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HomeMy WebLinkAbout1978DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.31 -2 -1 BOX 18 :1 Ir F : I 1 I no 01978 t PUTNAM COUNTY DEPARTMENT OF HEALTH ° Z. DI Y -ION,�OF�EN RO�TMEI�NTAL ALTH-SE-RYIC,E ....r ..., �'..._ .: ERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P - S 1 Located at Town or Village PATI-9F -4o 1 Owner /Applicant Name JPSaPH t7WHt CAL4 Tax Map Block �" Lot I Formerly Subdivision Name PViYJW LAVE Subd. Lot # C W& C �Ml; Mailing Address ^{-� Wl 1pf CIUP —y P-0 k0 M4ti 0f PQ,1 N`i� Zip I054 1 Date Construction Permit Issued by PCHD olb/ 15 j 01 Separate Sewerage System built by J &HC' G 46W,400 ��' Address $7 (A AME Nffi PAKAr4 , 4 O-Q4 Consisting of 10 °a Gallon Septic Tank and %00 Lf' N66, Other Requirements: Water Sunnly: Public Supply From Address or: x Private Supply Drilled by KOD�6) lzlV, Address K-1- fir' Pwm ogy, Building Type PZe6I lv. H i5"e Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed?� I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulationslof the Putnam County De nt f Health. Date: 04 K1 �� Certified by P.E. R.A. ;��si n essional) Address �l-0�0 �C i-L �� `a.1 ,J J � oS Q`� License # SM I�'�' Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are ject to modification or change when, in the judgment of the Public Health Director, such revocation, d'- icatio change is necessary. % By: `Y✓ Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 ti PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Nell TL� atioit Stree rest AWLIJ_I�LL T n/V'illag' =' „�,1/ ' Tax Grid # Map` b,�i Block 4- Lot(s) Well Owner: Name: Address: C/ / U�j {�1 rGh1 M''i Use of Well: 1- primary 2- secondary esidential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) 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 2/ ft. Length below grade l 9 .-ff: Diameter ” in. Weight per foot lb /ft. Materials: _V, Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: gL-- .Cement grout _ Bentonite _ Other Drive shoe: 2!L .Yes No Liner:_ Yes -g 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 1 Yield gpm Depth Data Measure from land surface-static ?specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sie,ve_analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface r G,,,� If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type :S v ik Capacity _74e !,� Depth 3 -3 a Model 7e- 1410.41 v Voltage Z3 o HP Tank Type w �-3oZ Volume 84- Date Well Completed Putnam County Certification No. Date of Report -7 O �S! Well Drill r (s' nature) - NOTE. Exit location of well with distances to at least two permanenyanarnarxs to De provided on a scparatc suc-upia►,. Well Driller's Name .a'/ . c Address: Signature: z .�,L�� 3- — Date: e White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller. Form A-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM �oSEe� 54- �roM ►t,w1 �� ►'�i � 1 Owner or Purchaser of Building Tax Map Block Lot J0 El- t\ 5WH1&,,j Building Constructed by Location - Street w6 wl-1 4 Building Type PNTT, H Town/Village . Pvi NN,I� LML5 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 a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County. Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: t ay Year �—OO�j Signature: c» r' Title: _L�v► tractor Owner) - Signature Corporation Name (if corporation) Address: u' • �_U � jtp #Who'PAc_, NY State t zip—( 0S4 ( Corpora on Name (if corporation) Address: ?7 14T/^ State /1« /-rb Zip /,2�Y Form GS -97 Rpr' 06 05 09:52a TOWN OF PRTTERSO 845- 878 -2019 P.1 - -- .+•�, r.ri "RHUY W NICHOLS 914 279 4567 P.02 4 - • '�At;iO�- '1t:'_1�QY'L+y " t•OR�1°1'A i�t6Lq1 •irit; F{:it9:�' ' 1r01k Nragh OLrua� •• • • - •' .�uoefarr PupUe,,Nrahh,,CWr� ter,.• -„ • • ^ •� �• Dfrrem. • d Yailui •Gerohq - _. w .. _ .... ,r.. - - DRPARTtvl ' OF • HBALTH .. .. ..�..... 1 Genova • Road .... _ .. �.... . Sromtor, Now Y4 1050 •_ _, w • •• ... .. ..L�rSr9apcoil) 11u1�1i(D:4y77i•61y0 PRiINj>t� -TTfI . n�n�a�.akrowt9tg3T7 .633x- •YPiCtT11ta7t�Ibib . A0147211.boil •.• • .. : u�trryutYU�..'oulair•�eu Prer�fal ptoa�r.ban rrtytgnr.ea�� 9tY Ann S�`�� y> �rcaTro FORM 0"F'Rs NOM, J P++ SR N►u� -i . £9I1 ADD'R�,SS;, . ,�� `• � r" r..� - 1 f - , • .. . AU•TSOIi�pTQWN,S��CUILt • ���••�� . ' (Stsn>aturo) .,. The Putnam County Departmtaat of Health wM not issue a •CeHrleate iof Construction Compliance•unlcss the above AM is. Completed; Le., a Iegal E911 • addrt:ss is assigned bx gn oithoaiaed town oft3ttal. 'phis form•is to be subotittcd -' -• ' -• - - -with the application for q Certificate of Constamctlon Compliance. _ ,. _._......... �.__._z ._.._._..__ "sir_..__. .. .._. ...... ,.� ._ .. ... _ __ ..... .. y _._. ..�..• . • . ., _..._ .mss._ ....... ... :._- .. , f, a April 6, 2005 Mike Budzinski, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279.4093 Fax: (845..,!s7-9--4TO " o -. Email: hnengineer@aol.com Re: Individual SSTS Compliance - Srednicki Putnam Lake Lots C2676 — C2698 South Lake Drive Patterson, NY 12563 Permit # P -81 -87 Dear Mr. Budzinski: Enclosed are the following: 1. Five (5) prints of Drawing S -2, "As Built SSTS ", dated 04/04/05. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 04/06/05. copies of ."Guarantee of Subsurface Sewage- T..reatment. __ ......... System ", dated 04/06/05. 4. Laboratory Report, dated 03/25/05. 5. "Well Completion Report", dated 05/10/02. 6. Application Fee in the amount of $300.00 payable to Putnam County Health Department. 7. "E -911 Address Verification Form ", dated 04/06/05. If there are any questions concerning the enclosed, please call. Very tr ly yours, Harry W. Nic Is Jr., P.E. HWN:gav 01- 009.00 PUTN.01 COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRMIENTAL HEALTH SERVICES. FINAL SITE MPECTION �111816 -9 169pec e y: Street Location 1_4k,6!500Xa -p'ZIVAE Owner pA/jc /<I Town 'PA I-FE zj!5ov, Permit # TM F" - 3&1 31 — .2- Subdivision Lot # ---- 1. Sewase System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ............................................ d. Stone, brush, etc., greater than 15' from STS area....:::::. e. 100' from water course/wetlands ................................... * 11. Sewaqe System a. Septic- tank size 000 1250 6th b7 eve C. minim o foundation .......................................... — M 2 ft-Original soil between box & trenches um e. Junction Box properly set .......................................... f. -1 renches Ao length Length required 36:> (:.o::> Length installed 2. Distance to watercourse measured-4 i o 0 Ft.......... 3. Installed according to plan ........................................ J� Eck 4. Slope of trench acceptable 1/16 -1/32" /foot .... 5. 10 ft. from property line - 20 ft.- foundations.......:.: A 10�o _) . epth of trench <30 inches from surface ........ ; ......... • 7. Room allowed for expansion, 100% ................ . 8 of gravel 3/4 -1%" diameter clean ........... -Depth -2"mir o gravel in trenchl uffum. 0. Pipe ends capped .................................. .................... o or Dosed Svstems ev619. ize ot pump c am er ................ ............................... tj 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/BuildinP_,,__"__1__ t app -.9' ous, r Y(M,-P b:�er of bedrooms '__........................ ............................... IV. Well b.—Tistaff6e—fF6m—,STS_Ee —`E ...... � �,; A C. Casi g M'above"graae ....... 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 watercourse COMMENTS lmr�� IMINWIFIA, OCT -31 -2001 06:23 PM HARRY W HICHOLS 914 279 4 56 7 P.01 PUTNAM COUNTY WARTit M 01 MALTS DY aSION 01 INMONMEN"I±AL HATS UXVM ATTZNTION ❑ 001 ENE • W[ YRST.. of MAL20�t''!� For:, Fill Al iatbrmation must be far ompletad prior to nay Trenahos � iaspecdou being made, PCHD Cotuwotioa emit IrOC1LtOd: y �f J 96 YitY4M _ 0mcdApplic at Nema: 571cmd .w L i T)d %I] Lot Parmerly'. — Subdivision Nataa: Subdlvltioo Lot # Ls sytteta Edl completed? `'-" Date:...._...... Is �yitom ctOM&Ca? Date: Is rystem coastni w'" qer plena? Is we0 drilioV ...... Date: Is wd locatd as per picas? Are crosioa cocrol ttsessv n In plate? I on* that the ayXOM(s), as 1%94 at the above prcm4es has been co=mcted and I have inspected aad verified their mpledon in eccords►nee with the issued PCFID Coumcdoa Permit ad - -Syprovcd•plaai..and the_$tnadards, Rules and Rosulatiow of the Putnam County Dtputraetit of Health. ._. - .�� Due: I(� �- "3_I_ I Certi$ed by: P1� , RA D Professional t . MOW: 2f. 2 Comtaeata: r r i Form F7,49 _ _- 0 _z - -BRUCE R. FOLEY Public Health Director T LORETTA� MOLINARI R.N., M.S.N. 1 Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 .. . November 2, 2001 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection Srednicki Lakeshore Drive, (T) Patterson TM# 36.31 -2 -1 Dear Mr. Nichols: In reference to the above noted project, the following comments-must be corrected in the field: Due to needed changes in the field, only the SSTS trenches' can be backfilled. Replace 90° elbows from the septic tank to the distribution box with 45° elbows. �3. The distribution box elevation needs to be lowered and crushed stone added below the ✓ Measurements taken by this Department indicate .the well was not installed in the approved location. Furthermore a measurement of eighty two feet (82') was taken from the well to the expansion fill pad. A minimum of one hundred feet (100') must be maintained. The silt fence is in disrepair. All silt fence for the SSTS and well must be fixed up and properly installed. An inspection of the house needs to be performed upon completion. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, ''� Gene D. Reed GDR:cj Environmental Health Engineering Aide 5 a SENDING CONFIRMATION DATE : NOV -5 -2001 MON 1016 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME : NOV -05 10:14 ELAPSED TIME : 00'42" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a k BRUCE R DOLBY LORETTA MOLINARI RN., M.S.N. MD. H.aM Q' t9r A=d labito Ma" Dpwe De.ea► of /.riser &'W_ DEPARTMENT OF HEALTFJ I Gooeva Road BMVSW, New York 10509 F...be... nwn (u5)37t -8170 F- (a4f)2711-7931 ff"Wa au".o(24Ar71•asit wtC(a45)27a -at7a Fn(945)774.00 a•b' I.W.ne9a (W)27a•ab14 F..(MR372AW Novcmber2.2001 P- 1- 1(94S)229-5917 W(945)222 -4113 . Harry Nichols, PE Patterson Park. Suite 106 _ .._.. _... .2050 Rouoe.2i...._.. -.. _ Brewster, New York 10509 Re: Field Inspection,- Srednicki Lakeshore Drive, (T) Patterson TM# 36.31 -2 -1 Dear Mr. Nichols: In reference to the above noted project, the following comments must be corrocted in the field: 1. Due to needed changes in the field, only the SS'TS trenches can be backfilled. 2. Replace 900 elbows from the aeptic tank to the distribution box with 450 elbows. 3. The distribution box elevation steeds to be lowered and crushed atone edded below the frost line. 4. Measurements taken by this Department indicate the well was not installed in the approved location. Furthermore a measurement of eighty two feet (82) was taken from the well to the expansion fill pad. A Minimum of one hundred feet (100') must be maintained. 5. The silt fence is in disrepair. All silt fence for the SSTS and well must be fixed up and properly installed. 6. An inspection of the house needs to be performed upon completion. If you have any further questions, please contact me at (845) 278.6130 ext. 2261. Very truly yours, ae.�� /9e 0 -1 Gene D. Reed GDR:cj Environmental Health Engineering Aide J BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 .t—..a..3+.r. ^. ..4ia � .: ✓ -: ..1 .s =K lsi.ae cs � ...srw -.'s9v CTA MOLINARI R.N., M.S.N. 2ciate Public Health Director director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 November 2, 2001 - Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection- Srednicki Lakeshore Drive, (T) Patterson TM# 36.31 -2 -1 Dear Mr. Nichols: In reference to the above noted project, the following comments-must be corrected in the field: 1. Due to needed changes in the field, only the, SSTS trenches: can be backfilled. 2. Replace 90° elbows from the septic tank to the distribution box with 45° elbows. 3... The.distribution box elevation needs to be lowered and crushed stone added below the frost 11ne. 4. Measurements taken by this Department indicate.the well was not installed in the approved location. Furthermore a measurement of eighty two feet (82') was taken from . the well to the expansion fill pad. A minimum of one hundred feet (100') must be maintained. 5. The silt fence is in disrepair. All silt fence for the SSTS and well must be fixed up and properly installed. 6. An inspection of the house needs to be performed upon completion. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide I O _ ._.. : BRt.J(1R -._R Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA. MQL JKAJ-U RN M.S.N. >.��Associale �Pu�lic �I�x�irector ` � ' _ �� Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Date: `7 To: a-z 'Q1 G-140z S 0 From: Gene D. Reed Putnam County Department of Health Fax #:,27 No. Pages IL (Including cover sheet) For your review As discussed Attached as requested Please call Notes/Messages j!9 )!5WlV e-49144 /`'1 In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. d BRUCE R. FOLEY Public Health Director LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva . Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113. November 2, 2001 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection Srednicki Lakeshore Drive, (T) Patterson TM# 36.31 -2 -1 Dear Mr. Nichols: In reference to the above noted project, the following cominents•must be corrected in the field: 1. Due to needed changes in the field, only the SSTS trenches can be backfilled. 2. Replace 90° elbows from the septic tank to the distribution box with 45° elbows. '3. _ The distribution box elevation needs to-be and crushed-stone added below the frost line. 4. Measurements taken by this Department indicate1 e well was not installed in the approved location. Furthermore a measurement of eighty two feet (82') was taken from the well to the expansion fill pad. A minimum of one hundred feet (100') must be maintained. 5. The silt fence is in disrepair. All silt fence for the SSTS and well must be fixed up and properly installed. 6. An inspection of the house needs to be performed upon completion. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDR:cj Very truly yours, ��EIF Z I Gene D. Reed Environmental Health Engineering Aide DIVISION OF ENVIRONMENTAL HEAL'T'H SERVICES CONSTRUCTION 1njLny-e-,- SEWAGE TREATMENT SYSTEM PERMIT # 9 Located at Town or Village Subdivision name Subd. Lot # Date Subdivision Approved Owner /Applicant Name J4-51 -,e Mailing Address 'a1,.- IV Amount of Fee Enclosed Tax Map `3 .31 Block '2. Lot 1' Renewal . Revision Date of Previous Approval Zip 16 Building Type R cS t d"JiJ Lot Area Q, G JoNo. of Bedrooms Design Flow GPD fe- 6Q Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of ; '6 a d gallon septic tank and 3 d d �� �� Other Requirements: To be constructed by T 13 1) Address Water Supply: Public Supply From Address or: V Private Supply Drifted-by ! t Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address P.E. 4,-" R.A. Date 3 1.4 _p ON, Y, License # 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 co idered neces by the Public Health Director. Any revision or alteration of the approved plan requires a new pe rt. A roved for s arge of domestic sanitary sewa a only � By: � Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Pr fessional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please 'print or type p_ ?CHD'Feinfit" Well Location: Street Town/Village Tax Grid # Lddress- pave_ P4 JfwvSU'i Map Block ' ..- Lot(s) Well Owner: Name- /j Ji. Address: a ,ln( _' 42, Use of Well: 'Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 5 gpm # People Served Est. of Daily Usage v6 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _1- Vew Supply (new dwelling) Deepen Existing Well Detailed Reason z C' , es 41' for Drilling Well Type _gilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No r/ Name of subdivision Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes —No Y Name of Public Water Supply: J' •9- _ Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separa sheet/plan. Date :., 3 --14 -o ;"- _.__ :- Applicant Signature::' AL.,- Y�l dV­ �7 PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Anj revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ell ller certi led by Putnam County. Date of Issue /I J— Permit Issuing €f ial: ,4 Date of Expiratio J D Title: Permit is Non - Transfer able 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 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 March 15, 2001 Putnam County Health Department I Geneva Road Brewster, NY 10509 ATT: Robert Morris,, P.E. RE: Trench Permit Joseph Srednicki (Formerly Colonna) Lakeshore Drive Patterson, NY Permit #P 81-87 T.M. #361.31-2-1 Dear Robert: The fill section for the above noted permit has been installed and inspected by Mr. Gene Reed for compliance to the approved plan. We are enclosing the following relative to the required trench permit: 1. Five (5) prints of Drawing SS-1, "Proposed SSTS," dated 3-14-01. -2. "Construction Permit,". dated 3- 14 -01. 3. "Well Permit," date 1-14-61. 4. Design Data Sheet with percolation test results of fill section. 5. "Letter of Authorization." Kindly issue the enclosed Trench Permit at your earliest convenience. Very truly yours, �rols Jr., P.E. Harry W. N HWN:his 01-009.00 r° 01 — ?� _7 PUTNAM - COUNTY DEPARTMENT OF HEALTH DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner ' 05 P'" S����N I CK � Address F S C � K Rb Pn c ,; YO 1 0 5 4\ p�> 1 Located at (Street) L Rk. S�\0��� ��. \� F Tax Ma Block .L Lot (indicate nearest cross street) Municipality Watershed FIST CRNN (,V\ SOIL PERCOLATION TEST DATA Date of Pre - soaking.. / 12101 Date of Percolation Test j 5 0 .... .:: ..... :.: .: : {... :; �: vr.,v /. ... {••:: v.^ :: ...;.:. y., :rK' }:W. :. . % };S. }•; {. }kv }�:• {: :v.'.:v♦ :.'C'k�: C.M1. :: .4: +: }... .�i.. �+yvrti `'i':::�t.., ?ri fi. to� :D `th�.yaietd�r .,�.... .: }.: ti wvwao-:. :Q'i�. �. rr.:...::'i.}�:.•.:i:i ..• 0.. . K8 ; Tirn. �. ,4. k'po r GeQ.... S:uctace< aches •�. ...� :X,;erel:' :' ':: =:percalatio�a: Rate :I Hole o%I IIC' : :•.: ::};ce:a.: ,�{;F,�j,{.l .a.10- •::rKCss..w.c....dw,•.(wie .: .......::::. �:::.,..:... }: ...:.:',: ••} {.: .. },'.. .:..:; }:!:: . 2 2; � 5 2',�� 2 1 Th I'5VI 4 _.. ?J 2 2, J� 3 , 07 322 5• 1 1 3 4 5 2 3 4 5 •,., • Lam• a V'Qu 16V W iqPpcatw"auuv uupui unin apprummatmy equal percaatlon rates-art obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 mu✓inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. PUTNAM COUNTY- ]DEPARTMENT OF HEALTH _ r Yu.:. SAO C►F` Ei�I�VIiZONI�iENTAE i Y� 'H SERVICES RE: Property of Located at LETTER OF AUTHORIZATION S, TX La. L-e-rS e i Tax Map # 3 <-- , 3 l Block :a_ Lot Subdivision of Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize / 1 Q,hrte► 1A1 . .A , ji. a duly licensed Professional Engineer ''&or Registered Architect _ to apply for the required wastewater treatinent and/or water supply permit(s) to serve the above-noted "property in accordance with the standards, rules or regulations as promulgated by the Public Ifealth Director of the Putnam County-Health Departrnent, and to sign all necessary papers:on:rny- behalf in connectionwith this maaer and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned: P.E., R.A., # S-60- 124 Mailing Address -L4 2a r utJ C ��- State A/ _Zip !0 Telephone:-- State /V Zip to r Telephone: BRUCE R. TOLEY Public Health Director DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509, LORETFA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 279 - 6130 Fax (945) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 February 13, 2001 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: Re: Field Inspection, Colonna, Linda & Renato Lakeshore Drive, Permit # P-81-87 Town of Patterson The following comments must be corrected in the field: • The fill pads are not installed according to the approved three (3) bedroom plan ' s dated August 12, 1987 and last revised June 5, 1998. Copies of the field and office sketches enclosed are provided for-your -review. Please make the. necessary revisions to conform to 7' the approved plan. If you have any further questions, please contact me at (845) 278-6130 ext. 2261. GDR:cj Very truly yours, 1� Gene D. Reed Environmental Health Engineering Aide \C \ W-- LN I N \ . r NO 1 .1 Al I 1 1 \ \S .. � Sp2` • \I nl 1\ � \ \� y1 ,32�,' - ,� - Sheet of PUTNAM COUNTY �DEPARTMEN.T= F �IEAIITH ) I�I gON' ii►rir�r.t`v'�IFi�Nii3t ;i�,';�'r�i. ;�f�e.�i'I J�J I S' r ICES.. .y04 W FIELD,ACTIVITY REPORT PIC .. §t' eef Town State - Zip PERSON T1V-'CHARGE f3 1 �� Name an Trtle TYPE OF FACILITY:_ . A a FINDINGS. L1 VIC IV. 3 n _ vz y �.r _ j Signature aril Title r f RRP(1RT RF('FTVR R Y' l acknowledge,receipt of this report:_` SIGNA.TTM 5 o2:/96 Title.. P ,. Y .� . r t t . - „ ... S t{ ' �� � t � �' �,... �y i - -"yw`- '� 'R�. y i,.,1 d ���M '� �� i S' ..� .,, u � a. h � r � Z.. • Q Jam. .Ya s- BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S.N :•. ��= �P'si&#ie�Ieslth- =�ExeeFOr -.__ ._ �::.._o,,:;�= �...., x <.:�.-a a=.>_,= ,......�.- .<,F.��r�..4ssoat+itt {iA= :�lcirERl�= Fir�cterx.: -. W Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845)278-6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 'Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 ■ Date: b2 / %- /,�2 / —� To: gle Hatt S Fax #: _ 41 J � 7 No. Pages `t (Including cover sheet) From: Gene D. Reed Putnam County Department of Health ✓..For your information __ ._ -_. _ _:..Pleases- -espond For your review Attached as requested /Please As discussed call Notes/Messages Jt SOME In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. FEB -08 -2001 01:05 PM HARRY W NICHOLS 914 279 4567 P.01 4 w ?MAN COUNTY DEPART== OF BULTS DM81ONI Of ZNVMONNMAL MUTE SERVICES ATTENTION Q ADAM ENE RBQTIES T,F0K.Em" 1 MZE= For:. Fill All irdbttttation must be racy ampleted prior to my Trenches inspections being wade, PCHD Const uadoq Permit # Located: k• S M 1Q4 ors o y Owaa/Applicaat Name:- _ -- Cs y n °l 1161 Block ?= _ Lot ,� formerly: IuMvisioo Nu nw. Subdivision Lot is $)stern an oompieted? X& _ Dato. 2- 5'- o i Is syrtem Complete? a Date. Is system constructed as per plans? ,,,,,r!'!'• —AAE_ Is weR drilled? Date: Is welt located as per plans? Are erosion control measures in place? _.,.,I I. certify that the sygo*sXv 994 at the above premises has been constructed and I have inspected aad verified their eompladon is accorbm with tha issued PCIM Conmvotioa. permit and approved plans and the Standards, Rulca and Regulations of the Putaam County Department of Healed Certiid by: PRA► �: De rousion Address', ?��- ��..s�t,. Commeaw foray FIR " tv N i e: at— S tJ •..,� I , � o \CN `` 1 M. NJ it a I 0 at ui \ . , •�. �.. � ; , t 1. �'*" \ �`, p TNAM COUNTY DEPARTMENT OF HEALTH ION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM !PE # _ g I _ b-I Located at L-� `a ° X9-1 y Town or Village PPtT ra9-1aON Subdivision name PUi"NAK LAS Subd. Lot # Tax Map Block 47 Lot HA6,16 Date Subdivision Approved Renewal X Revision Owner /Applicant Name W NQA t P-f,:�H TO C'oa ,JA Date of Previous Approval (011 p 11(0 Mailing Address 11cj lfiµE ,5Yt41p- DR1.i5-- Zip l0rj ©� Amount of Fee Enclosed 00 Building Type �`''�D E H Lot Area d` '� la No. of Bedrooms Design Flow GPD G06 Fill Section Only X_ Depth 'V Volume LAO c PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1060 gallon septic tank and ,4-,e,Z00 P-1 "1'I 9 N TJ: -E V 1 "i5 4j Other Requirements: 3' R-•o `$ - r—(P, To be constructed by T-4 '0 , Address t Op 1,1= �' N + OE Water Sup"ly: ..Public_ Supply_ From Address or: �4 Private Supply Drilled by T ` 1p- Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: P.E. � R.A. Date Ql Address License #6 �Zy APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified whe nsidered n ssary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe proved ischarge of domestic sanitary sewage only. By: Title: �� Date: J White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design ofessional . Form CP -97 Y ENVIRONMENTAL SERVICES 321 Kear Street �t2w � /�[��-�._'.��.~~����.=_��.���~���~.�����~ Albert H. Padovani, Director LAB #: 9.50051� CLIENT #: 57109 NON STAT PROC PAGE: 2 DATE/TIME TAKEN: 03/18/05 11:15 DATE/TIME REC'D: 5 O3/18/05 11:4 REPORT DATE: 03/25/05 PHONE: (845)-629-298O SAMPLING SITE: ED-JOE HOMES SAMPLE TYPE..: POTABLE : LAKE SHORE DRIVE, PATTERSON PRESERVATIVES: NONE COL'D BY: JOE SREDNICKI TEMPERATURE..: NOTES...: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ COLIFORM METH: N/A DATE FLAG PROCEDURE is suggested. RESULT NORMAL - RANGE pH pH SCALE IN WATER RANGES FROM 1-P4. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MlGHT 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 CAR8ONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. -S8FT-WATER:.0-70'MG/L --VBRyHARD WATER: AB8VE 300 MG/L ---.''_-`� MODERATEL. HARD WATER: 70-140 MG/1. MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: 0, Albert H. Padovani, M.T.(ASCP) Director METHOD ELAP# 10323 A P YML ENVIRONMENTAL SERVICES 321 Kear Street 'Yorkt)qwn (914) 245-2800 Albert H. Padovani, Director LAB #: 9.500512 CLIENT #: 57109 NON STAT PROC PAGE: I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE/TIME TAKEN: 03/18/05 I|:& DATE/TIME REC'D: 03/18/05 11:45 REPORT DATE: .03/25/05 PHONE: (845)-629-2980 SAMPLING SITE: ED-JOE HOMES SAMPLE TYPE..: POTABLE : LAKE SHORE DRIVE, PATTERSON PRESERVATIVESs NONE COL'D BY: JOE SREDNICKI TEMPERATURE..: NOTES...: COLIFORM METH: N/A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 03/18/05 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 03/18/05 LEAD (INS) 1.9 ppb 0-15 ppb 9003 03/18/05 NITRATE NITROG 0.74 MG/... 0 - 10 9052 03/18/05 NITRITE NITROG <0.01 MG A... N/A 9162 03/18/05 IRON (Fe) <0.060 MG/1... 0-0.3 mg/l 9002 03/18/05 MANGANESE (Mn) 0.018 MG/L 0-0.3 mg/l 9002 03/18/05 SODIUM (Na) 11.0 Ms /I... N/A 9002 03/18/05 pH 6.9 UNITS 6.5-8.5 9043 03/18/05 HARDNESS,TOTAL 158 M8/L N/A 03/18/O5 ALKALINITY (AS 138 MG /L N/A 900l ^7}3/18/0A ��. TURBIDITY- <lljR__ COMMENTS:! BACT THESE RESULTS INDICATE THAT THE WAT (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORD BE 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 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET- SUB- SURFACE`SEWAGE TREATMENT SYSTEM owner: 0 MPA � P-EH TO C_O( NN P, Address l ) I Ay- 6SnoPE PXNE Located at (Street) Tax Map- Block 03 Lot 'x,5,0 6 (indicate nearest cross street) Municipality PPrTr9_'C')0N Drainage Basin (,ROT-ON SOIL PERCOLATION TEST DATA Date of Pre - soaking g "/L. Date of Percolation Test Hole No. Run No. Time Start - Stop Ela se Time [Min.) De th to Water rom Ground Surface (Inches) Start Stop Water Level Dro In Incles Percolation Rate Min/Inch { 1 spy ail 2 K0 lS 31 4 9 �0 5 4 3 q 1 `b 3b `� l�'� �� 6 4 3, ASS 4� /LN 2� 5 1 - 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtamea at eacn percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' - 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' -.9.01 - 9.5' 10.0' 2 a TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. Z HOLE NO. 4 P(4-� 6' 11 1 . F-4GV-& Co' Indicate level at which groundwater is encountered koNL Indicate level at which mottling is observed MoNe Indicate level to which water level rises after being encountered — Deep hole observations made by: S (A6 P4t iA" Date 9'24 P�9 Design Professional Name: H- ' 1VY I NIL-ri UL--'7 pE Address: dLo MIL- L-70 "O k BR.67w,I–F- V— N► 10101 Signature; Design Prof'essional's Seal of NEW r01 Cli 4Z sV r 2e w LU No. SS124 \AROFESSIONP,,./� e., " SAN4i J. -oANA LO Am �1sor� °�I.rocnE P(4-� 6' 11 1 . F-4GV-& Co' Indicate level at which groundwater is encountered koNL Indicate level at which mottling is observed MoNe Indicate level to which water level rises after being encountered — Deep hole observations made by: S (A6 P4t iA" Date 9'24 P�9 Design Professional Name: H- ' 1VY I NIL-ri UL--'7 pE Address: dLo MIL- L-70 "O k BR.67w,I–F- V— N► 10101 Signature; Design Prof'essional's Seal of NEW r01 Cli 4Z sV r 2e w LU No. SS124 \AROFESSIONP,,./� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL or type '�... Well Location: Street Address: Town/Village Tax Grid # Lf1(1-45,X) 0R--E DR-4JE- pPrTTF_ �N Map l)b Block 'h Lot(s)g50,5 Well Owner: Name: UN9 &41EHM a"000% Address: Ij5 Lh1_G5140P-5 i)W145 6R•0W5T_E_T-- t4g1 05o Use of Well: X 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 _ 2+ gpm # People Served � Est. of Daily Usage �o po gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Y- Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision LA4-E Lot No. Water Well Contractor: 't–,e,10 Address: Is Public Water Supply available to site? .................................. ............................... Yes No )k Name of Public Water Supply: -- Town/Village — Distance to property from nearest water main: — Proposed well location & sources of contamination o be provided on separ she t/plan. J, Date: G, S - Applicant Signature: zz V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate el driller cert4fiedd by Putnam County. Q Date of Issue 3 �l�'�� / % Permit Issuing,Official: Date of Expiration 1,5 // b / ZyaY Title: Permit is Non- Transferkabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 -3 �1 I I 1 1 � y'•a.• - �-- - - -�•� - -I - - -- - - - -- ice: -- - - -- I - - - - -- �� � - - - -- -7,•o• - - - -- N qg��3 /ors r BATH 'r 2 9 ED I/ 1 ; r I T C IEN O o 9 BI=D RN/I I =i it N N O y �� 9; ; ; o u, BATH 0, 18 0 9 1 '�°i1S 1S N iw i 7=4�1 1 4 =10 i t 2= ill Z'•O i 2i 1 '07=1 I "/4 s, t nc w 111N.A STATE OryIS10'J Of _ NOUSINC A** '0 .....Ty REN_i A� STAKP OF APPROVAL FORA ;09EL OR COMPCItEriT C�YI:1I� >l AN UILOYII N0. Ol1C C! � �>Y'iYll 00361 NOV 12 1981 Cg;tC- rTYI.IIr!hµ SNlll CJi [sll(v( TN( wlNOr1C• 11''.;] fAOw IRS ►tgSK'LRi fOR Q(YIAIU[j f70� TN( lf- f':Y(G:CC :•CCIij [:a LO(S TO$ Afff-GY/.L R(IKYC NIN f'("I E(S/ONSIl11 ITT fCR C4N1S OR Ou1SSC -[S. IL EsgmR ST: PUTNAM COUNTY DEPARTMENT OF HEAT HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; , r17, OMS J Signature & Title c n PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE:' Property of 1-1 HDA + Pr--- WtKTO co >^o NMA Located at LxI.5,bwR-F- 0P_►4a T/V Tax Map # 38 Block Lot 1 A Al ib Subdivision of Pa"M LAw1^ Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize j4P�1� W ' Ni CHwb j�_ p1= a duly licensed Professional Engineer '� or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam C ry N Code. P�ti p y�� NICH 5 Q Very truly yours, w Countersigned: Signed: P.E., R.A., # 5G 1 4 a (Owner of Pr p rty) Mailing Address BP-e W ,!5 i Eg_ State NE' 141 i Zip �0 �t) � Telephone: NI') 2—l8 - GI08 Mailing Address: 111b LNVL -5 SiID l.; DR?-IUk $PIL-5V\(SrE jZ State I\I FV\I Y 0 p-� Telephone: Zip 105 °`I 0211L11%0 -1061 Form LA -97 _.e.,.... - .,_,,.,BRUGE�- R: -�-�' 013F 1�.•;: �;.___.:;��.:<:�,.:::.....�__.. .�.. -r .,. -.._ Public Health Director I0 E J14 iltI R.IV., M.S N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 February 1, 1999 Jeff Moore Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSTS: Colonna Lakeshore Drive (T) Patterson Dear Mr. Moore- Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows- The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1) Fill plans are to be submitted in accordance with the guidelines outlined in Bulletin ST=19 for fill sections greater than 2 feet. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve t / ly you s A' J1 I Robert Morris, P.E. RM:tn Senior Public Health Engineer LAURENT ENGINEERING j ASSOCIATES, P.C. MILLBROOKE OFFICE.CENTRE - Route 22 & Mill[own Road \(914)278-6108 e (FA)O 278-2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS June 5, 1998 Mr. Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Colonna Lakeshore Drive (T) Patterson Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -1 "Proposed SSDS ", dated 6/5/98. 2.. Five (5) prints of SF -1 "Preliminary Plan For Fill Placement Only ", dated 6/5/98. 3. "Short EAF ", dated 6/5/98. "Application For Approval of Plans For a Wastewater Disposal S stem ". 5. "Construction Permit for Sewage Disposal System ", dated 6/5/98. 6. "Application to Construct a Water Well ", dated 6/5/98. 7. "Design Data Sheet ". 8. "Letter of Authorization "; dated 6/5/98. 9.. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count 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. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Hry W. Nichols, Jr., P.E. HWN:JM:bd vL' Lk.'4L I i. -layey soil on, one at )f the f ill/%O" :'.Cttfta tht efACUMM $.iVUJty UeparTmemr. or Xewlta in no M re dlvxelp�i pf Envirciroptal Health servuQ try Wei t. r_ / scj�$ noted �.Cr conformdncre wift 200 si ve. OPP116ahj* Rules A!'i Reg.-Tilations of the i a I sh uld Pat nw Countv-- •.jl Department. oast Shall. "c Re v ? .6 IL - 96 Dw .2.0. e14 tst r cc V....41"A 05 el pfckcL-•, or 1 117• to :1 :'.Cttfta tht or tc-I'OT3 Isle shall be ptbtr. oast Shall. "c Re v ? .6 IL - 96 Dw .2.0. e14 ifLV• 3.2 - r 05 P140JECT PA r L,IN A K�NATO COLON NA i:c., 1,AK561,700KC (7-KNI,* ��Vikl Y6�KY RANI)OLPH W. L.A1JPr'J'(' A 'SOCIATES, P.C. CONSULTING SHE FNIGINEEPIS' F IPMAMINAKY LMAOK rOK ro 1, L. rlAW, M r K-f 0 K L,-f Q N-1 10 -08 -1998 08 :46AM FROM TO 92787921 P.03 • .. ,r•- -+^yF- •-.rte. - --�.,. .._..,- .,.,..�r..�.. � /. . :.._:�:- ._.... -_- � � - �' �1 9�/ AkSO��fI'!'�A�11�19"OF�'P.1LT@t .::. • .... :�:•.�.:.a,.._:.�:.,- _,.,�..::. ,..,, ... ._., -_,. ,_> . .. _ ��� DH4tise e119EelaosesAd Std 3teoleea Ctttistlr X.T. ISO is lbhie htMt! eoC8>tMICA1$OfWNWIJAM MW FOR WWA= DISH" 3YxlM frrt,It �r "t/ aer.tt / PS b o r e Pr "'ve pa e rs 4r N ff i« f IS% A Ta yw 36,3J Z. ... % �� rza.. � /hc�a b� �ena�0 Ca /arch °L• ,:".."'t � °,.t+�.°_ Ifrce et r+et�a.. Ap�eovat_�_ IKM% A"sea _. z a 4-611? or c Di-/v e Tows s l e " YV, I � p oe t T) Po Gl./ .___ lot Ater 0.19/0 FM S"Pe 0110 El p�.L Iilref��e D..3pt1s.0 P D �Q� 4cllnll. loo .leRette4al'OVtia.P@laee.pieeea af�elsei s•e�ee• —YOM IV cetatlst .e L C.Gto.ay'S'�spale Te>ilt x¢00 L Ali S• �r e c h PJ r..a. 3i be ae0.ti.a 9►4laa.5 c,--I psom p a Addtsw Sp* by-- 7" 8.1a • _—A,h.,. r ! rwotanl that 1 am wholly a" C.6moletaty, reloonsOtO for to deNen line MOCAt:on of the pellet" lyas(Mq; I) that iM 3e00fON tswaea hyewl tyRa«► *Coed dtwa" wit, he conftraeted at woven an the apOto.W aMMndnfent thorn, to and in ACCOrdtnp with IM itartaetdT, ruts{ s fqu .M+{ eT County 0SWI t1MI of ► WHN dive that on eonrOtatlen 1Mreef a "Ceft:f;Cate Of ConfU%Kt$O" Coe110V&ftCV' 24114¢00{917 to the CO ..ltd*nof er feeettnwgt be arernaled t0 the Depennttnl. one it written ruafantee wiU be turrlilhgt the owner, his Wcos"offr heirs of { oY fh0 Ouilow. that Ytd boo*" alts ohm to toond oowaline cNtdtllon MY Wt of tatd eawaee dtWodt ZA ul" this OW led Or tws (1) ?Hall M'nMlwetftel7 faiiewhq lift date of We qtu- uttt or the aPpoHl of 11641 COrafleate of Construction Centplance ftelMl Cyst a sn�; trst ete ;>!) hat M ar"w {fell detorAod 46r%10 WIN t o located n Via" 061144 approved Dian and that said well wilt M I eccOfde wdh 1 21 /rtdar ►alt Grid rq� ter P1tlMT Cwnty 04portfnont of man". . _ ` d,E..� 1l.AL --.—.. APPROVED FOR CONSTRyCTION, This iepoat 01100" two years from live date Iii-wed uniets eonstrvetio( of ter su; dine loll Olen and r4hin and H fr.O9Mb% for Ostrte sf rru7 U0 antsndsd Or r"00010e wMpn COnfldW.0 ftoeewrY by tna errufMlta;OMr of MMRR Any che"" or onteratteh of cehatruclbn fequIt" a Mw pannit• APWV*4d tot di20pfN Of dometlk Ynitary aOwNSr oovorM;vst0 water wpm only. .Olga °"e , as • r 10 -08 -1998 08:47AM FROM TO 92787921 P.05 9 h a ,.0o ry i 1 , Zt t } 41 !141 Q�( 19 TOTAL P.05 10 -08- 1998 08 :44AM FROM TO 92787921 P.01 1.AURENT ENGINEERING ASSOCIATES, P.C. PALLBROOKE OFFICE CENTRE Brewow. New York 10508 ("4)270.610® • (FA)Q 270.26W HARRY W. NICM XS JR.. P.E. CONSULTING SITE ENGINEERS PAX 22"SM OSION S883T Date: 10 $ -416 Job No: 31a lumber of pages � including this one: To: D- OOK A�10 Firm: K 14D FAx Pto .: ' -1% - From: dff,± Project: cot ykyAk Message: Vey AV %Wq Please call (914) 278 -6108 if there is a problem with this transmission. 10-e8-1998 08:45AM FROM 0 -rbM,1)w%AftcA,t- vATA Pwm IW\/ dt - 19 -lie 3.2? -% hop TO 92787921 P-02 fl�90WT a 1�. 191 t7& CE APP,710*VED T10' FILL ONLY In accordance With r-Ii-1 zablo :toles and io t�� Reg7elations o4- - Putnam Co,.:nlvy RealtA par M., -0p1w 012elo $17ch—ature a Title 00 PROJECT � bp to% m0p0!,:,A:;v S5 e,AT'r0Ke-5aN , WNRA 4 DRAWING TITLE 146W -f IT` I NA v WNW N 10 CO L,AK61?H0Ke 0MX Now YoKe RANDOLPH W. LAUREN." AS GS O,C-IA T ES; P. C.-- --- T3 FAIRFIELO DRIVE PATTERSON. NEW YORK 12563 1 914.278-6108 CONSULTING SITE ENGINEER- SCALE ft smowu DATIE DRAWN By CHECKED BY JOB No. No 15p-1 a • ElmLAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 8 Milltown Road Brewster, New York 10`'509 (914)278-8108 - (FN( ).278 CONSULTING SITE ENGINEERS To: P CA9 'tn6rivii Attention: Ar)a-'F -D< MCAP4� 1 ?F Date: j✓!9 Job No.: 9Ho4)� Project: �T 1 14 Gentlemen: We enclose (d ) copies of: • B/W Prints ❑ Reproducibles ❑/Reports ❑Tracings • Specifications ❑ Memorandum © Copy of Letter O Description: Sent Via: • Our Messenger • Your Messenger ❑ Blueprinter [Hand Delivery ❑ First Class Mail L7 Revision /Date No. O Special Delivery Copy to: Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. T. I l PUTNAM COUNTY DE?ARTMERr OF HEALTH Division of Had& Servbceo. Carseal, N.Y. 10512 to Fnvmo I'wtatlt 9 CO" N FERl1HT FOR SEWAGE DCSFOSAL SYSTEM iaeow at Ps b Or e .Drinve SarbAi.N . N /g Leer ti s® CEYTQRCATE OF COMPLIANCE Pes-it r P— 8/ — c9 / pe? e,-..T07? oarw or Y111ate Tax , 36 3J ll 2 / tau Lida � Fen o to Co /o h h °t, Reoewd_� a oa..r /App�eatae Na®e Date of Previous Approvals ' l iS La k�sti or e ri'v a Town Sr e wiler N, Y. zip oS-O 9 — Date Subdivision Approved Fee Enclosed ❑ Amn„nt- PeS 1'd eh y/nR l Lot Area 012/0 Fm sew X Only Depth Valle Nata►ber el Belisw®d Design Flow G P D J O 0 PCHD Nodikation Is Requbed Wben Fill Is Sepaeete Stmerwe Syd m is candst oQ Gallon Sepdc Tank To be owsbaceed by 7. S' Addreso Water S0lP*: // PdAc Supply Frew Addrasd on�l�_ lgh Supply Drilled by T B.D _Address. M Oeber saRw e®e.ta 1 represent that 1 am wholly and completely responsible for the dosign and location of the proposed system(s); 1) that the separate sewage disposal s atom above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regulations o nam County Department of Health, and that on completion thereof a "Cenificato of Construction Compliance" satisfactory to the Commissioner of Healthwlll be submitted to the Department, and a written guarantee will be furnishod the owner, his successors, heirs or assigns by the builder, that said builder will Piece in good operating condition any part of said sewage disposal systorn during the period of two (2) ys r�ljnmediately following thadate of the Issu- onq of the approval of the Certificate of Construction Compliance of rt o original system a an�c���pppMMMif t oto; 2) Mt the drilled well desalbsd above wIN W klcated as shdwn on tM approved plan and tMt pld well will be InstDll in accordsn with tl� standar s,% rub an ragu a— riloni of the Putnam County Departmw+t of Health. N / //, Date (0 `1 —�� S. nod _ P.E. R.A APPROVED FOR CONSTRUCTION: This approval expires two years from the date Issued unless construction o f revocable for cause or may be amended or modified when considered necessary by the 5:ommiWaner of Health. requires a new permit. Approved for disposal of domestic sanitary sowovq an4 /or privato water supply only. Data'.V . - -`.. •.iw '.2._. � ...... rye ,^V;�T"�'".'�'�..r�.......�_._ .. LY0I.Icense No ` 1 AL � 1 the building has been undertaken and is Any change or alteration of construction 1 J, TniW . 'i L' L tj Z:> L I I., -layey soil on, one at )f the fill .-uLtln; the c'UQL&w Vepartment or kealtx in no more J1V1BiLpn p; Environrptalj Health Servic , 4 11 by weight. Ajp��/d/�/as n�oed � orctnf:ozr�e wl-h 200 sieve. *pp11ca1Y13 Hules and Regulations of the i a l should fttna* Cognty--H th Department... LOgCthcr WMature 4 Tltl-p faco C ..l V Re v 6 - lo - 96 usefulness go V ("I - Pev.*-t- CIA KEN. laced C6-1 t�"'-. :ontow I - I I- -10 cl- cl pickets, or 1 112' to 2' _t_ .-uLtln; the Of 4". 1 or re-bars bale shall be LOgCthcr ztnL ihL11 . be Re v 6 - lo - 96 usefulness go V ("I - Pev.*-t- 11-410 KEN. 5- 21- qO t-I F_ V - I - I I- -10 K�V. 10-11-M k _t_ 61 PROJECT [ANPA K[�NAV COLONN/A RANDOLPH W. L.AURENT ASSOCIATES, P.C. CONSULTING SFFE ENGINEER,�; I T ff�WMINAKY P�cbIIOK rOK NIA, rMCr, M r NIT 0 N Lf a1F IN ' T I- 4 • DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 October 13, 1998 Jeff Moore Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSTS: Colonna .Lakeshore Drive (T) Patterson, TM# 38- 3 -(4 -8) Dear Mr. Moore: BRUCE R. FOLEY Public ` Health "Direclor" Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows- The.construction of this sewage disposal system may be subject to local,.wethnds_ regulations:.. S'or�-- - - - - -- .- x should contact local wetlands officials in this regard. 1) The slope in the SSTS area must be reduced to 15% by the addition of R.O.B. fill. This may involve a reduction in the bedroom count and /or a retaining wall. Upon receipt of a submission, revised to reflect that above comments, this application will be considered further. RM:tn Ve ruly yours, Robert Morris, P.E. Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES J FOR APPROVAL -OF PLANS -FOR . A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: LlHpA f 1LCF 4 ALTO C,01-oWNA 11-5 B 4-F-W `-r(� �4 i 10601 2. Name of project: �� H A N Di �1 i t-UPtL y„S 3 . Location TN: P/47 gF-35o M 4. Design Professional: MR* VS Hl(.i-gA 4-1M. 5. Address: U (iU'f'OWv 4 P-0 (V 6. Drainage Basin: G'19 -0r44 7. Type of Project: Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision '69-E°+J -S'T�lZ JJY f 0 60 �-- Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ....................... ......... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Exempt X Unlisted Ha 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 officials; ordinances? ..:::.:::......... -..:.........: ............................... YES 13. If so, have plans been submitted to such authorities? ° 14. Has preliminary approval been granted by such authorities? N(' Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) .......................................... ............................... 18. Is project located near a public water supply system? �0 19. If yes, name of water supply — Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system Distance to sewage system ' 22. Date test holes observed 4/1-41 M 23. Name of Health Inspector 24. Project design flow (gallons per day) (006 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? NO 28. Wetlands ID Number .... ............................... ..... .... ..... _ 29 Is Wetlands Permit required? .............................................. ...:........................... Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... . 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 DESCRIBE: No No Ho 33. Is there a local master plan on file with the Town or Village? ......................... �E5 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? No 35. Are any sewage treatment areas in excess of 15% slope? . ............................... Y817 Map .................... Map �� Block Lot H;616,� 36. Tax Ma ID Number ...... ............................... 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE- All.applications for review and approval of anew SSTS to be located within the NYC Watershed shall b e* serit'fo the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the- SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal I aw.,q SIGNATURES & OFFICIAL TITLES: Mailing Address: . ............ 20 m it -LrowM F-0 Pry bP-E0STCR NY 10-501 14 -16.4 (2187) —Text 12 ' PROJECT I.D. NUMBER 617.21 SEQR . Appendix C State Environmental Ouallty Review. . -,.. -- - r - ti..•. - SROAt'EMOONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME. I PHDA+ P-�EHATD C_s)L_g4HA r— oL6.mis4A IND1v1PVAL- 3. PROJECT LOCATION: PAT- IFF-15 W P UT H A M Municipality County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) L AV-L= rS H G11_E MV-415 E ( P UTIy AH LJ>I�) 5. IS PROPOSED ACTION: 9 New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: CAN�rT {��IGJ-t p�— Sl�efillf �N1iL� }�IDEt� 7. AMOUNT OF LAND AFFECTED: Initially �'�I acres Ultimately 0'91 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? IS] Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ® Yes O No If yes, list agency(s) and permiUapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ONo If yes, list agency name and permlt/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes 9 No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /sponsor ame: 14A M I H s P Date: 6. rJ Signature: i/ V If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (ro be completed by Rgency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency, ❑ Yes ❑ No _ — -- - C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain brlefiy: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced.by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other,effects not Identified In CI-05? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. -.D. IS THERE, -OR IS THERE_ LIKELY TO.BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?,-,.- ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (ro be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It Is substantial, large, important or otherwise significant. Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF andlor prepare appositive declaration. ❑ Check this box if you have determined, based on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency . Name of Lead Agency Date 2 Title of Responsible Officer Signature of Preparer (If different from responsible of icer) PUTNAM C NT :;OF 'HEALTH e ' Division bfi 6 virMMeni'al '" th> S ices, Ira�me/ N Y. `.10512 CONSTRUCTION PERMIT :FOR SEWAGE DISPOSAL SY�STEJ G,�I oZ 1 � - oP7 f To Village Locsted..a� ' • wn or - 3 " 'gIOCk `�- 1" Subdivision Lot'- Job' _Owner �4.� �t�I~�e►f .. K/ ' 'ti' %lr� 1 . .•�e L,Q� / dLY �Y io0V � Address r Building Type Lot Area . e' � j ?, Number, of Bedrooms�'ti°P Total Habitable Space ~ Square Feet I 1 Separate Sewerage System to. cOnsik of ®C7 -' Gal. Septic Tank > lineal feet X width trench To -be constructed by , - - Address. Water .Supply: = Public.SuPPIY From .. Private �Supp1Y to. be" drilled by Address n ap TT [ Other Requirements _� '� .7 �k�� iX M` ale^ I represent that 1 am wholly and -completely responsiblefor the design and location of the proposed system(s)-"1) that the separate. sewage'disposal system above described will b_ a constructed as shown on the approved amendment there to and -in accordance with the standards,. rules an regulations o the u nam County ;Department ;of Health that on completion thereof a. "Certificate of Construction Compliance!:' satisfactory to the Commissioner of Health will be submitted to the .Department, and .a written guarantee will be "furnished the owner, his successors, heirs or assigns by the builder, that said builder will , 'place in 'good operating 'condition.an y 'part of .said sewage disposal system during the period of two (2). years immediately -following the date of the issu- ance of the approval of .the' Certificate of Construction Compliance of the original system or -,any repairs thereto'; 2)'that the drilled well described above will be located as shown on the approved plan and that said well will be installed in accordance with. the standards, ruies and regula ions of the ..Putnam i County Department of.He � Ith. j � Date Signed P. E'. R.A. - Address „ License No APPROVED. FOR CONSTRUCTION This.approvai expires one year from the date issued unless construction of the building has been undertaken and is revocable for :cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of ra struction requires a :new permit. ApprJovQed�Jfor disposel'of• domestic nitacy -se. a an / prate water supply' only. Datd /��% L! / / gY Titl I JOHN H. PRENTISS, P. E. .'A`CO N`5 -U L'TPN G - ^E NG'IN EER - ROUTE Sp CARMEL, N.Y. (914) TRINITY B -6170 Putnam County.Dept. of Health County Bldg. Carmel, N. Y. 10512 Re: Parcel on Lake Shore Drive & Lakeport P1. Putnam Lake, T. Patterson, C. Putnam, N. Y. (Map #38, Block #3, Lots #85 -98 incl.) Gentlemen: On Dwg. 1.(Job SO443) by John H. Prentiss, P.E. the well separation from my own septic system is - -only - 75 ft. --instead of the required. 100 ft. Th=is is acceptable to me. 4 r i� r Putnam County Dept. of Health County Bldg. Cannel , N. Y. 10512 Re, Parcel on Lake Shore Drive & Lakeport Pl. Putnam Lake, T. Patterson, C. Putnam, H. Y. (1,11ap 038, Block 1113, Lots #85-98 incl.) Gentlemen: On Dwg. I (Job 50443) by John H. Prentiss, P.E. Vie well separation from my own septic system is only 75-ft. In.stead-of the required 100 ft.. This is acceptable to me. C 7 --N -,7 L, 7 _�T �7 0 7, 7 7 T 7':, -1 T TC Da, Re: L o c a it e d at, 7V Ala, t- BI o cl­: L o Gen lette_- IS 10 John H. Prentiss x a duly S 7 S 3-7 0 D S C' 0- L 7 d c �a t_ n La,.', t In- e P I c_ 1--_7 I t-1-1 Lam.. t he,� P u t n -a r, Co nt SZ tFry Code.. '01 c'erm-_v-- 10 T P E. 29206 R.D. 6, B. 353 - E_d7r:I_r6_S T'_- Carmel, N.Y. 10512 878-6170 Very S -L �-_ -ne d Adder e s s AESSIO A, Tele-oh-cne PR "t \��'i� Q 4b. 2920 S or THE E fi • PUTNAi1 COLCOUNTY DE? ?T T OF L LT'-I DIVISION OF E\VIRO` ­­ A L HEALTH SE?VICES DESIGN DATA SHEET - SEPARATE SE::':AGE S STEM' FILE NO. O�tirer •. _dd *waif'" BAddre ss Located at (S reet)._ U sets __--': Block L.ot (Indicate nearsst ero!'�S, s zreet) 4. Minicipality- t%7atershed 3 SOIL PERCOLATION TEST DATA REOUIRED TO BE SUn`,1ITTE D t:'ITH APPLICATION' Hole Nurrber CLOCK' TI`IE PERCOLATION PE RCOL_1TION_ Run Elapse Dep___ to ater ", "Level No. Time From Giround Surface i- Inc ^es Soil Rate Start Stop i Iin . Star = Stop D^op in Min/in . dre.p Inches Inc�.es Inc ^es 2 LC 3 `des —,� o- -- — ne 4 .. l� 2 4 5 '. Notes . 1) Z'ests to be ypeated Gt: sa ^e '?`oth uyil approi: -aye? :T ecuel soil rates are ob- tained,` a-t:::ea� ':percola`tion test hole. all datca to be submitted for revie:� . 2) Depth meis"2.re,- ,�?hnts to be 'made from top of hole . I`£ST PI"!" D.ZVTy R✓GUIP.Er` ._0 '?E ii3.":ITTED TH A'P-PLIC�"?`Ip�, DESCRIPTION, 'OF SOILS 1 UC E D I EST HOLES DEPTH: HOLE'r NO*. °:. .HOL , �0 HOLE \0 G' L y . 18" 2 4" 30" 3 6't 42" 48'r S 4" .. 60" 66" 78 8 4" INDICATE LEL L AT ?'IHICH GROUND T'ATER IS E \COU, TERED ®iAe INDICATE LEA EL TO iHICH ;INTER LEtrEL P.ISES AFTER 3EI \G ENCOTJ\TERFD C� TESTS LL4DE B.' a �tj4A �Q � Date T, Soi 1 R? �e c�y�� �Iir /� D_ o S.D. t s l o. ° No . of 8`droo- Sep t i e T?:,— C.� � —Gals. Type r Absorption =area Provided By L. F.x2- 36" V idth trench. Otiler �FESS IV Na �e John H. Prentiss , P.E. C.E.C. - Signature, — F' Address R.D. 6, . B 353 AT Carmel, N.Y. 10512 1 PUTNAM COUNTY DEPARTNE.VT OF HEALTH. ,oil Pate Approved Sq. Ft. /Gal . Checked by °FTHE St's " Date \ PUM AM COUM DEPARTMENT OF MUM to hiirW lwtalt% Ha Dmdisdi moMbSinlfee.Cfmoaol, N.Y. 1Df11 � „ _ m C8t_ vnWAW OF COMPU AM `% PEflD11' Ift MWAM DWOM SYS' = remit ' p gJ l , Loeobfl.t rte- y _.,F 4W �� • . .....,. =��ds'Ir�itrimi�ti .�....(l. / .!i.,••: - :C:�_ �5'ii .Yri.�_. .ilu- rrinv�_ �r.� � .,;_. �� . �_:.�__. at.M��'=•- • . .. , . -.: .. Omm/AppNowd LCJLL it 4 j D�fe d fie Adiou r L- ,�.�. /JYL ✓ {.. Town_ den ❑L Doman T, - �s'la%�, Ica Lot Area -Q s °! l � Fm Section 0i* Depth 3 ' Valens oo C Ntt mhi r of Heioonge _� Dodge Flow G P D SQ [� PCHD Neddcatlb Is Dequked'o" FM Is 5"weto &arega Syatan to boodd dI Z ZQ 6djob Sq* Tank med '�dlJ o To be, ea alas by ! R �% Adiltees wmw Stomp¢: - pine Saplb Fns - Adbeeo . . an 1, PAtab Std DrNW M T 1 0 �a�■•• 0 0 LtlltgrMb 1 ►eprelenKaMt 1 am wholly and completely responsible.fer the design and location of the proposed system(*); 1) that the separate sew di sal stem above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a rpu of o M County Dipertment of "=RD% and that on completion thereof a ,•Cwtificate of Construction Compliance" satisfactory to the Commissioner of Hea thwill be submitted to the Department. and a. written guarantee will be furniiMd the owner, his succ ssors; heirs or assigns by the builder, that aid, builder will gexe in good operating condition, any part of said "We" disposal system during the period of two (2) yews Immediately following thedate of too Isew allee of too appsoeel of too Cattifkate of Construction Compliance of the:00iginal system or any repairs thereto; 2) that the drilled,well,descrits" above WIN be touted as shown on the approved plan and that said well will be Instal In aeeoroanee with too eta rd r les and reg�ns of too Putnam County Department of Heanh. Date —� —�.4 . Sig P E./ . R:A• Address /<<f YO L' m License No APPROVEO FOR CONSTRUCTION: This approval expires two years from the date -issued unless construction of too building his been undertaken and is Ia110Cable /or cat+fa a may, be amended or modified when considered n_ ecessary - too Commissionar of Health. Any change or alteration of construction reOuNes ew P Approved for fposal of omest /oi private wafer soppy only.j�� Rev. 10/88 on By Title DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New .York 10509 (914) 278 -6130 APphICATION TO CONSTRUCT A WATER- WELL . __ .. ....... .....:.... PCHD PERMIT 4/O --110,11 'c4i,7 WELL LOCATION Street A dress To illage City Tax Grid Number r�� a 3 1 —2--_ OWNER N e Mail ' g Address L "dr- O vate lFriWELL O Public (3SE OF WELL 1- primary 2- secondary 'RESIDENTIAL BUSINESS O INDUSTRIAL O PUBLIC SUPPLY O FARM O INSTITUTIONAL O AIR /COND /HEAT PUMP O TEST /OBSERVATION O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 6?_ /EST. OF DAILY USAGE 9 0CJ gal 0 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13: ADDITIONAL SUPPLY EW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING zzj WELL TYPE RILLED DRIVEN []DUG O GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES f/ NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: f! n Lot No. WATER WELL CONTRACTOR: Name U D Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: /q YES t,-" NO NAME OF PUBLIC WATER SUPPLY: A-" TOWN /VIL /CITY _ DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: ` -00110V/�` = — LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET (date) 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 thirt3- (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 su51 a manner as not to degrade or otherwise a sur a e or groun ter. Date of Issue: 19- Z-C,_.� —✓�` Date of Ex ation 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 01 > PUTN� ._ GOUNT<Y,�DEPARTdf- DTT R �,HEALTHx - � w - .» . s . -•vwa —xi: R ^�mri•LC: >� _ _ - . � .of -.1 .� . w _ .. DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date-6, 2-6 / �9:i i Re: Property of L/PO/4- `, /2G/I -}TL> Located at L. Hole-&- 42,vL/ v,__7 (T) %.e 7 N Section Block ?� Lot C� Subdivision of Subdv. Lot ,y Gentlemen: Filed Map ## Date This letter is to authorizet?,�?� t a duly licensed professional engineer - L-/ or 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 Heal -th, and to- sign -all necessary I 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 Code. \ C Countersigned P.E. , R.A. , #; Address J N -2-7f & /OF Telephone Very truly yours, of Property yL Address c err �7e- A-) Town 7 Telephone LAURENT ENGINEERING �j ASSOCIATES, P.C. _. . MILLBROOKE OFFICE CENTRE . :f2ouie 2x6&M iHtoaaa -Rea ., ..Y ....._ I.... _... ,- Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278-6108 -(FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. \ CONSULTING SITE ENGINEERS Date: 6 -20 -94 To: Putnam County Health Dept. 4 Geneva Road Brewster, NY 10509 Attention: Mr. William Hedges Gentlemen: We enclose ( ) copies of: • B/W Prints ❑ Reproducibles • Specifications ❑ Memorandum Job No.: - 89034 Project: Renewal- Proposed SSDS- Colonna Lake Shore .Drive Patterson, NY 12563 • Reports ❑ Tracings • Copy of Letter ❑ Description: �r►-,, � 5,�4 -/ J c �C /jL� ti ' ` �,r -� 11. Revision /Date No. 1. !'Application for Approval of Plans for a Wastewater Disposal System" 6 -20 -94 2. "Construction Permit" 6 -20 -94 3. Application to Construct a Water Well 6 -20 -94 4. Authorization Form 6 -20 -94 Kindly process at your earliest convenience. u�vc�� l'� aYt.��► -- ,1 v�.�,��v�- �ve,� g ro �. � o-�w'I �.•� h � wi l7_ �. d� �0 J Sent Via: • Our Messenger ❑ Blueprinter CN First Class. Mail ❑ Special Delivery • Your Messenger C Hand Delivery ❑ Copy to: Ms. L. Colonna w /enc . Very truly yours. LAURENT ENGINEERING ASSOCIATES,P.C. Per AOL, Harr W--Nichols, Jr.,/ °E. PUTNA_M COiJNTY DEk�,A,RTI�(ENT OF' HEALTH " APPLI�CATION� FOR APPROVd 'OF PLANS FOR A NASTEWATER DISPOSAG .SYSTEM 1. Name and Address of Applicant: L11 cI - X1609, d C tm. +-14 2. Name of Project: / �-; 0f,:J 3.•_• Location /C: a'LL_ 4. Project Engineer: ��v -r�-� �k CG: a�. 5. Address: License Number: 5-�, 12-4 Phone: 6. Type of Project: �rivate /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 (SEQR)? Tvae Status (Check One) Type I.. Exempt Type II. Unlisted. L� 8. Is a Draft Environmental Impact Statement (DEIS) required? O 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name of Lead Agency t I. Is this ._project__i.,n.van•..ar.ea, under. the- control—of-A- cal-•pl- anni•ng; zoning, or other officials, ordinances? .......................................... A/0 12. If so, have plans been submitted to such': author. s tie s ?..................... A14 13. Has preliminary approva11 been granted by such authorities? Date Granted: tem Discharge.....•. Surface Water �GrOUnd Waters 14. Type of Sewage Disposal; Sys 15. If surface water discharge, what is the stream class designation ?........ :6. Waters index number (surface) ........... ............................... ✓" ;7. Is project located near a public water supply system? .................. a :8.. If yes, name of water supply /+� Distance to water supply :9. Is project site near a public sewage collection or disposal system ?..... 'Ala ,0: Name of sewage system N/ Distance to sewage system :1. Date observed: �'�t—�l `� 23. Name of Health Inspector: 1r1� lVti Gl 4. Project design flow (gallons per day) ...... ............................... 8 GO _ . 2. - :25.,_.:_>s ,Ste:;.Pol;l..ut. ant- .D:ischarge ,Elminataon.._ System :(SFD.ES,) Ee.rm..t..r_equired?,..,_,_ 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? .............:.................... ............................... o 28. Wetland ID Number,.. ........ ............................... ... qJ 29. •Is Wetland Permit• required?. .............. ............................... . /) o 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 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? 35w -Are any sewage disposal Areas•In - excess,of 15% slope? : ::: :..::.......:...:.. 36. Tax Map ID Number ......................................................... '3 ( 32 2 '� 37. Approved Plans are to'*be: returned to: ................ ' Applicant v Engineer If 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 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 be 1 ief. Fa Ise statements made herein are punishable as a Crass A Misdemeanor pursuant to Section 210.45 of the Pena 1 Law. SIGNATURES & OFFICIAL TITLES: 'AILING ADDRESS: rUTI M 000lfl'Y DEPAl1lM OF EMALTH DhMm d Rd& Se><vgen. COMOL N.Y low �R to PativWi Pfrdlt r w CERTMATE OF COMMA= Pseenr Fos BMA= DIMM" ST82M P`go" ' Two Or es e .Vrr've. t�aerSO rd.t . _ ...N...A... _... _ .. ` i,lit r • /✓� f! _ 36� 3J T Z t� ° Dane of Prsvisan Approval ,eMn Legg I i Ld lfesti �r e .i rAl a Town Ir •e wxler N; % 'Z1, io�s'd 9 Tate Subdivision Annroved Fee Enclosed ❑ Amn„nf- DiiL 1jM IC eS l sCd t?h iV, iiot Ares C7 9f D FM Seedsit olio X Depth Yotao ©c• Deccan Flew G P D 'S O 1 PCHD Natldc do b ltegahed Wbm Fm Is.oe MOed Sapaafils saw~ S7slas a exit d �awin•7 S"O Td; o L • " f l9 6 S • %r e o7 C . e-S TIa be.ounhuded.bp 7 �' 2, Afldteea Wader )Pile Sopply Frr Awe .a�PrL.�. s+pb Dtpdd by B.D • Address Met t- :t tt I am wholly and completely responsible for the design and location of, the proposed system(s); t) that the separate sever di al s stem above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regumxiols O na .County Department of Health, and that on completion thereof a -Certificate of Construction Compliance" satisfactory to the CommisalOmr of Healthwill be submitted to the Department, and a written guarantee will be furnished the owner, his succe —umjheirsor- s by the builder, that said builder will ie good opafatkHg condition any part of lid sewage disposal syR*ln during the period of twediately fo=Ing thedate of the Isau- anGe of the approval of the Certificate of Construction Compile a of t a original syst or an ) hat the drilled well described above wilt be located as shown on the approved plan and that said wall will . Inst 1 In accordsn with' ter • ragY ns of the Putnam Courtly Department of Health. . ••tIL _11 nrf' lr ���... t i(1 APPROVED FOR CONSTRUCTION% This SOW0491 expkes two years from the data issued unless constructed of the building has been undwUkin and is riVocsble for cause or may be amended Of modified when considered necessary by .the Commissioner of Health. Any change or alteration of construction mQukea a now permit. Approved for disposal of domestic nit y :ew of - t cater supply only. � � �� Rev . 10/p Title 88 vela DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New.York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT _A' WATER`WELL _._ PCHD PERMIT WELL LOCATION Street Address To Village City Tax Grid Number Z.gke Shore .l r ve e_ -36,,31-- Z WELL OWNER Name f Mailing Address f O �y khc% � IC eila& C��o�,� %IJ� keel ol-e , rivate O Public TISE OF WELL primary 2 - secondary RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP BUSINESS 0 FARM O TEST /OBSERVATION ® INDUSTRIAL O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED 6 /EST. OF DAILY USAGH90D gal EI REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION GIADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING Mew WeY eq WELL TYPE DRILLED ®DRIVEN []DUG [_]GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES V NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 410 Lot No. WATER WELL CONTRACTOR: Name � Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A/ NO NAME OF PUBLIC WATER SUPPLY: /V TOWN /VIL /CITY _._ DYSTANCE TO - PROPERTT . FkOM.. NEAREST. _WATER_ MAIN:__ .. ... .„ LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 010N SEPARATE SHEET (date) 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 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:3 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 t . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date 63 Io ��6 Re : Property of ,v D/4- `5 /2L /`C -{TU /-)N/9 Located at V/� (T) �a�e?-!540N � Section Y Block Lot Subdivision of Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize j?-��?y P"/. /y 'C -/7104,-,G a duly licensed professional engineer c-/ or 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 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 Code. \ C Countersigned P.E., R.A., Address i Telephone Very truly yours, Signed 0 e of Property Address ;V/ /OSO�� Town Telephone ��U'T'r7AL`� CUiC.7N`X"Y" JU]E�'.��.TM�N7' •U�' H�.A]L.`r� APP- L-ICA-TION -FOR=° APPROVAL'` //`QF'PLANS °'FOR A'KASTEWATER DISPOSAL' SYSTEM 1 . Name and Address of App-1 icant: Lt J!c7 A,-, o 4, 2. Name of Project: OS' Location /C: 4. Project Engineer: Lw�wU -�.T r��i, 1�scC. lOtC, 5. Address: AuLiocl e. 6)41, ' .. _ .. • � •• + � / l Y Gnu C ��r / �/ License Number: (2-4 Phone: 6. Type of Project: �rivate /Residential Food- Service ...Commercial , Apartments Institutional Mobile Home Park Office Building: :3• Realty Subdivision Other (specify) 7. Is this project subject' to State Environmental euality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted. l/ p 8. IS a Draft Environmental Impact Statement (DEIS) required? ... .. . . . . . J G 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 1014 10. Name of Lead Agency I i . I Is this. project in an area. under the .,cp tr.ol -oft local .planni.n-g -, 2. Is aState Po,l lutapt. , Discharge :El ir�tnatico _.ys:t.em (SP -. -D1 S),.rPer�n- tam =ret}r 26. Has SPDES Application been submitted to local DEC Office? ............... l/ 27. Is any portion of this project located within a designated Town or State �;! wetland? ........................... ............................... ..... � =o 28. Wetland ID Number ........................ ............................... c% 29. -Is Wetland Permit✓ required?•• .............. ............................... //U 0 Has application been made to Town or Local DEC Office? i 30. Does project require a DEC Stream Disturbance Permit? ................... 31. is or was 'project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal;; landfilling, sludge application or industrial activity? ........ YES or NO / d 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 comrmunity water, sewer facilities planned to be developed within 15 years? 35. Are any sewage - disposal .._..areas- :- .ra.._excess - - ®rb shape. .... ................ . 36. Tax Hap ID Number ................... ........................ .......... •3 x,31' 2 _I 37. Approved.Plans are to be: returned to: ................ App7licant v Engineer If the application is signed by a person other than the applicant shown in Item .1, the. °pplication must be -accompanied by -a Letter of Authorization: Failure to comply with this Drovision 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 state-;rents made herein are punishable as a Class A Hisde,-,eanor pursuant to Section 210.45 of the Pena 1 Lair. ;IGNATURES & OFFICIAL TITLES: AIL114G ADDRESS: 1-2),- ,,- , t, /Ul 3 o o Iso -' "0 C" A2 J 1 .1 12. ii . - :,,: � % OP --- )00 I 1- Mr Al. VL A. e. aE O.0 - OPP - wo rit 351.60' L z 99.22' PR 54 17 y 63 21 66 27 69 33 38 74 33 64 27 43 21 52 30 55 30 58 36 60 14 57 14 53 11 51 09 3 o o Iso -' "0 C" A2 J 1 .1 12. ii . - :,,: � % OP --- )00 I 1- Mr Al. VL A. e. aE O.0 - OPP - wo rit 351.60' L z 99.22' PR -.. - U . .11 . c c c DIIVENSION CHART (in feet) Number A 8 . 1 15 54 2 17 63 3 21 64 4 27 69 5 33 71 G 38 74 7 33 66 8 27 43 9 21 61 10 51 30 11 55 30 12 58 36 13 60 14 14 57 12 15 53 1 1 16 51 09 low dww� EXIST'