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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.56 -1 -14 BOX 18 ', , �� L, 0 �; 1A. ti. h I ,; '� E 02095 PUTNAM COUNTY DEPARTMENT OF HEALTH CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P 01 S-FQ Located at a PN5 Town or V Owner /Applicant Name �O & Formerly Ay6 v H Tax Map %�56 Block I Lot 1 + Subdivision Name JASP15P- WODV� Subd. Lot # Mailing Address P`�X y �`'� - jJ Zip l®rio 1 Date Construction Permit Issued by PCHD Separate Sewerage System built by y H 0P '56fr((' �YS m� Address '� f i F1LPJM M' &PF%P H1 6te Consisting of 1°L� Gallon Septic Tank and G16-1 Other Requirements: Water Sunaly: Public Supply From or: X Private Supply Drilled by MILL DP- "IH14) 1�4L" a Building Type _ Address Address 15 OP-EV6_19-.ti a �°i �E6i� - Has erosion control been completed? ' - Number of Bedrooms Has garbage grinder been installed? W I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam Cougty Department of Health. Date: O 02-10 Certified by &�av 4. , &,, _ I " P.E. R.A. AddressQ�? �° �`'� 22 �lnl �gn Profs at) ©,�/ License #� Zy `l Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, or c ange is necessary. By: �l 'L�a Title: Date: 41116411 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 P PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT ill Locatl6h 'Stre6i Address:- Rose.1-ane To wn/Vi I I -agb: Southeast Tax GfWff Map Block Lot(s) 6 Weil Owner: Name: Address: Custom Domes, omes, Inc, 'PO Box 525 Brewster, NY 10509 Use of Well: *-! primary 11�.,., '. 10econdary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary _ Cable percussion _X _ Compressed air percussion Other (specify) Well Screened Open end casing X Open hole in bedrock Other tasing Details Total length 117 ft. Length below grade 116 ft. Diameter 6 in. Weight per foot l 4/ft. -Drive Materials: X Steel Plastic Other Joints: Welded Threaded Other Seal: Cement grout Bentonite Other shoe: __I_ 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 __6 Yield LU+ gpm Depth Data Measure from land surface-static (specify ft) 30 During yield test(ft) 6 Depth of completed well in feet 305 Well Log If more detailed information descriptions or s ley, c analyses... yses- are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 25 Brown Sandy Clay 25 35 Gra y Clay 35 36— :Grave 1: 36 80 Hard Pan 80 .90 Brown Sandstone 90 300 .150+ GPM Granite If - yield was tested it different depths during drilling, Feet Gallons Per Minute Pump/Storage Tank Information .200 0 Pump Type S I, h Capacity' q2 Depth 160 Model -13-Ul.0412 Voltage 230 HP 1 Tank TypeB1 adder Volume 62 280 3 300 150 Date Well Completed ill 2 �1 -2 -21-0 Putnam County Certification No. 2 Date of Report 3/27/02 e n r ,pui-t: txact location of well wim aistances to at wast two permanent ianumarKs to DC PFUVIUUU U►1 d SUPdIdLU bUCCUPIdIl. Well Driller e MI D"IN VC. Address: 75 Putnam.AVe. Brewster., NY `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 -:x � VISIO I=O.FF .EN;:; I=IR ,.NME:NT-A-L?H LTH.SER: I.:�CF GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building BOB AJ6TI 1-4 Building Constructed by Location Street Building Type Tax Map Block Lot PQ H Town/Village J h' W aM Subdivision Name 0 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 Comity 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-properE• is- caused by`t he willfut-or negligent act-of the-occupant 'of the-building utilizing the system. The un.ders.igned. further.: agrees to accept as conclusive the determination of the Public Health. Director of the Putnam County Department of Health as to whether or riot 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: Writ Day �- Year o Signature;' Title: QwNE�L_ General Contractor (Owner) - Signature Corporation. Name (if corporation) Address: State Zip Corporation Name (if corporation) Address: f o BOX. �� Opy%(L_ State... Zip Form GS -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Biewster, NY 10509 Telephone (845) 2794003 Az Fax (845) 2794567 April 3, 20-02 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re; Individual SSTS Compliance - Austin Jasper-woods, Lot # 8 6 Rose Lane Patterson, New York Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS-8, "As Built SSTS," dated 412/02, 2. "Certificate of Construction Compliance for Sewage, Treatment System," dated 4/2/02. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 4/2/02. 4, Laboratory Reports, dated 4/1/02, Vell.completion Report," dated 3/27/02. ..., $-' I -f -'AYffi --C6 al li6ati.:n Fee in" the a'moufit of 200,60�joayable 0 -unty Health 6- .Application -- 9 Department. 7. "E -911 Address Verification Form," dated 1/3/02. If there ar e any questions concerning the enclosed, please call. Very truly yours Harry W. chol.s Jr,, P.E. HWN-.jmm 01-0399.00 CW ENVIRONMENTAL SERVICES 2 _ -, _. _ . >_, .... ...... .._ _._..._..- ... -_. _ 5 .MILL PLAIN ROAD . DANBURY CT 0681:- 1 . , _. __ . ,�� �n,� � - - -,_• � .__,,,:,.,,,. 203 -267 -6539 (FAX:SAME) ml--milliliter mg/L -milligrams per Liter ND=none detected MCL- Maximum Contaminant Level TNTC =Too Numerous To Count S.U. = Standard Unit NTU= Nephelometric Turbidity Unit TON = Threshold Odor Number * *Notification Level " "'Manganese Action Level= 0.50mg/L – Lead ActionLeve1= 0.015mg/L COMMENTS: -All holding times (were) met. - RESULTS BASED ON SAMPLES SUBMITTED: 3/20/002 & 3/26/2002 At the time of analysis, the sample [was] acceptable for total coliform. dieo6lc& sldent Samples Analyzed by: JMS Environmental Laboartory – PH#0218 -- ELAP#11715 WATER ANALYSIS REPORT TO: Mill Drilling, Inc. DATE SAMPLE COLLECTED: 3/20/2002 & 3/25/2002 75 Putnam Avenue TIME COLLECTED: 10:45 a.m. & 4:00 p.m. Brewster, N.Y. 10509. COLLECTED BY: Bob & Russ Mill DATE RECEIVED: 3/20/2002 & 3/26/2002 TESTED BY: ELAP#11715 FILE I.D. #.. _ .. CW- 211 & CW 216 REPORT DATE: 4/1/2002 SAMPLE SITE: Austin Custom Homes, Inc., Lot #6, Rose Lane, Patterson, N.Y. SAMPLE POINT: Water Tank SOURCE: Well TREATMENT: None DATE MAXEM M CONTAMINANT TEST PERFORMED RESULTS METHOD # TESTED LEVEL (MCL) OR STANDARD BACTERIAL: • Total Colifoim (Bacteria) 0 per 100 ml SMWW 9222B 3/26/02 0 per 100 ml PHYSICALS: • Color (Apparent) ND Units SMWW 2120 B 3/22/02 15 Units • Odor ND TONS SMWW 2150 B 3/22/02 3 TONS • pH 7.60 S.U. SMWW 4500 H B 3/21/02 6.5 to 8.5 S.U. . • Turbidity 1.41 NTUs SMWW 2130-B 3/22/02 5 NTU CHEMISTRY: • Chlorine Residual <0._I_ mg/L SMWW 4500CIG 3/26/02 -� •Nitrite Nitrogen <0.1 _ mg/L, SMWW 4500 NO3E 3/22/02 1.0 mg/L • Nitrate Nitrogen 0.327 mg/L SMWW 4500 NO3E 3/22/02 10 mg/L Combined limit for Nitrite plus Nitrate = 10mg/L • Hardness 144.0 mg/L SMWW 2340 C 3/22/02 — Chloride 12.0 mg/L SMWW 4500 Cl C 3/22/02 250 mg/L • Iron 0.161 mg/L SMWW 3111B 3/22/02 0.30 mg/L • Manganese 0.012 mg/L SMWW 3111B 3/22/02 0.30 mg/L * ** • Sodium 7.98 mg/L SMWW 311113 3/22/02 20.0 mg/L ** • Lead <0.015 mg/L SMWW 3113 B 3/22/02 0.015 mg/L* ml--milliliter mg/L -milligrams per Liter ND=none detected MCL- Maximum Contaminant Level TNTC =Too Numerous To Count S.U. = Standard Unit NTU= Nephelometric Turbidity Unit TON = Threshold Odor Number * *Notification Level " "'Manganese Action Level= 0.50mg/L – Lead ActionLeve1= 0.015mg/L COMMENTS: -All holding times (were) met. - RESULTS BASED ON SAMPLES SUBMITTED: 3/20/002 & 3/26/2002 At the time of analysis, the sample [was] acceptable for total coliform. dieo6lc& sldent Samples Analyzed by: JMS Environmental Laboartory – PH#0218 -- ELAP#11715 OWNERS NAME: TAX MAP NUMBER -E911 ADDRESS: W - -AUTHORIZHD TOWN OFFICUL: -- (Signature) DATE:` The Putnam County. Department of health will not issue a Certificate of Construction Compliance unless the above form is completed; i.e., a legal E911 address is assigned by an authorized town official. This form -islo 46 submitted with the application for a Certificate of Construction Compliance. (E91 i VERFltivi) . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: ,,U a 7 -F- St e i;oc�tioti=- ° >G' itiE� Owner ' .SUS 2'In/ Totitim _ �.¢ TT -gsoA/ Permit # P — �2_ 7 — TM r 6 ,G — 1 — /Z/ Subdivision Lot #, 1. Sewage Svstein Area 'Y 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. Sewage System a. Septic tank size -1,000 ........ ,2" .........other ................ b. Septic tank installed level .................. . ............................. c. 10' minimum from foundation .......... ............................... d. Distribution Bo 1. All outlets at same elevation -water tested ................. .2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... f. ren'I' c eFi s T.—E—en—gth required 6 4 7 Length installed 6 2. Distance to watercourse measured +loo Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 314 -1 %2" diameter clean .................... 9., Depth of gravel in trench ..� .. ipe T - cap` peg ..................... ............................... _ i0 : 'Pe g. Pump or Dosed Systems 1. Size ot pump 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.estimated flow /cycle........... III. House/Building a. house located per approved plans ... ............................... IV. Well - a. Well located as per approved plans . ............................... b. Distance from STS area measured #' /o o I}.,,.,,..,,. c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ..:............................ d. Backfill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate... .. .....................::....... NO COMMENTS DEC-21-2001 03:59 PM HARRY W NICHOLS' 914 279 4567 P.01 v • s 01 WLTS ormw &TTLMON Fors Im Ak WUUft 00 W � MVAW 009 So Pw con"" O wIW: paw. !�.a ls Syria -d rtpi Dam uWalmuld." peck — All aft -0 Sawk1w by: Addrus li Fam Mow DEC-21-2001 FRI 16:11 .w.- ludib"Wrow savodoo pook ud PR m TEL:845-278-7921 NAME:PUTNAM COUNTY nr:POPTMr:WT nr o 1 1 d CPA \ \ \ l \ s c _ ; - 6o N V -7 f ,� sO M' 0 ..,.... BRUCE' -R., r' OLE Y .. .:: ......r � „.. Public Health Director DEPARTMET JT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARi 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 December 27, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Field Inspection: Austin Rose Lane, Lot #8 (T) Patterson, TM# 36.56 -1 -14 Dear Mr. Nichols: The SSTS at the above mentioned lot can be backfilled. . —.. - The following corrLments- iiitst be-correeted-in -ihe-f eld:- • Install silt fence below the well. • A bedroom count needs to be performed by this Department (house under construction). If you have any further questions, please contact me at (914) 278 -6130 ext. 2261. 11 0 Very truly yours, Gene D. Reed Environmental Health Engineering Aide .BRUCE -R .�h�OLEY ; _ ..;:..�.:,.. -- ....:.._... .:..... Public Health Director ,.: LORETTA _N10LINARI ,R.N.,; M.S.N. Associate Public Health Director Director of Patient Services DEPARTMETJT OF HEALTH 1 Geneva Road Brewster, New York I0509 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 December 28, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Field Inspection: Austin Rose Lane, Lot #8 (T) Patterson, TM# 36.56 -1 -14 Dear Mr. Nichols: The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: - - - - -- I: - -- Silt-fence� has -not been. installed below the well. Please.bd advised.that all silt - fence. mint b_e -T properly installed in accordance with the approved plan prior to the start of any construction. It has been noted that debris from well drilling as been allowed to drain on the adjoining property. All debris must be properly cleaned up and silt fence must be properly installed. Please be advised, a Stop Work Order and Notice of Hearing will 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, /7 , /W I-� Gene D. Reed Environmental Health Engineering Aide GDR:tn SENDING CONFIRMATION DATE . DEC -28 -2001 FRI 15:45 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE 92794567 PAGESt 2/2 START TIME DEC -28 15:43 ELAPSED TIME 01'15" MODE G3 RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... o. rr HwkJ R POI.BY LOR6TCA MOLINARI R.N., hLR.N. P4arr reat7a Domro. A." Pvwr At." D&� D" of P m& 6•wr DEPARTNE11T OF HEALTH 1 Octfwa Road Brewate , New York 10509 rn.emaml 11-22 (215)772 -6110 P5) Ow5)776 -ram rnaq asr7re4 (945)776.6778 WW (647)774.6676 Fa(845)376.6aS a4ry hftrM0a4 (245)271.6014 nn(MS)n4 -6au r'reMM(945) 770 -7917 ht(445) ]78.6117 December 27,2001 Harry Nichols, P.E. Pattetsoa Park ... _.�-,� .. -.-.. �....._; . ..�.�- ... -•.• -- .....�.__ ..... �- .. -._,- -Suik ^106.....- -„-... � _ -•` c -- � . -- - _ . . __ •.. -� ...._._.. - ,......�_ ..... � ... �... -.. �--, . - ...... _..... -�. -,.� .. __._ c ,_ - - 2050 Route 22 Btcwstec, NY 10509 Re: Field Inspection: Austin Rote Lena, Lot #8 (T) Pettetson, TM4 36.56 -1 -14 Deer Mr- Nichols: The SSTS at the above mentioned lot can be beoksllcd. The following comments must be corrected in the field: 0 Install silt fence below tho wall • A bedroom count needs to be performed by this Department (house under coustructiou). If you have arty further questions, please contact mo at (914) 2784130 eat. 2261. Very truly yonurs. !/• Gera A Reed ODR:tn Environmental Health Pagiaxring Aide a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR S GE TREATMENT SYSTEM) PERMIT # ; O i Located at 6 R-0 ,56 1--d"44a Town or Village Subdivision name JKQO- W toD-) Subd. Lot # $ Date Subdivision Approved I 1 11I bb Tax Map '3G trUP Block Renewal i Lot 14 Revision Owner /Applicant Name 60b A06°ii �A Date of Previous Approval Mailing Address f ' 0 ' �' f 61-(,;- �"' Amount of Fee Enclosed Building Type RhlWILle Lot Area I, a O% No. of Bedrooms 4 Design Flow GPD Zip 109)'% Fill Section Only Depth Volume - PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 'iP-IF'" L1.1 Other Requirements: To be constructed by 11-150 gallon septic tank and Address Water Supply: Public Supply From private- Supl?IY Drilled -by- 1 - - -• �. �. : • ,- Address '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, sy 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: Hn P.E. R.A. Date 1 �� Address Zplry �� ''�'f6fL y 10507 License # 5C % Z4 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage trea system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w n c nsidered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires anew perm' . proved discharge of domestic sanitary sewage only. By: ? Title: U Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 .2-q' PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES'- 1-07 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM 17 Owner �Q!2. Address dos p_ Located at (Street) y-K4tPF_jZ Tax Map 36 ,66 Block (indicate nearest cross.street) Municipality_ 'PAI-n 4z,501J Watershed - I r o gg,*ve SOIL PERCOLATION TEST DATA I Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, 15 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 F.. ....... z.Y ..4;... Ve . . ......... ... ....... . qe::� df . .... .......... ...... . . T ..-AiNe Time rom., .... . ... ta, Surface kol ikh&` S 0!iii!: ... . eve. C Axe :.. Percolation 30 /j3 30 3 > 4 5 01'/ 12,14"? 0 7,' Z) 2 57 30 — /9 ;-1W 3 /h'30 42t'Ob 30 9 Yf 4 5 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, 15 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 Indicate level at which groundwater is encountered -- Itlon;�- - .. Indicate .level._at_whch.mottling is .observed Indicate level to which water level rises after being encountered Deep hole observations made by: 6. ���� �, c ,p, H, Date Design Professional. Name: Address: Signature: - - - Desigq Professional's Seal _ ... _ TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED,IN.TESTROLES�, DEPTH HOLE NO. _� HOLE NO. HOLE N0. G.L. 0.5' 6 f, T- 1.5' 2.0' 2.5' r1e,,Q, . 3.0' Go►v��1, SaH 4.0' :w /ocic 5 5.0 AleA _ ._... - 5.5' - 6.0' 6.5' 7:5' 7'� ©" 8 5' .10.0' Indicate level at which groundwater is encountered -- Itlon;�- - .. Indicate .level._at_whch.mottling is .observed Indicate level to which water level rises after being encountered Deep hole observations made by: 6. ���� �, c ,p, H, Date Design Professional. Name: Address: Signature: - - - Desigq Professional's Seal P UTNAM COUNTY DEPARTMENT OF HEALTH ... : D1 ON OF ENVIRONMENTAL HEALTH SERVICES - INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project _ 4t1t5 7 /,y (T)(V) E&r=5eA/ County ! u 7-IV4111 Site Location Building construction begun Alo Extent Is property within NYC Watershed ? ................. Zyes. F--J No SECTION B. TOPOGRAPHY (Please check all appropria 'boxes) 1. a Hilly 0 Rolling a Steep slope - Gentle slope Flat 2. F--J Evidence of wetlands 0 Low area subject to flooding Q Bodies of water Drainage ditches - - Rock outcrops 5 �r{ace 8ovlder s 3. Property_ lines. or corners evident ................. Yes No 4. Do water courses exist on or adjoin the property? ...........:...............: F7- Yes 5. Will these affect the design of the sewage system facilities ?............ 0 Y No .._ 6. Do watershed regulations apply in this development ? ....................... Yes a No 7 Will extensive grading be. necessary? ................. .....:......:::................ F`1 Yes FNo 8. Will extensive fill be necessary for SSTS? ......... ............................... Yes 9. Do filled areas exist within the SSTS area? ..:..... ......................... ....... Yes If yes, what is the condition of the fill? - - -- SECTION C.-- SOIL OBSE ATIONS 10. Appearance of soil: Sand 0 Gravel. F-� Loam f---J Clay E] Hardpan .a Mixture 11. Observed from: - a Borings a Bank cut a Backhoe excavations 12. Soil borings/excavations observed by G', ZE,5 b Pe, -e- on S 3 I o 13. Depth to groundwater A/gA/0�F on 14. Depth to mottling ,A/,!7A/j�E on 15. Are test holes representative of primary & reserve areas ...:.. ............................... Q No 16. Soil percolation tests made by A( &/1 /(/11- wo z s on _ 17. Soil percolation tests witnessed by on SECTION D (on back) - - Form ST -1 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? F-1 Y6s Q N 19. Will groundwater or surface drainage require. special consideration? ..................... ffYes' f ---- ] No ' 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... a Yes No SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... F__J Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................... ......................:........ ffYes No 23. Additional comments ��y a 4/e/(!5 24.. Site observer /inspector and title 7D N, 25. Date(s) of observation(s)inspection(s) S7 TEST PIT PROFILES Hole # Lot # Hole # Lot # . Hole # Lot # Depth to water P Depth to water p Depth to water Depth�ta mottling Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L _.. .... .. ... G.L.. 0.5 0.5 0.5 - 1-0 -- 1.0 _..1.0. ...... ..... -- 2.0 2.01 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 A p T ty Af Rl PPI AA 4 } f v x1 �; � �' ...�tk � 7 � tic { '` ,.lr- '� - �,g)� s�y;�- �.•' - � ' _ �. ll ,. e JJJ �;- •k•,,x� quay, d -..� � T ^ ���� r ri/'_ �/ , ry� ,� • , , �, w � � f fir'. :�s+�, �� :'. * � �� 4 R • .. r: 1 �, `. r 1i � • � rT `F � �' � *777 . � �. \4 � '- `�.•� �y ^wj, ... � -a1 � � I ,. 7 F 'Al `� '�. 'x .';3p4�. a� �`"'�� y. \ \ t 'r' \� •� _ ', � � p -Y. �� r - `q l'� � t Q `x � a� Y.� i � � ..�yj1y � =4 t ,.11 r � .•i,' yea f � �T.. `�.�_�t ... �y _ �� �r� `!y -*fir 1 '�\,� �.�� +� �` f 5 °4 � Jrr�� �5. any 'L. i i < \' �( �' a t fi+{ �. � +r • �.! i •` � r+•'S � �' � � � 1� w y � T�1t 1 I i:A .� - 1 i r Y!•- i -- , ji �...� � .� � `l t � f 2 ` ! J`� .`• 1 `� (�YY) �` y``7 J��'FY � ` \ � � 6 � � • .T � ti Shect i of PUTNAM COUNTY DEPARTMENT OF HEALTH FIELD ACTIVITY REPORT Street Town State Zip PERSON IN CHARGE nR TNTF.R VTP -WPT) ,� Gi /, �fG /�O6 S /� E T)atP Name and Title , TYPE OF FACILITY • S FINDINGS: Z-(2 TS 4 —7 - g - - -- v TNCPFC'To R .�r�irc� l �!� !.✓ /tz TFT Signature and Title I acknowledge receipt of this report: SIGNATURE: ✓. 02/96 Ti n- MAY - 1$-2001 09:12 AM HARRY W NICHOLS 914 279 4567 P_01 BRUCE R FOLEY.._ _ .- �r =. "`.'"" Lbl+fEi''A MOLINARI R.N, M.S.N. - - "Pv6Ji2`-11r7iis_:'Dkretair Mtn+ M Pw6lk Health Dtreeta Drsetor of. Faun Smokes DEPARTMENT OF HEALTH I Oeneva Road - Brewster, New York 10509 REQUEST FOR FIFILIDIFISMG ATTENTION: o ADAM STTEBELI G AGENE REED All information below must be f& completed prior to any scheduling. DATI?• �$1 ENGINEER OR FIRM: A M'1t'1 . W . Hium'` r ') FRONR 0: � oq REASON: ROAD/STREET: TOWN: SUBDIVISION: DEEPS: V-'. PERCS:, PUMP TEST: D OWNER: � E> �`J � ) Y£S o Proposed SETS within the draiaage basin of West branch or $.oyds Corner Reservoirs. o Proposed SSTS within 500 feet of a reservoir, reservoir stem or control a Proposed SSTS within 200 feet - --Propose 4 SSTS destia now greater than 1000 gallons/day or SPDES Permit required. C3 Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above ittrormation prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered ytt to any of the questions, NYCDEP 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 witness the soil testing, it will be the sole responsibility of the design professional to schedule re-witnessing of the soil testing with NYCDEP. FOR COUNTY Ust OBEY - - is�ts: `J ® 3:30 TDM: 3 (FtELDTEST) . . N VO a` O Viet ' ��• A a ♦` e • co — — nth, r O r 2316,• P - \ ilia as V xiX rn e I I ..rl .. .. ... _ _ 2423 000.00 . to 'v � � � • � — � 00.00 g N :n� - - -- 100.03 C , it u76 r 23a" o' 5 - - — — — — _ 9 ! 201.06 CD "{ .g .. � •'_- - -- 90301 . .. a tit • � 4� — 10a.°i g M _ — — _ _ p •. tl _ _ _• �1 — S ILM81 2079 :FIELD CO. ;nau 445 1443 000301 t. - - •NEW FAIRFIEL.D,CT PUTNAM COUNTY DEPARTMENT OF HEALTH ` DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS - REVIEW SHEET NANIE OF OWNER: STREET LOCATION: REVIEWED BY: RM, GR, AS, SRDATE: 1' i1Q DOCUMENTS )PERMIT APPLICATION ( 4(,- )WELL PERMIT OR PWS LETTER U PC -97 6ELETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) ((__)CORPORATE RESOLUTION (SHORT EAF C.-THREE SETS vUHOUSE PLANS - TWO SETS U( )ARIANCE REQUEST SUBDIVISION LEGAL SUBDMSION C _�USUBDMSION APPROVAL CHECKED ( )PERCRATE .6r DEPTH RTAIN DRAIN REQUIRED GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP (� DELEGATED TO PCHD (�DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED (_ EX- APPROVAL SSDS ADJ, LOTS WETLANDS (f OWN/DEC PERMIT) REQ'D ?) DATA ON DDS PLANS & PERMIT SAME ((PRE 1969 NEIGHBOR NOTIFICATION LETTER- BI/ZBA -.- �� " -( C�100YR 'FIW OD ELEVATION W/I200' ( JI( )SOIL TESTING LOTS >10 YEARS OLD SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 - - - -- - . DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS iUSDA SOIL TYPE BOUNDARIES ITITLE BLOCK; OWNERS NAME ADDRESS TM"., PE/RA; NAME, ADDRESS, PHONE# PATE OF DRAWING/REVISION )DATUM REFERENCE )LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. )PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS )WELLS & SSDS'S W/IN 200' OF SSTS )PROPERTY METES & BOUNDS )EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 101/00 AX 1QAP #- (CONFIRMED) Y (REQUIRED DETAILS ON PLANS CONT'D HOUSE SEWER FT. 4 "0'; TYPE PIPE CAST IRON NO BENDS; M.AX BENDS 450 W /CLEANOUT RENEWALS U(_)SITE NOTE (NO CHANGE) FILL SYSTENTS 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS/ FILL NOTES 1 -5 FILL PROFILE & DIMENSIONS (� FILL IN EXPANSION AREA FILL GREATER TKAV 2 FEET CLAY BARRIER FILL CERTIFICATION NOTE DEPTH GAUGES (__)VOL. ON PLAN FOR RO.B., UNCLASSIFIED &.Ib1PERVIO US SEPARATION DISTANCE FROM TOE OF SLOPE TRENCH �(e�LF TRENCH PROVIDED LOFT MAX. PARALLEL TO CONTOURS 100% EXPANNSION PROVIDED (__) DETAIUDUST FREE CRUSHED STONE OR WASHED GRAVEL V(�GEOTEXTILE COVER EPARATION DISTANCES ON PLAN - FROM SSTS 0 P.L. DRIVEWAY, LARGE TREES, TOP OF FILL CO FOUNDATION WALLS TO WELL, 200' IN DLOD,150' TO PITS TO STREAM, WATERCOURSE, LAKE (Inc. espaa) . f 0 CATCH BASIN, 35' STORIVIDRAIN, PIPED WATER CO v ERLINE =(p! .2T).. NTERIINIITTENT DRAINAGE COURSE /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (72(J10' MIN TO LEDGE OUTCROP - SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL WELL (___)(ZJDIiNIENSIOi iS TO PROPERTY LINES - . __........._ . - -_- - .- -.... . .. Llj LOCATION OF SERVICE CONNECTION �NIIN 15' TO PROPERTY LINE / SLOP (_)! (z) SLOPE IN SSTS AREA (920 %) . REGRADED TO 15 %, IF REQUIRED k DOSE/PUMP SYSTEMS Ui1IP NOTES OSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED ,ETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) IT AND D -BOX SHOWN & DETAILED DAY STORAGE ABOVE ALARM CURTAIN DRAIN TANDPIPES, 5' BOTH SIDES, DETAIL 5' MIN to CDS= >5 %, 20'4%,25'-3%,35'-l%, 100 % -<1% 0' MIL I to CD DISCHARGE /100' with 182 cons day discharge 0' hIIN to NON- PERFORATED PIPE Harry W. Nichols Jr., P.E. Patterson Park,. Suite 106 . Reuie 22" _ s_ :.; .-.�> .....,.., . _<. Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 June 5, 2001 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Jasper Woods - Lot # 8 Rose Lane Patterson T.M. #.36.56 -1 -14 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -8, "Proposed SSTS," dated 6/13/01. 2. Short EAF. 3. "Application for Approval of Plans for a Wastewater Disposal System," dated 6/13/01. - 4; '- "Constructibn =Perm for_S.ewage Digpos�.l. Systc�,';s ated- 6/1.3/0 : ' 5. "Application to Construct a Water Well," dated 6/13/01. 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 W. chols Jr., P.E. HWN:JM:jmm 01- 039.00 . 14.18.4 (9195) —Twd tZ PROJECT I.D. NUMBER c.: 817:20. .SEAR State Environmental Quality Review SHORT ,ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS:Only. PART 1.1-' PROJECT INFORMATION (To be completed by Applicant or Prolect "sponsor) 1. APPUCANT)SPQNS0 Pb 4, jj j 9 4 2. PROJECT NAME -5,5?" 3. PROJECT LOCATION: P .. Municipality -..... . County PRECISE LOCATION (Street addpat and road Interaectlona, prominent landmalka, etc., or provide map) yy4. 5. IS PROPOSED ACFKft, :. Ig New ❑ Ownabe ❑ Modlfloatlon W1WatWn a: DESCRIBE PROJECT BRIEFLY: jNDlvlt�%Rt, hST� , yew �6ior--M(,� 7. AMOUNT OF LAND AFFECTED: Initwly I • fad ad" Ultimately OQ, aorea 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? 04Yea ❑ No It No, deacrlbe briefly 9.. W T IS PRESF,NT LAND USE IN VICINITY OF PROJECT?. . bMabentlal ❑ Indniblw- _ ❑ Commercial ❑ Agdoultun ❑ PuWForaUOpen apace ❑ Dow - 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCALP 13y" o _ If ya>ti ttat aomay( ,vW pertnitlapprovala .... _. . . 11. DOES ANY ASPECT OF THE ACnON.HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yis . ONO`; If yaa; Wt 49*M name and permlf/appmai 12. AS A RESULT OE PROPOSED ACTION WILL EXISTING PERMIT APPROVAL RECWRE MODIFICATION? ❑ Yea ' . 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE, IS TRUE TO THE BEST OF MY KNOWLEDGE AJ AEM' ; 1101 Appllctaponso nma • r Signature: If the action is In the.Coastal Area, and you are a state.agency, complete the,. CoastehAssessment Form before proceeding with'thta'assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 8 NYCRR, PART 61TAV If yes, coordinate the review process and use the FULL EAF. .. ._ p Yes.. - ❑ No� : _ _ • M ..,., ,,,. .�r;i;..,..,. }.,: �-_ ...:.,-.. - ... ..... _ .q, ... ...,,.. ,.. Y.... -. , ;, S. WILL ACTION RECEIVE COOROINATEDAEVIEW'At PROVIDED FOR UNLISTED ACTIONS IN 8 NYCRR, PART 817.8? If No, s negative declaration. may be superseded by anotl e!%Invotyad 419411% C3 Ye: O No x, r C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface of groundwalfr quality of quantity, noise levels, existing 081110 patterns,'tolid waste production or disposal, potential for erosion, drainage or Rooding proWema? Explain briefly: ,s C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or•nelphborhood character? Expiain..brlefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: 04. 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 Ilkely to be Induced by the proposed.actlon? Explain briefly. 08. Long term, Short term4 cumulative, or.other effects.not Identlllsd In C1-05? Explain briefly. C7. Other Impacts (Including changes In use of either Quantity or type of energy)? Explain briefly.;., 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHA_ RACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? _ _..(3 Yea_ E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS ?� ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether It is substantial, large, Important or otherwise significant. Each effect should be, assessed In connection -with Its (a) setting (i.e. urban "or rural); (b) pr' bability:of occurring; (c) duration; (d) Irreversibility; *(s) geographic scope; and M magnitude. If necessary,'add attachments'or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relilvant adverse Impacts have -beei IdenUfied'andadeg4tely addressed. If Question D of Part 11 was checked yes, the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. .O Check this box If you have Identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive_deciarat Ion . Check thil; box -if you ,have.: determined, Oased on. the Information :and analysle ,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:`{ t Name 61 Lead Agency Print or ype amt of espons er .. a my ... .. ... Title o espons a Signature of es a eMy tore of reperer„ event rom_respons e officer) Date ✓E PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,,SE t ; RONMENTAL HEALTH - SERVICES ,...w..�_.... ... Ln.� :..APPLICATION- FOXAPPROVAL OT -PLANS A WASTEWATER .TREATMENT SYSTEM 1. Name and address of applicant:, .Bob N449 -!. . p- ,.�J�rR. N4 cos 0©1. 2. Name of project: );Jz�r b, 3. Location 4. Design Professional :4040 HVALSJ'k 5. Address: pso 2` 6. Drainage Basin: l� l h1 7 Nh w5M 7. Type of.Proiect; . Private/Residential Food Service Commercial Apartments Institutional . Mobile Home Park Office Building Realty Subdivision ,_ Other (specify) 8. Is this project subject to State�Environrnental Quality Review (SEQR)? Type Status (check one). :Type I Exempt .,Type H Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No 10. Has DEIS been .completed,and found acceptable by Lead Agency? ............... l� 11. Name of Lead Agency (� -12 Is. this project iif an area under the coritroT of local planning; zoning; or other.: officials, ordinances? :::....:::::......................:...........:..::.... ..............:........... :...; 13.., If so, have:plans been submitted to'such authorities? ::.::::: ::::................. .........., NP 14: Has preliminary approval been granted .by such authorities? ldQ Date granted: fI 15. Type of Sewage Treatment System Discharge :.......::::..:.: surface water �G groundwater 16. If surface water discharges, what is: the' stream, class designation? .:.::.............. 17. Waters index number ( surface) ::: :.:..........................:.:..... ..... :......................... _ 18. Is project located near a public water supply system? ....... ............................... 1 !' 19. I f yes, name of water supply NA Distance.,to water supply rl C 20. Is project site near a public sewage. -collection.or treatment system? .:..::.::: :.:::' ' NO 21. Name of sewage system, Cl Distance to sewage system OA 22. Date test holes observed' .5 .j �� 23: Name of Health Inspector 6 &4E REED 24. Project design flow�(8allons- per�day) :,..:......:: ............. ............................ ....::... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... N A 26. Has SPDES Application been submitted to local DEC once? .:....................... 2 27. Is any portion of this project located within a designated Town or State wetland? W 28. Wetlands_ID Number...eo d►. ; ...•.•..00.•.... o.. .aoo.o.o.r...�••.�:..:�::::.::: 29. Is Wetlands Permit required? ..........:....................... ...0.........0....•.:.:......., M D Has application been made to Town or Local DEC office? ......:..........:............ 30. Does project require a DEC Stream Disturbance - Permit? .. ............................. ... by h 31. Is or was project site used foc agricultural activity involving application of pesticide +s to orchards °or other crops, solid or hazardous waste disposal, -- landfilling', sludge application or industrial activity ?_ .. ............... Yes/No �4s� 32. Is project located within 1,000 feet of existing or abandoned landf, ff, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No Ma DESCRIBE: 33. Is there a local master-plan on file with the Town or Village? ... 1Fr7 ...................... 34. Are community water and/or sewer facilities planned to be developed within. 15. ye,ars in or adjacent to project site ? ............... ................. ..... _ � V Pao 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number ............................................................ Mapil"I Block 1 Lot C� 37. Approved plans are to be returned to ..... Applicant Design- Professional NOTE: All applicarions for review"and approval 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 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 10.45 of the Penal L w. SIGNATURES do OFFICIAL TITLES. Mailing Address: .... ............................... ) -V PUTNAM.C.OUNTY DEPARTMENT OF HEALTH :.: YI LC�N =_OF NVI ZOI IME-N- - DESIGN DATA SHEET SUBSURFACE SEWAGE.T-REATMENT SYSTEM t Owner � Addiess_.� ©'� 5 WEW�; -t 1aQ' ( Pi�i�i Located at Street ) . % .J P-o6D Tax Map.�6, Block i Lot w (indicate nearest cross street)._ Municipality Watershed 4 SOIL- PERCOLATION TEST.DATA`. ", Date of Pre - soaking r Date of Percolation Test. 51Mi` Ai < Hole No% k� ' �F,,,r.3•, nY,.%t°.'it4Cwi� t ;' ;Y•� V.� '` • �" ap <..nbrfACeac13.4s�;� r: ". '�(•M,!ri.q. ..wJG:�t�:``i+ "!' :�Start:�Sto • > . V'°. y 'x yJn � w: .% `t�R }... . 'Tercalatio >.: `Rate: •�< Mitt�IDc . 3 "may., 4 _. 10 i8� ►2y r V 1lie if SIT .q _ 5 3 _ ^ • a • • %1464 11V 6-9 1FtivaLw at Nuuv uvpu7 unui approximatety equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min7inch) All data to be submitted for review, 2. Depth measurements to be trade from top of hole. TEST PIT DATA - DESCRI TION OF'S :OILS ENCOUNTERED IN TEST HOLES , —.-D EP-Tli PIO1: E NO.` .. �. G.L. t 1.5' - 2.0' 3.0' tY1�abl,�r+Q.sp 4.5' taiP 5.5' 6.0' 6.5' 7.0'u 7.5' 8.0' 8.5' 9.0' - 9.5' 10.0' Indicate level at which groundwater is encountered Indicate level at which mottling is observed._ wpA Indicate level to.which water level rises after being encountered OfL Deep hole observations made by: (AfW P-EO f i WaNt�ttt s f I� �E� Date 51 IMol Design Professional Name; Address: o� NEW vo Lull Signature; X6124 ITOFESSW Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIJON- O��E1�fiV7[RONME- NTAL�EALTIH[ SE-t'VT£ES= LETTER OF AUTHORIZATION RE: Property of AU �Tl �A - Located at G F-6 15 LAl`-1� TN PMT4-!W H Tax Map # 6, S Block Lot Subdivision of JM?� ©�m� Subdivision Lot # B Filed Map # Date Filed Gentlemen: This letter is to authorize W" Ht V my i t-- Q � a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatirtentand/or. water supply permit(s� to serve the abovanoted property in accordance ' with the standards, rules or ragulations as promulgated by the Public ffcalth Director of the Putnam County ealth Department, and. to sI all.necess pa person. m behalf in connection with this. ry . P 8n any p P _'� <.. ti - - -- - - mat er-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-icalth Law, and the Putnam County. Sapiya —Code. �tipF NEby�f ' Very trul Y Y ours Countersigned: P.E., R.A., # — Mailing Address State �aQ zip i QG'Zf\ Telephone: (93�) Signed: (Owner of propcm) Mailing Address: __PQ BOA ez) -5 State zip- Telephone: 0(t) 40A " A -1 �► - PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT AXATER WELL, please print or type ~ ~� PCHD Permit # Y Well Location: Street Address: TownNillage Tax Grid # a Poi515F LAPS FAI ®H Map `S Block I Lot(s) Well Owner: Name: Address: Use of Well: _J 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 Est. of Daily Usage eLeq 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 5Z Is well located in a realty subdivision? ...................................... ............................... Yeses` No Name of subdivision J W)tEP -. Lot No. e Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No ` Name of Public Water Supply: `� TownNillage _ Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separat sheet/plan. Date - `® A licant Si nature - A� 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. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well 1 ller certified by Putnam County. Date of Issue 2- Permit Issuing Offi 'al: Date of Expiration Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 FIREPLACE FAMILY ROOM 14' -0" X 21' -1" Craz. r,T WOOD DECK i 1 COUNTRY KITCHEN x1a' —s" v�NyL' DINING RM. 13' -0" X 12' -5" orate- TNAM COUNTY DEPARTMENT O f l HEALTH NS APPROVED FOR BEDROOM COUNT ONLY, BEDROOMS LAUN. vleuyi- L' 11. d� t' C� 1' STUDY X 10' -I" C^-RpW. r FOYER o� ONC: PORCH Tr, _.. j, gt7Bg � . � i NS TOT SE HOUSE UPPER LEVEL PLAN PLANS UST ,u °' PCDOH FOfRL LEVEL PLAN 2 5 FT. 53' X 26' SIGNA E & TTTLE DATE "THE, KEUNFIELD99 { 4 t; a 1 R�I I � 1 t . G; Roro� S� .� � .. ...: ... �. DIMENSION CHART (in feet)_.. Number 2 100' -3 —4 78' 5 loz, 76' (o 105 76' 7 /05, 74 '75 q loq' 75' 74' 114 76' 12- 116, 76 , 1.5 lzo, 7(o' 1 150 20 2-2- I6t3 , 25 170' 1:54 zli 1&0&' 1Z`1' F2,5 - 155' - ►140, NOTES : c