCE IL FOLB1f ` .... -. , ....'.WRMA' MOLINAR1r RN., KS.K
rubric Ncvkh P&CW. Am#,*fr rrbtk:. mfjb .QYrpa ...... .
„ Dk"W ' 6N Sevlen
. ,. _..... _ I RPARTIaNT OF IMALTH _ ._ .. .. ............
Brewitar, New York 10509
91Nr1MsaW Ham 0141111-silo TM1914) 276•1"I
$W IWI. OnUu PIQ3714S58Wtc(Y14�111•iNi .PU(#t4)3"-6QU
.. .. L1t1)'1tltrri :3ba'(4lgifr -601 Pewe�ai 541 <)2f1i0q lalPi6)sfr•6(AT .
E911g RRSS•VERIFiCATIONF0RM
OWftRS NAM: `- o�4`Q{`fl°H tF+�Fe+E s,l�Grns,er- �uvr't�
TAX' MAP NUM SM . j. A ii _ ............. _.
&911 ADDR ES;
T0'0N. •pp ¢_ M
A U.TRORi' p T0WI1.!DMCLLb,:.
The Putnam Cou o Department of health will not issue a "Ceitificate of
Construction Compliance unless the above form is•comgleted; Le,, a legal E911
address Js glaned by,, as auithorixtd tM official, This ferm4s to be sub,mlttea_'
syitb -the 9pplicatioa for CertEAcate of Cdostrtactfoaa Compliance. :...:._..._w
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
&-4P 4P -7 WELL COMPLETION REPORT
W�11 Location
Street Address:
Town/Village: ' ` "
�#�c
e-(E5Q
Tax Grid#
3�.
Map 6 Block 5 Lot(s) 1
Well Owner:
Name: Address:
'Tlf� 10 C mine FLML 1d 4ITE F01471 � 11060 1
Use of Well:
1- primary
2- secondary
Residential I Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing Open hole in bedrock Other
Casing Details
Total length j_ft.
Length below grade _,2_0 _ft.
Diameter _ —in.
Weight per foot / lb/ft.
Materials: 7 Steel _ Plastic _ Other
Joints: _ Welded Threaded _ Other
Seal: —Cement grout _ Bentonite Other
Drive shoe: Yes No
Liner: Yes No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes—No
Hours
Second
Well Yield Test
_ Bailed _Pumped - Compressed Air
Hours (S
Yield � gpm
Depth Data
Measure from land surface - static (specify ft)
During yield test(ft)
Depth of completed well in feet
101-
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
pief
' e I "S's
_......_
_.
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Stora a Tank Information
Pump Type $OU Capacity J Z
Depth 2-6& Model 76,505
Voltage a! 30 �,,,,, 1 2
Tank Type WAI'' -, IrWolume o^'1
Date Well Completed
Putnam County Certification No.
007
Date of R port,
Well Driller (signature)
NU7Y: Mxact location of well witn instances to at least two permanent iauamarKS to De proviaea on a separate sipeuptan.
Well Driller's Name /V1 a Address: wir /11c , 311 h� l�/V.
Signature: Date: l U
F'
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH 1/7190'5•- OK
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
' FINAL SITE INSPECTION
Date: JI 2 5-103
Inspected by:
Street Location SyI Vira- lea v�l,�c✓ Lrfa�i Owner p'�, � 'g�,� 1,0w Corr.
_.,...._ _..::....�_ . . _.,: _... �_..,.. ...._
- ovrn.... ac'�'c.�5mol ..... . ..: _.._ � .:.... Pernirt..#�'..�v l�. °__�� .. _
TM # 3-Z-. - - - -30.-7 Subdivision Lot # -7
1.
U.%1_.U1'1rJGl:L1U11 - UdLG U1 plat Unicl11
3:1 barrier Lgth. Width . Avg.Dpth
c. Natural soil not stripped ................... ...............................
d. Stone, brush, etc., greater than 15' from STS area..........
e. 100' from water course /wetlands... .............................
II. Sewage System
a. Septic tank size - 1,000 ...:....1,250
........other ................
b. ' Septic'tank installed level ................ ...............................
c. 10' minimum from foundation .......... ...............................
d. Distribution Box
1. All outlets at same elevation -water tested .................
2. Protected below frost .................. ...............................
3... Minimum 2 ft. Original soil between box & trenches
6. JrnctionsBox - properly set .......... ...............................
1. Length required #ou;> Length installed �o fili
2. Distance to watercourse measured-/-fe�� Ft..........
3. Installed according to plan ......... ...............................
4. Slope of trench acceptable 1/16 - 1/32" /foot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface ..................
7. Room allowed for expansion, 100 % .........................
8. Size of gravel 3/4 - 11/2" diameter clean
9. Depth of gravel in trench 12" mim rn . Q`'
10 Pipe ends canned
g. Punrp or Dosed Systems _ .
1.' Size of pump cham _ ber ........... ......_.........................
2. Overflow tank ............................. ...............................
3. Alarm, visual/audio. ........
4. Pump easily accessible, manhole to grade .................
5. First box baffled .......................... ...............................
6. Cycle witnessed by H.D.estimat d.tf
III: House/Budding
a. House located per appro plans_
b. 1Vum3er ofbedrooms
IV. W ell- -
Well located as per approved pl ns........ ..
bt ;..:Distance from STS-,area- easur
ry
v
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 .............. d
e. Curtain drain & standpipes installed according to plan..
f. Curtain drain outfall protected & dir.to exist watercourse _
g. Footing drains discharge away from STS area ...............
h. Surface water protection adequate:.:' .. ....:..........................
i. Erosion control provided ..............
Rev. 12/02
NO
_ea
SEP -24 -2003 09:43 AM HARRY W NICHOLS 914 279 4567 P. 01 '
` PU'TNAM COUNTX DEPARTMENT OF HEALTH
DIMMONAW ENVIRONMENTAL HEALTH SERVICES
R. FQtMRj FOEL 172W, JNSP&?nN For- Fill
Date: 5R',lxa� %off....._, Trenches
t ,
PCHD Construction Permit P 14 0&
Located: - SYJV -4 6hQ1nj. VIAN . e„ (T) M _ Pw
Owner /Applicant Nasie: nii - N Lq t * -3 cagg. TM 3$ Block „ S_ .
_. Lot ;
Formerly: Subdivision Name;,,,,`
Subdivision Lot #,�,_
Is •systebi'M completed ?" , Nzg
Is system complete? ,,,,p• ,
Is system constructed as per plans?
Is well drilled?
Is well located as per' w? -s .
Are erosion control memwes iu place?
Date: _firg_j . 22 j a
Date: Awn
Date: Tseo #., . 2 z j 3 ,.
I certify that the system(s), as listed, at the above prenuses 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.
Date: _ : Certrfied by;-
DesigI _—_?_
ss
Address: aoso fZo� T 29 821t,, ,lag 4 Lic. #_.56„1,2-4
Comments:
FOR: 0 ADAM
X GENE
4
(NAME)
Form FIR-99
SEP -24 -2003 WED 10:00 TEL:845-278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1
LORETTA MOLINARI R.N., M.S.N.
u•.. —m w 'fjublic Health £rirector
w. ,. R.OBER1 J. BONDI-
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648
September 29, 2003
Harry Nichols, PE
Patterson Park, Suite 106
2050 Route 22
Brewster, New York 10509
Re: Field Inspection — The Barlow Corp.
Sylvia Barlow Way, (T) Patterson
Lot # 7, TM# 35. -5 -38.7
Dear Mr. Nichols:
The following comments must be corrected in the field.
1. It appears the SSTS may have moved and /or rotated which may affect the
overall approved design. The property line below the system must be staked
along with all expansion trenches in order to properly locate the system. -
_- 2.. -- ..-TWQ.feet.of`901 pip:�:.must "be. iris ±tilled betwser. junetion boxes and trench'
laterals. All laterals must be 45 feet of perforated pipe.
3. All silt must be cleaned out of trench laterals and boxes.
4. It appears the house has rotated from the approved location.
5. Upon inspection of the house, it was noted that the attic was being finished off
giving a total bedroom count of (5).
If you have any further questions, please contact me at 845 - 278 -6130, ext. 2261;
Sincerely,
Gene D. Reed
Environmental Health Engineering Aide
GDR: cj
SENDING CONFIRMATION
DATE SEP -29 -2003 MON 16:46
NAME PUTNAM COUNTY DEPARTMENT OF HEALTH
TEL 845 - 278 -7921
PHONE
: 92794567
PAGES
: 1/1
START TIME
: SEP -29 16:45
ELAPSED TIME
: 00'41"
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: G3
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FIRST PAGE OF RECENT DOCUMENT TRANSMITTED...
LORE"A MOLINARI P.M. M.S.N. ROBSRY 1. BMMI
DEPARTMENT OF HEALTH
I GCnom Read. Bm ater. New York 10509 ,
Immme "tat R dth (545)279-6130 Ras (845)178.7921
NeNaB aervim (645)278 -d538 VnC (846)378 -6678 Fm(245)278 -6085
Bdry Ieten4Mlodhnehe•1 (849)278 -6016 Fu(14S)279.6648
September 29, 2003 "
Fatty Nichols, PE
PedersonParlr. Suite 106 -
2050 Route 32<
Brewster, Now York 10509
Re: Field Inspection -The Harlow Corp.
Sylvia Harlow Way, (T) Patterson
Lot # 7, TM# 35.- 5.38.7
Dear Mr. Nichols:
the following comments must be corrected in the field.
1. It appears the SETS may have nwved and/or rotated which may affect the
overall approved design. The property line below the system must be staked
along with all expansion trenches in Order to properly locate the system.
Two feet of solid pipe must be installed between junction boxes and trench
laterals. All laterals must be 45 feet of perforated pipe.
3. All silt must be cleaned out of treach laterals and bo)ms.
4. It appears the house has rotated from the approved location.
5. Upon inspection of the house, it was noted that the attic was being finished oft
giving a total bedroom count of (5).
If you have any further questions, please contact me at 845 - 278 -6130, exL 2261:
Sincerely,
Gene D. Reed
Environtttental Health Engineering Aide
GMci
,.. LORETTA-- ..MOLINARI
~ Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 ,Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
November 12, 2003
Harry Nichols, PE
Patterson Park, Suite 106
2050 Route 22
Brewster, New York 10509
Dear Mr, Nichols:
ROBERT J:-BONDI "n..,,�
County Executive
Re: Field Inspection — The Barlow Corp.
Sylvia Barlow Way, (T) Patterson
Lot # 7, TM# 35. -5 -38.7
A re- inspection at the above referenced lot has been completed. There are no further
comments to be addressed.
_.._....., , If you -have any- fiarthcr, questions, please contact meat- 845 - 278- 61.3 -0, =ext .- - 2261:
Sincerely,
x4z'- V. -94
Gene D. Reed
Sr. Environmental Health Engineering Aide
GDR: cj
SENDING CONFIRMATION
DATE NOV -13 -2003 THU 10:11
NAME PUTNAM COUNTY DEPARTMENT OF HEALTH
TEL 845 -278 -7921
PHONE
: 92794567
PAGES
: 1�1
START TIME
: NOV -13 10:10
ELAPSED TIME
: 00'39"
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: G3
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:. OK
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a
t.OBFITA MOIA4ARI
pWk 77mna Df. —
DEPARTMENT OF HEALTH
( Geneve Road, BICwnter, New York 10509
Fmtreamesal Ban ( &5)278.61)0 Fa(845)278.7921
NoMlq f5e. 6, (845)278.6$58 WIC (845)278'-6678. Fax(045)27940115 Harry M f
Iev—tW/Few (945)279-6014 F. (245) 278 -6642
November 12, 2003
Harry Nichols, PE
... �._. .._.._- ...__��— __._.�_..._.__.� . �_-...._.. �.. Pat2 (St3ffF8r�SUit6106.._..- -_.•.� � •._...._........_.- ..._..._:._.
2050 Route 22
Brow2ter, New York 10509
ROHfiRT I. BOND!
Ro: Field Inspection — The Barlow Corp.
Sylvia Barlow Way, (T) Patterson
Lot # 7, TM# 35. -5 -38.7
Dear W. Nichols:
A re- inspection at the above referenced lot bas been completed. There are no filtthor
comments to be addressed.'
Ifyou have any further question's, please contact me at 845 - 278-6130; art. 2261.
Sincerely,
Gcne D. Rood
Sr. Environmental Health Engineering Aide
GD1L•cj
BRUCE R. FOLEY
Public Health Director
DEPARTMENT OF HEALTH
I Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
—Associate Public Health Director
-
Environmental Health (914) 278 - 6130 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
DELEGATION STATUS
FOR
SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM
PROJECT:
&--, -
TOWN: C S t PV DATE SUB'D APPROVAL: izca
7-
NOTICE. OF COMPLETE APPLICATION DATE:
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_,.r.,:.,.:- CONSTRUC -TION PERMIT- FOR- SEWA- GE,T,REA-TM- E-loTT- SYST -E-M .. _...�:.._.�.... _... ___.
PERMIT #
Located at 5y"lik bf- �� /4� w a I`� own or Village
Subdivision name r Apf %
Subd. Lot # 1
Date Subdivision Approved ol<-119 1
Owner /Applicant Name Tf4f b Af--niN
Mailing Address 10 CcffA61� ,PLAN
Tax Map Block Lot f)`�`�
Renewal Revision
C G 9 - Date of Previous Approval
W $E WJAIT6 PLNW), OY
Amount of Fee Enclosed tP rn m 00
Building Type h4) Q5,H 6-E:_ Lot Area 1% 4 51 No. of Bedrooms 4
Zip ioG0
Design Flow GPD 800
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of 0 �'��� gallon septic tank and 490 Lr— Pr-b-5
.MH&A
Other Requirements:
To be constructed by
Water Suuuly•
TBO
Public Supply From
Address
Address
or: Private .Supply Drilled by TAU 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
thered6 a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Deparrtment, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder vl+ill 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. /7
Signed:
Address I ��-
_ RE
i::�
X R.A. Date 1 x_410
1G5r) A
License # 5 0 N
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 wh Lconsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new pertrti ve discharge of domestic sanitary sewage only.
zt)By: Title: Date: (��23 `--
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL
please pant or, type, _; ..
PCHD Permit
Well Location:
Street Address: Town/Village Tax Grid #
",�
)Yoyfnk - i.Q'vi 1N'I"' F A1T DH Map t�, Block '� Lot(s) 411
Well Owner:
Name:
T�td by hNJ G0
Address:
10 Gaftbt
Use of Well:
Residential Public Supply Air /Cond/Heat Pump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought 03t' gpm # People Served � -(i Est. of Daily Usage dbCt gal.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Type
Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
.......................... ...............................
Is well located in a realty subdivision? .........t Yes No
Name of subdivision Lot No.
Water Well Contractor: Address:
Is Public Water Supply available to site? .................................. ............................... Yes No �C _
Name of Public Water Supply: :_ Town/Village '-
Distance to property from nearest water main: •
Proposed well location & sources of contamination to be provided on separa , sh t/plan.
Date: Applicant Signature: 9,-1.4 A -AA k".
1
PERMIT TO CONSTR CT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Director. Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a wat w 1 driller certified by Putnam
County.
Date of Issue 713 lAq*27 J Permit Issyx fficial:
Date of Expiration "D Title:
Permit is Non - Transferrable
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
Harry W. Nichols Jr., P.E.
Patterson Park, Suite 106
2050 Route 22
Telephone (845) 2794003
Fax (845) 2794567
April 24, 2002
Robert Morris, P.E.
-Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSTS
Sylvia Barlow Way - Lot # 7, Farese Subdivision
Town of Patterson
Dear Robert:
Enclosed are the following:
1. Five (5) prints of SS-7, "Proposed SSTS," dated 4-24-02.
2. "Short EAF," dated 4-24-02.
3. _ "Application for Approval of Plans for a Wastewater Disposal System."
.4. "Construction Permit for Sewage Disposal System" dated 4= 24-00.
5. "Well Permit Application," dated 4-24-00.
6. "Design Data Sheet."
7. "Letter of Authorization."
8. Corporate Owner Application,
(22) copies of Residence Floor Plan(s)-for "Bedroorntount Only."-
10. Review Fee in the amount of $300.00.
We would appreciate your review, approval and issuance of the Construction Permit at
your earliest convenience.
Thank you.
Very truly yours, ... .......
Harry W. Ni ols Jr., P.E.
ITY
HWN:JM: s
00-096.07
t � 16-1 (9IG6} --Tact 12 . .
811:20
SE
PROJECT L0. NUMBEA
State Envlronatental Guallty R�rl�w
- - -
SHORT ENVIRONMENTAL ASSESSMENT FORM.
For UNUSTEP �4C,,rONS OW
PART 1_.PRD.IEC'T INFORMATION (To be oomPieted by Applloont or PMJeot IPOA r) -. ::•:
t. APPUCAHT(SPONSOR.Ti f &�U\%% C-p"v WQy,,,l
t. PROJECT NAME
3, PROJECT LOCADW. . �
IWunklpalk County
A. PRECISE (W"I addrw and road IntarHatiana, prominent 19n4rnuka, etc, or provide map)
/LOCATION
S. 13 PROPOSED ACTiM' . .
New .. . _._D Expanalon ❑ Modul"UoNalteratbn -- -
a. of case PROJECT BRIEFLYI
7. AMOUNT of LAND ECTR _._.__. ... ..-- ... ........
^� w
Inluly UI Wei
8. WILL PROPOSED ACTION OOMKY WTTH OGSTIMG ZONING OR40THIR EXIMG LAND USE RESTRICTIONS?....:::...
Yes D.No Ir Na d.sarlb. orl.ly ,. .
- tI . w>{AT I8 PRESENT LAND 1A 0 VK UM OF PROJEOTT '"
al
ILTRasldantlal D tndwtrlal D Canrnaral ❑ Aprloultum D Parklft( WOpen apace .- ❑ OtMr
._..OsicrtoK - .. .
,..
to. DOES ACTION INVOLVE A PERMR APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOYMMENTAL AGENCY TWERAI,
STATE OR LOCAP
D Ilal - -
Yea o p ya. apenoM and penrJtl ppmde
t 1. DOES ANY .. Of Tli� AGTiQN HAVE A JRR [NTLY VAUD PLRWT OR APPROVAL(.
...
D Era+. -@�NNo : u rw, ua<i�.r►or !wn. +nc wm+lwvp►orN _._ ___. .... ..... - - • ...
12. AS A RESULT PFi0P68E0 ACTION WILL IXIBTING PF.FWRMPPROVAL RAMRE MWI%ArjW
D Yes No
1 CERTIFY TNAT THE INFOR&IATION PROVIDED ABOVE IS TRUI TO THE BEST OF WIOiOW fLi J: '
ADDUcanUlponso[ � Y'r''.. j" 1t ,SL '•� � • _
i'�--
De tK
Slpnslurc
It the action Is In tho Coastal Area, and you are a state agency, complete the
Coastal Assessment Form'before procesding with this assessment.
r'AHI II— t:NYINVr4Mt1`4IAI. A3*9"rdGN1 11v vii vVrnyrvwv yr r�avnvrr
A. DOES ACTION EXCEED ANY TYPE I THR99HOLO IN a NYORR, PART 01TAV If yes, 000rdlnate'tlie rwlew process uld ua" ALL tJ1�
_ [� Yea
B. WILL ACTION RECEIVE COORDINATED 1`111 VV As PROVIDED FOR VNUSTEO ACTIONS IN 6 IVYCRR, PART ®1T.®1 II tVO, s hpaiiv® lii8taliogon-°
may w auporae4e4 by another.tnvolwd agency
❑Yoa 13 No
COVLO ACTION RESULT IN ANY ADVERSE EFFWTe ASSOOIMTW WITH THE FOLLOWING, (Anewere me!y be hw 4wrltlep, 11 leQlble)
C�. Existing. all puallty, WrlsOO yr groundwst}r guallty or ousntlty, polo® Iew(s, exl #tlrW ualf.Ita pit)o!!LS,.e01�4 waeta P(?!40cn-or•41spo&al,-
potantlal for oroalon, drakwp or flooding proWsalsf Explain briallyt
Cz. Aostnok, aprlCUnural, orchaoologlcal, historic, or other natural or cultural resources; or community a_nelphb (hood cheracteR Explain brlony:
CJ. vegotauon or fauna, Ilan, shellllsh a talldllfe species, significant habltots, or throatono4 or ondangored species? Explain brlelly;
C4, A community's existing plans or9calls ae 911101 fly adopted, o(& chango In use w Intensity of use of. land or.other natural.resourccesTExDlatn briefly
CS. Orowtn, auo"quont Oovelopnwnb or rolate4 sotlyltles likely to be Induo®d by the proposed eotlon? Explain briefly.
U. Long form, abort torn, c YmIatlye, or other effect& not Idenultod in CI-M? Explain briefly. _
C7. Otner Impacla (including change# in use of either Quantity or typo cf onorgy)? Explain briefly, .
o. WILL THE PROJECT HAVE AN.IMPACT -ON THE. ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A ^CEA?-
15 THERE, OR 19 THERE LIKELY TO BE, 0OKLROYER3Y.R9LAT9bTQ POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
C3 Ys* ONO If Yes, ixplatri brbfly
ART III — DETERMINATION OF SIGNIFICANCE (To be completed by'Agency)
INSTRUCTIONS: For each adverse effoot Identified above, determine whether it is substantial, large, Important or otherwise significant.
Eacn OHKI ahouid be- aaseasad In oonneotlon with Its (a) setting 0.e, urban or rvra lk. 4bLpn DbaWllly .of.."yalnp;..(cj.duratfon; (d) ..
irreversiblllly; (o) eeo�graphlc ao"; and M�1.m..agnitude. If nowsary, add attao ownts or referonoe supporting materfal3. Ensuro that
explanation& contain aufflolent deWl to sNw that all relevant adverse Impaote hive been Identifled.and adequately addressed. It
Question 0 of Part II was checked yes, the determination and slgnliidance must evaluate the potential Impact of the proposed action
on the onvlionmenta) characteristics of the CEA,
CD Check this box If you have Identified one or more potentlally large or significant adverse Impacts which MAY
occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration:
O Check this box If you**haVi. determined, aced on tbo 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: _._.
anw of tead;qmxy
r,nt or Typt Ham er., ncY Two of Vospomwk OIIk41 .
i&Ntvra o as taro (spire( stall rpa rtapona o or
1511A
PUTNAM COUNTY DEPARTMENT OF HEALTH.
DIVISION: OF. ENVIRONMENTAL -HEALTH :SERVICES:' `"
_. APPLICATIONFOR�PIQR(?VAL :OF.PLANS FOR
A. WASTEWATER TREATMENT SYSTEM ° ^5
1. Name and address of applicant:
2. Name of project: 3. Location TN:..
4. Design Professional: H 66'06 ' 11' 5. Address: 'yon
6. Drainage Basin:�G
7. Tv�. ne of Project:. .
7< Private/Residential Food Service Commercial . -, ,,:; r
Apartments Institutional -Mobile-Home Park
Office Building Realty Subdivision.. -Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR) ?'
-.., T e Status check. one ....:.......:.:................ Type. I ; : , Exem. t .
. yP .(.:.: ) ................ ......, yP P
Type II ' ` Unlisted ' )c
9 Is a Draft Environmental Impact Statement (DEIS) required?
10. Has DEIS been completed and found acceptable by Lead Agency?
11. Name of Lead Agency
- 12 Is this - project in. an area under the control of local_ planning, zoning, or other i
officials; ordinances? ' ... " - .
13. If so, have plarns` been submitted to such authorities? .............................. ... hI D
14 .Has prelimmary approval been:granted.by such authorities? t0: Date granted: N'
15. Type of Sewage Treatment System Discharge ............... ... surface water -)t- groundwater
46. If surface water discharge; what is the stream class designations ;= ' NA
17. Wates'index number ( surface) ....................:.....
18. Is project located near a public water supply system?
19. If yes, 'name of water supply t` Distanceao water: supply!
20. Is project site near a public sewage collection or treatment system? . ....: "
21. Name of sewage system Distance to'sewage system'`Y
22. Date test holes observed t -1)9- 1(v 23. Name of Health Inspector .RkI g 600) -AH f
24. Project design flow (gallons per day) ................................. ............................... ;;
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?...
26. Has SPDES Application been submitted to local DEC office? .........................
__...:. Form PC -97
2
27. Is any portion of this project located within a designated Town or State wetland? ' iqO
28. Wetlands ID Number ........................................................... ............................... NA
Wetlands t required? .. .............. .......................... ............................... N0
Has application been made to Town or Local DEC office? .................
H A
30. Does project require a DEC Stream Disturbance Permit?
>�o
31. Is or was project site used for agricultural activity involving application of
pesticides to.orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ... Yes/No�
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination? ............................... Yes/No
140
DESCRIBE:
33. Is there a local master plan on file with the Town or Village? .........................1
34. Are community water and/or sewer facilities planned to be developed within
15 years in or adjacent to project site? ................................ ............................... D
35. Are any sewage treatment areas in excess of 15% slope? . ............................... NQ
36. Tax Map ID Number .......................... ............................... Map `0 S- Block - -.5 Lot N'l
37. Approved plans are to be returned to ..... Applicant Design Professional
.....,..._ "_. ,NOTE A.11 applications for review and approval;of anew. SSTS.to be located within -the I�TYG Watershed shall
be 'sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP
approval of the SSTS prior to final approval by the Department. Projects within the watershed may also
require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of
impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from
DEP and submit those forms to DEP for review and approval.
If the application is signed by a person other than the applicant shown in Item I .,the application must
be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision
may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this form is true
to the best of my knowledge and belief. False statements made herein are punishable as
a Class A misdemeanor pursuant to Sectiop 210.45 of the Penal A7w,j
S*I -TURFS &' OFFICIAL TITLES:
S� -9e r
`tAd4res . ......................:........
4LEW -5r5 .- P-t-11 10 5 0 I
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_ DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner b 4 N Coe+ Address 10 CO f!- Nl� KF vjkll NA4 1�601
Located at (Street) EkL4 4-� Wk Tax Map 'b5,
(indicate nearest cross street)
Municipality p(f,VXj Drainage Basin
Block �` Lot . `6'1
SOIL PERCOLATJON TEST J)A.TA
Date of Pre - soaking , ' Date of Percolation Test
Hole No.
Run No..
Time
Start - Stop
Ela se Time
(PI I,n.)
Dep th to Water
)From Ground
Surface (Inches)
Start Stop
Water
Level
Drop n
Inches
Percolation
Rate
Min/Inch
i
2
10
2
3
2��
4
5
3
4
5
1
2
3
4
5
1VU1 EJ: 1. 1 ests to t)e repeatea at same aeptn unui approximawiy cyuai Nciwiauuu 1aLca aim "- ---
percolation tf hQle,. 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. 90 UdV 00
2. Depth ineasS&i�#gts,fd -,be made from top of hole.
�l.�lf7Q�1 /`i 3
Form DD -97
TEST PI'S DATA
DESC TiON'OtAQliS 9NcoVnF,RED.1N -T4ST H010 ES .
HOLE N0.
r . TnQS�ii.
F i
cm�C UQ
•, S a
A. s'
^
J.0
n d c a t e Isvcl. at. which groundwatcr Is encountcred N DNS.
r.d;cate level at wtuch mottling Is observed �+a �+�
.!ndicatel,evci to whlch water lcvcl rlso after being encountered NA -
Deep hole obs-ervati -ons- made. by: . -MIX �►-4,60 'k4 -CT Loil ;nNo "JOi Datc `VVI -(
design Professional.Name�._►�P�' �+� �►1�� -s ,��,Q�,� ���rr . .� .
Address: - 4-:05170
Signarure
Design Professi.onal'.s Seal
NICINq
JtL
J'R No. 56124-•
0
A ®FlESSip�
PuTNA.M COUNTY DEPARTMENT OF HEALTH
_DIVISION OF.ENVIRONMENTAL , EALTFL :,SERVICES
LETTER OF AUTHORIZATION
RE: Property of 'THe
Located at �; L JA Bee-LZ YJ K
TN PAT115 C)H Tax Map # Block Lot
Subdivision of F
Subdivision Lot # Filed Map # �� Date Filed
Gentlemen:
This letter is to authorize hA w` tj j (,tAe_6 , jr,— fr,
a duly licensed Professlonal Engineer )d or Registered Architect to apply for the required
wastewater treatinent and/or watdr supply permit(s) to serve the above -noted" roperty in accordance
-wi th the standards, riles or ragWadous as promulgated by the Public Health -Direct'or of the- Putnam
County Health Dcpartment, and to sign all necessary papers'on my behalf in connection with this
_- maner:and to supErulse the constiiictlon of said wastewater tretment and/or w "atdr " supply systems in
conformity with the..provIsto s 3cle 145 and/or 147 of the Education Law, the Public Health
Law, and the Putn _ u tarp Code.
NICNC�
Very to
,
Q
Countersi d: Signed:
P.E., R'.A., # 0. No. 66124 b
N�
Mailing Address'-:_qQF
'yam
State �s // j!) 01
Telepht:,,i,y�',vf
Mailing Address:Co �� ,� 2� 1�
State W6>;..A 1 1r .`Zip 0
Telephone: GS 9 �..Z�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
AFFIDAVIT - CORPORATE OWNER APPLICATION
FOR PERMIT APPLICATI-ON S'U'B*MITTED T'O'P'U'* *AM COUNTY.HE'ALTH DEPARTMENT....
To: Public Health Director
In the matter of application for:
I. R e
represent that I am an officer or employee of the corporation and.am authorized to act for:
Name of Corporation: THE BARLOW CORPORATION
Having offices at: 10 Cottage Place.9- Apt. 8E, White Plains, NY 10601
Whose Officers Are:
JOSEPTI A. FARESE
President - Name:
Address: 10 Cottage Place, Apt. 8E, White Plains,, NY 10601
Vice Preside6t - Name:
Address:
Secretary -Name:
Address:
Treasurer - Name:
Address-:
and that I am and will be individually r e sponsibldforafty and all acts of the corporation with respt-et
to the approval. requested and all subsequent acts relating thereto.
Signed:
Title: A's A. Farese, Pres.
\j
. Sworn to ef ore Tne this 7 day of
April, , 20 2
Notary Public
kSERT A.. CAPEWN
NWARYV
. JTT: -
j(j a(, Ac'a,
Corporate Seal
PUTNAM COUNTY DEPART JITNT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS
REVIEW SHEET FOR CONSTRUCTION PERMIT
:NANU1 OF O'c;A [ - STREET LOCATION:
REVIEWED BY: Rift, GR, AS, SRDATE: TAX hLAP=: (CONi M%IED)
Y N DOCUMENTS Y �N (REQUIRED DETAILS ON PLANS CON`T'Dl -
�(� PERMIT APPLICATION (�j HOUSE SEWER -' /P FT. 4 "0'; TYPE PIPE CAST IRON.
NVELL PERMIT OR PWS LETTER \0 BENDS; AIAX BENDS 45° NUCLEANOUT
PC -97 RENEWALS
LETTER OF AUTHORIZATION ( K3SITE NOTE (NO CHANGE)
DESIGN DATA SHEET (DDS) TILL SYSTEMS
CORPORATE RESOLUTION 'HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE
ULJSHORT EAF fF LL SPECS.' FILL NOTES 1 -5
vUPLANS -THREE SETS LL PROFILE & DIMENSIONS
UUHOUSE PLANS -TWO SETS LL D EXPANSION AREA
UUVARLANCE REQUEST L GRE.AlER ?W,4.V 2 FEESUBDTVISTON LAY BARRIER
LEGAL SUBDMSION ILL CERTIFICATION N OTE SUBDMSION APPROVAL CHEChtD EPTH GAUGES
PERC RATE OL 01 PLAN FOR R.O.B., UIN ASSIFIED &IMPERVIOUS
FILL REQUIRED DEPTH (�USEPARATION DISTANCE FROiI TOE OF SLOPE
CURTAIN DRAIN REQUIRED TRENCH
GENERAL U� LF TREK CH PROVIDED 6OFT MAX.
(�( LOCATED IN NYC WATERSHED �pAR LEL TO CONTOURS
(� .. PLANS SUBMITTED TO DEP - ..... ,
�10� /° EXYA: SION PROVIDED
DELEGATED TO PCHD DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL.
(DEP APPROVAL, IFItEQ'D �GEOTEXTTLE COVER
DEEP TEST HOLES OBSERVED
SEPARA:TIO`i DISTANCES 0\ PLAN : FIiO iy1 SS-['S - :: _
PERCS TO BE WITNESSED
- L6� 10' TQ P.L. DRIVEWAY, LARGE TREES,TOP OF FILL .
EX- APPROVAL SSDS AD7, LOTS ' -OJO FOUN WALLS
U - ET. LANDS 'fTOW,NIDEC.PERry7.REQ'D ?) 100' TO WELL, 200' I`(.DLOD, ISO' TO PITS
Dp,TA Oi 1 DDS:FLANS. &: PERIIIIT SATti1E oL-j:)D' 100' TO STREAM, WATERCOURSE, LAKE (ii . espau) PRE 1969 NEIGHBOR NOTIFICATION TO CATCH BASU` , 3T STORNIDPLAr , PIPED WATER
LETTER BUZBA :. ( 10' TO WATERLINE (pits -201)
100 YR. FLOOD ELEVATION W/I200'
_ J50 1ti'TERMITTENT DRAINAGE COURSE : _.....
_ ._..• ............ �-- •------- .........._... ...._.._.� - -- ..
REOUTRED DETAILS ON PLANS 00'/5 00' RESERVO ETC. 150' GALLEY SYSTEMS.
(10'.MI�NTO LEDGE OUTCROP ,• _ ,.,.,.._
- SEWAGE SYSTEM PLAN- (NORTH-ARROW), SEPTICTANK
(. III- )SSDS HYDRAULIC PROFILE 10' FROM FOUNDATION; 50' TO WELL
U GRAVITY FLOW �-yELL
( �( ....CONSTRUCT I9N.NQTES-.L-15. — .- --.----- . - - - -- ._._. __.._.;..
DESIGN DATA: PERC & DEEP RESULTS U - DIMENSIONS TO PROPERTY LL`iES
2' CONTOURS EXISTING &PROPOSED �LOCATIOi i OF SERVICE C0a Ii �'ECTION
(__ L_)MLN 15' TO PROPERTY LINE
(DRIVEWAY & SLOPES;. CUT SLOP _-
/� FOOTING /GUTTER/CURTAIN DRAINS BR_JREGRADED � SLOPE IN SSTS AREA (520 %) 4
(� USDA SOIL TYPE BOUNDARIES ° IF REQUIRED
C_ffLj TITLE BLOCK; OWNERS NAME ADDRESS TO D S
/ TbIR, PE/RA; NAME, ADDRESS, PHONE#
pOSE/PUZti1P SYSTEMS
(�(, )DATE OF DRAWING/REVISIQN
DATUM REFERENCE .
UULOCATION OF WATERCOURSES, PONDS
y LAKES,WETLANDS WITHIN 200' OF P.L.
(/ _-_)PROPOSED FINISH FLQOR AND
/ BASEMENT ELEVATIONS
(�(JWELLS & SSDS'S W/IN 200' OF SSTS
C.J( _)PROPERTY METES & BOUNDS
,EROSION CONTROL FOR HOUSE, WELL &
SSTS, EROSION CONTROL NOTE .
COMMENTS:
(ItusurT)09I01 /Od
PUMP NOTES
cly DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED
(DETAIL FOR FORCE MAIN, (PIPE TYPA, ETC.)
PIT AND D -BOX SHOWN1 & DETAILED
Ul DAY STORAGE ABOVE ALARM
CURTAMRATN
STANDPIPES, 5' B 0TH SIDES, DETAIL
I5' bIL`ito CDS= >5 %,20'- 4 %y25'- 3 %,3�' -1 %,100 % -<1%
20' MIN to CD DISCHARGE /100' with 182 cons day discharge
10' MhN to NON-PERFORATED PIPE
S. . IDO
. 4000
00
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DIMENSION CHART (in feet)
Number
A
Q
I
32
25
2
54
38
3
60
41
4
66
46
5
72
51
G
78
55
7
93
94
8
88
91
9
83
89
10
77
85
11
72
2I
i z
76
26
13
8o
31
1 I
64
36
15
89
42.
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