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HomeMy WebLinkAbout2100DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourclocs.com 631- 589 -8100 36.57 -1 -4 BOX 18 'ITw I '. '7 T I,yti r on I 1 610 k;A T �� ma }'I F � . I F. �'to ' _ no . r T 02100 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION-OF _ENV I�IZONIVIENTAF. AL.''H: SER)CES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P ' V0 'a 6 -W . Located at ��� Town or Village P�0H Owner /Applicant Name UJ rS':P Tax Map '° Block f Lot Formerly Subdivision Name J p6pa' W ooQ5 Subd. Lot # J Mailing Address U b W1,-60M l- 01i- l''j� � 1`i 8 Zip I esol Date Construction Permit Issued by PCHD Separate Sewerage System built by Consisting of I �� 0 Other Requirements Water Sunnly: LoJi 5 ii /0i I D'L Mho Address 10 ga,660 '`' LA45 oy in S(A Gallon Septic Tank and 5 -)1 L-r- P(M : 1) 6HOR Public Supply From Address or: �4- Private Supply Drilled by Bd ' - -- Building TTypd- Pze 61:De- be Number of Bedrooms VZIA, V'iL4 WLA Address LO'"t K 5� - C EL- 06ZF'0A Has erosion control been completed ?' Has garbage grinder been installed? H-? 4' 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 regulatiops pf the Putnarp. County Department pf Health. Date: E Address P.E. N R.A. 5Co f A 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 subject to modification or change when, in the judgment of the Public Health Director, such revocatiodifica2 or change is necessary. By: Title: -Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 Harry W. Nichols Jr., P.E. " Patterson Park, Suite 106 2050 Route 22 u ,......:. . , ...,. - _ Brewster; NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 June 13, 2003 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance - Marmo Jasperwoods, Lot # 5 12 Rose Lane Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -5, "As Built SSTS", dated 04/24/03. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 06/13/03. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 06/13/03. - - - 4: Laboratory Reports, dated, 05/23/0 Vii, 06/1.3./03:..::�T 5. "Well Completion Report", dated 12 /18/02. 6. Application Fee in -the amount of $200.00 payable 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, —))�L Harry W. Nichols r., P.E. HWN:gav 02 -082 -00 5z %nc Za ,I, to .¢. Ct w�. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .. ........ GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 1-0 J Owner or Purchaser of Building Tax Map Block Lot Loy T1` � 01D Building Constructed by TownNillage t 1�_ JA/DP64, Wow Location - Street Subdivision N � Building Type Subdivision Lot 4 -represent that I am wholly and completely responsible for the location, Workmanship, material, construction and drainage of the sewage treatment system serving the above-described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department artment of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in gobd 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 Constructio n Compliance" for the sewage treatment system, or any repairs made by me to such system, except' where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as towhether or not the failure of the system to. operate.-was caused by the willful or negligent act of the occupant of thO building utilizing'the system. Dated: onth J0 057 Day 1� Year UO'b Signal Title: General Contractor (Owner) - Signature Corporation Name (if corporation) Address: 9-0 L ` 6TW_ State Zil) Corporation Namp! (if corporation) 1 Address: State r3 V, zip I Form GS-97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 . ' `A.' (91 14 >' 245�2800~ Albert H. Padovani° Director I LAB #: 93.301320 CLIENT #.- 55391 NON STAT PROC PAGE 1 MARMOr LOUIS DATE/TIME TAKEN: 05/22/03 1O:45 20 BLOSSOM LANE DATE/TIME REC'D: 05/22/03 11:40 BREWSTER, NY 10509 REPORT DATE: 05/23/03 PHONE: (845>-494-O987 SAMPLING SITE: 12 ROSE LANE, BREWSTER, NY SAMPLE TYPE..: POTABLE : WELL TANK WHOSE PRESERVATIVES: NONE COL'D BY: LOU-MARM8 TEMPERATURE.-.:—<4C NOTES...: COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL .-- F0NGl:-- 05/22/03 NF T. COLIFORM ABSENT /100 ML ABSENT 1008 ` �- COMMENT�_: BACT THESE RESULTS INDICATE THAT THE WAT AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDlp���f�'THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED' AT THE TIME OF COLLECTION. . SUBMITTED BY: C&C rv� --_°, --- _-, M.T. (ASU'l Director B-AP# 10323 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 '(914)-245-28(>0`�'�'-,�,-`� Albert H. Padovani, Director LAB #: 93.301359 CLIENT #: 55391 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MARMO, LOUIS 20 BLOSSOM LANE DBA GEMINI CONTRACTING BREW8TER, NY 10509 DATE/TIME TAKEN: 05/2B/03 09:30 DATE/TIME REC'D: 05/28/03 10:O0 REPORT DATE: 06/13/03 PHONE: (845)-494-0987 SAMPLING SITE: 12 ROSE LANE, PATTERS8N SAMPLE TYPE..: POTABLE : WELL TANK W HOSE PRESERVATIVES: NONE COL'D BY: LOU MARMO TEMPERATURE..: < 4C NOTES...: COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~'~~~~~~~~~~~~~~~~~~ DATE FLAB PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 0508/03 LEAD (IMS) <1 ppb 0-15 ppb 9101 05/28/n3 NITRATE NITROG 1.16 MG/L O - 10 9139 05/28 NITRITE NITROG <0.01 MG/L N/A 9146 05/28/03 IRON (Fe) <0"060 MG/L 0-0.3 mg/l 2037 05/28/01 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/1 2037 05/28/03 SODIUM (Na) 6.46 MG/L N/A 05/aS/qy pH 7.3 UNITS 6.5-8.5 9043 05/28/03 HARDNESS,TOTAL 144 MG/L N/A 05/28/03 ALKALINITY (AS 118 MG/L N/A 05/28/03 TURBIDITY (TUR <1 NTU 0-5 NTU COMMENTS: Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead 0Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more . than 15 ppb and-a COPPER value of 143 mg/L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. , ` YML ENVIRONMENTAL SERVICES 321 Kear Street `Yo , '10598 ' ,914, 245--2800 Albert H. Padovani, Director LAB #: 93.301359 CLIENT #: 55391 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MARMO, LOUIS 20 BLOSSOM LANE DBA GEMINI CONTRACTING BREWSTER, NY 10509 SAMPLING SITE: 12 ROSE LANE, PATTERSON : WELL TANK W HOSE COL'D BY: LOU MARMO ' NOTES--.- � _DATE FLAG PROCEDURE DATE/TIME TAKEN: 05/28/03 09:30 DATE/TIME REC'D: 05/28/03 10:00 REPORT DATE: 06/13/03 PHONE: (845)-494-0987 SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COI-IFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD Hd TOTAL- IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM ' ' RATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARD ' '� S MAY RANGE PROM O TO HUNDREDS�OF MG/L, DEPENDS ON THE .SOURCE TREATMENT TO WHICHTHE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATERz ABOVE 3O0 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLTGRAM PER LlTER HARD WATER: 14O-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Director ELAP#.10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT yell Lpcatlgr ., ... Street, Address: . , _, -.. ���jf/� Town/Village: - • Tax Grid-#,-;— ---- �- .. - � -�- MaP%41 Block I Lot(s) 4 Well Owner: Name::G,� Address: Use of Well: 1- primary 2- secondary _V Residential Pub is Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _>/ Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock _ Other Casing Details Total length _,ZZ ft. Length below grade /;L/ ft. Diameter (G in. Weight per foot lb /ft. Materials: L( Steel _ Plastic _ Other Joints: _ Welded X Threaded _ Other Seal: �CCement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes _(No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First _ Yes—No Hours Second Well Yield Test _ Bailed _ Pumped -)i-. Compressed Air Hours Yield & gpm Depth Data Measure from land surface- static (specify ft) / Av During yield test(ft) b Depth of completed well in feet 6225 Well Log If more detailed information descriptions or sieve- analyses _ e ar available, please attach. De th From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ne4 Nib C� ' A 6-Ctv 7711 6 6-1 v,-,, sf If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ' Capacity & So/6 Depth / Model C- R4W41I &I Voltage HP Tank Type i , AV& Volume 11i29"'*+ , Date Well Completed Putnam County Certification No. Date of Report Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be providq4',-6n a separate sheet/plan. lln � A_, Well Driller's Name ,v Address: G Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 8786343 P.01 MAR -1 ? -03 08:43 AM PATTgRSON TOWN HALL 914 :( 1 BRUCE R. FOLEY * * L4RB'f'TA MOLMW`RN, F,.? : r. - ...,.,...�.. , : Ptibrre° AherrA OWerar: ;"� -- • .. .. ' ' � : ,;; .,I�aolaN /'ublft.. �ialbs ' LaVrc�a ... .... � .. 1: Otractw at/ radial' &MM DEPARZ'Ta M OF BEAM R _ . 1; 10eaeve • pmd _ c &woter, New y0jx 10509 to WMUW 1491b 014)171.6130 hi(114) 171 MI 14,768 Win 011)371.055. 1MtC t91�171.1611 ft 14,768 171.60f! • .._ . • . .�.. - tart "litwuHoa'pl { }!7f•f114 Prntleot(41y37ti0l3 P plb)!76'•64+t ( OWFfERS K M�; A�— HO t rp~ Woop 3 Lol 6 E911 AMMS, PATi�R TOWN,. -M �• AU.T110 QED TOWN,Q>FRiML -, (Signature) _... ... r ;f 1 The Putnam Couldy Department of Health will no issue S CertifiC410 'of Construction Compliance anleas the above form is co m leted' t,e.,_a legai•,E911• ...:.a dress is s$i�tled by. an aithorlxed town.0MCI�l, fibis' orm is to be subtniitted With 11 pplicatloti far a Certificate of Construction C nlpliance. I' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,3 FINAL SITE INSPECTION a• Date: 3v o3 Inspected by: 6, e 6o Street Location. 17-0!;,15 L. .0 _ Qw�er /,�r �9 _i•.� Town::iti rr�� 5�ty Permit # P-- 3 3 — o2 TM # 36, 6-7 -- / — Subdivision Lot # t 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. 1 00' from water course / wetlands ...... .......:....................... H. Sewage System a. Septic tank size - 1,000 ...:....1,250 ....other ................ b. ' Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ..............:.. 2. Protected below frost .................. ............................... 3 Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6, renc es .1. Length required 5-7 Length installed 5 7/ 2. Distance to Watercourse measured -f-1 0o Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped................... ....:.... ................................. . - g.: Rump -or- -Dosed -Svstemg-._.— _. _ .._ 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........... M. House/Buildin� a. House located per approved plans•...... ... b. Number of bedrooms ........................ ...1...�.............. IV. Well Well located as per approved plans ......... .............. .......... b. Distance from STS area measured f (oa - ft........... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........ ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :............................ i. Erosion control provided ................. ............................... Rev. 12/02 APR -28 -2003 10:08 AM HARRY W NICHOLS 914 279 4567 P.01 70 _ PUTNAM COUNTY DEPARTMENT OF HEALTH DIYISION.OF INMONMENTAL HEALTH SERVICES LaQ1XgT.FOR EN& WSP .CTION For: Fill Date: Aoa.%1. IIL03 -` Trenches ✓ PCP3D Construction Permit Located: 12 2,02: L60% .1. (T) (V) F aIT QWo,z Owner/Applicant Name: �y� '� KATN t =tom HwQ M� TM s , §3 ' Block ,,.j Lot Formerly: Subdivision Name: Subdivision Lot # Is 'sysieui•'fill completed? - It system complete? ' W-i Is system constructed as per plans? Y91% Is well drilled? Yes Is well located as per plans? ,izs Are erosion control measures in place? ,Xes Date: Date: ' AP.&i L 1'2 41 ; Date: A e& j- e l L0 3 I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and .verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. - Aate;.._ _.Q. `1 `7 0 Certified . b Y• Desi rofessional Address:..' 1050 2-2- 10569 Lia. � 5612 I ._ rnmmante• FOR: C] ADAM . 4ENE Q :.... .... (NANO ...,�. Form FIR-99 APR -28 -2003 MON 09:22 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 I 0 LORETTA..MOLINARI R.N., M.S,N_ Acting Public Health SDirector ' Director of Patient Services May 1, 2003 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 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Marmo 12 Rose Lane, (T) Patterson Lot # 5, TM# 36.57 -1 -4 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. There are no outstanding comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, ROBERT..J- 13ONDI _. ..a 'County Executive .. Gene D. Reed GDR:cj Environmental Health Engineering Aide I BRUCE R. , FOLEY Public Health Director DEPARTMENT 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 November 6, 2002 Harry Nichols, P.E. Patterson Park Suite 106 Brewster, NY 10509 RE: Maino 12 Rose Lane, Lot #5 (T)Patterson, TM# 36.57 -1 -4 Reservoir Basin Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on October 11, 2002 is complete. The Department .wilLnotify ;you by November.22,. 200,2 of its determination..: ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a prof ect, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of d Letter to:.Harry Nichols, P.E. - .November 6, 2002 -2- Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. V ry y yo / �&* TA rU/I� Robert Morris, PE RM :m Senior Public Health Engineer BIRUCE R. FOLEY �- - -- Public Health LORETTA, .MOLINARI R.N., _ M,5 N,_!, -• Associate MPublic Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road - Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 TO: DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM All PROJECT: If 1A TO ,.:. C SF PV DATE SUB'D..APPROVAI;: NOTICE OF COMPLETE APPLICATION DATE: f 5 �— Ov 1. State �� zip Q X01 Telephone: l �-1 4 oo`� P -J .. _. . State I� Zip Telephone: Form- LA -97 . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL, P"CHDPeririit #�. :u Well Location: Street Address: Town/Village Tax Grid # 1�_ ky6 LA CE P MJ_E 0 9 Map/?(• TI Block I Lot(s) Well Owner: Name: Kft Address: BO6, 500 LAMS 8 b-8— iv) 10001 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 ra -r gpm # People Served i- (o 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 _ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision j 1 "5 PELF-- W pD0 5 Lot No. 15 Water Well Contractor: P Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: -m Town/Village -- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separates et/plan. Date: 19 0 .- . Applicant Signature:., _. . L/ PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED.FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration . of the approved plan requires a new permit. Well to be constructed by a water+ y e driller certified by Putnam County. 1 Date of Issue 0 Permit Issui cial: Date of Expiration I 6 Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 - ••PUTNAIVI COUNTY DEPARTMENT OF:HE'ALTH r r DIVISION .OF- ENVIRONMENTAL HEALTH SERVICES r F = k • DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM �•:. Owner iOJ% kA 4L 0 .K -Q.�fl Address 2a :�t. ®sSne -c I I ri . l ... • .. .... Located at (Street)- i�L �o i_ Tax Ma 51 Block (_ 'Lot ' "4 (indicate nearest cross street) M, Watershed 'a SOIL PERCOLATION TEST DATA Pre Date of - , s oaking `o --6:z- 0 z Date of Percolation Test to 61rv� a, :.:....... Depth to Water Water From Ground Level Tercolatiou , i Ela se Time Surface (Incbes) Drop:Iu Rate Hole No. Rum No.:.. Start'. Si`op Min.). Start, Stop IncP}ies jVhoJlncb a :. .3 4 f... :. 2..16- 3'. to 22— 2S 3 . 5 4 2. , 4 s 4 a 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 1 min for 1 -30 min/inch, :g,2 min for 31 -60 miii/inch) A11 data tso be subrn "fitted 'for-- r-evie-w...... . 2. Depth measurements to be made from top-of hole. Form: DD -97 1 1 . -:: - . - - - -' TEST PIT DATA DESCRIPTION OF :SOILS ENCOUNTERED IN TEST HOLES' 1' � � �� a z MPTH HOLE _ a y a v.. _ NO 7'0 *.- t -HOLE -NO. °TP 2'. G1! HOLE NO n 1 it ' SUP st�4 31 7.I�y , �© Lo oJ%i0:1;�i Zv/a�c ,[ p- ,.�LI.i6 P, •'f 'il y'Iri{jy 7 : r 2� f 2.5' MoS' W n 1 3 0' 4.0' J. . ... , ter... 1 r"GI� r(S .. A• , �g� 1 rs� o. g �s .0.5f.' y. 1 -7# / 1 ° r tu�•t13L r I' �! 7 Q' —7 1' 4.V. _:,..• :. _.._ t Lysu nn � iw N +r pa:,,¢�a,.,�71` 7.5 I• r �q 8 of!! dui -- OT C�/��y a ykf'F �ly 8.5 1 �A% S +bffi ��'�, x•1_76 .. a i n�• r IJ' I. t t I 11: i Indicate level at whiz ch groundwater is encountered 0 � Ih { at Indicate level at which mottling is observed Indicate level to which w ` ater level rises after being encountered . : nJ Y, } rk Deep hole observations made by: RA- Date fc Profe � • ssional Name• (.�,,p.� � t � ' ` ' rp Address: P� r -EWE_- ^ p t _. i Nlcy 5 Signature: LU wx +,? Design Professionaps Seal No. 5o "124�� 'J�!j Harty W. Nichols jr., P.E. Patterson Park, Suite 106 2050 Route 22 Biewster, NY 10509 Telephone (845) 279 -1003 Fax (845)'2794567 October 8, 2002. Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Jasper Woods - Lot # 5 Rose Lane Patterson T.M. # 36.57 -1-4 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS-5, "Proposed SSTS," dated 10/8/02. 2. Short EAF. 3. "Application for Approval of Plans for a Wastewater Disposal System," dated 10/8/02. 4. "Construction Permit for Sewage Disposal System," dated 10/8/02. �.... _._ ..... r -5. -- - "Application to Construct a Water Well; "-dated-10 /8/02: 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 $300.007 If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN:JM :jmm 02 -082.00 14.16.4 (9/95) —Text 12 PROJECT I.D. NUMBER - 617.20 " 'SEQR` Appendix C State Environmental - Quality,Revlow. SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) Date: Signature: - If the action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding•with this assessment OVER -- 1. APPLICANT /SPONSOR 2 2. PROJECT NAME — 3. PROJECT LOCATION: _ - D prMh Municipality fir i 4. PRECISE LOCATION (Street address and roaa Inteorsectlons, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: pirwew ❑ Expansion .❑ Modlflcatlon/alteratlon 6. DESCRIBE PROJECT BRIEFLY: li�l�►�if�J�t•. �� 7. AMOUNT OF LAND AFFECTED:: Initially d 8. Wl.L j PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? Z�yes.. _.... ❑ Ko.. It No, describe briefly 9. WHAT. IS PRESENT LAND USE IN VICINITY OF PROJECT? 4FIesidentlal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Y Yes o If yes, list agency(s) and permit/approvals 11. DOES ANY AqPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes 49,No `If yes, list agency name and permit/approval • 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes o ` „ I CERTIFY THAT THE INFORMATION PROVIDED L LABOVE I I Appilcant/sponsor name: � If the action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding•with this assessment OVER -- .. PUTNAM COUNTY DEPARTMENT OF HEAL -TH -- " DIVISION: OF ENVIRONMENTAL HEALTH,.SERVIC-ES`_"',. ` `:.:' _..: . APPLICA'TIO FOR APPROVAL F P FOR, A WASTEWATER TREATMENT SYSTEM;; 1. Name and address of applicant: 1,:4U 1 fjj 2. Name of project:�r�? i �7 -- 4. Design Professional:�;1'�'� W, Ntv?L� j1L 6. Drainage. Basin:�S 1µG 7. Type of Project:: 3. Location T/V:. f-1 5. Address: - R51-- Private/Residential Food Service Commercial___ Apartments.. Institutional Mobile Home Park Office Building Realty Subdivision _... Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQk)? ET e Status check one Type I­! xempt :. =' Type II : Unlisted i X 9. Is a Draft Environmental Impact Statement (DEIS), required? ......................,...... _ 1.0.. Has DEIS been com leted and found acceptable by Lead Agency? N • . 11.- Name of Lead Agency - 12. Is_ this. project -in an area under the control ,of.local planning, zoning,. or other _ .. _ .... officials; ordinances? .................................. -13. If so, have plans been submitted to such authorities? . .'.........:.. ... 14; Has preliminary approval -been- granted by such authorities? I'`i� Date' granted: 15. Type of Sewage Treatment System Discharge ................. surface water _groundwater 16.. If surface water discharge, what is the stream class designation? :.. ............. ,: ..:.. 17. Waters index number (surface) ................ \ N:Q 18: s project ocated near a public water supply system? ....... .............................,, ND A-9. If yes, name.d'water supply: Distance;to water:su 1 AJA PP-Y "' -20: Is project -site neat a public sewage collection or treatment system? 21. -Name of sewage system Distance to 'sewage system 22. Date test holes observed i 4 0) 23. - Name of Health Inspector 666E Q-GL"D 24. Project design flow (g allons per day) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?:.. N� 26. Has SPDES Application been submitted to local DEC office? NA ................. Fonn K -97 NOTE: all applications for.review.and,approval of a new SSTS to be located within the NYC, Watershed shall "ba sent "to'the`Department, and `need not be °serit-in d Up ri daTF to -the D2P, d11liough the project may require -1) 1)EP-- approval of the SSTS prior to final approval by the Department. Projects within the..watersnd =y also require PEP review and approval of other aspects of a project, such as storm water plans..or tkcre9'n of impervious surfaces, and the.project applicant should obtain the appropriate forms for such aQviggrzm 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 app'Ratig iTst be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with teis, p ion may be grounds for the rejection of any submission. 1 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 hereijr are punishable as a Class A misdemeanor pursuant to Sect' n 210.45 of the Penal w. SIGNATURES & OFFICIAL TITLES: Mailina Address 10 So 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number .......................................................... ............................... _ _.�:9: 'Is Wetlands Permit required? ....... .::....:.....:.. ::..:...... -, a �..: ... : ::.::::....................... Has application been made to Town or Local DEC office? ................................ N A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... f 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, 00 landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ..............•..•............. Yes/N6- ­DESCRIBE: _ 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within _.. 15 years in or adjacent to project site? ...........................•.... ..........................•.... W 35. Are any sewage treatment areas in excess of 15% slopes tip 1.6. Tax Map.ID Number ........ ........... Mai)� Block Lot 37. Approved.plans are to be returned to ..... Applicant Design Professional NOTE: all applications for.review.and,approval of a new SSTS to be located within the NYC, Watershed shall "ba sent "to'the`Department, and `need not be °serit-in d Up ri daTF to -the D2P, d11liough the project may require -1) 1)EP-- approval of the SSTS prior to final approval by the Department. Projects within the..watersnd =y also require PEP review and approval of other aspects of a project, such as storm water plans..or tkcre9'n of impervious surfaces, and the.project applicant should obtain the appropriate forms for such aQviggrzm 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 app'Ratig iTst be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with teis, p ion may be grounds for the rejection of any submission. 1 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 hereijr are punishable as a Class A misdemeanor pursuant to Sect' n 210.45 of the Penal w. SIGNATURES & OFFICIAL TITLES: Mailina Address 10 So PUTNAM COUNTY DEPARTMENT* OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES X77� = DESIGN DATA SHEET -- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner /SAP? /lap Address. -Rc7:5 6 4 64, 2. � " ;z fl" located at (Street) Tax Map 3 ",5 loc.k Lot (indicate nearest cross street) Municipality Pe � - 27�j Watershed j6�S-7- 237XAlelgf SOIL PERCOLATION TEST DATA Date of Pre-soaking /a Date of Percolation Test ............ . lro;i7 U Pk ...... ... 3,7 2 -zl 6,7 3 2:x.0 - I- _31 I 4 3;10 5 C9_ -0 3 my --A; g-7 /5- 4 5 2 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, 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 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH ' ..... , , .� ff0t1 NO. G.L. 0.5' . 1.0' G 2.0' 2.5' 3.0' 3 a'! . 3.5' 4.0' 4.5' - 5.0' 'pre S 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' 2 a. "HOLE NO.' Indicate level at which groundwater is encountered v o,y45 Indicate level at which mottling is observed 1. Indicate level to which water level rises after being encountered - Deep hole observations made by: �?, J2 `�, G, f- (, �, Date Design Professional Name: Address: Signature: Design Professional's Seal /aaS F IM _ z _ a KriOWIeCtge;1`eCelpt;;gl ; thl5 Tep01v - J1LiNAl'UKL; If ►2/:96.- _ Title; .. a KriOWIeCtge;1`eCelpt;;gl ; thl5 Tep01v - J1LiNAl'UKL; If ►2/:96.- _ Title; PUTNAM COUNTY DEPARTMENT OF HEALTH OF .ENVIRONMENTAL HEALTH SERVICES... _ r INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project 0(V) &7222 ?!�� County Site Location J2c���/ ��� ! 7 / �� Building construction begun Extent Is property within NYC Watershed? ................. lzryes F-] No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. Hilly. 0 Rolling 0 Steep slope dGentle slope F__] Flat 2. Evidence of wetlands Low area subject to flooding F__] Bodies of water Drainage ditches F-1 Rock outcrops 6ovllev s 3. Property lines or corners evident .................... .............................. E�Y-es 4. Do water courses exist on or adjoin the roe Yes 5. Will these affect the design of the sewage system facilities?............ F__] Yes 6. Do watershed regulations apply in this development ? ....................... Yes 7 Will extensive grading be necessary? ................. ............................... Yes 0 - -8 - Will extensive fill be-necessary for SSTS? _ ... "- — ' Yes 9. Do filled areas exist within the SSTS area? ........ ............................... a Yes If yes, what is the condition of the fill? E] No 0 No EFfNo 0 No fNo No SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: 1 Sandy F__� Gravel E�L o Clay O Hardpan D Mixture 11. Observed from: a Borings Bank cut am Backhoe excavations 12. Soil borings /excavations observed by %��Ea � H, "�, on le i� o 13. Depth to groundwater y olvC -- - - - _ - - on 14. Depth to mottling �— g '' �32 ") on 15. Are test holes representative of primary & reserve areas .......................... ........... 16. Soil percolation tests made by / Gri' /Uo�/�C�t S r , on 17. Soil percolation tests witnessed by T> G �F on SECTION D (on back) l�l r•7 Form ST -1 2 ' _ ...- s;.>-; w. a -:`.w;c....%•c- xaM...:.-r..vs- r;isa:;,�� <..al. ._w... yi-- ,._::,_�...+r.. ,.. >w.._ -. ..rea: _ TIOMD ..:DRAINAGE�.�o:r,.k..._,.~..._ 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes �No 19. Will groundwater or surface drainage require special consideration? .,Vk- d/t!a9 ... �Yes a No . 20. Will gullies, ditches, etc., be filled and watercourses be relocated ?..... .. ................... F7 Yes E 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? ................................ ............................... Yes rNo Inspection data 22. Do adjacent wells and/or sewage systems exist ?. Ali. -ifi.....r...+'. :............ Yes 0 No .. 23. Additional comments 1.0 2.0 24. Site observer /inspector and title, 25. Date(s) of observation(s)inspection(s) TEST PIT PROFILES Hole # Lot # Hole # 'Lot # Hole # Lot # Depth to water Depth to water Depth to water De th t p o mottling .. Depth to mottling ptt. _:mattliag: Depth to rock/imp, Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. a 0.5 .0.5 0.5 1.0 1.0 1.0 2.0 2.0 2.0 3.0, 3.0 3.0 4.0 4.0 4.0 5.0 5.0 . 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 M 10.0 9.0 10.0 M 10.0 NV` Q o. c cz of n m cp - 111 co fn N - Q O S Ln r 6 o d z o, � I I I l� / 9 4 I r / o; • \ Q / IL Ic 1,121 s -- + ! i I J 1 D n AUG-16 -2002 12:17, PM HARRY W NICHOLS BRUCE R. 'FOLEY P.br;r Mrolth..Q/rector ATTI NTIO,X; 914 279 4567 P.01 LORETTA MOLINAW R.N., M.S.N. Assoalaif Public Health Director DbvotAr Of .POtlfTtf $trviCPJ DEPARTNENT ­OF HEALTH _ .._,.. 1 Genova Road _ — Brewster, New York 10509 RF 1 .ST FQR .FIR n JESTIN ' . o ADAM{ STIEBELING ;ENE REED .- )lihformailon itlow mast be fuU't=ompleted prior to any scheduling. DATE: EiNGINEER OR FIRM: }� '�~W ' i"�� L�-i0 PHOINE #: REASON, D�EEnPS:. )�J PERCS: *. PUNIP TEST: o ROAD /STREET; �"'� ' 'LAHF TOWN! ' + EP-6DH TASK W#; iff-'S -' SUBDIVISION: JWIM- %JAppS LOT #: WVAR- baCDZE CRIJEBTA `FOR JQINT RE,VIEVY An VATVw S(F SQjL TESTINC. Froposed SSTS•within, the.drainage basin of dYe$t Branch or Boyds Corner Yieservoirs: - Proposed SSTS within Soo feet ore reservoir, reservoir stem or control lake. O Proposed SSTS within 200 feet of A watercourse or a DEC wetland 0 Proposed SSTS design flog greater than 1000 gallons/dayor SPDES Permit required. Proposed SSTS.W a Commerical Project. - It is the responsibility of the design professional to provide the above information prior to -s9.11 testing. This Department will determine the IYYCDEP project status (Joint or Delegated) based on the response. It you answeredym to any of the questions, NYCDEP must witness the soil testing. This Depariment will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. _.. ..If a project has beew-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. - �, / L1• y FOR t;OUS -fY USE ONLY � y /1,30 DATE: �!1 / sZ �.W�... TDIE: %�© � G+� (F-E XTEST) AUG-16 -2002 FRI 12:31 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 N 966000 MAW ULSTER ROAD - - — — — — � — — -- — — — — I 33r 16 1moo 100.00 m � 8 — — — — — — — - 1K/ IOa00 • O 1 101 -'1,.ir ;: .i,:.e 8- _ _ 9"._" —$ Zr: - - _ .__�;� - -. = ---• �. <- ra. -.' ..T I I 1 exi moo 8-- -- - - -$ I rnl 1 - - - - - -- 'trig in 11r 1Ba06 IlI1"V °� IM39 8- - - - - -- - - — — — — — . r.It ow 21 I P.tV 3oRO M 3a 19 _ _ _ — r&V �ut iff 1 6m a l c Ig I 113 1 I$ I I I I D a I °aoo x01 AV ( I I I I I I I 3ao1 1 110a3s1 1 I I I I 1 97.09 I I WESLEY 16►o uaoo ROAD 1 I ) I ) I MOO I 1 16a99 I i 1 20 ► I i Q I► I I 1' I I I I eaao , 1911 ) 8 I I I I I I I I I 1 I I I ( I 1 1 I S 1 I 1 0l 1 171 I I I I '► 1 1 I I 1 r I I � I I I ar9 1 j/a I rii 11M0o1 nr I rir I AS j/6 1 1 ria r I I I I I I I I I I I l5roo rir IOO.00rir 13TG tr/ I � I ) .av 1 I I I I I F- 17A50 Xj 160 Aw art I m I .rrB .vs 14CL 1 U r 15269 U-1 LL- a ry ° 2 0 ck: LL- Q W 400 111.00 NANCY LANE 146.16 1q.10 1% rr 43 i l � � - N ten' S 197.20 moo T p Lu - - - - -- - -'- -s. �__... -- - - -- -- - - - - -- h P o/ CV., -.- _ L R:: 35.00' L= 220 0 j� O6'► R 05E I- A N 5 DIMENSION CHAR.T. (in' feet) Number ze 5z 31 40 3 37 46 4 44 S3 5 51 60 7 64 9 78 88 10 94 94 .91 101 0-7 is 1 3 82 78 14 81 74 77 68 16 74 63 17 58 19 67 so ^ ^ � 00 �