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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.57 -1 -2 BOX 18 ,� l • . I. '.IN '�I L 9■ ti ��� I yl F ,� l • PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well- a � -m.r.. trir�ti Address .� ,: -���,��-.. �,�" � z Towri/ 1illage:.,— er ax°Gri~d Map e.51 Block 1 Lot(s) 2 Well Owner: Name: Address: Use of Well: 1- primary 2- secondary �_ Re ' ential 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 _,k Open hole in bedrock _ Other Casing Details Total length Length below grade _103ft. Diameter _Zin. Weight per foot 1•7 lb /ft. Materials: X_ Steel _ Plastic _ Other Joints: _ Welded R Threaded Other Seal: _ Cement grout, X Bentonite Other Drive shoe: Yes No Liner: Yes X 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 77 Hours � T Yield L6 gpm Depth Data Measure from land surface- static (specify R) 4 During yield test(ft) 1610 Depth of completed well in feet T � Well Log If more detailed information descriptions or sieve analyses:-,: - are available, please Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ISF �.- (% A If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/ Storage Tank Information �j Pump Type . s Capacity o Depth 4/00 Model i O Voltage '0 HP ���� Tank Type / Volume Date Well Com leted / Putnam County Certification No. 007 Date of eport / �"' a�. Well Driller (signature) NOTE: `Exact location of well with distances to at least two petmanelht landmarks to be provided on a.separat ylleettplan. Well Driller's Name ;r i 14,4- Signature: Address: 6 3114 ' 'i`sm Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 6 T_ PUTNAM COUNTY DEPARTMENT OF HEALTH � :_.:�:HI I - r+OF-ENVIRONM- ENTAL--� EAL-TH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # ?' Located at I P—ID 15i� L-Wi�— Owner /Applicant Name Formerly 411.L`( C.0i-H e:Frwcn1)H Town or Village _ Tax Map ���1 Subdivision Name Subd. Lot # PAT -rE:1Z Block 1 Lot I- J A45 9EIL X1009, S Mailing Address �l� ��- IJ� Zip t' Date Construction Permit Issued by PCHD 6 q l Separate Sewerage System built by 6iJP0- Co NiIZAt'7044 Address 00 ON W- Ba "J M 1040' Consisting of 1'W) © Gallon Septic Tank and (/ V7 fir- A65, -rr,.6 NCA Other Requirements: q-, FILL Water Supgly: Public Supply From Address or: � Private Supply Drilled by .��� M, 14Y. A�IT 450 Address ) 0 40 1ZT °I II FA a� t 12 , 0 Build n ...T'.e. ' _ s .. 'n" g yp R ��i) (�'E Has erosion control been completed? _ Number of Bedrooms Has garbage grinder been installed? _YE__ r_ A/0 I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam Co Department of Health. 0 Date: Certified by P.E. R.A. CD � n Professional) Address �� dr V- I� y��� tiy (©4 tot' License # 1� 6 l Z,4 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 ar subl ct to odification or change when, in the judgment of the Public Health Director, such revocation, ,- dif atio hange is tsary. By: Title: Date: G White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT We11 Location Strut Address b-AE ..._ .. Rose -T wnN.illa.ge!,f,;-,..-;m- .7Tax- te 14 Grid -4 i 6 1 Lot(s) 2- Map Block Well Owner: Name: Address: JYO V LA 10S01 Use of Well: 1-primary 2-secondary Re6dential 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_X-1 Open hole in bedrock Other Casing Details Total length _Zo_f �ft. Length below grade _Zja3ft. Diameter in. Weight per foot 17 lb/ft. Materials: Steel Plastic — Other Joints: Welded X Threaded Other Seal: — Cement grout X Bentonite Other Drive shoe: Yes No ILiner: Yes Y No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test Bailed Pumped YL Compressed Air Hours Yield _L6 gpm Depth Data Measure from land surface-static (specify ft) Tcc I During yield test(ft) 867,�OLM J1416 Depth of completed well in feet IJ-11-e -V 7-1-J Well Log If more detailed information descriptions or sieve analysqs. are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 'IF C16 I In IM If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/,Storage Tank Information Pump Type _A2_ Depth Oa_ Model 7d 5'i 0 Voltage � HP L_ Tank Type Volume A) Date We Corn eted ;XZ Putnam County Certification No. 007 DRepor /t well Driller (signature) Nurt: jbxact location oi well wlUl UlStanCUS to ttL IOUSL LWU PU11114UMIL IMILKIMI&O LV UV, FIVVIU�U V1■ " F 7""' Well Driller's Name i k Signature: Address: 160 AY 311 Date: V White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC-97 Bnwncr, New Yq* 10509 "Ear4oaauWitaltEpN)37�•61jp raC111}!1t rill . Mwalq.su+taap�q�ri•es7e wtcpu)�r•arn .tp igne•eots &N�Tiieevta38e'(911)�Tr•eole Pratloot pldlTtd017 / Ql4)!1r•6d41 OWNERS NAM: RLILL'f C.t►H<r . CX10 J Woop'.. Lf TAX-MAP NY]MBRR: �G.Sh- ►- �. .. E911 ADDRESS: _ os� G4 �f TON' N: AU•TaOiiZ I) TOWN.(FIUCIAL; / 01guature) • DATE: .. .... . � /� O The Putnam County Department of Health will no issue a CertUkats of Construction CompHance unless the above form is com pletedy Le., a legal E91I address is as�igued by 819 authorized town official. 7U, farm is to be submitted - with the aPpUcation for a Cerdfleate of Coostruction.0 ,apajace. _ (1911 v8Rt7K- - _.__... t MAR -12 -03 09:41 AM PATTER$ON TOWN HALL 9148786343 P -03 7 LEY sAUCa a FOLEY LOUYTA MOUNM- ii.N,, MAN. l+�lfk Neaftl� (iljat 1C• • .Aaadlak h01YPedkr+f R PM . _ . ... ..... WARTMENT OF HEAT Bnwncr, New Yq* 10509 "Ear4oaauWitaltEpN)37�•61jp raC111}!1t rill . Mwalq.su+taap�q�ri•es7e wtcpu)�r•arn .tp igne•eots &N�Tiieevta38e'(911)�Tr•eole Pratloot pldlTtd017 / Ql4)!1r•6d41 OWNERS NAM: RLILL'f C.t►H<r . CX10 J Woop'.. Lf TAX-MAP NY]MBRR: �G.Sh- ►- �. .. E911 ADDRESS: _ os� G4 �f TON' N: AU•TaOiiZ I) TOWN.(FIUCIAL; / 01guature) • DATE: .. .... . � /� O The Putnam County Department of Health will no issue a CertUkats of Construction CompHance unless the above form is com pletedy Le., a legal E91I address is as�igued by 819 authorized town official. 7U, farm is to be submitted - with the aPpUcation for a Cerdfleate of Coostruction.0 ,apajace. _ (1911 v8Rt7K- - _.__... : -. :ET- TN- AIV.i- COQ WY- DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Reilly Construction 36.57 1 2 Owner or Purchaser of Building Tax Map Block Lot Reilly Construction Building Constructed by 2140 Route 22, Brewster, NY 10509 Location — Street Residential Building Type Patterson TownNillage Jasper Woods Subdivision Name 3 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 it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules, and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except - - - - •where -the -failure to operate properly is-caused by the willful or- negligentacf6f the bccuparif of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month 3 Day 10 Year 2004 Signature: Title: President eral Contractor ( caner) — Signature Corporation Name (if corporation) Address: 2140 Route 22, Brewster State: New York Zip 10509 Burdick Contracting Corporation Name (if corporation) Address: PO Box 532, Brewster, State NY Zip 10509 NORTHEAST LAB ®RAT®RI ES f INC. 129 MILL STREET - BERLIN, CT 06037 -9990 NORTHEAST LABORATORY OF DANBURY c - (DTaEnL.�NE: by. — b M ADCP, . Pryame rop fe:. . r To Free (in CT) 800 - 826 -0105 (Outside CT) 800 -654 -1230 Berlin /Hartford Area: (860) 828 -9787 Danbury Area: (203) 791 -3874 FAX: (860) 829 -1050 REPORT TO: E -Mail: NELABSCT ®AOL.COM www.NortheastLaboratories.com REILLY CONSTRUCTION ATTN. TOM BIGILIN 2140 ROUTE 22 BREWSTER, NY 10509 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: • Total Coliform (Bacteria) • E. Coli (Bacteria) PHYSICALS: • Color (Apparent) e Odor pH • Turbidity CHEMISTRY: •. - Alkalinity_ • Chlorine Residual • Nitrite Nitrogen • Nitrate Nitrogen DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: DATE TESTED: LAB I.D. # REPORT DATE: 9 ROSE LANE, PATTERSON, NY WATER TANK WELL WATER NONE RESULTS ABSENT per 100 ml NEGATIVE per 100 ml 3/4/2004 7:45AM TOM BIGLIN 3/4/2004 LAB# 11471 3/4/2004 — 3/11/2004 D0402970 3/16/2004 MAX11" CONTAMINANT LEVEL (MCL) OR METHOD # STANDARD - SM 9222B 0 per 100 ml(ABSENT) SM 9222B Negative. DATE TESTED TUWfE TESTED WHERE APPLICABLE 5 mg/L EPA 110.2 15 ND mg/L SM 2150 Not to exceed value of mg/L EPA 236.1 0.30 mg/L* 2 on scale of 0 -5 635 MkIL ASTM D1293 -99 64 to 10 Range <0.20 NTUs EPA 180.1 5 NTUs <5. mg/L_ SM23:20 .` ._No deemed-1i.•taits* - <0.001 mg/L EPA 239.2 0.015* <0.05 mg/L 4500CIG - - -- <0.005 mg/L as N EPA 354.1 1.0 mg/L <0.05 mg/L as N EPA 353.3 10 mg/L Combined limit for Nitrite plus Nitrate= l Omg/L as N 3/4/2004 @ 3:30PM 3/4/2004 @ 3:30PM 3/4/2004 @ 3:30PM 3/4/2004 @ 3:40PM 3/412004 A 3:40PM 3/4/2004 @ 3:40PM - 3/4/2004 3/11/2004 3/4/2004 @ 3:40PM 3/5/2004 @ 11:30AM 3/9/2004 @ 10:25AM • Hardness 12 mg/L EPA 130.2 150 mg/L ** 3/5/2004 • Iron <0.03 mg/L EPA 236.1 0.30 mg/L* 3/10/2004 • Manganese <0.01 mg/L EPA 243.1 0.50 mg/L * ** 3/10/2004 • Sodium <Q 1.9 mg/L EPA 273.1 28.0 mg/L ** 3/10/2004 ml= milliliter mgfL=milligrams per Liter ND =none detected MCL=Maximum Contaminant Level TNTC =Too Numerous To Count * *Notification Level ** *Action Level <Q= Analyte detected below quantitation limits. Data deemed estimated 3=Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing more than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with all State of New York regulatory guidelines, however, the pH falls below US Public Health Service range of 6.4 -10.0. pH deifnes the hydrogen -ion concentration in water and represents the aggresiveness of the water toward pipes (e.g. a low pH being more corrosive). -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or UOTPOTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Laboratory Director CT Cent. #PH -0606 & #PH0404 NY Cert. #11471 EPA Cert. #CT -024 USDA Cert. #0976 FDA Reg. #3001743770 DEA Reg. #624 U Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 -Bievvkerq4Y i Telephone (845) 279-4003 Fax (845) 2794567 March 17, 2004 Robert Morris, P.E. Putnam County Health Department I Geneva Road Brewster, NY 10509 Re: Individual SSTS Compliance - Reilly Construction Jasper woods - Lot # 3 9 Rose Lane Patterson, NY 12563 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S-3, "As Built SSTS", dated 03/10/04. 2. "Certificate of Construction Compliance for Sewage Treatment System", dated 03/17/04. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System'-', dated, 4. Laboratory Report, dated 03/16/04. 5. "Well Completion Report", dated 01/22/04. 6. Application Fee in the amount of $300.00 payabe to Putnam County Health Department. 7. "E-911 Address Verification Form", dated 03/12/03. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni ols Jr., P.E. HY,TN:gav 01-040.00 - ..F'`rsWx_. ..'.. .. _ n- ": '.a �...•.•. .� � i sw..a .cy -: l ic. .- �..i:..s'<%iv.v.��.. >sY.m..cr +C. .. oM1 e_wn.:.T1� -•»..: -.tY`O —Z CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # f- V -0 c)-,. Located at le o s Q_ e, Town or V�age Subdivision name dss 4jn, W-&- j� Subd. Lot # 3 Tax Map 36,57 Block 1 Lot 2— Date Subdivision Approved 1 - `w Renewal Revision Owner /Applicant Name R t-,, 01 (2,tsl . Ca, Date of Previous Approval Mailing Address /SS' E-ts Zip 16 iQ Amount of Fee Enclosed Building Type Lot Area No. of 1_ Design Flow GPD 941 l/ Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage _System to consist of 125+0 gallon septic tank and Other Requirements: To be constructed by _-7-6)) Address Water Supply: Public Supply From Address Pnvat6- Supply Dn1Ted by' 7.R_i3 - - .. _. _ , .. _ .. - . Addr'es r5 represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the selparate.sewage treatment system described above will be constructed as shown on the approved amendment thereto and in - accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years imnediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original systm or any repairs thereto. Signed: Address R.A. Date License # �'41 7-4 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the se-Age treatm stem has been completed and inspected by the PCHD and is revocable for cause or may be amended or molified w n co sidered essary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it proved r ischarge of domestic sanitary sewage only. By Title: Date: - Ar to copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 4 PUTNAM COUNT' DEPARTMENT OF HEALTH DIVISION OP ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Street Location F Town TM# 3G, S7 ._ 1. Sewage System Area a. STS area.located as per approved plans ........................... b.. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped .................................................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ....... ............................... II. Sewage System a. Septic tank size - 1,000 ...:..:. ,250 ........other ................ b. ' Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Boat 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 .......... ............................... 6, renT' hes 1. Length required 7 Length installed G� 7 2. Distance to watercourse measured 4-/ 00 Ft.......... 3. Installed according to plan ......... .............................:: 4. Slope of trench acceptable 1/16 - 1/32" 7foot ............. 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 ends capped ..................... ...... .......................... _g..Pum' b or Dosed Systems. 1. Size of 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............ b. Number of bedrooms .......... .................... /......... IV. Well Well located as per approved plans . ......:........................ b. Distance from STS area measured ;. -t 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..... I. ............................ d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate..'......: ........................... 1. Erosion control provided ................. ............................... Rev. p2/02 l''Snow Cover Inspected by: Owner Permit Subdivision Lot # 3 --301 t ' Q' LORETTA MOLINARI Public Health Director .s..s +v w.s :^xa .r e:s+n --. r, v .. .. -s �e _ r •. <... -.�s •._ ..... �. . � r. �n�..._. ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648. March 11, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Reilly Construction Rose Lane, (T) Patterson Lot # 3, TM# 36.57 -1 -2 Dear Mr. Nichols: The above referenced separate sewage treatment system can be bacicfilled. There are no open comments to be addressed. 1. Connection from house to septic tank has not been completed. 2. Erosion control measures have not been installed below the House and well -. _constru i. g u_axeas per,the._apprs2Xed'glans.:Please note-that `all.erosion_b4ntral_ measures must be installed prior to the start of any construction. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, r" 2 4''r Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj S. LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 CERTIFIED MAIL Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 RETURN RECEIPT REQUESTED OFFICIAL NOTICE OF NON - COMPLIANCE March 11, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Reilly Construction Rose Lane, (T) Patterson Lot # 3, TM# 36.57 -1 -2 Dear Mr. Nichols: ROBERT J. BONDI County Executive You are hereby notified that the following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: 1. Erosion control measures not installed below house and well construction areas. Failure to correct the above stated violation(s) immediately will make you liable for additional penalties provided by law, including prosecution on a charge of committing a violation punishable by a fine or imprisonment, or both such fine and imprisonment as prescribed by law, in addition to such other actions as may be prescribed. It is sincerely hoped that the above - mentioned further action will not be necessary and that you will cooperate by securing the correction of this condition. This Department must be contacted upon the correction of the violation(s). GDR:cj Sincerely, x4ne . Gene D. Reed Sr. Env / ental NwIth Engineering Aide Robert Morris, PE Sr. Public Health Engineer MAR -08 -2004 04:29 PM HARRY W NICHOLS 914 279 4567 P.01 �.wrY ..- ..wx v _.. -a-.r .w4".:r.w =S :rt.'P' -K.t :.�. .._'_'.- _ .. ..�- .- .r <, .r--- a ... -.w_r .. v ✓w _ � ax ...._vSr�....u= c•- ..�... < -Y.r. PUTNAM COUNTY DEPARTMENT OF HEALTH DYVISION.OF ENVIRONMENTAL HEALTH SERVICES $BQ 1EST p FR, TNAI, INSPECTION For: Fill Date: �U WW-yt osr• /A44 Trenches PCHD Construction Permit # P - Y 2w D 2 Located: _..� R+oK 16416 , (T) X FA sr i-) Owner/Applicant, Name: Po i l l,. xoa aL cb - TM Sd.5h... Block I Lot -L— . Formerly: Subdivision Name: JASftL 1A.WCdA Subdivision Lot # Is'system* 11 completed ?" Is system complete? v>� Is system constructed ss por plans? V96 Is well drilled? vas Is well located as per plans? Are erosion control measures its place? Date: Date: ga -cf -Wi Date: ft-Olt-01 I certify that the systciD(s), as listed, at the above premises has been constructed and I have inspected and verified their Completion in accordance with the issued PCID Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Da ;e: MAnza oIV /nom 4 Certified by: ,✓ RA Desi rofessional Address:* 2fl,.% Ro z 22 Ang Q:s��j &x JOSO9 Lic. # S6L2•� _ • Comments:. FOR: Q ADAM X OEM D :... (NAME) _. Form FIX-99 MAR -R -PM4 mnN 19:4A TFI : A45- P7R -7gP1 NAME: PI ITW0M f ni INTv r1F130BTMFAIT nr D 7 t LORETTA' MOLINARI,. ROBERT J. BONDI Public Health Director �16'W Y n, County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 . Fax (845) 278 - 6085 . Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 March 18, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Reilly Construction Rose Lane, (T) Patterson Lot # 3, TM# 36.57 -1 -2 Dear Mr. Nichols: It has come to this Department's attention that the proposed SSTS expansion area is within 200 feet in direct line of drainage to the proposed well on lot # 2. Measures must - - _....... _...._.:. _ ...be taken to prove out 100 % expansion prior.to this.Dep artment '.s -final approval. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, /- Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cj Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 205i�Route-21` Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 July 16, 2002 Putnam County Health Department One Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Re: Individual SSTS Jasper Woods - Lot # 3 Rose Lane Patterson, NY T.M. # 36.57=1 -2 Dear Mr. Morris: The previously excavated deep test holes reflected spotty mottling at 2' - 0 ". Accordingly, a cutoff trench and monitoring pipes were installed and monitored from 4/10/02 thru 6/17/02 to determine the effectiveness of a curtain drain. The results reflected a stabilized ground water at 4' - 1" below grade. :.The. enclosed_plan.reflects 2' -0" of fill being placed over the system area -to _provide the _._ .__.. required. 6' - 0 ' to ground water. Enclosed please find the following: 1. Five (5) prints SS -3, "Proposed SSTS - Lot # 3," revised 7/5/02. 2. "Construction Permit," revised 7/5/02. 3. "Ground Water Monitoring Results," sheets 1 and 2 of 2 dated 7/10/02. Kindly continue your review and issuance of the construction Permit. Very truly yours, Harry W. Nic s Jr., P.E. HWN:imm QS 01- 040.00; nr f z nd PUTNANI COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATDIE \T SYSTEN is REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: �`' �"�U STREET LOCATION:4{ t REVIEWED BY: RM, GR, AS, SRDATE: Y \ DOCUMENTS *�LETTER PERMIT APPLICATION WELL PERMIT OR PWS LETTER PC -97 OF AUTHORIZATION (J(JDESIGN DATA SHEET (DDS) UUCORPORATE RESOLUTION (_)(_,SHORT EAF UUPLANS -THREE SETS UUHOUSE PLANS - TWO SETS ULJVARLANCE REQUEST SUBDIVISTON (J(JLEGAL SUBDMSION UUSUBDMSION APPROVAL, CHECKED UUPERC RATE UUFILL REQUIRED DEPTH UUCURTAIN DRAIN REQUIRED GENERAL LJLJLOCATED IN NYC WATERSHED UUPLANS SUBMITTED TO DEP ( JLJDELEGATED TO PCHD (JLJDEP APPROVAL, IF REQ'D (_ )UDEEP TEST BOLES OBSERVED UUPERCS TO BE WITNESSED (J(JEX- APPROVAL SSDS ADJ, LOTS UUWETLANDS (TOWN/DEC PERMIT REQ'D ?) (__)( _JDATA ON DDS PLANS & PERMIT SAME (JLJPRE 1969 NEIGHBOR NOTIFICATION (__)(__)LETTER BI/ZBA { )LJiQQYR,-FLOODELEVATIOrN -W/I -200' - (J(L-15SOiL TE.' MG LOTS >10 YEARS OLD REOUTRED DETAILS ON PLANS (•J(JSEWAGE SYSTEM PLAN - (NORTH ARROW) (JUSSDS HYDRAULIC PROFILE (J(JGRAVTfY FLOW (__)UCONSTRUCTION NOTES 1 -15 UUDESIGN DATA: PERC & DEEP RESULTS (J(J2' CONTOURS EXISTING & PROPOSED UUDRIVEWAY & SLOPES, CUT (JUFOOTING /GUTTER/CURTAIN DRAINS ( _) JUSDA SOIL TYPE BOUNDARIES (JLJTTTLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# (JLJDATE OF DRAWINGIREVISION (JLJDATUM REFERENCE (J(JLOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. (J( )PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS (JLJWELLS & SSDS'S WAN 200' OF SSTS (J(JPROPERTY METES & BOUNDS (JLJEROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS- (REVSHEET)09 /01100 T.kX FLAP =: (CONFIRMED) Y N (REQUIRED DETAILS ON PLANS CONT'D) UUHOUSE SEWER -' /�" FT. 4 "0'; TYPE PIPE CAST IRON UUNO BENDS; bIA\ BENDS 451 W /CLEANOUT RENEWALS (JOSITE NOTE (NO CHANGE) FILL SYSTEMS (J(J10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (J(JFILL SPECS! FILL NOTES 1 -5 (__)UFILL PROFILE & DIMENSIONS (JL)FILL I\ EXPANSION AREA FILL GREATER THAN 2 FEET (JU CLAY BARRIER (J(JFILL CERTIFICATION NOTE UUDEPTH GAUGES UUVOL. ON PLAN FOR RO.B., UNCLASSIFIED & IMPERVIOUS UUSEPARATION DISTANCE FROM TOE OF SLOPE TR_ EN CH (UULF TRENCH PROVIDED LOFT MAX. (_J(JPA -kLLEL TO CONTOURS (_)(J100% EXPANSION PROVIDED (J(JDE,TAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL ((_JGEOTEXTILE COVER SEPARATION DTSTANCES ON PLAN - FROM SSTS U(J10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL (J(J20' TO FOUNDATION WALLS 0(___)100' TO WELL, 200' IN DLOD,150' TO PITS (__)(J100' TO STREAM, WATERCOURSE, LAKE (inc. expan) (J( j5G' TO CATCH BASIN, 35' STOR.1•IDRALN, PIPED WATER (J(J10' TO WATER LINE (pits - 20') : N ! � {J50' LNIERtiIITTENT DRAIIIAGE COURSE (__)(200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (J(J10' MLN TO LEDGE OUTCROP SEPTIC TANK (J(J10' FROM FOUNDATION; 50' TO WELL WELL (J(JDIMENSIONS TO PROPERTY LINES UULOCATION OF SERVICE CONNECTION (J(JtiILN 15' TO PROPERTY LINE SLOPE (J(JSLOPE IN SSTS AREA (__)(JREGRADED TO 15 %, IF REQUIRED DOSE/PUTVIP SYSTEMS (__)(__)PUMP NOTES (J(JDOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (J(JDETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) (__)(JPTI AND D -BOX SHOWN & DETAILED (J(_)1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN (J(JSTANDPIPES, 5' BOTH SIDES, DETAIL (J(J15' NlE4 to CDS = >S %, 20'A%, 25'-3%,35'-l%, 100%-<I% (J(J20' MIN to CD DISCHARGE /100' with 182 cons day discharge (J(J1U' DIL`i to NON - PERFORATED PIPE Public Health Director `—` ` -LO'RETTA MOLINARI'-R.N., 'M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 . Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: Reilly Construction 9 Rose Lane, Lot #3 (T) Patterson, TM# 36.57 -1 -2 Dear Mr. Nichols: August 5, 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. Please find enclosed a letter from this Department dated August 6, 2001. This letter states that the groundwater level must be monitored from March I' - June 30' due to mottling at 2 feet. The data submitted notes that groundwater was only monitored from April 10th -June 17, 2002. Please explain why the groundwater was not monitored from March 15' - June 30 'h. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon {receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours Robert Morris, P.E. Senior Public Health Engineer RM:tn _ .. BRUCE R, FQLEY, ,n=,...,:..._.. ,...... Public Health Director DEPARTMENT OF 1 Geneva Road Brewster, New York HEALTH 10509 f LORETTA MOLINARI RN., M.S.N. Assucioe� ^.F�vzic== �`Ic�l:i �Dirscter ..... ..., 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 August 6, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: Application to Construct a Subsurface Sewage Treatment System at Reilly Construction Rose Lane, Lot #3 (T) Patterson, TM# 36.57 -1 -2 Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on July 19, 2001 is incomplete. Please be advised that the of owing Ymforratloti 1s requ:.-ed befd.e -t..e Department -ma} .,cmrnen„e Its r. �i,,... • The Design Data Sheet submitted by your office notes groundwater at 2.5 feet. However, the Design Data Sheet recorded by Gene Reed, Environmental Health Services notes mottling at 2 feet. Therefore, the groundwater level must be monitored during the seasonal high groundwater period of March 15 - June 30. Please refer to Bulletin ST -19 for current guidelines. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166. I. T4 Ve ly your 'r Robert Morris, P. E. Senior Public Health Engineer . ° PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �o DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner e 1 z-t y Address Zc? S i=_ z-,#. Located at (Street) 22SPICR Tax Map 36'r57Block:::`'' l Lot :2 (indicate nearest cross street) Municipality2S�,u Watershed C-�4 5 i'j? c %/ SOIL PERCOLATION TEST DATA Date of Pre - soaking a_ V -0 / Date of Percolation Test 5°"Zz fc�/ th fVatedr T3ep. L afel rom roue eve'. Percolation Hole Run No' Fame Start Stop Ia se Time Min) surface (Inches) Start Stop n WK... Ine es 12at Minilnch - '3 a 2-1.- 22�/'y 1 % �2 �y 3 ro; ll;t� 30 %g 4 .. 5 _ 3 '30 1-7 - 4 2.. _- _._. -.... _ . 4 5 NOTES:.. J. Tests to be repeated at same depth until approximately 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 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 - - - - d '- Indicate level at which_motting Indicate level to which water level rises after -being encountered eetve.y't� Deep hole observations made by: � o �, n, ,�, Date s d/ Design Professional Name: Address: - Signature:.- Design Professional's Seal ®' 7 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO., HOLE NO. HOLE NO. G.L. 2.0' 2.$' ,. die 3.5' r: Say C Sa�� etlwke,, 6e 5.5 6.0' N , 6.$' 7.5' 10.0' Indicate level at which groundwater is encountered - - - - d '- Indicate level at which_motting Indicate level to which water level rises after -being encountered eetve.y't� Deep hole observations made by: � o �, n, ,�, Date s d/ Design Professional Name: Address: - Signature:.- Design Professional's Seal ®' PUTNAM COUNTY DEPARTMENT OF HEALTH = D MSION - GF-ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION - Name of Project --12!g CL y —M(V) PPrr� ��ory County Pte; n��A7 Site Location 7Z os,5 L&AVC Building construction begun dV O Extent Is proverty within NYC Watershed ? ................. EEJYes W. SECTION -B. TOPOGRAPHY (Please check all appropriate - boxes) 1. Hilly _ Rolling _- __ _....Steep slope Gentle slope — == Flat _o _ D _ a ❑= 2. F_� Evidence of wetlands 0 Low area subject to flooding F_� Bodies of water Drainage-ditches Rock outcrops 3. Property lines or comers evident ....................... ............................... F__J Yes 4-Do water courses exist on or adjoin the property? ..........::........... :..:. Yes 5: Will these affect the design of the sewage system facilities ?............ Yes _... -6: —Do watershed re g ulatiors a pp1 y.in - flue- develo pm.ent ?.:.:.:.:::.-...... - Yes 7 —Will extensive grading be necessary ?: :::: : ................ .... a Yes 8: Will extensive fill be necessary for SSTS ? ........................... 9. Do filled areas exist within the SSTS area ? ......................... _ If yes, what is the condition of the fill? �r ED No . No No No �Np ........... ? [:] Yes Q No ........... a Yes ErNo SECTION C. SOIL OBS RVATIONS - - -10.— Appearance of soil: Sand Q Gravel . Loam Q Clay [7 Hardpan Q Mixture 11. Observed from: Borings a Bank cut Backhoe excavations 12. Soil borings/excavations observed by S�, ZgrL) lRC, lam, N, on 13. Depth to groundwater �} — O � on 14. Depth to mottling �{ — O on 15. Are test holes representative of primary & reserve areas ...... ............................... 16. Soil percolation tests made by /n1i c �/a� S �, on 17. Soil percolation tests witnessed by _ Tc'c E D P, C "r f on SECTION D (on back) 0 Form ST -1 t-79ECTIbN- °])RAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent area 19. Will groundwater or surface drainage require special consideration? ..................... 20.. Will gullies, etc., be filled and watercourses be relocated ? . ........................... SECTION E. REMARKS 2 F __] Yes- E(No Yes � No F]Yes � No 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 Yes 22. --Do, adjacent wells and/or sewage systems exist? ............................................... ....... 0 23. Additional comments 24. Site observer /inspector and title )Fr-_g D J 2.5. Date(s) of observation(s)inspection(s) -5- zt leI - TEST PIT PROFILES Hole # -Lot# ...__._LHo1e# Depth to water Depth to water Depth to water -- Depth to mottling Depth 1o.-pqql Depth to roddimp. Depth to rockJimp. Depth to rock/imp. G.L.- G.L. G.L. 0.5 0.5 0.5 .1.0 ...... 1.0 1.0. 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 4 N Hv eon, �CT-' �� /� / —� 3 SG•C�' // / _� 73i •�� c4 / � Z• � O / � , ./ „ J ` /! "� 5° / � � MAN. /� / / „ ,, / � i 8; r � N � 6 scats;, • L- 27/.93" i/ 1 �. '" I v =/� °�t3_o �• ° 9.35 ' . 1, / t4 lit VIA% .c 02:%96 Rev. I G C11U 1111C of this report SIGs Harry W. Nichols -Jr., P.E. Patterson Park, Suite 106 2050 Route 22 - BrewsteF, NY 10509 • f!.w: - - :, 279.4003, Fax- 27944587 'aONSULTING SITE ENGINEERS ;OB No. 01 -0`f0 ' Rost: !-"5 —'44T-V-3. SHEET No. -'OF Z COMPUTED BY RSG DATE 7-10-02- CHECKED BY _ DATE 7- i I - o Z_ M O �1 !TO RI /y�.�$ULTS l lu -- TA. F� To o� GS'��+� �w►•�` Cirgoi� E eV� A q', 3'.O 9,50' 51L 710 •5 - - -- G Ll1 3' - ►I�' CoS�. 1 - -_ -_ c - -- S -8 - oZ S� -!o -!dg�� (� s8.7 -. - -- -- - - - - -- — — �; 6G.. G vi, 9' -2- ' /i' (072—.8 -- - S,► 'Z-02_0A: _ ze I p�,q�, 7! 3'� .............. - - -.... - - - -• -- - - - - -- - - - -- � No.$e124 - to 4 3' `f rah E lo' - 11 " (��-�1' - G' 2- T— i � 3'- ► I '" S� �. -a (o SS CeS3.0 — Harry W. Nichols Jr., JOB OB No. D 1-040' Rose LA•J�iC Patterson Park, Suite 106 2050 Route 22 SHEET No. p. ' , °OF Z. Brewster, NY 10509 _ - _ . _. _ _ _- .. .. _ GOMPUTED.BY_ ...RSA _. _.__4t1TE__ __ }(_ —•) 279 = 00 ;-F4)E 27f- 4567.K< e. EB_ CONSULTING SITE ENGINEERS CHECKED BY DATE Z C;...t U Ut�9 A/�4J2 ft—, tt1 p >J 1 To Rt /�Ca_ T S ! - bz.41 '16 r t- ., - - To of �+c'�`K; F'tis4,` Grg). GEN, _ A 9 {_ -- .. ---IT— — c- - 9r_ce., A- — -- g�_ -7 7L1" 49 4.9 _ -1-7 -02- - %3 - -- -- All T F No: 56124 <� OF1 ! ! i Q i PUTNAM COUNTY DEPARTMENT OF HEALTH /IVISIrON OF ENVIRONMENTAL HEALTH SERVICES r v.,`t? -` t:' ' `;',' 1''lPLICATION TO CONSTRUCT A WATER WELL WellUcWio ISM&ddress: Town/Village Tax Grid # n 1 Q-015E I.�v MaP U SI Block ] Lot(s) %- Well Owner: Name: Address: 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 05+ gpm # People Served '6 - ra Est. of Daily Usage _gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling . _�( New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type YZ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision J M Q GIB— of m m Lot No. Water Well Contractor: Ifl Address: Is Public Water Supply available to site? .................................. ............................... Yes No X Name of Public Water Supply: Town/Village Distance to property from nearest water main: -� Proposed well location & sources of contamination to be provided on separ a sheet/plan. Date: �� �o� 0 \_..__ .._ Applicant Signature: -- 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 ell driller ifled by Putnam County. Date of Issue (! Permit Is Offi Date of Expiration b Title: Permit is Non-Transferrfifile White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 July 16, 2001 Putnam County Health Department One Geneva Road Brewster, New York 10509 Att: Robert Morris, P.E. Senior Public Health Engineer Re: Individual SSTS Jasper Woods, Lot #3 Rose Lane Patterson T.M. #36.57 -1 -2 Dear Mr. Morris: Enclosed are the following: 1 2 3 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 -, ; &ewsterr� -A�IY d 059'9.•.. �....�,,.<u,.� -.��. - „- M.�.... . 4 Telephone (845) 279 -4003 Fax (845) 2794567 Five (5) prints of SS -3, "Proposed SSTS," dated 7- 16 -01. "Short EAF," dated 7- 16 -01. "Application for Approval of Plans for a Wastewater Disposal System," dated 7- 16 -01. "Construction Permit for Sewage Disposal System," dated 7- 16 -01. "Application to Construct a Water ..Well,'.'_ dated. 7- 16 -01.__ ` 'Design'Data-Sheet. "' "Letter of Authorization." Corporate Owner Application. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." We would appreciate your review, approval and issuance of the Construction Permit at your .earliest convenience. Very truly yours, -ik� Harry W. Nichols Jr., P.E. HWN:JM:his 01- 040.00 4. 5. ..,..... _ 7. 8. 9. Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 -, ; &ewsterr� -A�IY d 059'9.•.. �....�,,.<u,.� -.��. - „- M.�.... . 4 Telephone (845) 279 -4003 Fax (845) 2794567 Five (5) prints of SS -3, "Proposed SSTS," dated 7- 16 -01. "Short EAF," dated 7- 16 -01. "Application for Approval of Plans for a Wastewater Disposal System," dated 7- 16 -01. "Construction Permit for Sewage Disposal System," dated 7- 16 -01. "Application to Construct a Water ..Well,'.'_ dated. 7- 16 -01.__ ` 'Design'Data-Sheet. "' "Letter of Authorization." Corporate Owner Application. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." We would appreciate your review, approval and issuance of the Construction Permit at your .earliest convenience. Very truly yours, -ik� Harry W. Nichols Jr., P.E. HWN:JM:his 01- 040.00 PUTNAM. COUNTY DEPARTMENT OF HEALTH l�N' 'IRONIEN'l['A%- iE'H�,'VICE... ........L.TM_.., .. DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner R-FDW —f C.OH j'(4 CTIDI4 Address )66 G� ('1tt�r�M �,�'• �iR.�J`; - �ilASc�°� Located at (Street). Ff6E LP-M6 JM% Tax Map X6.51 Block t Lot (indicate nearest cross.strect) MLMicipaliry �P�t"Tr F— ��oi -1 Watershed i SOIL PERCOLATION TEST DATA Dale of Pre - soaking 25 12At o,. Date of Percolation Test °51251 of Hole r`io'r �+ 'r s -, <A;.. bum 1lrom a, �,.: FFLQ ►sG:Ci 3i to *.�w gkIN yo ercala twa ate M1t1�DCl3 1 io � �Q•_ �Q �� titi l� �1 l - 2 10 %A6 _ t 11�- 1 2I�11g -711 3 � '� - Itll :50 24-'18 11/� 1-7/1 j 4 2- 1 I D ° 21 dto�12 3 4 _ _ 5 -• 2 3 - 4 kj I-V Q 5 •Lam• a %1w'w V9 IcpcaLw a; Wag ucput unn► approxtmatety equal pemdlation rates are obtained at each percolation test hole. (I& s 1 min for 1 -30 min/inch, s 2 min for 31.60 miiRinch) All data to be submitted for review. 2. Depth measurements to be made from top of hole, TEST PIT DATA DE SCRIPTION,.O..F'S,OILS ENCOUNTERED IN.,TEST. WOLFS HOLE N0 Tai _ 1.0' ---- p it :SA.c�. S� SP 2.51 LOAD V1 a A.p, 1-o w SEEP �4i�p .5' C.c- \ 6.0' 6.5' 9: 5 .. - 0.01 . - !ndicace.level at which groundwater is encountered'-Q" irdicace level at which mottling is observed !ndicate level to.which.water level rises after being encountered Deep hole observations made by: 4W Vv,. A�CHd.6, wi BE 1,&�W M' Date 619 -4101 Design Professional Name: l w� Address: - 0-015--C) �� ��P��� �i�c,,a° � I 0 �VO°\ LM >1g71aC1lre: ��F No.66124 FM Design Professional's Seal HF'K -L`J' -Ltlb 1 1 1 :94 N,9 HHKK Y W N 1 UHULS -1 BRUCE R. FOLEY _ � ... � = �1Rttr; .Xcata� -�: L?lreaaz•_.. ...� ,.." . "_ .. _ _ ...r ..... 7 1 9 L r I --- . LORETTA MOLINARi _ RN., M.S.N. Dtr`ietor- Dtrre[a gJ.Partenr Sewtevi DEPARTIVIENT OF HEALTH - 1. Geneva Road Brewster, New York 10509 RE,QUESI FOR FIELD TE TIN ATTENTION: o ADAM.STIEBELING ' ENE REED All information below must be A,& completed prior to any scheduling. DATE: ENGINEER OR FIRM: r r. %��. PHONE N: 79 —f VO 3 R1:Asoiv: DEEPS: Vii PERCS: ( PUMP TEST: o ROAD/STREET: tie- l y S c TOWN: 0t %te rrCt6 TALC Mak 3Q, SUBDIVISION: uj"' "LOTH: OWNER: ITS NO a P� Proposed SSTS within the drainage basin of Nest Branch or Boyds Corner Reservoirs. o 31< Proposed SSTS within SW feet of a reservoir, reservoir stem or control lake. C3 pd Proposed SSTS within 200 feet of a watercourse or a DEC wetland. _.., O- Proposed SSTS des19ikA9H.greatc_ thanA000.g lto ia/sl�ty or- 1PDES 1Pcrmit-required: :� Proposed SSTS for a Commerical Project. It is the 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, NYCDEP must witness the soil testing, This Department will coordinate a mutually suitable time for Geld testing wlth 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 court rY USE ONLY D47E: 15 Z_;' TIME: LL-X!5_-7 (FIELDTEST) Lm j. Mou i DA avila Oflow YO o� f `'. .. .. .... _. Q 2 O Tl ► DENS o NILES ..8 leyS 11/ KE Op NIEE%10(0 ND DH $ RT $ ' T10"Anr u cr / 3 N't _. J a a �' n R..i) �t3i a�at Mum - rn r $ ;Lost 4 % �F d' l ` `'�� r ,ttt• 1� � i � 3 '� l o ' , p r Lake 4 RENDS m harles 4 9�Er 3 no UPI �que Area Mount Ebo ' DeF i l Corporate ;} �� p 65 0 of c o Corner _.._.. Pond 1 = �=� a qD t• .,�" �a — —wa - JASPER coast . • wN u t0, 10, / 7 l \ A \ b \ o.I 2 $ \\ a n - iol•�;.. .:. Ion -� -_ -.� ._- 100.7p Y — P = 8 _ 910i cz usu" sass tqz :s a m l000e —e w FYI II cd • CA A ''' $ v — 00.001 WH N 100.00 X 6174 _ i__ �w LO ! _ _ out Is A NAM CO. " ' M46 "'s I�su 00.001 LAFAYETT. :FIELD CO. a NEW FAIRFIELD,CT �•• Wt h._.. 4:..u�`������i' T .;.R ,n5������' rg9A��.?�� �Z �` 5 t � i.9"�p ECG' .t,.y: IgSji ". �`+'`- �r"t- .a,7rn'f' 4 Y. Rene 27t t� x�`� O E :r;� '''k e + , - '7r �.^ttr, MC ... a....r -., -'-``= `sr r• BfCWStCfyNY °iQsn9�� #Z'``'°s"�"�t'x�vt��t 1 e ephone 84 279 ( 5) fl /� 4' d 2001 ''.. „ is Robert Moms, P.E.` Putnam County Health.Department j One Geneva Road _. Brewster, New York 10509 E Re: Individual SSTS Jasper Woods - Lot # Rose Labe f Patterson t T. M. Dear Robert: Enclosed are, the following: 1. Five (5) ints ofDrawin` SS, % "Proposed SSTS," dated '. Q Q 8 ) P g -� P , 2. Short EAR 3. "Application f r Ap roval of Plans for a Wastewater Disposal System," dated c - 4. '"Constnzction Permit for Sewage Disposal System," dated l . `ll d 6 0 01 `5 "Application °to` Constru-.t a Watec%A" date. 6. "Design Data Sheet." - 7. `.`Letter of Authorization." 8. Two. (2) copies of residence floor?lan(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 i O1 -03"0 :' 14-115.4 WWt -Tact 12 . PROJECT I.D. NUMBER ,: 61T:Z0 SEQR Appendix >- - � �°"�'" • f �a "Eil�IronmentiT' dwfi�yRivlew� SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART (— PROJECT INFORMATION fro be completed by Appllcant or Prolect sponsod 1. API�dCCANT lSPO R CW 2. PROJECT NAME J. PROJECT LOCATION:, p c p N Municipality i` �t`�� C;ounty 4. PRECISE LOCATION (Street address and road inlerseotlons, prominent landmarks, etc., or provide map) S. W PROPOSED ACTKU Now O Expansion O Modlllcatlordalteratlon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: p � 110 Initially acre Ultimately acr" e. W14 PROPOSED ACTION COMPLY WITH EXISTING ZONING OROMER EXISTING LAND USE RESTRICTIONS? ee O No IT No, describe twisty ` 9. WHAT IS PRESF,J'R LAND USE IN VICINITY OF PROJECT? . DI Resldentw. O industrial ❑ Commercial -O Agriculture .0 Park/FowwUOpen space • 9 [� OtMf ; .. _ ... 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAQ? - O Ya I Uo . It yes, Bet agency(s) and PeftvaJ>Drov+ls 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Ya. • CLIo ... u; r0�. 04 .o•nor nartls and prrml Wpprov4 12. AS A RESULT PROP.dW ACTION WILL EXISTING PERMTTIAPMWAL REQWRE M001FICATIM O Yes - I CERTIFY THAT THII INFORMATION, PROVIDED ABOVE IS TRUE TO THE BEST OF My KNOWLEDGE Applicant/sponsor name: Date: �+- 1 J. J Signature: It the action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment AVER .. 1 PART ll— .ENVIRONMENTAL ASSESSMENT (To be Comcleted by AaencY) — A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 0 NYCRA, PART 817.4 ?' If yea, coordlnate'the review process and use. the FULL EAF. ❑ Yes ❑ No o., . ! . - �4rnTtON BECEIVA:C00ADit�ATED RE1ligW A$ PROVIi1ED'FOR UNUSTtA'ACTIONS IN 6 NYCRR;PART 817:6? " 1f'No,�iiiopifMQ'doclarillon` ' may be superseded by another, Involved agency,' ❑ Yes ❑ NO G i. C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwrlllen,.if legible) Cl. Existing air quality, surface or- groundwat0r quality or quantity, nolse level$, exl$ting traffic pattsms, ,aolld waste, productlon or disposal, . potential for erosion, drainage or flowing problem$? Explain briefly C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or nelghbortmd characteR Explain briefly: C3. Vegetation or fauna, fish, shellfish or %,Ildllfe species, significant habitats, or threatened or endangered spocles? Explain briefly: G. A community's existing plan$ or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly Cs. Growth, subsequent devebpment, or related activities lWely to ba Induced by the proposed action? Explain briefly. C8. Long term, short te(m, cumulative, or other affect& not identified In C1-05? Explain briefly. C7. Other Impacts (Including changes In use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTAOUSHMENT OF A CEA? ❑ Yes ❑ No _• .' . -. .E.._t&- HERE, OR IS THERE - LIKELY -TO -BE, CONTFtOVEWY'iFtLAfEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yas, 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 conneotlon with Its (a) setting (i.e. urban or rural); (b) probability,of.occyrring; (c) duration; (d) irreversibility; (e) geographic scope; and (Q magnitude. It necessary, add attachments or reference supporting materlals. Ensure that explanations contaln sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. If question D of Part II was checked yes, the determination and signlfldance must evaluate the potential Impact of the proposed action on the environmental characteristic# of the CEA. ❑ 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 declaration. C3 Check this box If yo'U hav ®.determined, used on the Information and .analysts :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: Name of Lead Agency . Pr ot or Type ame of K.. n Lead Ageaq Tide R ResponslbW Officer, ianaturt of es in y <. wre offrepaw different from respons e o ice, Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,,QF,: W ; RONMENTAL HEALTH.SERVICES Q&T — .,FQR:�PRovAL OF�PLANS =I.OR= :_M.,:.. - ,; *' A WASTE. WATER .TREATMENT SYSTEM 1. Name and address of appjicant;li –�j CQM�"VG'T10 ; 2. Name of project: L� /b'�ifi'S 3. LocationT/V: =_ r: 4. Design Professional: W QE 5. Address: USO 6. Drainage Basin: 7. Type of Project; , X Private%Resident'lal Food Service Commercial Apamnents.,. , Institutional Mobile Home Park Office Building Realty Subdivision Other (;pecify) 8. Is this. project subject to State�Environmontal Quality Review (SEQR)?, •* _ Type Status (check one) ....... ...... :.,....... ................:......:..,...; , Type..I �„ ' Exempt_ . ypa II Unlisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... NO 10. Has DEIS been "completed and found acceptable by Lead Agency? ......,.,...... 11. , Name of Lead Agency Iy 12. Is this project iii an_arsr control. :of local planeing; ionrng, or, other "- officials, ordinances? - ::::: :............ 13. If so, have Plans been submitted to'such authorities? :::::.:: ..:::........... ....... ........ N 14. Has prelim nary ppr`.oYal been granted >;y suc4.autborities ?.No Date granted: N N 15. Type of Sewage Treatment System Discharge:..:....:::.:::`. surface water _ . _ �. _ _ -L —groundwater 16. If surface water discharge, what is.tha:s ra• treaclass designation? :.:::.:..... ... :., ::: NA 17. Waters index number ( surface) :,.:..:...::::....: .:::.:..........:... gee ....... ........................ ... N -P� 18. Is project located near a public water supply system? ................... :..... �a ............. 19. If yes, name ofwater supply° Distance to water supply )4A, 20. Is project site'neir:a public sewoge.collection or treatment system? ....... ::: :::::: _ 21. Name of sewage system N N Distance to sewage system R 22. Date test holes observed i-5 � D 1 23. Name of Health Inspector 6i EH F j� 59 24. Project design flow(gallons per day) :..:.......................... . ......................... ...::... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... N 0 26, Has SPDES 'Applicatian been submitted to local DEC office? .:.:.................... N 21 27. Is any portion of this project located within a designated Town or State wetland? �a i!;!41%IMplalp.!X,r. MIt!��ge�e0,aaooyle��eg q.�o.eao e,o..e�Ye.�s �.e..T. •.•.•... •. .. . �� 29. Is Wetlands Permit required? ............................................. ............................... MO Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .............................. ry 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, -- landfillin sludge a ication or it dustrial activity? ............ Yes/No,�0 g, $ PPS: ty ....:............ WA 32. Is project Iodated 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 fl DESCRIBE: 33. Is there a local master plan on file with the, Town or Village? ......................... Yr r 34. Are community water and/or sewer facilities planned to be developed within . 15 years-in or adjacent to project site? ................................ ............................... _ NO 35. Are any sewage treatment areas in excess of 15 % slope? .................................. NO 36. Tax Map -ID Number �Sl i .:........................ ............................... Map'�b Block Lot 1- 3 7. Approved plans are to be returned to ..... Applicant A Design Professional NOTE: All applications forrevietV and approval of anew 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.:Prcjects 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. f the application is signed by a person other than the applicant shown in Item 1.,thd application must )e accompanied by a Letter of Authorization (Form LA-97). Failure to comply with this provision nay be grounds for the rejection of any submission.. 1 hereby affirm, underpenalty ofper/ury, that Information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section, 210.45 of the Penal4aw. SI GNA T URES dc. OFFICUL TITLES: Mailing Address: ......................... PUTNAM COUNTY- DEPARTMENT. OF HEALTIi TCHVIT5 MMU Dj�-qS 0 OF1 NW9 -A LETTER OF AUTHORIZATION RE: Property of Kkl•I'q C-jo �>-� _ Located at q TN PKI-W.-OH Tax Map# 0)6' 51 Block Lot Subdivision of lNt2?(�F W (3'rJV 6 Subdivision Lot # Filed Map # Date Filed Gentlemen: This leaer is to authorize J a duly licensed Professional EngWeer or Registered Architect to apply for the required wastewater treatinent and/or water supply permit(s) to serve thi above-noted -property in accordance with the standards, rules or iiiWations as promulgated by the Public Ifialth Director of the Putnam 4 pr all nec ary—papm- . -= my, �ehi If in-connection W-ft'i'th"i matter 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.Eduq _fi� ,,the Public Health L a w, and the Putnam CojuAt3?1widwy Code. Countersign) P,E., R. A., # I tiUr 3%1[;Vv k _." N N I CHO, N Mailing Address State - W - Zip Telephone:. Al Very truly yo u Signed: gor of Mailing Address: State Telephone: �i �p -5, DIMENSION CHART (in feet) Number I I as 32 2 35 61 3 33 55 4 33 so .5 34 45 36 40 39 36 43 32 9 47 29 10 5Z 34 54 31 41 29 13 66 14 .7 a 1.5 113 91 16 109 so 17 10V; so 18 101 180 19 as so zo 95 81 23 89 96 24 66 89 25 96 92 26 85 96 27 fs 99 i .572 °58 116 °E 173.50 N cli EXIST WELL 11 I I 1. I -L i — 251521f W O S E LAN E It -- so. 00 1 L= 31.'l41 &-- 36*Z2 R- 3S 00 1 R 'ZSO CAL SEPTIC T4A(k j� �ti � ��j , m So�� p�� s SDR-35 3 O It -- so. 00 1 L= 31.'l41 &-- 36*Z2 R- 3S 00 1 R