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BOX 18
02094
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
W.ell_LoeatigA - --
Strr:et Address: =
Tawn/Village: -
- -
TiVGrid #`
iMapo.,4BIock % Lot(s)
Well Owner:
Name: Address:
kLI'—t11 Aeg
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 aft.
Length below grade ft.
Diameter in.
Weight per foot lb /ft.
Materials: YSteel _ 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 surface- static (specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sieve analyses.,,
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type ezmdl,% Capacity 1
Depth Model '
Voltage 22,0 - HP
Tan Type Volume _jhgaW
o
20
2A4
Date Well Completed
Putnam County Certification No.
Date of Report Well Driller (signature)
NOTE: Exact location of well with distances to at least two permanent landmarks to be prov' d on a separ ate heet/plan.
Well Driller's Name Address:
Signature: Date:
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
._.,. -. ..... .y,, c \ ': . ? ^cK'1 1. fig.. q. .. ... „ ... ...... •7''; +{K'. -" :41 " .. ,.yr K "' 1'.t a t`J..rv-Ti y, h•
Tu
_ .S1O,N ® E V1R
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREAT1bSF;IV'I' SYS'I'EIdI
_1PCHD CONSTRUCTION PERMIT #
Located at 1. -A1-a Town or. Village
Owner /Applicant Name �Zv 15 ��� (141.1 ,•1 NI O Tax A�Iap i. 6 Block 1 Lot t �
Formerly Subdivision.IVame �S 004
Subd.. I,ot. #
Mailing Address °l 4 @�Lp qtr � %W r_ �� � s �` Zip �.
Date Construction Permit Issued by PCHD 101
4_
Separate..9e erage System built by 0 mo .1v1t ' Address `
Consisting of 1 �S D Gallon Septic Tank and . ��� L f� , ,k16 9 -�1G•y
Other. Requirements:Si1 -�(a. �IQ.1.1oa -9
Water'Sup l : - Public SupplyZOb�r`% Address
m�a Private Supply Drilled by W 'El t. Lo, I0(, • Address 195 4 '�'S7 (, �(tt 1'05'!2.!
_Biuldang. Type. _._., ..ipl -! Has erosion, comp YE
Number of Bedrooms A- Has garbage grinder been installed? � 4
I I TI I I TAI '
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 regulation's of the Puuiam CountibePartment of Health.
Date: +1 VJ Certified by
Address '�D e o K %I-
P.E. )4 R.A.
Profe�sigpal) �% ;
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 Isueh usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and. the approval
of the private water supply. shall become null and void when a public water supply. becomes available: Such
approvals are subject to modification or change when, in the Judgment pf the Public Health Director, such`
revocation, mo catio r change is necessary.
Date: B Y Title• V % S �
l�--
l�
White copy - HD File; Yellow copy - Building Inspector; Pink. copy - Qwner; Orange copy - Design Professional
Form CC -97
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Associate Public Health Director
Director of Patient Services
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113
Harry Nichols, P.E.
Patterson Park
Suite 106
2050 Route 22
Brewster, NY 10509
Re: Proposed Compliance: Marino
8 Rose Lane, Lor #7
(T)Patterson, TM# 36.56 -1 -13
Dear Mr. Nichols:
May 20, 2002
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: _
1. Final as-built inspection indicates that there is no silt fence for the well.
2. D -box requires a 90° elbow.
3. Well Completion Report does not note the duration of pump yield test.
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.
Upon receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Vey yours,
v
Robert Morris, P.E.
Senior Public Health Engineer
RM:tn
Harry W. Nichols Jr., P.E.
Patterson Park, Suite 106
2050 Route 22
' " "' • `_ 'Brewster, NY 10509 —"
Telephone (845) 2794003
Fax (845) 2794567
April 30, 2002
Robert Morris, P.E.
Putnam County Health Department
One Geneva Road
Brewster, New York 10509
Re: Individual SSTS Compliance - Marmo
7asperwoods, Lot # 7
8 Rose Lan
e
Patterson, New York
Dear Robert
:
Enclosed are the foll
owing:
1. 'Five (5) prints of Drawing SS -7, "As Built SSTS," dated 4/30/02.
2.. "Certificate of Construction Compliance for Sewage Treatment System," dated
4/30/02.
3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated
... _.. , _..41301 0
.._ 2.,
_.�.._._._. ^..4:... __.Lafioiafory Report's; 'dated`4 /18/02. - - _ _ • . - -- -_... _._ - - - -..... __.._ __ - �.._._ ...._... _ . _ _... _ � . _ . _ .
5. "Well Completion Report," dated 3/27/02.
6. Application Fee in the amount of $200.0 ayable to Putnam County Health
Depart
ment.
7. "E -911 Address Verification Form," dated 1/3/02.
If there are any questions concerning the enclosed, please call
.
Very truly ours,
r
Harry W. Nich is Jr., P.E.
HWN:JM:jmm
01 -0
41.00a
BRUCE R. FOLEY * �.�►. liAltl. �.N,, 1�i.�.N•� k _ .
AaroMeu PuNk NoaM' Dbvcra
Dfrnra q/ -PO" &rikU
DEPARTMENT OF HEALTH
.1 Oereva .Road
Brewster, -New Y,9 ,w 10509
z0*9oossnW,He4&h (914)`278 • gi39.1.1&410. 278.7921
Norsla6 Servlca (910278.63 {i WIC (911)278.6678 .F#X(914) 279.6013
Early'lo—kriWr6o'(914) 278%, 6014 '\Presabool (9L4)279-6082 Fa (916) 27r• 6648
E91.1 ADDRES§ VERIFICATION FORM
OWNERS NAME; vos or) '11... .
TAX MAP NUMBER:'
E911 ADDRESS:
TOWN:
AUTHORIZED TOWN OMCIAL:
(Signature
.. ,DATE;'- -
Piifnam" "County Department of Health will not' issue a Certificate of
'Construction Compliance unless the above form is completed;..i.e., alegal E91 -1
address is assigned by an authorized town official. This forbris-to be subtaitted' ."
with the application fora Certificate of Construction Compliance.
(E91 I VERFR _
PUTNAM. COUNTY DEPARTMENT OF HEALTH,
I�IVISI0N _�Fxl� ' RONMEN-TAL HEALTH- �SER'�ICE =Sn � ^s. ,..• :
v.
.GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM.
Owner or Purchaser of Building
Building Constructed by
Location - Street
Building Type
Tax Map Block Lot
TownNillage
5 Pte- Vjoop�
Subdivision Name
Su.bdivisi6n 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:
�_.:_.. operar..e_properly_is caused -by t ie- wi-llfW- or-negi- gent-act-bf 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 uti-liz -iirg the
System.
Dated: Month Day � Year �02
G neral Contractor•(Owner) - Signature
Corporation Name (if corporation)
Address:
State /V. Zip Odd
Signature:
Title:
PA
�El /�l�G�' L-d�LY �c�.C7L I ►� 9
Corporation Name (if corporation)
Address: PC, 16-0,k, �5-'3
State / y K..... Zip
Form GS -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES .
. FINAL SITE INSPECTION
Date,4;' 98i- o
I s ecte'x .�, _
tr acation- w- ....... - I ° y .- ,�,. �
ma c =.- G- : i` m. ,2.� <�.- -, `0wrier
Town Permit # 7f — 3 7!5 ^Q(
TM € 3 G, S! - / —/ Subdivision Lot # 77
1. Sewage Svstein Area
a. STS area located as per approved plans ...........................
b. Fill section = date of placement
3:1 barrier Lgth. Width Avg.Dpth
c. Natural soil not stripped............. ...............................
d. Stone, brush, etc., greater than 15' from STS area..........
e. 100' from water course/wetlands,..... ............................
II. SeN aQe System
a. eptic t�an.k size - 1,000 ......:.1,25 .........other ................
b. Septic tank installed level ................ ...............................
c. J0' minimum from foundation .......... ...............................
_..- -
2. Protected below frost .................. ...............................
3. Minimum 2 ft.Original soil between box & trenches
e. Junction Box - properly set ........... ...............................
f. Trenches
T Length required 8 pp Length installed ita)
2. Distance to watercourse measured -f- t Do Ft.......... .
3. Installed according to plan ......... ...............................
4. Slope of trench acceptable 1 116 -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" minimum ..................
_.., . 10: Pipe a �PF d.....:...:.. ............ ...............................
g. umn o ose stem
ize mp chamber .. ............... ...............................
2. Overflow tank ............................. ........... .....................
3. Alarm; visual / audio .................... ........................... .....
4. Pump easily accessible, manhole to grade .................
5. First box baffled ........................................ ; ........... ..... ..
6. Cycle witnessed by H.D.esfiinated flow /cycle............
III. HouseffluildLng
a. liouse located per approved plans .............. .....
b. Number of bedrooms ...... .........................'�..,. .
IV. Well e.<
a: Well located as per approve plans.......... ... ..... 70-6,0M
b. Distance from STS area measured -f- i d� ft.........:.
c. Casing 18" above grade .................. ...............................
d. Surface drainage around well acceptable .......................
V. Overall Workmanship
a. Boxes properly grouted .................. ...............................
b. All pipes partially backfilled ........... ...............................
c. All pipes flush with inside of box ... ...............................
d. Backfill material contains stones <4" diameter ..............
e. 'Curtain drain & standpipes installed according to plan..
f. Curtain drain outfall protected & dirto exist watercourse
g Footing drains discharge away from STS area
4h Surface `water:protection'adequate; ....... :... :_ ........
i
'i.�Erosion control provided .........................
l�
COMMENTS
1
V, -:� -i
EMMI,��®
TIMU",
I/�FW
I N"
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL IJEATLH SCR ICES. -:.
T�x� FIELD ACTIVITY REPORTu�
NAMF� OSTW7.
ADDRESS: Z-A
f
Street Town State Zip
PERSON IN CHARGE
OR TNTFRVTF /a �q2
E] PUMP TEST 91,50SE TEST
(D °
-Y
REQUIRED GALLONS® S'
4 oel
6-x >c 7, V-0 :-- 3.8 g -
EL. START _
oa
A EL. STOP
Signature and Title
RF_PORT RFC'.FTVFT) RY,
I acknowledge receipt of this report: SIGNATURE:
02/96 Tit
Rev.
APR -19 -2002 01:45 PM HARRY W NICHOLS
- - -- - 914 279 4567 P -02
... pUT'NAM CQUPIx7! WARTUM S �
IDTMMN 01 ZNVMON> MAL SALT
4TTEN ION O ADAM GENE
For: ,Fill
AII Wormation MUlt be WYOmplctcd pdar to my Trtnchat .. --
Wspecdons Was gads,
-
Loceted, F-059
0"er /ApPUMtNerve;
SubdMgon Nwu: '° = w� -L---
porcculy; — - 7
Subdii slop Lot #
Is rystun fill complatad? Date:
is sys<isn compute? Date: _ - �►,,.�_.._._..
is "cm conswotod.aa pec piRO?
Is wendrWW? Y- Data:. + t6- - 02'
Is wcU basted SS per plans?
Are Croft control mmums in puce?
i ca* tbat the sygem(sl as paced, at the above pct:mises has boa GOW Mtod aW i biv* i ?Mfd
sad vcriLcd theft camnplation in wosdanee with the issucd PCHD Construction Permit cad
spproved:plus* sod the Standards, Ruics sad Regulations of the Puttum County btpwment Of
Diu, °�� ` — Certified by: PE . L e RA
'' D Ptofcysioaal
Address' ie - ,....._._..�,,.
_, Cotumcati: •
r '
Form Fitt -99
APR -19 -2002 FRI 00:58 TEL:845 -278 -7921
NAME: PUTNAM COUNTY DFPAI?TMFti-r nc o -,
Public Health Director
April 26, 2002
__ = LOREIT4 :�iC)L11�TARi R.N., M.S.N. " Y
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
Harry Nichols, PE
Patterson Park, Suite 106
2050 Route 22
Brewster, New York 10509
Re: Field Inspection - Marmo
8 Rose Lane, (T) Patterson
Lot # 7, TM# 36.56 -1 -13
Dear Mr. Nichols
The above referenced separate sewage treatment system can be backfilled. The following
comments must be corrected in the field.
I., The distribution box inlet pipe need a 90° elbow.
2:. Silt fence is not installed below the well area. All silt fence must be properly installed
prior to the start of any construction.
If you have any further questions, please contact me at (845) 278 -6130 ext. 2261.
Very truly yours,
E ll
Gene D. Reed
GDR:cj Environmental Health Engineering Aide
�_.:._. BRUCE R. F4I,$X�
Public Health Director
April 26, 2002
DEPARTMENT OF HEALTH
I Geneva Road
Brewster, New York 10509
LORETTA- MOL- INARI R.N:, -M.s.N. ;
Associate Public Health Director
Director of Patient Services
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113
Harry Nichols, PE
Patterson Park, Suite 106
2050 Route 22
Brewster, New York 10509
Re: Field Inspection - Marmo
8 Rose Lane, (T) Patterson
Lot # 7, TM# 36.56 -1 -13
Dear Mr. Nichols
The following items are in violation of Article III, Section 2C of the Putnam County Sanitary
Code:
• , Silt fence is not installed below the well area.
A formal notice of hearing may be issued if the violation is not corrected within 5 days. It is truly
hoped that the above violations are corrected without having to take legal action.
Very truly yours,
Gene D. Reed
Environmental Health Engineering Aide
GDR: cj
SENDING CONFIRMATION.
DATE : APR-28-2002 SUN 21:00
NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH
TEL 845-278-7921
PHONE
: 92794567
PAGES
: 2/2
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: APR-28 20:58
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: 01'13"
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: G3
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FIRST PAGE OF RECENT DOCUMENT TRANSMITTED..
9wc1a IL FOLZV LORMA MOW wu &N., msX.
AM& RwM Dei,ea. A.—J1 P.M. Y-M D&v�ear
1*. S.W-
DEPARThMNT OF HEALTH
I Geneva ROM
BIW3101, New Yak 10509
mma.ea R.M ("s)"A - 6110 P.(445)271-7P21
wfC(B0)2M-6S7J P-(W)M-6M
1---r- (6/3)271.6014 6a (N3)271.6614
ft.d.d a" W-5912 F.(940212-6111
April 26.2002
HarryNichoL%PE
PattemaPar1r. Suite 106
2050 Route 22
Brewster, Now York 10509
Ret - Field Inspection -Malmo
8 Rose Lam M Pattmon
Lot 0 7, TIM 36.56 -1 -13
Dear 1&. Nichols
The following item arc in violation ofArdetc lZ Section 2C of the Pumam County Sanitary
Coda:
• Silt ftee Is not installed below the well area
A formal notice of eazing may be issued if the violation is not corrected within 5 days. It is truly
hoped that the above violations no corrected without having to take legal action.
very truly yours.
Gene D. Reed
Envirommental Health Engineering Aide
GDP--cj
° SENDING CONFIRMATION
DATE : APR -29 -2002 MON 01:08
NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH
TEL 845 - 278 -7921
PHONE
: 92794567
PAGES
: 2/2
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: APR -29 01:06
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: 01'13"
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: G3
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BRUCE R. FOM LORBTTA tv MWAw am., xs N,
P.bfh Hra" Db— Apo= hMk NtalN nY'.ruar
Deverw of ParlsN Sa.rav
DIPPAR hEgNT OF HEALTH
1 0*Ma Road
Brewahc, New York 10509
Lm— wa,w mw (a/s)1n -elt0 P4(45)171 -M1
nmq.a strolW l 27=-051 W[C(113)171 -[s78 F«(a1e)"s.eat
grg Atenmeapeslln•es" ae(w)rn.eew
Pr.a.d(a(5)21a -9911 1.(":n-et()
April 26, 2002
Harry Nichols, PH
Patterson Pgdt, S,dte 106
2050 Route 22
Browgter, New York 10509
Re: Field Inspection - Matmo
9 Rose Lane, ('I') Pattason
Lot N 7, TMK 36.56.1 -13
Deer Mr• Nichols
17re following items are in violation of Article 111, Section 2C of the Putnam County Sanitary
Code:
Silt Gnoe is not IOVA ed below the well area
A formal notice of hearing may be issued if the violation is not corrected within 5 days. It is ttttly
hoped that the above violatians are coneeted without having to take legal action.
Vcry Only yours,
Crew D. Reed
Bnviro=MW Hcabb Roginc=ing Aide
ODR:cj
YML. ENVIRONMENTAL. SERVICES
321 kear Street:
Yor k:town H;i9tlt,, N.Y. 1059FI
( 91'4) 245-2Qi: 0 ' " _
Albert H. Padovani., Director
LAD #a 93.200984 CLIENT #: 55391
NON
STAT PROC
PAGE 1
MARMO,. LOUIS
DATE
/TIME. TAKEN; 04/10/02 t:a:_ytOOP
20 BLOSSOM LANE
DATE
/TIME REC ' D :; 04/11/02
12:15P
BREWSTER, IVY 10509
REPORT
DATE 04 /18 /02
PHONE
n (845)-490-0907
SAMPLING S I TE g 0 ROSE LANE. , BRE:WSTER ,
NY
SAMPLE TYPE ..4
POTABLE
n WELL- PORI'
PRi- GERVAT I VE S a
NONE
COL ' D -BY,. LOUIS 141AR110
TEf' PERATURE i . ;
`: 4C
NOTES ... g
COI_. I FORIyI MI :'1"H n
III:-
DATE FL_AS PROCEDURE
RESULT
NORMAL -- RANGE:
METHOD
PUTNAM CNTY PROFILE
()4/11/02 MF T. COL. I FORM .
ABSENT /100 iriL
ABSENT
1008
04/11/02 LEAD (IMS)
1.5 ppb
0 -•15 ppb
9101
04/11/02 NITRATE N I TROD
6.70 MG /I__
0 - 10
9139
04/11/02 NITRITE: N I TROD
<0.01 MG /L.
N /A
9146
04/11/02 IRON (Fe)
0.066 MG /L
0-0.3 mg/1
2007
04/11/02 MANGANESE:: (Mn)
•=:0.010 MG /L
( 7 -0 . , 3 mg / l
2037
04/11/02 SODIUM (Na)
6.61 MG /L_
N/A
04/11/02 pH
7.5 UNITS
6.5 -8.5
9043
04/11/02 HARDNESS , TOTAL
140 MG /I__
N/A
04/11/02 ALKALINITY (AS
118 MG /L
N/A
04/11/x2 _.TURBIDITY (TUR
<1 NTU
0-5 NT_t.l...._
COMMENTS
BACT THESE= RESULTS INDICATE THA"f THE WATER (WAS) ( WAS
NOT) OF A
SATISFACTORY SANITARY QUALITY
ACCORD I rHC::
NEW YORK STATE:
AND EPA FEDERAL DRINKING WATER
STANDARDS, FOR
THE PARAMETERS
TESTED„ AT THE TIME OF COLLECTION.
Pb /Cu LEAD limits for p
EPA Lead & Copper
than 10% of their
than 15 ppb and a
treatment must he
potential..
_b l ic: schools are set at 15 ppb.
Rule for Public Systems requires that no more
distribution points have a LEAD value of more
COPPER value of 1.3 mg /L, else water
undertaken to reduce the waters corrosive
Fe /Mn If both iron and manganese are present:, their total value
combined shall not exceed 0.5 mg /L.
Na No limits for Sodium are proscribed. Suggested guidelines state
that for people on a sodium restricted d:i et, the water should
contain no more than 20 mg /L of Sodium. For those can
moderately restricted diet, a maximum of 270 mg /L of Sodium
/ YML ENVIRONMENTAL SERVICES
321 Kear Street
Yorktown Y
o�n ����!�wtLc�.,~r
(914) 245-2800
' Albert H. Padovani, Director
LAB #: 93.200984 CLIENT #: 55391 NON STAT PROC PAGE 2
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MARMO, LOUIS
20 BLOSSOM LANE
BREWSTER, NY 10509
DATE/TIME TAKEN: 04/10/02 05:00P
DATE/TIME REC'D: 04/11/02 12:15P
REPORT DATE: 04/18/02
PHONE: (B45)-494-0987
SAMPLING SITE: 8 ROSE LANE, BREWSTER, NY SAMPLE TYPE..: POTABLE
: WELL PORT PRESERVATIVES: NONE
COL'D BY`: LOUIS MARMO TEMPERATURE..: < 4C
NOTES...:' COLIFORM METH: MF
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE' FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
is suggested.
pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH ]S ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5.
Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM
CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE
HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
SOFT WATER: 0-�0MG/L��' VERY`HARD WATER A 300 MG/L-'' -
' MODERATELY HARD'WATEK:' 4 .'��G7(- - '�`| .~IG- AM PER LITER `----^' --^
SUBMITTED BY:
Director
ELAP# 10323
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
66NSTRuftic N'PERMIT ;rM- A- TMENT:SYS -EM= -�.�,., -- .. -
PERMIT # 3 3 -O
Located at s P 66 L xH 5
Subdivision name J_AA5V— VtiWJ 05
Date Subdivision Approved
Subd. Lot #
/(z/ eje
Town or Village NTTEQ
Tax Map Block ) Lot
Renewal Revision
Owner /Applicant Name �Q AS 4 KANLE_tW / W"O Date of Previous Approval
Mailing Address 10 6146,6 I vin L/I N IF Zip 10 5 D 1
Amount of Fee Enclosed ' J� l�� ��
Building Type �E4 @EM L-6 Lot Area No. of Bedrooms 4 Design Flow GPD
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of (Z�o gallon septic tank and � /`_ Lf- M5
Other Requirements: 00511,,P/► 5 (P f nt)
To be constructed by Address
Water Supply: Public Supply From Address
Supply __ ..
- , Pnvhte . Drilled by: _ _ ; ... _ . . _. .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 s, sti tem 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. X R.A. Date
6 t z-� I
Address '7®�I F"� 2 `2- p"`l ZF.(Z l� j l�-2QiLicense #
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the
sewage tr e t system has been completed and inspected by the PCHD and is revocable for cause or may be amended or
modifieVte onside r essary by the Public Health Director. Any revision or alteration of the approved plan requires
a new ppprov f discharge of domestic sanitary s77�
By: Title: Date: A 0
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
WELL COMPLETION REPORT
Well Location `'
Street Address: °" ' "" °
Town /Village:
Tax Grid'#
Map oo Block tot(s)
Well Owner:
Name: 'Address:
�14 019
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
Length below grade ft.'
Diameter in.
Weight per foot - 49 IbIft.:
Materials: Steel _Plastic _Other
Joints: _ Welded Threaded _ Other
Seal: Cement grout _ Bentonite Other -
Drive shoe: Yes _No
Liner:_ Yes yNo
Screen Details
Diameter (in)
Slot Size IL
ength(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 surface - static ( specify ft)
During yield test(ft)
Depth of completed well in feet
Well Log
If more detailed
information
descriptions or
sleye.artalyses�_ ^:.
are available,
please attach.
De' the From
Surface
Water., .
Bearing
Well
Diameter(in)
Formation
Description -
ft.
ft.
Land Surface
:'
`
_ :.-
jib.
r _ .
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type egadlA Capacity (h_
Depth Model
Voltage 226 HP
TatType Volume
9,j Lzlz 2- o
Date Well Completed
Putnam County Certification No. ' ..
Date of Report well Dnl. r (signature), _
NOTE: Exact location of well with distances to at least two, permanent landmarks to be prow d on,.. separate sheet/plan.
Well Driller's Name Address:
Signature: Date:
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL _
please print or type PCHD Permit # ' w�
Well Location:
Street Address: . TownNilla a Tax Grid #
�j Ht-- I 0
E- L-N Map )b /� LBlock Lo t(s)
Well Owner:
Name:
Lout ,5�
Address:
&05iom [-hi-t5 8 T -W 105ol
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 gpm # People Served 4- Est. of Daily Usage bgC 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
No
Is well located in a realty subdivision? ...................................... ............................... Yes
Name of subdivision ) k QQ- \,fW 0S Lot No.
Water Well Contractor: D Address: '--- --
Is Public Water Supply available to site? .................................. ............................... Yes No 'A
Name of Public Water Supply: '-- Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separat sheet/plan.
Date:_: _ Applicant. Signature: -
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. y revision or alteration
of the approved plan requires a new permit. Well to be constructed by a water el driller certified by Putnam
County.
Date of Issue Permit Issui }ci�al:
Date of Expiration' Title:
(,,� %r""
Permit is Non- Transfe ale
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
APR -29 -2001 11:45 AM HARRY W NICHOLS
"A
BRUCE -k-1
Public &CDkwoor
914 279 4567 P.09
l =Ift PuNk H9M Amotor
DEPARTMEW OF HEALTH
1 Geneva Road
Brewster, New York 10509 % G.
RM MOR EXAM
ATTEN'T'ION: o ADAM S$'IEBELING ENE REED
AN Information below must be fift completed prior to any scheduling. DA`T'E: J -2-7 - G
ENGINEERORFIMI: :200
REASON:
_PEEPS: . PERCS: MR' TEST: .o
ROAD STREET:
YES NO
Proposed SSTS within the drainage basin of West Eranch or Eoyds Corner Reservoirs.
Proposed SSTS within 500 feet of a reservoir, reservoir stem, or control lake.
o ML Proposed SSTS within- 200_feet of o wstercourse-or a DEC Yy tlarl(L._
- � - P : Zi- 'Proposed SSTS.-desiiti flow greater than 1000 gallons/day or SPDES Permit required.
o Proposed SSTS for a Commerical. Project.
It is thi responsibility of the design, professional to provide the above information prior to soil testing.
This Department will determine the NYCDEP project status (Joint or Delegated) based on the
response. If you answered j= to any of the questions, KYCDEP must witness the soil testing. This
Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design
Professional and NYCDEP.
If a project has been determined to be Delegated based on the above response and then subsequent
information indicates NYCDEP is required to witneso the soil testing, it will be the sole responsibility
of the design professional to schedule re- witnessing of the soil testing with NYCDEP.
FOR CoUM USE o.4Nt.Y
DOE: NAM:
L 03 TV
S=11M
IMLOTEST)
MCA
- - 4 - - - - - - - - - -
Mal Z078
NAM CO. " LAFAYET
Hats tats mats ooroo�
;FIELD CO.
NEW FAIRFIELD,CT
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Associate Public Health Director
Director of Patient Services
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
Preschool (845) 228 - 5912 Fax (845) 228 - 6113
July 20, 2001
Harry Nichols, P. E.
Patterson Park
Suite 106
200 Route 22
Brewster, NY 110509
Re: Proposed SSTS: Marmo
Rose Lane, Lot #7
(T) Patterson TM #36.56 -1 -13
Dear Mr. Nichols:
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.
1. The minimum of 0.5 feet of fill is to be provided for the pri mary and expansion area: The
fill is to extend 10 feet horizontally past the edge of any trench and slope 3:1 to grade.
Upon. receipt of a submission, revised to reflect the above comments, this application will be
considered further.
Very tru ours,
r ���tsL✓
Robert Morris, P. E.
Senior Public Health Engineer
RM/jp
—S..
BRUCE - R.�._� eQ .._..a.....,
Public Health Director
. ,._ - -� b��-t�1v10i;INARI •R.N.; R�I: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 July 20, 2001
Harry Nichols, P. E.
Patterson Park
Suite 106
2050 Route 22
Brewster, NY 10509
Re: Marino
Rose Lane, Lot 7
(T) Patterson, TM #36.56 -1 -13
Dear Mr. Nichols:
The Putnam County Department of Health (Department) has determined that the above referenced
application, including fee, and received by this Department on July 6, 2001 is complete. The
Department will notify you by August 10, 2001 of its determination.
The Project has been delegated to the Putnam County Heath Department for review pursuant to the
guidelines set forth in the Watershed Agreement.
If the Department fails to notify you within the above referenced time frame, you may notify the
Department of its failure by certified mail, return receipt requested. The notice should be sent to my
.:attetuion.at theaabove. address._: This. notice :must -i'ik tide:Yddr'ti6rhie, the. location. of the - .project; - the' --.
office with which you filed the application originally, and a statement that a decision is sought in
accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed
Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the
notice, your application will be deemed complete, subject to standard terms and conditions as set
forth in the regulations.
Please be advised that projects within the NYC Watershed may also require Dept. of Environmental
Protection review and approval of other aspects of a project, such as stormwater plans or the creation
of impervious surfaces, and the project applicant should contact the Dept. of Environmental s
Protection regarding such activities to see if Dept. of Environmental Protection review and approval
is required.
If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 2166.
Ver ly yours,
Robert Morris, P. E.
Sr. Pubic Health Engineer.
RM/jp
Harry W. Nichols Jr., P.E.
Patterson Park, Suite 106
2050 Route 22
' Brewster
Telephone (845) 2794003
Fax (845) 279-4567
June 26, 2001
Robert Morris, P.E.
Putnam County Health Department
One Geneva Road '
Brewster, New York 10509
Re: Individual SSTS
Jasper Woods - Lot # 7
Rose Lane
Patterson
T.M. # 36.56-1-13
Dear Robert:
Enclosed are the following:
1. Five (5) prints of Drawing SS-7, "Proposed SSTS," dated 6/26/01.
2. Short EAR
3. "Application for Approval of Plans for a Wastewater Disposal System," dated
6/26/01.
---:4-,--------"ConstructionPemlitfor Se, 4wd. 6126/01
-wage Qi.sppsal, System
5. "Application to Construct a Water Well," dated 6/26/01.
6. 'Design Data Sheet."
7. "Letter of Authorization."
8. Two (2) copies of residence floor Plan(s), for bedroom count only.
9. Review Fee in the amount of $300.00.
If there are any questions concerning the enclosed, please call.
Very truly yours,
Harry WI.i c h o Is Jr., P.E.
HWN:JM-jmm
01-041.00
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION „0XE )URONMNTAL HEALTH.SERVICES
APPLICATYONYOR AIPPROVAL OFPLANS�'OR ��tV_
A WASTEWATER .TREATMENT. SYSTEM
1. Name and address of app cant :.
2. Name of project: 3: Loeatton T/V:
4. Design "Professio Address: P60
6. Drainage Basin:
■;.. a .. .
7. J, aey, of ProjM;
Private%Resideotial Food Service Commercial
Apartments „ Institutional .. Mobile Home Park ' '"
Office Building Realty Subdivision Other (.$pccify).
8. Is. this project subjcct,tg StatedEnvironmsntal Quality Review (SEQR)?,'•?
Type Status (cl}eck one)....,,.....,;......., ..• ................,..:......., , Type I Exempt
Type II Unlisted:•”
9. Is a Draft Environmental Impact Statement (DEIS) required? .........................
10. Has DEIS been completed "and found acce table b Lead Agency? ..............,.. .."
.. P Y
11. Name of Lead Agency = f 4A
• •• .111 .. , •:ir�' _
�_1,2 :�'Is:this.project"m an area under the control -o flocal-plannmg, zoning, of
officials, ordinances ? ..........................
........... .......•........,......,....,..
13. If so, o
hate; pleas <beeasubraitted i'such
..c . ., . •,�• - ,- „:'. .... X14
14: Has preliminaryDp ;oval beeii'granted by such authorities? (� Date granted• ' [J
15. Type of Sew age_Treatment System Discharge:: : :::::.::.::;_,_, surface water A ” groundwater
16. If surface water dischar a what s,tho :stream class designation? :::;.. : ::..:
„ 8.,.. �.
17. Waters older number (surface) .,.:::..:: � .:..:.:.:.:.:...:............:::: :::.: :.................... :.... .
Iv
18. Is project located near a public water supply system? ........ ...........+..........:...•...�
19. If yes,.name ofwater supply` ` l Distance,to water supply (�
20. Is project site`near a publiC' ewage collection or treatmenfsystem?
21. Name of sewage system N Distance to sewage-' system N C
22. Date test holes observed-` 0 23. Name of Health Inspector 6 &H5 READ
24. Project design flow(gallonsper :.......................... .......................:..::... �•� .
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?...
26. Has SPDES 'Applicatiaa been subnutted to 'local DEC office? .:.- .....::.:.:....:.:... -P�
2
2 7. Is any portion of this project located within a designated Town or State wetland? 0
28. Wetlands ID Number _ n _ �4
,. ,r.r. .: .. 0?! eyy, ��.. �g0, }�O,..i.r�eea,e.�.o...osf.. eoote eoo. e000PO'0'OVOado'00o'O0O000oo6ob 00di'oo /'0'o 80eoo so.o�i'.' "'' �� "
29. Is Wetlands Permit required? .:: .:......:.::............ ........ ............ :.......................... a
Has application been made to Town of Local DEC office? ........................... 0
3 0., 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'Mustrial 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:
33. I s there a local master plan oa file with the Town or Village? ....... .. .........:..: by
34. Are community water and/or, sewer facilities planned to be developed within. -
15 ye rs-M or adjacent to project site? ................................ ............................. .1. IJ\D
3 5'. Are any sewage treatment areas in excess of 15% slope? ........... ......,..........�... NO
36. Tax Map ID Number .......................... ............................... Map &,` .t Block Lot
37. Approved plans are.to_be returned to..,..., Applicant
"NOTE: All applications for ieview and a'p' proval of a new SSTS to be located within the NYC, 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,Deparunent. :Projects within: the watershed may.also
require DEP review and approval'of other aspects of a project, such as stormwate.r plans or the creation of
impervious surfaces, and the projeet"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 OM. the applicant shown in Item 1.,the application must
be accompanied by a Letter of Authorization (Form LA -97). Failure to eomply'with this provision
may be grounds for the rejection df any submission.
I hereby affirm, under penalty of perjury, 1/1 at information provided on this form is tree
to the best of my knowledge,and bellefe False statements made herein are punishable as
a Class A .misdemeanor pursuant to-See l n 2210. -S-of the Penal w.
r1
SIGNATURES & :OFFICIAL TITLES:
`
Mailing Address, ..... .: ��
...................... 2�� =,L, 2�-
- PUTNAM COUNTY DEPARTMENT OF HEALTH -
-- DIVISION OF ENVIRONMENTAL EALTH .
L ��
H E.R'V. ,ICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM �
Owner Louti� ` Ft�M . Address m B ," 1
Located at (Street). Ljc� `.1 JMQeg-R,�D, Tax Mape��15� Block Lot
(indicate'nea.rest cross street)
Municipality �ATI J�FR_, Jc) H Watershed
SOIL PERCOLATION TEST DATA
51 %0 0"
Date of Pre-soaking � - � Date of Percolation Test:. _.
.. .
.! .
.. .
. {. .. . Y :
: yr V . •i + ^.'•yi +
+.
..'..` ::;�y3u�.{'Y .
.I:{•✓ XT':i�:� ;� <:r. '
��y'1"��/1t[. :�1) :
:,,yv,�s+ X �}� {
P erctila �:
Hole No
i 2
2 h
his
bo
4 . .
_.
..
2 t
tool_ � ` o
o
-� 3A .
.... 1
140 (
4
S
2
4
5
N 0TT'.0 1 T
Tc is t bo c
s o repeat at same epth until approximately equal percolation rates e.re obtained at each
percolation test hole. (i.e. s 1 min for. 1-30 mWinch, s 2 min for 31 -60 rniii%inch) All data to be
submitted for review.
'.. Depth measurements to be made from top of ho1c.
TEST PIT DATA
DE SCRiPTiON•O..F'SO,ILS ENCOUNTERED Y.KTES'T HOLES
DEPTH, 1-IQE;:NC �l iL.E-NO..: -
�._
HOLE NO.. _ - - _.. - -
tu
'tip
MeD
1.5'
2.01
SR -
3.0' _
;.5'
Y,
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
Ell - " , I nuin -
T
Indicate level at which groundwater is encountered
Ind-icate level -at which mottling is observed 'rzt--lb '
Indicate level to which water level rises after.being encountered
Deep hole observations made by;r N�o��, ; �' Lro Date
Design Professional Name: RAWTJ, N�Udbt.s
Address:
Signature:
Design Professional's Seal
NJ
Clio
s
�z Uj
C1 , W
No. 66124
�oA�OFESStO�P`•
11.164 WW)—T- *4 12
PROJECT .IA. NUMIBEA:.
�SEQR
Suite lEnvironmental Quality Review] . .
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNL18T -EP �1CTIQNS.Only,
PART 1— PROJECT INFORMATION fro be completed by Applioant or. Project sponsor? `
1. APPLICANT )SPONSOR
f, L EEC - dip
Z. PROJECT NAME
Lo-r . -1 _ 4,7t?l"�..:
S. PROJECT LOCATWIk
F' + 1 1''� P HA M
MU11101pift . . 4 : Coon
1. PRECISE LOCATION .0 addraN and road Interaeottona, prominent Iandmarla, eto., or provide map) ....
�,.
N. ❑ Expanalon ❑ ModllloatloNalteratbn
6.' DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF D
�—
InIWIy aces UIUM091Y acne
8.: WLL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING MND USE RESTRICTIONS?
Ja lrea ❑ No If N% dworibe brlally . '` ..o , • : ;, :;. ,
9. WHAT 18 PRESENT LAND USE IN VICINITY OF PROJ#Ci7
Qoinmerclal Park)FareattOpen•spaco- - Q Other
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL.
STATE OR LOCALV •
[1Y" No If Via, )tat apenoM and pem VeWovale .. .
11. DOES ANY AVWOF THE ACTION HAVE X CURIMMY VALID PERMR OR APPROVALt ;., :.
..
Yaa No �,�. �ri1' Wt,.,�►ay � ar►d WtmlUapProvy.. .. ,:, ,
u. As A RESULT OhF� PRO?dBED AGTION,WILL EXISTING PEAMRIA!'PR0IIAL REQUIRE MODIFICATION?
DYa '. �TNo h .
: -. 1 CER'TiIFY THAT THE INn�FOiRMATnION PROVIDED'ABOVE IS TRUE To THE BE/1S/T OF MY KNOMJLEDGE.. ,
'
' " ` ' + "1 ' J ✓a 1 ' J V P E t 1 7 t t�1,eHr .
)►DpllcanNaponacr natm�c oat«
Slpnatur«
If the action Is in the..Coastal Area, and you are a..stgtt agency, complete the .
Coastal Assessment Form before proceeding with -'this assessment.
AVER.
PUTNAM COUNTY DEPARTMENT. OF HEALTH
LETTER OF AUTHORIZATION
RE: Property of
Located at LAS �
TN Tax Map # '�J (� � �y �O Block Lot
Subdivision of
Subdivision Lot # r Filed Map # '���� Date Filed
Gentlemen:
This letter is to authorize
a duly licensed Professional Engineer or Registered Architect _ to apply for the required
wastewater treatinent and/or water supply permits) to serve the above-noted property In accordance
with the standards, rt les or r gWations. as promulgated by the Public. Kaalth Director of the Putnam
�C.9tatLty: Health .DGpar tea :.and: io_ Igit -all . necessar _ y.- papers ion my behalf in-coamection with this
maser 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 1-iealth
Law, and the Putnam Co_�__unty Sanitary Code.
/ of NEW r 9
NICHp��
Countersigned
P.E., R.A., #
..:
Mailing Ad
Very truly yours,
Signed:
L _
(Owner orpmPC y)
r
State Zip
Telephone: (�� "
Mailing Address: 20 BL-05s w\ \ CR9L--
State \Ay Zi p `Osoci
Tcle P hone:64"� 1 61-1 -
:•II.
tip•:
r•�lH : •;r•r
r/
I•
r BATH
~ '
BEDROOM A \ .,• ')I.
DRESSING•
BEDROOM J. �. WALK'
17' -0" x 1 0' -0" "� 1 ..IN
\ CLOSET
_ aL
MASTER BEDROOM
BEDROOM 2 OPEN N 17'-0 a 16,.8**
11' 0' • x 15..8
1
quTlAkM COUNTY DEPARTMENT H
F HEALT
ROUS L� APPROVED FOR BEDROOM! COUNT ONLY,
- - -- _ _.__...�.L.�. --
SECOND F L O.O R BEDROOMS 4828 =. •13 4 4 S F
ALL SqrkEQUEN RI TiONS TO THESE HOUSE
12CIn011 FOR 4 PPROVAL i
_ 0. r - -
Si -aft •IT E DATE Cj(- �. �•
•• KITCHENK•��/
DINING ROOM p MORNING AGOM ~�
1.7 07 w 12.,0•.
IN
• ', /� mil"
• —' Lam. !i r.. •.. � .� - \ . �. .. _
-t
OPEN
ABOVE -
LIVING MOOM FAUILY PIOOM
17 0 • x 1 i'•0" 17' 0" a 17' 0-
FOYEM �•
FIRST FLOG fi
PUTNAM COUNTY DEPARTNIE \Z OF HEALTH
DIVISION OF ENWIRONNIENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SENVAGE TREATDIENT SYSTEiNIS
NAME OF O7Y. R:
REVIEWED RM,
DOCUI• i'TS
PERMIT APPLICATION
STREET LOCATION:w4
AS, SRDATE: TAX 1`LAPe: (CONFIR%iED) �� l
ELL PERMIT OR PWS LETTER
LETTER OF AUTHORIZATION
DESIGN DATA SHEET (DDS)
CORPORATE RESOLUTION
SHORT EAT
((__)PLANS -THREE SETS
(U(UHOUSE PLANS - TWO SETS
(_)(_)VARLANCE REQUEST l /
SUBDIVISION Z
UULEGAL SUBDIVISION
UUSUBDIVISION APP AiV C hED
L,(�PERC RATE '
U(__)FILL REQUIRED H
UUCURTAIN DRAIN R IRED
GENERAL
L)LOCATED IN NYC WATERSHED
( / u )PLANS SUB�ITTTED TO DEP
/ DELEGATED TO PCHD
( .. DEP APPROVAL, IF REQ'D
DEEP TEST HOLES OBSERVED .
LPERCS TO BE WITNESSED .
(0, )EX- APPROVAL SSDS ADJ, LOTS
LJ(WETLANDS (TOWN/DEC PERMIT REQ'D ?)
(� DATA ON DDS PLANS & PERMIT SAME
L:_:':�JPRE 1969 NEIGHBOR NOTIFICATION
L LETTER BUZBA. - _.- .- ....... -
. •..�...' ,�- ��100 YR ..FL'OODE%;RVATYO'`t i" //i20`J'- �`:—�:.::
1' (REOUiRED DETAILS ON PLA \S CON'T'Dl
/(�(6HOUSE SEWER -' /l' FT. 4"0'; TYPE PIPE CAST IRON
UNO BENDS; DIAX BENDS 45o W /CLEANOUT
1110'- . RENEWALS
10' HORIZONTAL; PAS RENCH SLOPES 3:1 TO GRADE
EILLSPFZSF- OTES 1 -5
FILL PROFILE & DIMENSIONS
IN EXPANSION AREA
FILL GREATER TITAX2 FEET
CLAY BARRIER
CERTIFICATION NOTE
'TH GAUGES
.. ON PLAN FORRO.B.,UNCLASSIFIED & INIPERVIOUS
ARATION DISTANCE FROM TOE OF SLOPE
TRENCH
LF TRENCH PROVIDED 60FT MAX.
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
(� DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL
C_ILJGEOTEXTrLE COVER
SEPARATION" DISTA`i CES ON PLAN - FROM SSTS
)10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL
20' 0 FOUNDATION WALLS
100' TO WELL, 200' IN DLOD,150' TO PITS
L X100' TO STREAINI, WATERCOURSE, LAKE (Inc. espau)
(__) 50' TO CATCH BASIN, 35' STORRtiIDRAN, PIPED WATER
10'TO.WATERLINE (pits -20') _....,.� ....t._,•--- .:..__._ ._ _ -.
1 LJ50 LN TER�tii�i ?Ei�T DRAL`IaGE COiIR$E � -~ ' ^ �ry -• �r
TOIL TESTING LOTS >10 YEARS OLD L_)( _)200'i500' RESERVOIR, ETC._ 150' GALLEY SYSTEMS
tEOUTRED DETAILS ON PLANS 10' tiILY TO LEDGE OUTCROP
SEWAGE SYSTEM PLAN - (NORTH ARROW) U SEPTIC TANK
SSDS HYDRAULIC PROFILE (�( 10' FR0�1 FOUNDATION; 50' TO WELL
GRAVITY FLOW WELL
CONSTRUCTION NOTES 1 -15 DIMENSIONS TO PROPERTY LNES
DESIGN DATA: PERC & DEEP RESULTS LOCATION OF SERVICE CONNECTION
2' CONTOURS EXISTING & PROPOSED U MLN 15' TO PROPERTY LINE
DRIVEWAY & SLOPES, CUT ' SLOPE
FOOTING /GUTTER/CURTAIN DRAINS o
(USDA SOIL TYPE BOUNDARIES SLOPE IN SSTS AREA (520 /o)
ITITLE BLOCK; OWNERS NAME ADDRESS UUREGRADED TO 15 %, IF REQUIRED
TMn, PE/RA; NAME, ADDRESS, PHONES DOSE/PUh1P SYSTEMS
)DATE OF DRAWINGIREVISION
(/ )KJDATUM REFERENCE
L� LOCATION OF WATERCOURSES, PONDS
LAKES,WETLANDS WITHIN 200' OF P.L.
(�V )PROPOSED FINISH FLOOR AND
/ BASEMENT ELEVATIONS
WELLS &. SSDS'S W/IN 200' OF SSTS
PROPERTY METES & BOUNDS
L _)EROSION CONTROL FOR HOUSE, WELL &
SSTS, EROSION CONTROL NOTE
CONINIENTS:
(ItEVSIiEET)09 101 /00
L j( _JPUjiP NOTES
U( _JD,OSE 75% OF PIPE VOLUNIE/DOSE VOLUME NOTED
L� ETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.)
PIT AND D -BOX SHOWN & DETAILED
LJ(U1 DAY STORAGE ABOVE ALARM
CURTAIN DRAIN
(�( STANDPIPES, 5' BOTH SIDES, DETAIL
Lj 15' D1L`4 to CDS= >S %, 20'A%, 25'-3%,35'-1%, 100%-<I%
Lj 20' Nn. 'N to CD DISCHARGE /100' ivith 182 cons day discharge
(�( -10' INIIIN to NON - PERFORATED PIPE
PUTNAWCOUNTY. DEPARTMENT OF HEALTH
,DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner AfAjrl ow Address C
Block'-
Located at (Street). t7,ofsp,53Z Tax Map 36,576
Lot 3
(indicate nearest cross street)
Municipality B4:ff gjjz5,28Z Watershed 61¢, i 131Z#Ale,14
SOIL PERCOLATION TEST DATA
Date of Pre-soaking 5 3oz-n I Date of Percolation Test Z -5
....... . . .
a............
...........
.. .......... . . . . ...
...... .... ..... . . ....
I . . .................... .
4
.3
4
F-1 5
NOTES: 1. Tests to be repeated at same depth until approximately equal, percolation rates are obtained at each
percolation test hole. (i.e. :5 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
/091 1tv
2
3
11;17 - 11;47
o
10
4
5
. ......
A0
T-
7/ !!7
7,7
4
.3
4
F-1 5
NOTES: 1. Tests to be repeated at same depth until approximately equal, percolation rates are obtained at each
percolation test hole. (i.e. :5 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
3
TEST PIT DATA r .2.
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTH ��
HOLE N0.
HOLE NO. HOLE NO.
G.L.
1.0'
2.0'
-1 1m�wi
2.5'
3.0'
3.5'
4.0' :._
. ......... .. . . . .
h .
6.0''.
6.5'
ry.E
70
ate,
x,
7.5'
_.. :. - - -- -- - --
:8.5'
- --- - - - - -- - - - -- --- ._._ -.. -- - - -
- -- - - -- -: -... - --------- -..... - - -- - - - -- - - - - - - - -- - - -- -- -
90' _..:._.___...
- -- _ . ...__ -..
_.__..__ — - - -- - -- -_ - _ _...._._..._.
10.0'
Indicate level at which -groundwater is encountered - - -- -- - - —
Indicate level at which_ mottling is: observed_.. -__
Indicate level to which water level rises after being encountered .
Deep hole observations made by: C, -F F- C n j—,,!::--, D, H . Date. S 31 o
Design Professional Name:
Address:
Signature:.
Design Professional's Seal
PUTNAM COUNTY DEPARTMENT OF HEALTH.,
-D SION OF ENVIRONMENT AL,'HEALTH SERVICES
INITIAL I OWMAL /COMMERCIAL SITE INSPECTION FORM
SECTION A.,,�GENERAL INFORMATION - - - -
Name of Project _ 11-jzIA-Al (T)(V) _7>41'rEizS,oAZ County PaLV¢
Site Location 'Zcx,- g5 G,* ,y&—
Building construction begun A10 Extent `--
Is prorty within NYC Watershed ? ................. Yes No
SECTION B. TOPOGRAPHY (Please check all appropria bones)
1.. _ illy Rollin Steep slope.. e_-_ -Flat
2. F__J Evidence of wetlands a Low area subject to flooding Bodies of water
Drainage-ditches Q Rock outcrops L�l y v c e- 3ovlt(e rS
3. Property ' 0 Yes No
lines or corners evident .:..................... ............................... -
4.--Dowater courses exist on or ad'om the roe a Yes No
1 P P rty? ........... ......
5. Will these affect the design of the sewage system facilities ?............ a Y s No
6.--Do watershed regulations apply in this development ?.:�.::::::: :::� -- Yes F IR6
7 Will extensive grading be necessaryT. —. -, : _ Yes_ .N _ . _ .._ :__._.....
-7 Will extensive fill be necessary for S STS? ......... .... .I.......................... 0 Yes No
9. Do filled areas exist within the SSTS - area ? ............. F__J Yes No
If _yes, what is the condition of the fill?
SECTION C. SOIL OBSE VATIONS
- -10.— Appearance of soil: Sand _0 Gravel a Loam F-_� Clay. Hardpan Q Mixture
11. Observed from: 0 Borings F__J Bank cut Backhoe excavations
.12. Soil borings/excavations observed by.
461 %� EEt� };C ,1j, j/� on
13. Depth to groundwater on
14. Depth to mottling n/oeV� 62,1ryD on
15. Are test holes representative of primary & reserve areas ...... ............................. ...
16. Soil percolation tests made by on
17. Soil percolation tests witnessed by G, Tzo�, -h J'�� G� ij�H, on
SECTION D (on back)
Form ST -1
9
v
PA
SECTION D. DRAINAGE
18. Will proposed grading materially alter the natural drainage in this or adjacent areas? 0 s No
19. Will groundwater or surface drainage require special consideration? ............... Yes F-eN
20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... Yes
SECTION E. REMARKS
21. • If a common water supply is proposed, has an inspection been made of the
existing or proposed source and facilities? .......................... ............................... 0 Yes No
Inspection data
22. Do adjacent wells and/or sewage systems exist?; ::::::.............. .......... .................. ... Yes � No
23. Additional comments •t 'Ro -posE_:"p
24. Site observer/inspector and title
--
- ' 25.JDate(s) of observation(s)inspection(s)
3.0
TEST PIT PROFILES
- -- -
Hole # Lot # " :_ --Hole # _. _ .----Lot #. : -..-
-_Hole #
Depth to water _ - Depth to water
- Depth to water - - - " - - -" -- -
Depth to mottling Depth to mottling, -
Depth to mottling `
Depth to rock/imp. 'Depth to rock/imp.
Depth to rock/imp.
G.L. G.L.
G.L.
7.0
0.5 - - - -- . -..- 0.5
7.0
1.0 . _- _._ 1.0
.:.1.0.
2 0 - ------
2 0
3.0
3.0 .
3.0
4.0
4.0
4.0
5.0
5.0
5.0
6.0
6.0
6.0
7.0
7.0
7.0
8.0
8.0
8.0
9.0
9.0
9.0
10.0
10.0
10.0
Sheet i of -
PUTNAM COUNTY DEPARTMENT OF HEALTH
VIRONNl�11WI L HEEL) .L11 S..i�, IC
FIELD ACTIVITY REPORT
NAW., TPl•
AmRESS: ro545 L. 7'477- s ^,J /f-11
Street Town State Zip
PERSON IN CHARGE
nR INTTFR VIFWRT). .41, / /� /!oL S i� ,E T)atP -30101
Name and Title
TYPE OF FACILITY: S, S, j S e
FINDINGS:
AJ01--- .z
z,—
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Signature and Title
I acknowledge receipt of this report: SIGNATURE:
02/96, Title:
Rev.
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