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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.57 -1 -5 BOX 18 ., I i 1 1'6 ' #� ' 1 F . IMN11 4immi 02101 PUTNAI%4 CnI TNTV DEP A R TMRNT OF RVALTII DIVISION.OF— ENVIROlo1MI$NTAL EAL,TH. SE1tV CES CERTIFICATE OF CONSTRUCTION COMPL.IA AGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P_ Z�yO 1 Located at Town or Village P�ROI -t Owner /Applicant Name Eh ��1�� Tai Map's Block Lot Formerly Subdivision Name �hri QaQS . $ubd. Lot. # Mailing Address P LP�C N J Zip Date Construction Permit Issued by PCHD f i Separate Sewerage Systenn built by ��'� 5 4L �ihT��S Address -A 'FA�po Poe wm w" Ni oSo'6 Consisting of l o Gallon Septic Tank and.64° Other Requirements: Water Supply: Public Supply From Address Private Supply.Drilled by ���� tJEt� (.01f-o�' Address ioSH 52, CIP- fR'A�� -Building-Type Has erosion control'been 6omvleted ?- of Bedrooms 4- Has garbage grinder been installed? Mo .-Pcertify that the system(s), as listed, serving the above premises were opgstructed 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 regulatio of the Putnam Couigy Department of Health. Date: 4 4 1 0 �" Certified by J4 P.E. X R.A. Address USo K 24- �R W6TV - License # Any person occupying premises served by the above systems) 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 ppbl }c water supply becomes available. Such approvals are subject to modification or change when,. in the judgment of the Public Health Director, such revocatio odificati n or change is necessary. By:. AVI/ Title: �Y" Date: 6_1a0162_- 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 Weli Locatioliir-' : Street Address: - Towa- Village: . -' � Tax Grid'# Mapo, 7Block / Lot(s) Well Owner: Name: Address: el Use of Well: 1- primary 2- secondary Residential Plublic gupply Ai cond/he t pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion 11>1/— Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter in. Weight per foot lb /ft. Materials: Steel Plastic Other Joints: _ Welded Threaded Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes _Z No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Z Compressed Air Hours , � Yield gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in-feet Well Log If more detailed information descriptions or sieve analyses' are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface ' 2 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type S v Capacity _9_j2 Depth 30© Model 7 h if to -112 Voltage 2,16 HP 1 Tank Type foy.3 .Z Volume _2jO6:41 , Date Well Completed Putnam County Certification No. 7;77 _4�99 Well Drillerxsignature) 1 NOTE: Exact location of well with distances to at least permanent andmarks to be provid n a separate t/plan. Well Driller's N 10, Address: Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 r 6 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 - .. :8rewAer;- NY�49509 -•- zz Telephone (845) 2794003 Fax (845) 2794567 April 30, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance - Thompson Jasperwoods, Lot # 6 10 Rose Lane Patterson, New York Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -6, "As Built SSTS," dated 4/30/02. 2.. "Certificate of Construction Compliance for Sewage Treatment System," dated 4/30/02. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 4/30/02. 4. Laboratory-Reports;-dated 4 /18/02. 5. "Well Completion Report," dated 3/27/02. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. "E -911 Address Verification Form," dated 1/3/02. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols r., P.E. HWN:JM :jmm 01 -024.00a Z0 :� Hd 9- AvuZp. 9 214 A N3 YML ENVIRONMENTAL SERVICES 321 Kear Street _ Yorktown Heiohts, N.Y. 10598 -,^ ' � ---'- ' ' (914) 245-2800 Albert H. Padovani, Director LAB #: 93.200983 CLIENT #: 55390 NON STAT PROC PAGE 1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ THOMPSON, NANCY 2 GRIFFON PL RYE, NY 10580 DATE/TIME TAKENs 04/11/02 11:30A DATE/TIME REC'D: 04/11/02 12:15P REPORT DATE: 04/18/02 PHONE: (914)-588-3499 SAMPLING SITE: 10 ROSE LANE,BREWSTER,NY SAMPLE TYPE..: POTABLE : KIT TAP PRESERVATIVES: NONE CQL'D BY: NANCY THQMPSON TEMPERATURE..: < 4C NOTES...: COLlFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE ` PUTNAM CNTY PROFILE 04/11/02 MF T. COLIFORM ABSENT /100 ML ABSENT 04/11/02 LEAD (IMS) 1.3 ppb 0-15 ppb 04/11/02 NITRATE NITROG 1.03 MG/L O - 10 04/11/02 NITRITE NITROG <0.01 Mdn. N/A 04/11/02 IRON (Fe) 0.303 MB /L 0-0.3 mg/l 04/11/02 MANGANESE (Mn) <0.010 MG, /L 0-0.3 mg/l 04/11/02 SODIUM (Na) 11.4 MG/L N/A 04/11/02 pH 7.3 UNITS 6.5-8.5 04/11/02 HARDNESS,TOTAL 140 MG/L N/A 04/11/02 ALKALINITY (AS 108 MG/L N/A 04/11/02' TURBIDITY A7UB. <1 WTI.) 0�5 NTU�`� ` - COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATE AS NOT) OF A SATISF CTORY SANITARY QUALITY ACCORD! NF��� �THE NEW YORK STATE AND EPh FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg/L, else water treatment must be undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a�odium restricted diet,the water should contain no more than 20 mg/L ofGodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. METHOD 1008 91O1 9139 9146 2037 PO37 9043 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 Albert H. Padovani, Director LAB K 93.200983 CLIENT #: 55390 NON STAT PROC PAGE 2 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ THOMPSON, NANCY 2 GRIFFON PL RYE, NY 10580 DATE/TIME TAKEN: 04/11/02 11:30A DATE/TIME REC'D: 04/11/02 12:15P REPORT DATE: 04118102 PHONE: (914)-588-3499 SAMPLING SITE; 10 ROSE LANE,BREWSTER,NY SAMPLE TYPE..: POTABLE : KIT TAp PRESERVATIVES; NONE COL'D BY: NANCY THOMPSON TEMPERATURE..: < 4C NOTES...: COLlFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL -- RANGE METHOD 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. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF M8/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MOIL VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MOIL MG/L = MILLIGRAM PER LITER -----~--�-W-ZQ`4JATERm-14{+`300MOIL ° C:) was o �~ mcz =' ~ CA2 Ch .' its SUBMITTED BY: Albert H qA6z7,,, Director - ELAP# 10223 . YML ENVIRONMENTAL SERVICES ' 321 Kear Street ' Yorktoly Hei ' Albert H. Padovani, Director LAB #: 93.201107 CLIENT % 55390 NON STAT PROC PAGE 2 GRIFFON PL DATE/TIME REC'D: 04/23/02 L0:45 RYE, NY 10580 REFoRT DATE: 04/30/02 PHONE: (914)-588-3499 SAMPLING SITE: 10 ROSE LANE, 8REWSTER, NY SAMPLE TYPE..: POTABLE : KITCHEN TAP PRESERVATIVES: NONE COL'D BY: NANCY THOMPSON -'- TEMPERATURE..: NOTES...: COLlFDRM METH: N/A DATE FLAB PROCEDURE RESULT NORMAL - RANGE METHOD COMMENTS: Fe/Mn if both iron and manganese are preseht, their total value combined shall not exceed 0.5 mg/L. SUBMITTED BY: Albert H. Padovani,'M.T.(ASCP) �^ AnM Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -... C GRANTEE ®F SUBgUR- FACE`SEWAGE' 'TREATMENT "SYSTEM JPOE5 � H�oc� Owner or Purchaser of Building Building Constructed by �0 P-C) cd� VAH� Location - Street P_54;�DE��AC,;� Tax Map Block PAITU -6 off TownNillage JAW- W ooh Subdivision Name Building Type Subdivision Lot # 5 Lot I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. jj Dated: Month Days Year Signature: s/ %Ian General Contractor (Owner) - Signature Corporation Name (if corporation) Address: I- 4 (��H Q� �E State �'� Zip (a Q Title: 1� `f Corporation Name (if corporation) IF hc r l �. �_ em- :�; :4ve s.._ Form GS -97 AUTHORMED TOWN OMCLAL: (Signature) DATE: The .Putnam 604,n,ty. - Department of Health will 130t. issue Cekiiiicate of Construction Compliance unless the above form is compl@.tedA.e.j-a.leg;l E91-1 addfdss is assigned -by an authorized town official. This form-Is-to-be-submitted with the application fora Certificate ofConstruction Compliance. (E91 I VERRLK PUTNADI COUNrTY DEPARTib-IENT OF HEALTI-I o DIVISION OF ENVIRONMENTAL HEALTH SERVICES . FINAL SITE INSPECTION Date:�2S o Inspect Town F,OZ�7�017.,o,ci Permit # TM # G, 5 7— — S Subdivision Lot # 1. Sewage Svstein Area a. STS area located as per approved plans ........................... b. Fill section = date of placement 3:1 barrier Lgth. Width Av D th c. Natural soil not stripped ... ...........................g... p............. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Selvage System a. Septic tan.• size - 1,000 ......:.1,25 .........other ................ b. Septic tank installed level .......................... :..................... c. 40' minimum from foundation .......................................... d. Distribution Box . All out ets at same elevation -water tested ................. 2. Protected below frost ............... ........................... ..... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ....... ............................... f. renc s 770 1. Length required_ 7 Length installed 2. Distance to watercourse measured {— ObFt.......... 3 _Installe3 aecordmg xt lap .............. _ 4. Slope of trench acceptable 1 /16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100% ...:............. ... . ... 8. Size of gravel 314 -1 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum .........:..:...::. 10. Pipe ends capped . ...... : .......................... . ..... ... ... ......... g. hump or Dosed Systems 1. Size o 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.estunated flow /cycle.......,... III. House/Buildin a. tiouse located per approved plans ....................._,,.. a:—Well located as per approved plans ..:: b. Distance from STS area measured fi 1 ©4' 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 --Mr a n-drat on utf l t cted 8c diito exist watercour �. Footing drains discharge away from.STS area...: .... i. Erosion control provided ................. ............ .................... r5-.. un-7 NO COMMENTS ASSmrir n 4 011 �® APR -19 -2092 01 :45 PM HARRY W NICHOLS 914 279 4567 P.01 dT . � r r +•+... ay.�::.'N:.:YUrrn i�..�.e rw.l+ +Y.v+ 4..Y..f. - PUTNA1Vi COUNTY DWARrT=M OF MQTB ntvOOK 0V ZNMOM"nA1.8 L<fL MCZ$ 4rmNnON ® ADAM GENE , • • ttfahT T1�CT TmR F(P%�,�T1�iCp17C'i'(�N For: , Fill Ail latotm don must be WI- computod prior to nay 7tsachos iaspecdoas bolas =do. PCHA Consuuc ou Permit # OwaerlApplioaat Name: /ee�el_u` Formerly, ubdivisba No=.• S ubdivislom Lot # I.4.axitcm 511 completed? Date. If syiem com,�lote? ....�._��...... yeL— Dater •„ , �--� Is eysteoi tonstNfota4,aa yor plans? � Is win drillvd? Date• ,�G ...`...._�.,■ ... It wcA located u par plans? ,......,_.�.. r- Aso orosion control aaeas" is place? Or I ca* tbat d:A ayuom(:j as &4 at the above premises ban been► coasttueted and I bave Wpocted Lod ycrificd theif ;omplWon In accosdim with the issued PCHD Coastrttctiaa Permit and - appr4YSd plaas,aud the Smaduds, mules and Regulations of the•Putnam County Depa Ucat of Darts. ,OZ�• -- CarsiSe6 by; PE rPLA • • D I'tofeasional ` _ 1 o i Fora SIR -99 APR -19 -2002 FRI 00:57 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT nF P , BRUCE_ R... FOLEY _. _ ... .�...- ,..._ „• ���_ Public �Health�.Director �. � _ , � . , � ��~ .... � _..� -. -✓ April 26, 2002 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Thompson Rose Lane, (T) Patterson Lot # 6; TM# 36.57 -1 -5 Dear Mr. Nichols: The following comments must be corrected in the field. 1. The curtain drain outlet was not found upon inspection. 2.. A bedroom count needs to be performed by this Department (house was locked). 3. Silt fence is not installed below the well area. All silt_ fence must be properly installed prior to the -start `of any construction: If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide . .: . :.:BRUCE ...R.:;.FQLEY._'..,a.. ,a.-, , *,;r- Public Health Director April 26, 2002 , a. LORE'ITA MOLIN��: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)Z78-6678 Fax(845)278-6085 Early Intervention .(845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Thompson Rose Lane, (T) Patterson Lot # 6, TM# 36.57 -1 -5 Dear Mr. Nichols The following items are in violation of Article III, Section 2C of the Putnam County Sanitary Code: Silt fence is not installed below the well area. A formal notice of hearing may be issued if the violation is not corrected within 5 days. It is truly hoped that the above violations are corrected without having to take legal action. Very truly yours, Gene D. Reed Environmental Health Engineering Aide GDR:cj 41 SENDING CONFIRMATION vi- DATE : APR -29 -2002 MON 01:06 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 2/2 START TIME : APR -29 01:04 ELAPSED TIME : 011 1211 MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a BRUCE R. POi.$Y i09MA MCILWA81 R.N., M.5.N. NMI Xmas DWMabr An ..ft PxW Xmas Dj aw Ah'aw I PaNw S—A- DEPARTMENf OF HEALTH 1 Geneva Road 8lumht, New Yak 10509 aeM +eeml Brld (pJ)27�•613a F.(M5)27[.7971 Nmhe /7sr.ka (166)2n -65st w1c (as)27t -6671 Fa(915)278-o0ts es "mwnee. CM271 -6014 vap43127t -660 r—h.w P+slm.s912 n-WP221.4112 April 26, 2002 Harty Nichols, PB PeHetaon Psrlt, Suite 106 2050 Routo 22 - - Brewster, New Yodc10509 Re; Field hlspection - Thompson Ruse Lore, (T) Patterson Lot p 6, TAM 36.57 -1 -5 Dear Mr. Nichols The following items are in violation of Atticlo 11; Section 2C of the Putnam County Sanitary Code: Silt fenoo is not installed below the well area A formal notice of hearing may be issued if tho violation is not corrected within 5 days. It is truly hoped that the above violations am conected without having to take legal action. Very truly yours, Gees D. Rood Environmental Health Engineering Aide GDR:ej Igo Mill!, it -, ., '� 7 "./z� 9c q �/f k 7 � 't �'4 q @ � 'l,� �. ` � f � � � S 4,,,y � ° � '-� • M1. � +a. ;r �til 14 ` °I Isl b PELT # f - ,QL L - O I Located at Fd5Ai:;' L,4..1-40� Town or Village Subdivision name J.4 "VM �V"0'5 Subd. Lot # Date Subdivision Approved 1 / 12 IA8 Tax Map x,57 Block I Lot Renewal Revision Owner /Applicant Name JAlt'16 5 4 NANCJ 7"14JAW104 Date of Previous Approval Mailing Address iL� ,, M • i Zip I Q'90 Amount of Fee Enclosed �%OD Building Type ;2615 1,CIC NC.E Lot Area °�`�� No. of Bedrooms 4 Design Flow GPD 6' Fill Section Only Depth Volume PCH D NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 17-50 gallon septic tank and Other Requirements: C,() j?-rX1 N pal f� To be constructed by 7 -'6,D. Address Water Supply: Public Supply From Address or:- Y- Private Supply Drilled by .:_ ._._ ®r, - = - Address Y 15 I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will. place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address 7e 5L-- /07— ZZ- Aj Y P.E. X R.A. Date 6 1510 I License # -34'a, 41 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w n nsidered necessary by the Public Health Director.' Any revision or`alteration of the approved plan requires a new pe I oved discharge of domestic sanitary sewa ly. By: Title: Date: f White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _,. , _,....•.....t .. .. •- please print or type- Well .r -• ..... .... PCHD "Perinit # - - -- � Well Location: Street Address: Town/Village Tax Grid # yg k56 LAcME5 PNTTEP-SOH Map Al Block 1 Lot(s) 5 Well Owner: Name: Address: 4tIVR.0y/tikom0 16 N 6 el�N rwc He � Nf Y i0 Vo Use of Well: X Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought e?t- gpm # People Served _4-6 Est. of Daily Usage O 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 A Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision JA6 POD W0095 Lot No. 4; Water Well Contractor: TT P 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 sep ate sheet/plan. Date: 6 Applicant Signature._.. -1 ... . 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 e 1 driller celtified by Putnam County. Date of Issue to /24 Permit Issuing cial: Date of Expiration b Title: Permit is Non- Transfe rabl White copy - HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: age._...._. _ Town/Vi11 �_ . ._. ... . Tax. Grid;# = - Map %, %Block Lot(s) Well Owner: Name: Address: Use of Well:. 1- primary 2- secondary Residential ublic ripply Ai cond/he t 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 ft. Length below grade ft. Diameter in. Weight per foot lb /ft.. Materials: Steel Plastic Other Joints: _Welded Threaded _ Other Seal: X Cement grout — Bentonite _ Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First r, Yes No Hours Second Well Yield Test _ ,Bailed _ Pumped Compressed Air Hours I Yield gpm Depth Data Measure from land surface- static (specify R) During yield test(ft) Depth of completed well in -feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing `Well. ' Diameter(in) Formation Description ft. ft. 'Land Surface / 4 1`- If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information I Pump Type Capacity Depth Model Voltage HP Tank Type Volume Date Well Completed Putnam County Certification No..: Date of Report Well Driller.(signature) NOTE: Exact location ofwell with" distan at least az}ent andmarks to be provid n a separate shot/plan. Al Olkl Well Driller's N Address: Signature: Date: White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 a 7 of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Ot & 7�7Owner Address Located at (Street) _Tax Map 36.57 Block, Lot- (indicate nearest cross street) Municipality Watershed j514sj]3Te4A1c,14 SOIL PERCOLATION TEST DATA Date of Pre-soaking '5430101 Date of Percolation Test 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, -.q 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from tot) of hole. Form DD-97 ..... . . ... �7. ....... ...... 3 2- ..... .. ... 3 2_ 0 4 5 2 01 3 3 -30 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, -.q 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from tot) of hole. Form DD-97 2_ 3 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, -.q 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from tot) of hole. Form DD-97 TEST PIT DATA P 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST DOLES N.O.. _,.,..�. �...- `.... _. :y _ ,.. ;.� L ,� . - .. .= HOLE NU. DEPTH - . � -HOLE _ .., _ HO ,.�:.NO.,_ �, G.L. _ Ile Indicate level at which oundwater is encountered - -- - - ' - Indicate level at which mottling is observed..,.,.. avzf Indicate level to which water level rises after -being encountered Deep hole observations made by: C, ?'fin �, 1-f , Date S 3 o/ Design Professional Name: Address: Signature: Design Professional's Seal e PUTNAM COUNTY DEPARTMENT OF HEALTH -DT SIONr - EN'VPR -ONMENTA:L HEALTH'SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION - Name of Project County To TW,#,lv7 Site Location ,ROS LXni, Building construction begun 0 Extent Is proVerty within NYC Watershed ? ................... ffYes 0 No SECTION .13. TOPOGRAPHY (Please check all app ropri fe boxes) I. Hilly _ Rolling __ _ . Steep slope_ _ - Gentle slope.— _- Flat 2. a Evidence of wetlands 0 Low area subject to flooding D Bodies of water aDrainage'ditches Rock outcropssv�Lac e ��u1de r s 3. Property lines or comers evident ....................... ............................... - - - -- - 4 —Do water courses exist on or adjoin the property? ............................ 5. Will these affect the design of the sewage system facilities ?............ b.--Do watershed regulations apply in this 7 —Will extensive grading be necessary?:::::....:.::: ::.. ............................... 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? Yes Q Yes a Y Yes :Yes cap.__. 0 Yes Yes f. EjNo No N No SECTION C. SOIL OBSE ATIONS _... - - - -- . -.____A( -_-- Appearance of soil: Sand Gravel a Loam Clay Q Hardpan D Mixture - 11. Observed from: 0 Borings 0 Barik cut ffBackhoe excavations .12. Soil borings /excavations observed by tom; R6Er,> P G, D, H, on 13. Depth to groundwater � —0 `' on . ...... -- 14. Depth to mottling A/oive FotiaiD on 15. Are test holes representative of primary & reserve areas ...... ............................. ... 16. Soil percolation tests made by W., f�, A) > c h69L 5 � F—. on 17. Soil percolation tests witnessed by 6. Jgg gn . 1i,- G, J>, H, - on SECTION D (on back) a Form ST -1 L l 2 SECTIONS D DRAINAGEY - u* 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? YPA ENo 19: Will groundwater or surface drainage require special consideration? ...................... - � Yes F� N 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... ❑ Yes No SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ..................... ............................... Inspection data ...... F-1 Yes EZ /No - ❑22. Do adjacent wells and/or sewage systems exist ?::.- ................................................ . Yes No 23. Additional comments1;rcSPosF__P .ar6E7LLS 51 - 24. Site observer/inspector and title 6E,vo n - 25. Dates) of observation(s)inspection(s) -5- TEST PIT PROFILES - - Hole # Lot # :._ -.Hole # - -- -Lot # .... _.. -- -=Hole # - -- - .... -. °Lot # -- Depth to water. Depth to water - Depth to water - - - -- -- - Depth to mottling.......... ._ . - -_ -- - -Depth to mottling = Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. 0.5 - - -- 0.5 0.5 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 3. "4ti .,; - 8RUCE R. FOLEY. �P +a�lts_:Pleolti�:::�Dtreetar�= • = -. �- - - -.�° ,. � --.. o l - 0.24, a.o 10R MA AJdociate pwk Health Director Dwelor of .AallmNt &Fvked DEPARlMNT OF MALTH 1 Oeneva Road Bfov Mr, . Now York 10509 REQUEST F0 MELD nSlING ATTENTION: ® ADAM STMBELING )((;EC REED Ail information below must befutcompleted prior to any scheduling. DATE: ENGINEER OR FIMI: J-1c, r• PHONE #: REASON: DEEPS: )(- PERCS: K PIMP TEST: o ROAJj�STREET: TOWN: �w��rst1� TAX N: 34,T7 — i— 5" SUBDIVISION: ,�Q v M unha LOTM OWNER: CL_� -�•• YES NO o CK o ;1. o � Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake.. Proposed SSTS within 200 feet of a watercourse or a DEC wetland. Proposed SSTS design fior SrWer them 1000 gallons/day or SPDES PeitWt required. Proposed SSTS fora 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 ya to any of the questions,. NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOIL 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 C MY USE ONLY DATE: _ J 3O �% -3c" 3�y 'drlm Z3 l lzq o �;QJf�iF1'YS; (FMLDTEST) - - _ JASPER _... - ....._ ._ ...__._ _. '_ _....._._ _ ..._. - ..._. coast o •- � A • a - Vies !FIELD CO. A r \ K36 a \ K36 2eL23 100.00 anon yZ 6LZ6 23095 e — — — — — — — — — — - — — — 201.06 g �- .A. — - — — — — — — — — — — • •LM x lob .. • iO Iea00 — — — — — — — — . y„. P 8 P — — — — — -- • � ee.�- :..:.x- .:w:,..�>.. -s •_.. -,., v..,�.•.w.,.. �.t. wee... �.... Y....n.+..- _�r.�„I..n >.�,ae.v. ..u..s•..w., ., Le.:�.:.. -.m_ �. i u��._':R.•..!!t�sr.. -.r _ 26e1 -- _:. 2oz6 _ _ LAFAYETTI k' X615 116 a OOWI _. NEW FAIRFIELD,CT a. Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 2794567 June 5, 2001 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Jasper Woods - Lot # 6 Rose Lane Patterson T.M. #36.57 -1 -5 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -6, "Proposed SSTS," dated 6/5/01. 2. Short EAR 3. "Application for Approval of Plans for a Wastewater Disposal System," dated 6/5/01. 4., "Construction Permit for Sewage. Disposal System" ._dated_6 /5 /01; - - -- - 5 "Application to-Construcf a 'dater Well," dated 6%5/01. 6. "Design Data Sheet." 7. "Letter of Authorization." 8. Two (2) copies of residence floor Plan(s), for bedroom count only. 9. Review Fee in the amount of $300.00. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. chols Jr., P.E. HWN:JM :jmm 01- 024.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION.,ORENVIRONMENTAL HEALTH • SERVICES _. - -___._ A'P�,ICA.TXON. FOR APPROVAL_OF.PLANS_EOR__ - -.__.- _. A WASTEWATER. TREATMENT SYSTEM 1. Name and address of applicant: JAMS% 4 tJ 4NLV. , THdm p ioN 2. Name of project: L0— 3. Location TV: 10A 4. Design Professional: MIP-Pi kc-(4t -, X K-5. Address: _&I 5e tZ T— 2 � 6. Drainage Basin: 7. Type of Project;.. X 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 (SEQR)? TypeStatus (check one).. ...................... ......................:.......: : Type J Exempt ,:.... Type II Unlisted X 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 1v6 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency tj;4 f. 12. Is... s.projects i an area under the control of local planning, zoning, or other offidials,°ornmances? ............. ...................................................... ....... .....:...................... .. 13. If so, have, plans. been submitted to such authorities? ......................................... No 14. Has prelimina 7:!pR royal been.granted> y such authorities ?. Nd Date granted:. N)k 15. Type of Sewage Treatment System Discharge........'....,-...-.'.* surface water groundwater 16. If surface water discharge, what is.the:stream.class designation? .:.:...:...........: N�4 17. Waters index number (surface) tdA- .......................................................................... 18. Is project located near a public water supply system? .................................... 19. If yes, name of water supply ' 'N4- Distance to. water supply PA 0 20. Is project site near a public sewage. collection or treatment system? ................ N 21. Name of sewage system Distance to sewage system 22. Date test holes observed 5 M 23. Name of Health Inspector GE,4 F-E69 24. Project design flow'(gallons per day) ................................. ............................... 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... . ! 26. Has SPDES Application been submitted to local DEC off ice? .:....................... Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? 00 28. Wetlands ID Number ...... :................................ ........;.,,..,......: ...,...............,.........._ 29. Is Wetlands Permit required? ....................................... ............................... .......... IUD Has application been made to Town or Local DEC office? .....6 .............. 30. 31. Does project require a DEC Stream Disturbance Permit? .. ............................... Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No Nf0 t�0 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No (40 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? ................................ ............................... rJo 35. Are any sewage treatment areas in excess of 15% slope? .............................. 36. Tax Map ID Number .......................... ............................... Map3L'ql Block i Lot 5 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE : -,A ]applications for review-and'approval of a new S`STS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities -from DEP and submit those forms to DEP for review -and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A ,misdemeanor pursuant to Seclio 210.45 o th e Penal W. SIGNATURES & OFFICIAL TITLES:. Mailing Address: ................................... 4 ., 14.18.4 095)—TOM 12 PROJECT I.D. NUMBER . 81130 "SEAR Appendix C S ._ .�.=- ..�:�,:. - - .-n-•- • - -• �.:. - 1st® Ertr�irrentdei�tei Guajiility Rev6ew•� SHORT ENVIRONMENTAL ASSESSMENT FORM For ., .... Fo UNLISTED ACTIONS Only . PART 1— PROJECT INFORMATION (To be completed by Applicant or Project `sponsor) 1. APPLICANT /SPONSOR JAM t NMNC;rl rlt H 2. PROJECT NAME c.oj 3. PROJECT LOCATION: pp Munklpalty`':: , PA •T'N County 4. PRECISE LOCATION (Street addrs" and road Interactions, prominent landmarks. etc., or provide map) 518 PROPOSED ACT10t8.:; ; New ❑ lbomalon 0 ModltloatlWatlaratlon 8': DESCRIBE PROJECT BRIEFLY. INVNIOLIAl. T. AMOUNT OF LAND AFF O Cj I d • 91 1 Initially • sores Ultimately aana 8. WI _ PROPOSED ACTION COMPLY WITH EXISTING ZONING OR •OTHER EXISTING LAND USE RESTRICTIONS? Yea ❑ No It No. describe !aridly ~ 9. WrreHi�1AIT Is PRESENT LAND USE IN VICINITY OF PROJECT? . la�Reaidsntlal - `❑ Industrial O Commercial ❑ Agriculture ❑ ParWFomIlOpen epees ❑ Other Describe: + . w 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)?,��yy I& No No If Yee, 141 agp!acY( +)_and pormillapprovale .... ... _ _ 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes . ( No : If res„ Ile; a9wocy Ranee and parmltlapprovd 12. AS A RESULT OF PROPOSED ACTION WILT. EXISTING PERMITIAPPROVAL RS WRE MODIFICATION? ❑ Yee 19 No ; 1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE I$ TRUE TO THE BEST OF MY KN0W =E' :' H,4 _Oates 6141-0 1 Applicant/sponsor names Signature If the action is•In the..Coastal Area, and you area state agency, complete the . Coastaf Assessment Form before proceeding with this assessment OVER 1 PART I1— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 8 NYCRR, PART 817.4 ?' If yes, coordinals',the review process and use the FULL EAF. ❑ Yes ❑ No 'e� vviCl ACTION`RECEIVE COOROINATF.O REVIEW'AS�PROVIDEO FOR UNUSTE6 AGfilal�SlA-�'NYCRR; PArtT 61t':0? ' 'If�No: a negative declarailon " may be superseded by anothor Involvoll agency a ❑ Yes No C. COULO ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Cl. Existing air Quality, surfaco or groundwetar quality or quantity, noise levels, existing traffic patterns, solid wsete; product(on or disposal, . potential for erosion,.dralnage or ems? Explain briefly. C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood. character?;Explaln briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change In use or intensity of use of land or other natural resources? Explain briefly C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly. 06. Long term, short term, Cumulative, or. other effects not Identified In C1-05? Explain briefly. - C7. Other Impacts (Including changes In use of either quantity or type iof onargy)? Explain briefly...; D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABUSHME14T OF A CEA? ❑ Yes ❑ NO `-IS"TFiERE; 'OR IS`TGIEAEUREL 76OI:. CONTROVERSY RE(.ATtc TC POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ' ❑ Yes ❑ No If Yes, explain briefly rAK I 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 shouid,be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occOrring; (c) duration; (d) irreverslblllty;'(s) geographic scope; and (f) magnitude. If necessary, add attachinents or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part I) was checked yes, the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if 'you have Ideatlfled 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. O Check this'box If you ",have determined, based on the. Information .and: analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: - faw of LeR Agency Print or Type Narng oflesponsible Of ficerja a . ncy Title of esporu Officer Signature of espon e K e y x• turo.e„ ;reperer eront rem response e officer) Date 2. PUTNAM , OUNTY DEPARTMENT. OF HEALTH DMSION OF ENVIRONMENTAL HEALTH SER'VTCES DESIGN DATA SHEET - SUBSURFACE. SEWAGE TREATMENT SYSTEM Owner J I`l h}1C.� �li� s�P l-i Address U O pLP& I* W IK&D Located at (Street). kG5 fJ WIR — Tax M.ap Block Lot (indicate nearest cross - street) Municipality Watershed. SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 5 °r ..., .:;.' a Hole NorR. .•,,, j.,•.0 i'i,' � �` � >7�1..•3:..r,• A: ?Or .:�<� •., •g f0 ; Yx' 4' `�h `G �f.�iay',' ft: • �... : �,,�; <,.� i °<��• &'I ps�e:'�'itp »r:'� (iu:)':'�' . t�,•'` . •� ' �, lkI�e �tb {qL .�fet•.' y:, from �ta 'n,UCfAees 4i�T T'�o. :zStarf :; Sto' -+ •'V�.{►,t�r;{:�`� :;. 1�XCl � SL .t.i1 , < p'e3,: :C2 ��' ,;<. <�, ercalat3GA .RSte., >'Miu1lRCt� � � 1 to °� : lfl�'s• ?�o. 21 _ ���h j fi�� {� 3 i 4 .. 2 { 0 �.� 11 �� {� dry 21- I IN 3 � � " 11 1 �� Mm 94 114 4 S 2 4 �'OTES� 1 5 T bo ests to 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 miMnch) All data to be submitted for review, 2. Depth measurements to be made from top of hole. y TEST PIT DATA ` DESCRIPTION OF�SOI�- ENC ®. INTERED IN�TEST HOLES H ALE _ NO _ 0.5' 1.5' - - 2. 0' 3.0' 3.5 Y . 4.5' 5.0' 5.5' . 5' 6.0' 6.5' 7.0' 7. 5' 8.0' 8.5' 9.0'. 10.0' indicate: level at which groundwater is encountered Indicate level at which mottling is observed. Indicate level to .which water level rises after being encountered Deep hole observations made by: 10+4 w' WLA-i%,�+ 4- PE Date 6jS( t)i Design Professional Name: IAP-1zY Wd W,fk", d(L, Address: , 9-K1 Signature: Design Professional's Seal NICH cc W No. 56124' oA9OFESSia� ..' PUTNAM COUNTY DEPARTMENT OF HEALTH DI :' BSI- Q1�t= �JF�:E iR.ONVMENTAI�_HEALTH, SER'q LETTER OF AUTHORIZATION RE: Property of TJ'�N1f55 . NA�e,( T1- k0Mp�oH Located at k6Eu LAPF- T/V PAST 'R- N Tax Map # S(v Block 1 Lot Subdivision of Subdivision Lot # Filed Map # !y�G Date Filed Gentlemen: This letter is to authorize . RAW V, k\ C4A %A J F ' M a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatinent and/or water supply permit(s) to serve the above = noted" roperty in accordance with the standards, rules or regWadons as promulgated by the Public Kealth Director of the Putnam County Health Department, and to sign all necessary papers Ion my behalf in connection with this . mancr -wid to v- supervise-the construction of said- wastewater1retrnent and/or -water suPP Y - � � l ' s stems -in ° Y conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam Cowity-4Wtuy Code. Countersigned: P. E., R. A., # J Mailing Address -� r � State h50 YOtt' -- zip � o soOi . Very truly yours, Signed: (Owner of Property) Mailing Address: 2.. (aP4Ff©M PLALF, State NEW t 0I - Zip Telephone: (&6) Telephone: PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT.SYSTENIS REVIEW SHEET. FOR-CON STRUCTION':PERi41IT NAIAE OF OWNER: STREET LOCATION: / REVIEWED BY: RM, GR, AS, SRDATE: TAX bLaP -: (CONFIRMED) 17 N DOCUNTENTS Y \ (REQUIRED DETAILS ON PLANS CON'T'D) PERi`IIT APPLICATION (� HOUSE SEWER -' %" FT. 4 "0'; TYPE PIPE CAST IRON )1VELL PERMIT OR P1VS LETTER ( . 0 BENDS; MAX BENDS 450 11' /CLEANOUT 77�PC - CHANGE) 97 RENEWALS LETTER OF AUTHORIZATION SITE NOTE (NO CHA ( lk )DESIGN DATA SHEET (DDS) FILL SYSTEi`TS L__1(/ >`� CORPORATE RESOLUTION LIO'HORIZONTAL-, PAST TRENCH SLOPES 3:1 TO GRADE ( k )�" SHORT EAF U FILL SPECS/ FILL NOTES 1 -5 (_ __)UPLANS -THREE SETS FILL PROFILE & DIMENSIONS UUHOUSE PLANS -TWO SETS U FILL IN EXPANSION AREA C-) VARIANCE REQUEST FILL GREATER TH.A V 2 FEET SUBDIVISION CLAY BARRIER LEGAL SUBDIVISION (�} FILL CERTIFICATION NOTE SUBDIVISION APPROVAL CHECKED U DEPTH GAUGES �PERC RATE ��� j�� VOL. ON PLAN FOR RO.B., UN (CLASSIFIED & IMPERVIOUS FILL REQUIRED DEPTH U SEPARATION DISTANCE FRO�1 TOE OF SLOPE (-_)( JCURTAIN DRAIN REQUIRED TRENCH GENERAL (� F TRENCH PROVIDED LOFT MAX. LOCATED IN NYC WATERSHED PARALLEL TO CONTOURS (PLANS SUBMITTED TO DEP ' 100% EXPANSION PROVIDED DELEGATED TO PCHD DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL ( DEP APPROVAL, IF REQ'D )(� )GEOTEXTILE COVER DEEP TEST HOLES OBSERVED %— SEPARATION DISTANCES ON PLAN - FROM SSTS PERCS TO BE WITNESSED U( 10 TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL EX- APPROVAL SSDS ADJ, LOTS L20' TO FOUNDATION WALLS WETLANDS (TOWN/DEC PERMIT REQ'D ?) (� 100' TO WELL, 200' IN DLOD,150' TO PITS DATA ON DDS PLANS & PERiV1TT SAME 100' TO STREAM, WATERCOURSE, LAKE (inc. espaa) PRE 1969 NEIGHBOR NOTIFICATION U 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER LETTER BI/ZBA (10'•T0. �YATE WE (pits : 20') v BO YR.`FLOOD ELEVATION W/I "1001"` " °"� "`� "" ° DRAINAGE COURSE (� SOIL TESTING LOTS >10 YEARS OLD (_)0200'/500' RESERVOIR, ETC_ 150' GALLEY SYSTEMS Z(e REQUIRED DETAILS ON PLANS U(%10' MIN TO LEDGE OUTCROP SELVAGE SYSTEM PLAN - (NORTH ARROW) (� SEPTIC TANK SSDS HYDRAULIC PROFILE U 10' FROM FOUNDATION; 50' TO WELL GRAVITY FLOW WELL CONSTRUCTION NOTES 1 -15 - - - � DI}IENSIO; iS TO PROPERTY LINES - DESIGN DATA: PERC & DEEP RESULTS LOCATION OF SERVICE CONNECTION (_j 2' CONTOURS EXISTING & PROPOSED �I N 15' TO PROPERTY LINE DRIVEWAY & SLOPES, CUT ' SLOPE FOOTING /GUTTER/CURTAIN DRAINS SLOPE IN SSTS AREA (5206/6) U USDA SOIL TYPE BOUNDARIES REGRADED TO 15 %, IF REQUIRED TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# DOSE/PUIy1P SYSTEMS U DATE OF DRAWING/REVISION PUMP NOTES (DATUM REFERENCE DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED U LOCATION OF WATERCOURSES, PONDS U DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) LAKES,WETLANDS WITHIN 200' OF P.L. H PIT AND D -BOX SHOWN &DETAILED ( PROPOSED FINISH FLOOR AND 1 DAY STORAGE ABOVE ALARM CURTAIN DRAB BASEMENT ELEVATIONS STANDPIPES 5' BOTH SIDES DETAIL WELLS & SSDS'S WMI 200' OF SSTS 15' MhN to CDS = >5 %, 20'-4%,25'-3%,35'-1%, 100 % -<I% PROPERTY METES & BOUNDS I�C� 20 ' MIN to CD DISCHARGE /100' with 182 cons day discharge U(-_)EROSION CONTROL FOR HOUSE, WELL & 10' bIL�1 to NON PERFORATED PIPE SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)n /01/40 l0 �� w h 1 o� ... •..r:. _+ .-a- �..,a...v_ n •.. +r�-.R ,- �e C....a +- .v..C.. w.ru. _ -..rn- wt^_. —at.t .. .v. � ....rs`t w c. ,c-e,rbe. ..v--. �'-.f- .�-r�+FV � .JCC' s.r, y...va�...... m. nw.T aays> +.awr. ,. _.. v .v» nr . y1 � 1 RESIDENCE \ N t3 d � GAL. a a° 1) oko tv O 4t 23,10 5 i Roy z LANE