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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -1 -33.1 BOX 23 NJ 11 IN or ,. rm 'IN : � IN i T ^� IN 6 IN 02767 1 ti PUTNAM COUNTY DEPARTMENT OF HEALTH ! .:`� _ . _ .. ��E T�..- ��'��'!.? �:.�.,' . �'��,,T� ��r��]�_� ?1p� 'fir�.�.�*►T.'Z^�� AA �� _ i� '1"r'�_ �"- �?S�-'�-. �`;"y.ry.. _ ., ......,. _ ..... . ..�... i i .i ivl � "�1 �L` l` '1-��1'�-ii`,'lJ'1`'11��1J1 \'�1 t�� ����A� 1 i��- ►:�L�� �i���� CERTIFICATE OF CONSTRUCTION COMPLIANCE F REATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 599 - Located at c')60"e- w—eV 10 1,-eV %1e-, %? d Town or Village Owner /Applicant Name o7ef ,fig 7 G.& ,� Tax Map 14 Z Block i Lot 53.1 Formerly, Subdivision Name %A.^ z2gl- re,l. y Subd. Lot # r // Mailing Address y h? Zip 10s'7 • Date Construction Permit Issued by PCHD Separate Sewerage System built by el' Address Consisting of / ��� Gallon Septic Tank and �� ') , 'r tie Other Requirements: 2e:- o1/5'.7 f ICA-w Water Supply: Public Supply From. Address or: ✓ Private Supply Drilled by Pr ,-rn d--77 447 elal.:% er7Address 4;.c0 � %� J✓ Building Type d e4'9 GC Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed? Al"42 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 ths.,issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Department of Health. Date: /d Certified by ol 41 Address 2V;77- I���'i'✓ u rn _ � P.E. i"' R.A. License # Z y S'%4� Any pers /hoccupying premises served by the above sys promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modific ti on or ch ge is necessary. By: �- Title: ave- Date: 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 Well Location Street Address: `AO �,�- T alp: '-)Map Tax Grid # 6?. Block Q Lot(s) �, 0 Well Owner: me: Address: 5? ��, �D. Use of Wel ➢:Resi I- primary 2- secondary ential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling ]Equipment � Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _Z Open hole in bedrock Other Casing Details Total length -" 1 ft. Length below grade /9 T►_ft. Diameter in. Weight per foot /lo lb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded _Threaded _ Other Seal: ,�j Cement grout _ Bentonite Other Drive shoe: /-Yes _ No Lin er _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield 7—r gpm Depth Data Measure from land surface - static (specify ft) O , During yield test(ft) Depth of completed well in feet P- -�4-0 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 C/ U v If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type &a 9 Eli Capacity Sy &- Depth Z' Model aAe,+�,aLi Voltage 1,7-0 HP -� 4 Tank Type 1J9L,�-,AoL Volume to Date Nyell Completed � 10 Putnam County Certification No. q Date of R ort /0 Well Driller (signature) NF'1* N;: Yxact location of well wttn atstances to at least two perm tanagaarxs to De provtaea on a separate sneevpian. Well Driller's Name`G�Le� -r- rim Address:/S Signature: Date: 0 IN g White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 OG4-26 -99 03:03P PMAM COUNTY DEPARTMENT OF HEALTH RM WELL COMPLETION REPORT P.Ol Well Location Street AddrM. Resiregial T Tax Grid d • Map Block Lobs) Address: We110waar. IIsa of Well: I- prinaery 2 -secondary Buainou ..___ Industrial Mile Supply Air cendAts pump tr6gatio6' w Fame Tesdmoniterieg Other(specify) Institutional Standby Dr IM itgalpment ' Rotary Cable pereltitsion Compressed ck pacmioa _ Odra (qpeeitj ) Weil Type Screened end culn Open hole in bodmek , Outer CaAM Ustsils Total length Long* below grade Diameter Weight per foot i & 19 6 " in. d tIft s. Steel Plastic Other cam Welded �Thra ded Other rnol;MW Cemtat gout _ 8entonite Other Drive ": „L Yes _No Litter. Yes No. Set"* DeatBa Diameter (in) Slot Sits hength(ft) Depth to Streets (R Dewkped? First Yq No Kowa Second Well Yhld Tat Balled Pumped Compressed Aw wom2tl Yield DevwD ata a yield MM Depth o eemp Well in raft Well LQg if more detailed info:madon escriptions or Sim . analyses an. avedabk, pitm attach. Depth From Surface Water 1krAft Well MOCOW 0) Formation Deacri tioa it. ft, Laud Swam 6 yield was tested at ditlerem depths during drilling, list: Feet Gallons uto Pum Tack Infomudon Pump Typo apaci O MsarS th cZ Model Voltap O X HP Tank Type W4i� X�kDWOlume 10 3QR e a I0 9 7 7 9 e s nyrE: enact [action of well with dutanees to It tetras two 707 M y�Qstdh 3 t Well Driller's Name Address; • sigttaoies: Des. � ��� 9 White copy: HI) Fite; Yellow copy - Building Inspector, Pink copy . Owner; Omnge dopy • Well drWer Fume WC-97 �l 1Z6.B.ZH61 nt1 G 'vi_ ._._..— H:11d3fl ;tai 11 NMI KI PUTNAM COUNTY DEPARTMENT OF HEALTH GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM[ ;; C�e /_;;;I 2-2- 33.1 Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Town/Village Location - Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam 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 ..oncr0e. properly .is..caused_by, the .willful or negligent act-of tbP occupant.ofthe- building - utilizing the..:. . system: - -... _. d - 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. Dated: Month Jam' Day Year S General Contractor (Owner) - Signature Corporation Name (if corporation) Address: State Zip Corporation Name (if corporation) Address: State Zip J� °� '�7 Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES +�•.. —_, ....' 1^ -s ;: G ..lr n�-�.. �>.av e..v - -..-a \'i i�:TfL':'Y-1 �"L -�1.• q I'� T YYiL' l i i"1vf�'Fi ry�':Y1si'• RE: ' Property of " Located at�Ci,� �� U ��� o u T/V Aa�� �• �� �� Tax Map # 4 Block Lot3.1'f Subdivision of e- -'e-'Aa e,r-n en Subdivision Lot # Filed Map # Date Filed Gentlemen: `This.letter is to.authorize a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, .anad the Putnam_. County. S_anitary Code. Verb. truly yours, Countersigned: 2y/ �, % y� Signed: (Own r of Pro ) Mailing Address State "Telephone- Mai State Zip 10,13 Telephone: P e Form LA -97 .. ^^ `Y YML ENVIRONMENTAL SERVICES 1now LIVE �'���������' - Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 32.906349 CLIENT #: 11264 NON STAT PROC PAGE 1 JACOBS, JOHN DATE/TIME TAKEN: 10/04/99 10:30 574 OSCAWANNA LAKE RD ' DATE/TIME REC'D: 10/04/99 11:05 PUTNAM VALLEY, NY 10579 REPORT DATE: 10/09/99 PHONE: (914)-528-3438 SAMPLING SITE: SAME : COL'D BY: SAME NOTES..": KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 10/0409 MF T. COLIFORM absent /100 ML ABSENT 1008 10/04/99 LEAD (IMS) 1.0 ppb 0-15 ppb 9101 10/04/99 NITRATE NITROG <0.2 MG/L O - 10 9139 10/04/99 NITRITE NITROG <0.01 MG/L N/A 9146 10/04/99 IRON (Fe) <0.060 MG/L 0-0.3 mg/l 2037 10/04/99 MANGANESE (Mn) <0.010 MG/L 0-0.3 mg/l 2037 10/04/99 SODIUM (Na) 6.29 MG/L N/A 10/04/99 pH 7.2 UNITS 6.5-8.5 9043 10/04/99 HARDNESS,TOTAL 84.0 MG/L N/A I3/04��q' 10/04/99 TURBIDITY (TUR COMMENTS: BACT THESE RESULTS INDICATE THAT THE WATER AS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN E NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. } Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive Fe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted 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. ^^ ^^ � v� � . YML ENVIRONMENTAL SERVICES (914) 245-2800 | A%bert H. Padovani, Director LAB #: 32.906349 CLIENT #: 11264 NON STAT PROC PAGE 2 JACOBS, JOHN DATE/TIME TAKEN: 10/04/99 10:30 574 OSCAWANNA LAKE RD DATE/TIME REC'D: 10/04/99 11:05 PUTNAM VALLEY, NY 10579 REPORT DATE: 10/09/99 PHONE: (914)-528-3438 ' SAMPLING SITE: SAME : COL'D BY: SAME NOTES...: KIT TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE.": < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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 MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. -c` .-.` x 7`,_-0, :R~_,`P�~R. ~,,YE _� | HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) � SUBMITTED BY: �T�e r+ -P �.—Fayco v a n i T.( Directov- ELAP# 10323 ]PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMP.LET-ION R1ElP ®I-T: . Well ]Location Street Address: T 03,vm /V-ffl ag : Tax Grid # Map Block Lot(s) Well Owner: me: Address: >1lse of Well: 1- primary 2- secondary _Resi ential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment' >< Rotary Cable percussion, Compressed air percussion Other (specify) Well Type Screened Open end casing -2,!� Open hole in bedrock Other Casing Details Total length 2 1 ft. Length below grade /9 Tuft. Diameter G " in. Weight per foot /lv lb /ft. Materials: X Steel Plastic _ Other Joints: _ Welded _Threaded _ Other Seal: L4-L Cement grout _ Bentonite Other Drive shoe: /-Yes No Liner _ Yes x� No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test Bailed Pumped Compressed Air Hours2. Yield ZSr gpm Depth Data Measure from land surface - static (specify ft) 02 O During yield test(ft) Depth of completed well in feet Well ]Log If more detailed information descriptions or are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface p If yield was tested at different depths during drilling, list: Feet Gallons P ute Pump /Storage Tank Information Pump Type Capacity Depth Model Voltage X HP Tank Type Volume Date jell Completed /0 y Putnam County Certification No. t of R ort Well Driller (signature) N ?"li'lE: ]Zxact location of well with distances to at least two permaneryY lan a ro se arat Well Driller's Name A -r Address: 36' Signature: Date: 0 " IN/ 9 White copy: HID File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Gl�r,� JOSEPH F. SULLIVAN, P.E. YORKTOWN HEIGHTS, N.Y. 10598 (91 4) 962-4248 1 U-) > ED C.--) ....... ... co 7. U-1 '15 � o� i �z .............. .. 2 -7t- (a 2� 3z31 s� C�az. 0 i ru I AADY1 COUNTY DEPARTN'IENT OF HEALTH DIVISION OF ENVIRONNNIENTAL HEALTH SERVICES FINAL SITE INSPECTION i Date: Inspected by:" Street Location 574 Owner. t r � - - Perini TIM r � � — i --?, 3 : I Subdivision Lot 1. Sewage SN•stem Area YES 0 I CO` fEi\'TS a. STS area located as per approved plans ........................... b. Fill section -.date of placement 3:1 barrier Loth. Width Avo.Dpth e. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/ wetlands ...... ............................... II. Senvage System a. optic tan. size - 1,000. ......1,25 other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Pistribigion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - roperly set .......................................... Le 91 required rev Length installed .,...... �. 2. Distance to watercourse measured Ft.......... 3. Installed according to plan ......................................... o, 4. Slope of trench acceptable 1/16 - 1/32 ", oot ............. 5. 10 ft. from property line - 20 ft: foun , tions.......... 6. Depth of trench <30 inches from a ................ 7. Room allowed for expans' , 0 .... ............... 8. Size of gravel 3/4 -1 %2" et cl ....... ............ 9. Depth of gravel in trenc 2' m 'mum ........... .... cZ _ 10. Pipe ends capped ... ............................... -a. P�iir�rror.Dosed S_stems o _ -1. Size of pump c�iam�er................................... .... ....... ......................�........ 2. Overflow tank . ............................... 3. Alarm, visual/audio ............... ......................... 4. Pump easily accessible, m ole grade....... ... 5. First box baffled ..:................... ..................... ............ \-L 6. Cycle v;itnessed by H.D.estimated flow /cycle.. ... III. HouseBuildinQ tl a -house owed per approved plans ............................: b /lumber of bedrooms ................. ............................... ... IV. Yell a Vell located as per approved plans . ............................... b. Distance from STS area measured ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall orkmanshin a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... : d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 1/97 l7 i ►F' L Z W, NFA # ►� -- UM-1 M C PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OIL ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # N l o 1 "% Located at�i 051"h lv,�r Town or Village Subdivision name,a�. G��►'!Subd. Lot # Tax Map " Block d Lot Date Subdivision Approved' ` `�`� Renewal Revision Owner /Applicant Name L)00 d-A "O'7 Mailing Address 41 C- k 1PPa -JA r-P Amount of Fee Enclosed Date of Previous Approval q i j Pi irk VA, Zip Building Type ry�'`�`d Lot Area ' 3 J'4 No. of Bedrooms 4 Design Flow GPD VAV ]Fill Section Only ]Depth Volume PCHID NOTIFICATION IS REQUIRED WHEN ]FILL IS COMPLETED Selparate Sewerage System to consist of roc Other Requirements: )- 11li-��— =�'� gallon septic tank and To be constructed by T-6.P; Address wateu' Su�m�ly: Public Supply From Address our: Private Supply Drilled by "��� Pr Address 05,00 yr- App 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: P.E. R.A. Address l l 4111-IN Imo- j3P-&W j%&K- NK I Oc/j License # Date D 110 I ,66124 APPROVEID 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 when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew a it. Ap roved for disch rge of domestic sanitary sewage only. By: Title: �. IybLoc �Yiz7-�t Date: 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 Well Location.: Street Address: Town/Village Tax Grid # 06<-AW#WA L AILS RU PCPW 4AWXy Map fo Block Lot(s) Well Owner: Name: Address: Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 6* gpm # People Served Est. of Daily Usage 800 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling k 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 _ t� Is well located in a realt subdivision? ...................................... ............................... Yes X No Name of subdivision a'} n,9 L"tQ- Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: ,. Proposed well location & sources of contamination to be provided on separate hee plan. Date..- m !%' 4 °L �� .Anrlicarit Signature: PERMIT TO CONSTRUCT A WATER WELL This permit. to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue S1 I Permit Is wing 0 ` cial: 14661 - ��A. — Date of Expiration o o • Title: s uw I c P. '4 5, , Permit is Non- Transfe ra White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PC -1 PUTNAM COUNTY DEPARTMENT OF HEALTH ;,� -.,i •.v. a•.. _ "o. :rte. .r. yam.. APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: --�a14 C (41 PPr -WAS l7 105-71 2. Name of Project: windwood M?;/ 3. LocationoV /C: n —, a �� 4. Project Engineer: ahv 5. Address: c�(�rovlce,e %J Y License Number: SCE (?�{ �� Phone: 6. T e of Project: Private /Residential Apartments Office Building Food Service Commercial Institutional Mobile Home Park .Realty Subdivision Other (specify) , 7. Is this project subject to State Environmental Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name of Lead Agency :..f _ 11. Is this project in an area under or other officials, ordinances? 12. If so, have plans been submitted 13. Has preliminary approval been gr+ AZ / X the control of . local • planning:. zoning:.• O to such authorities? .................. anted by such authorities? Date Granted:�/i 14. Type of Sewage Disposal System Discharge...... Surface Water round Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. o' 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... �v _ 20. Name of sewage system // Distance to sewage sys em 21. Date test holes observed: 22. Name of Health Inspector:./ 'e' 23. Project design flow (gallons per day) ....... ............................... 11/93 • 2. yGrhrn. < m!Y!�atior - 25. Has SPDES Application been submitted to local DEC Office? ............... .� 26. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... G 27. Wetland ID Number ........................................................ 28. Is Wetland Permit required? .............. ............................... � Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ................... O 30. 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 or NO A10 31. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO W o DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ........... E.5 33. Are community water, sewer facilities planned to be developed within 15 years? NO wugP_ (Q S,.�Sri �� FAS _i. ,:c?,X,�ac , ��f�i ti��c_ nr�o ..- . �,- .r•.w, dV _ . 35. Tax Map ID Number .......................... ............................... "1 -131 � 36. Approved Plans are to be returned to: ................ Applicant 41 Engineer If the application is signed by a person other than the applicant shown in Item 1, the application must be accompanied by a Letter of Authorization. Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this. form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of the Penal Law. . I _ A n i SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: i .... >... _ .�• _r• i .n � CN"'•Yr—v��..` � �-- s47.r^•. ��TtA.�,nr. T ..4 �r�^�!j?. ��., ....,......•._......: � '�Tvl •,. .�.. .., .... .� - - , - `•o:�•' >�..�,'�;; .� , _ �,, � T.�I?':.E ..ter a;� .., .Ei.�s. .�i` :. :..E:. � F:.:,s,.: -::� � / rr 0 wnerrn0 %LU ��tl��t L�PI— r ' Address . 3J //� ,� •� /*7 Ir / , '�' (� S > , Located at (Street) - j ,, z►- // / Sec. Block Lot (indicate nearest cross street) Municipality { V Watershed SOIL PERCOLATION TEST DATA RBXXTIFtED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking -f /8 c1 Date of Percolation Test `f- -%? HOLE NUMBER CL= TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 2:(0 2 2: Z- .-141 : 30 ZI& 2 .30 4 5. 2? 5/g P-Z ;3 C3 Z3� ; z ss 161 2� 4 5 it Z:6Y- Z: Z(, : N 71t z7 S/1 s 2 Z : 27 - 2 :. +7 POO PA 3 C 3 4 5 I NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates i are obtained at each percolation test hole. All data to* be submitted for review. 1 2. Depth measurements to be made from top of hole. rev. 9/85 TEST MC DATA REQUIF= TO L-E 1—�'7 IZ � DESCPJ-PTION DEPTH HOLE NO, I HOLE NO. L HOLE NO. G.L. t 21 30-nexq 31 41 OT Q ro-,v e,� 5' 1 61 ro C, 5I_o„ VA 81 91 10, 121 13' ca Of 01 INDICATE LEVEL AT WHICH GROUNDWATER IS E=NTERED INDICATE 1= TO WHICH WATER L= RIS A1=71 BEING. ENMUNTERED I/cf-to DEEP HOLE OBSERVATIONS MADE BY: 0,0,nk y- A4. l� &f<- DATE: 4-ZO 40 DESIGN Soil Rate Used Min/1" Drop: d.,?o S.D. usable Area Provided No. of Bedrocais Septic Tank Capacity /0-1:;,0 _ gals. Type 64'111C, Absorption Area Provided By $-00 L.P. x 24" width trench Other N r Name d5515c, C4Signatur Address v e-, SEAL (P 0. 0 THIS SPACE FOR USE BY HEALTH DEPARM14FM ONLY: Soil Rate Approved 5Q ft /C;R 1 FT.jn-1,MM MTN?TY T)F.PARTMF-NT OF HEALTH DIVISION OF ENVIMZfla1IAL HEAIfrH SERVICES DESIGN DATA SHEET-SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Located at (Street) Sec. Block Lot (indicate nearest cross street) Municipality \/&�U — Watershed SOIL PERCOLATION TEST DATA P3QU= TO BE SUBMITTED WITH APPLICATIONS Date of Pre-Soaking c14 Date of Percolation Test 4 HOLE NUMBER CI= TDIE PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time . Ground Surface In Inches Soil Rate Start-Stop Min. Start Stop Drop In Min/In Drop 21 Inches Inches Inches 1: 4-0 2Zt Z � A-- 2 4, 11 2 Z: I Z ,+I I 16 ' -L3 2'`t� 3 tl %- Z iS 4 5 z� Z 2� 5/� 3 �/� S C3 23 % T:SS l�0 21 4 5 N 2 7,: +7 J 3 9;• Z-t 3 4 5 N=S: 1. Tests to be repeatoSd A same depth until approximately equal soil rates are cbtaiig(g\4t!each-,-oeroolation test hole. All data to* be submitted for review. 2. Depth meas QQ from top of, hole. rev. 9/85 TEST PIT DATA RE)QU= TO BE SUEMITII;D WITH APPLICATION DESCRIP`T'ION OF SOILS ENCOUN`irERID IN TEST Fnr VC DEPICH HOLE 'NO i HGLE ;v0:- G.L. 02 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' r'oC (0-5 (-oil ^a 14.'. INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED y►.let- INDICATE LEVEL TO WHICH WATER LEVEL RIS AFTER BEING EV � ED DEEP HOLE OBSERVATIONS MADE BY: �%% . j( C' oc_�� gr- %/% • ke � DATE: 4 - Z O —9 O DESIGN Soil Rate Used /(-/S Min /1" Drop: j .(?p S.D. Usable Area Provided No. of Bedroans �' Septic Tank Capacity /250 gals. Type GonC Absorption Area Provided By $0 O L.F. x 24" width trench Other Name L G, e-eY G Signatur 64 Address % 3 JI� On V el, SEAL ar z g y _ } / ! / �o � � � �'o. 0451$1 ^ �0 THIS SPACE FOR USE BY HEALTH DEPARDTM ONLY: Soil Rate Approved sq.ft /gal. Checked by Date ` PUTNAI l COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'T_T:E':-",�rF•. mac. RE: Property of Located at �� �JS�.�W��lI`� L4L9 PAD T/V MNAM v�u�r' Tax Map # &t Block Lot Subdivision of IUI -10; -J V - DENt- "e tEI -', Subdivision Lot # Filed Map # � Date Filed Gentlemen: This letter is to authorize 4W 0' 'ilil- tOV-2, jg' a duly licensed Professional Engineer ' A or Registered Architect to apply for the required wastewater treatment and/or water supply permits) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with th ;,provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putna' i C� f Code. = � der ��� • � ', , Countersigned: k P.E.; R. A., 0.5 24 — 07q "SS i(0N�i'r. Mailing Address F State Zip Telephone: 1--Z-1- 4"P/Le 10,50 1 Very truly yours, Signed: (Own r of Prop ) Mailing Address: 49 GI4I PFWA P P07HAM VAt..1 —EY State NFnq ' -f04_ Telephone: Zip $4 11u - 114116 Form LA -91 . C':.' o PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date. Re: Property of 7c)IIN .7,4GD$S Located at 0$C/4WIfA14 44AKf R ,04D (T) PIi%/114141 %/¢Section 2 Block Lot Subdivision of WIA110WOOD rRIf /l- Subdve Lot # Filed Map # Date Gentlemen: This letter is to authorize Rirr /vev�G r / l� a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said "syaLem or systems' iii conio"rmity with the provision's 'of Article 145 or 147., Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly yours, Signed 1 Countersigns P.E., R.A., # 5 Z� NI /d1 ,gR0 OK'E 0 �F /C,' C,�:NT/Z G Address .Z R 67W YT(i Al, / 1714 Z 7& Telephone er Jeff Prolerty 1 Addre's / 11' 'T mhy"- I Town lephone i I .✓ 1 ..,...._ ...,. _ �_ :.�;... .•. ,... ...._ .. _ .. , .[. Rci` �' SVi�1` f•° �tivillvTs�� .1- �,�;t�"3.�c1��I�t" "�`t�.s,.� ;_• .... M .. �.. :....._ �. .<._...�... _......., , ,<.:.... DXWiSZON OF FNVXRONMEr4j% -AJ.4 HE kLTH SERVICES ' Date= Re., Y?;ropet ty Qf �LZ4 v Lat r eL . L-1-- — - - -r Located at ! ...... �r...�-- +a.-- _... -ti ......�........ ' w�r,...�.���..,��.., -�-- - -n.�. =....ter... -....- - - .Subdv. iota..._._._ -- fixed Map #r; W. -.,, Date ..�.�_ I G+�ntXr�rnen s ' This letter, I6 to author izo it a duly engineer for registered razohitect Undicete j"�" `�" . to apply for a Construction Permit for a oiparate sewage • syst em j to Serve 'L'he' above noted property in acoordan a with the standards, rtxles or re, ilatfons as promulapted by the Commistioner o£ the Ilutnam Couxity Departanou't of Health, ar�ct to sign ali tieces eary Papei`s on my bahsilt �.a comsat tion� with this mattor `tend ��to �eupervide t*ti©, +construct I xi system or systems in conformity with the pjov;Lsiono ore Article s45 or r 147, Education Lt-two the 'public HeAlth x,avv land the P'utnem County Sani- tary Coda. Very trtizy y'otu.•s 441 4.4 Si ins d Owner property Tir a�.g ned: • ` . _,33 A� cit'e�srta own - �1 zs�� � ��`l• �'3�- 30�` •Telaphono 7Co.�.eptatarte , r / LAASSOCIATES, P C�,NG jj PILLSAC4K_ OPF;CE CENT ?5 \ R�uta 22 6 M Ittown RsaC j , \\ Brawsror,NowYark iCSC9 �. WNSUC'rIVC ST- � � • ��� 313Qii3 January 18, 1999 Mr. Adam Stiebeling Putnam County Health Department: 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS (RENEWAL) John Jacobs Oscawana Lake Road Town of Putnam Valley Dear Adam: Enclosed are the following: 1. Five (5) prints of SS -1, "Proposed SSDS," dated 1 -4 799. 2. "Construction Permit for Sewage Disposal System, dated 1- 15 -99. 3. "Letter of Authorization," dated 1- 15 -99. 4. Review Fee in the amount o1' $300.00 We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:his 90012 a j , A. -,- LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE _ a.... -_- "±.,- .. :.__...,tl...j.., �.,..... .... _r....�..:- r.�.t,..- .._...r� --- :..c ��i .�. Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FA)Q 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS September 26, 1995 Mr. Robert Morris Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS - Renewal Oscawana Lake Road Putnam Valley, N.Y. PV 12 -90 Dear Robert: Enclosed are the following: 1. Four (4) prints of Drawing SS -1 "Proposed SSDS - Lot V, revised 9- 25 -95. 2. "Application For Approval of Plans For a Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 9- 25 -95. 4. "Design Data Sheet ". r _ _ _ ..._ _.._... ....... _. l� -zte: 2f =15. 6. "Letter of Authorization ", dated 9- 25 -95. 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. �AaA,�t Harry W. Nichols, Jr., P.E. HWN:bd 90012 enc. cc. Mr. J. Jacobs w /enc. Public Health Director March 2, 1999 .-LORE.-'TAial i�Y��iYF�1lI Associate Public 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 Fax(914)278-6085 p Early Intervention (914)278-6014 Fax(914)278-6648 WIC (914)278-6678 Fax (914) 278-6085 Mr. Moore Laurent Engineering Millbrooke Office Centre Route 22 & Milltown Road Brewster, New York 10509 Re: Jacobs, TM# 62 -1 -33.1 Town of Putnam Valley Dear Mr. Moore: This office has received and reviewed the most recent set of plans for the above mentioned projec . We would like to offer the following comments for your consideration. Please submit Well Permit Application (WP -97). _ 2. Show layout of proposed expansion trenches in -- -�— � –.� to be*used -to maintaiii-maximum 15% slope~ +- - over area of SSTS. Provide dimensions of fill area on plan (length x width). This office will continue its review upon consideration of the above mentioned comments. Please feel free to contact us if any questions arise. Very truly yours, Adam B. Stiebeling Assistant Public Health Engineer ABS:cj LAU RENT ENGINEERING ASSOCIATES, P.C- Route 22 & Milltown Road j \ Brewster, New York 10509 HARRY W. NICHOLS JR., P.E. (914)27"108 - (FAX) 278-2658 CONSULTING SITE ENGINEERS March 4, 1999 Mr. Adam B. Stiebeling Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Proposed SSTS Jacobs, TM# 62-1-33.1 Dear Mr. Stiebeling: In resonse to your review letters dated March 2, 1999, we offer the following: WP-97 is enclosed.' Expansion trenches are now shown in tbr-profile. A note has been added to the profile stating that R.O.B. fill is used to maintain 15% slope. Fill dimensions are now provided. We trust the above adequately addresses your concerns and request the issuance Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. 1-917 Harry W. Nichols, Jr., P.E. HWN:JM:hs 90012 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER REVIEWED BY RAI, GR, AS, MB, BH DATE � � �% TAX NJAP # Y j OCUFENTS *PRESENTATIVE 2 PERMIT APP - - --- ION CONTROL: OUS ,W L, SSDS & DEEP HOLES LOCATED ERMIT WS LETTER OF PRIMARY & EXPANSION ETTER RIZATION TION MAP D IGN DATA SHEET (DDS) AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE RPORATE RESOLUTION IF PUMPED, PIT & D BOX SHOWN AILED SHORT EAF OUSE - NO.OF BEDROOMS PLANS - THREE SETS ELLS & SSDS'S WAN 200' OF PRO D SYS. UPUSE PLANS - TWO SETS P AePERTY METES & BOUNDS ARIANCE REQUEST 119USE SETBACK NECESSARY (TIGHT LOT) FEE OUSE SEWER -1/4" FT. 4 "0; TYPE PIPE SUBDIVISION 41NO BENDS; MAX.BENDS 45° W /CLEANOUT LEGAL SUBDIVISION FILL SYSTEMS SUBDIVISION APPR9yAL CHECKED CLAY BARRIER — L P C RATE �� 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE L REQUIRE DEPTH FILL SPECS FILL NOTES CJJRTAIN DRAIN REQUIRED (,�r,��e FILL CERTIFICATION NOT ANDPIPES GENERAL ICATED IN NYC WATERSHED ANS SUBMITTED TO DEP 'LEGATED TO PCHD :P APPROVAL, IF REQ'D 'EP TEST HOLES OBSERVED RCS TO BE WITNESSED. ;-APPROVAL SSDS ADJ. LOTS z,TLANDS (TOWN/DEC PERMIT REQ'D ?) ETA ON DDS PLANS & PERMIT SAME E.1969 NEIGHBOR NOTIFICATION FLOOD ELEVA' REQ'D PERMIT) EWAGE S TH ARROW) FILL IN EXPANSION AREA TRENCH F TRENCH PROVIDED (500 60 FT MAX. ARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS 0-1 TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL -- ! i'_ _%'v�rOi1I'�iif�Ti01°voJN�•.<L$ :" _ i:5. "�F „a.,L'- Gi1' -L..:. `...._ 0 ' TO WELL, 200' IN DLOD, 150' PITS 0 'TO STREAM WATERCOURSE LAKE (inc. expan) 0' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 0' TO WATER LINE (pits -20') 0' INTERMITTENT DRAINAGE COURSE 0'!500' RESERVOIR, ETC. _150' GALLEY SYSTEMS CONSTRUCTION NOTES DESIGN DATA: PERC & DEEP RESULTS I' CONTOURS EXISTING & PROPOSED [DRIVEWAY & SLOPES, CUT 'FOOTING /GUTTER/CURTAIN DRAINS 'SsOIL TYPE BOUNDARIES (� TITLE BLOCK; OWNERS NAME,ADDRESS �7 'CM #,PE/RA; NAME,ADDRESS,PHONE# %ATE OF DRAWING/REVISION DATUM REFERENCE jACATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED WSH FLOOR AND BASEMENT EL. 15'MIN to CDS= >5 %,10'- 4 0/o,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <I% WMIN to CD discharge /I00'with 182 cons day discharge SEPTIC TANK tV FROM FOUNDATION; 50' TO WELL / WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION 8 COMMENTS: r--C, rA_ (Al” i of C - �� pil,►�t�(' S r� S 0TV �� i� YI of hilr _ >a �� pil,►�t�(' S r� S a . r.. --e..� '':....�. ... >.::. t..�:r- .T- .r:.M•M'. �.� vIK'.:� r..aIIYAt<..`...r ..'.. R.. >^ .. •. r•... 7 ...: .� �:..-- w:.�.....- '...:� ♦:.�.� • r.. • .. ..r. �..... —.•rV .a h ♦Twb. .V.� f. •., �.:.. • s .... r •.... Bedroom 12'x 11'2" Bedroom 18'2" x 12'4" i Bedroom 12'x 11'6" Bedroom / 12'/0 V6 MEEEEI PUT NAMI•COI UiJTY DEPA T ENT CAF' MALTH pa-P;g A- DP- R -OVEP FOR BEDROOM COUNT ONLY; 50.0 EDROOMS . qs Wood Deck a 8' x.12.' _ ' .. i I Breakfast Area ' Living 12'4" x 11'4" Family Room Room 13'2" x 21'4" 13'x 23'4" Kitchen i 10'2" x 7'8" i • I DiningRoom 12'4" x 12' Foyer i • i L7- • � I 1. rv-r� � � I•m a w.� uF � +. ° � pt?9rt[av7 a1 s two-' 4I r}a � MVCi—= dMMb==u 2 M2 2M G.b • = PIT- f! Jzp= ° . * W M13 i : comma= a= m f 1•m saM U pt=ci • Potr.lxii' +,r t Tl,o1 . i`f?R MIGi U012 StS`+V t (r.IC- UHl',S rO M 1 S 1 9-fT-'M ! v LIi.�.. tiads�l . i•i•a \ .yu I '( J .1 Od r /, -,I I i 1 • i 11 ay ..n iiY.,K.k I ,,,n.,.,, ti • Mt.� Ae®ra.. ebippeva ; , J)atg Subdivision •• • -• Fee Enclo4ed[3 A'mnlint sLdfiaErkbu,y i r F" v - I . Am _ FE , nMzm tlr * IUoy t,h ,wini my R•iselsor d F33d� '� Dti:.ayim MW7, G Y II' �t�l Y KIrfU ��x,t1L- .r,w,n I• F..,;mili�,•.,1 Wlx.n F'll'.Il i.,•mmi�e...d Sbywr.,w k < �r� a ', >.� w :+aa�Lw ®( � I ,. �sq�x,6 ._, i . m.:d � L�1: a.+rtsl /+•1►I y_ l�<_ �i���:�i�.ws 4. w •ee,. \arc,yJc. F'ad,.t�L '. a�pply i'rvo �,�L�brrw v.r � W�iv u�.. �•ipy�J. hlr�jt� h, .�� � \,�h�lirc.0 1 roprownt ".thot 1 am wholly and Complotoly rosponsiblo for tho design and location of tho proposed systom(s); 1) that tho mporote waw000 disposal system above doocribod will bo constructed as shown on tho approved amendmont thero to and in accordance with the standards, rubs a rcgu ens o ham County DWrtmcnt o9 Health. avid that on completion thovoof a "Cortificoto of Construction Complianco" satisfactory to tho Commisolone7 of Health will la m0rnI ed to tho Department. and a written ouarantoo will be furnished the owner, his cuccosears. hairs or assigns by tho build=, that said Wed= will Dmo iA Guam ov=tW condition any port of old mwago disposal syotom.durine tho period of two (8) years Im . lotoly followhq tAo.dato of the IMu- ov= o9 the oNwoyol of tAo Covtifkato of Construction Complioneo of the original system or any repairs tA=oto; that ho rilled well domiol a6ovo will Do Cmcatcd as a A=n on tho approved pion and that said well will bo inatol in accordance witA no ndards. a a u ono of tho Putnam County DpOgartntont of Health. Health. Date 1` I) SIned p.C:. i@eRy�. Address t iconso No APPROVED FOR CONSTRUCTION: This approval ettpiros Uno year orn the d to issued unl onstruction of the building has boon undortakon and is rev�eablo for eouso or may 0 omonGcd or modifiod ashen consider - ry the Co mi of Health. A4n���iii---eee�Me or alte7otlon of construction vCBuiros a now o mi , ro gd disposal of domestic oni ` o, /or Dr' at orator W y only. Rev. / 1088 DatO ®y Titb PUBUMCGIUMMMAMEMORPIUMM 3 Q'� dDlw�lel Bag1� SonOe�e. Qlaaal. N.T.1d81t M Ao-we Pdt 1 6 � Z�OF IIM MWAM DVWMEGM rams # �4_ t Z ' 9 0 Flc.'4 t4a., Vga Ile 1 .0 � wit/ Dab d Wefts Adeoa I' �% ?yew Appwd or DP Subdivision / Approved /; Fee Enclosed lad Amnr,nt ! �D • ©O pgoft � D_:S i e ice r- e &mot Am I 3 � FE sedgy 0* LJ nspt6 v.w.. Nave d yoi eeila Dotlp not, G P D P ®NG11 Mndsil k ROM& W Wbfa M b a mplided $MGM& Swamp Sydm to NNO fof '�) Gi w SOP& 110k D 1�r�C 'f1e bo.emok aagW 1IFT � x d AM. Wader &9* plena Addles• acs- Pel..t. Sm* DiiMed by T 8, e� �,b g Gilbae 6t�eiaeole 1 repressnt'.thet 1 am wholly and Completely responsible for the design and location of the proposed system(q s 1) that the ate sew di vl stem abmo desatbed will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a ngu ns o county Deportment of Waft and that on completion thereof a "CertNicate of Construction Compliance" satisfactory to the Commissioner of Mealthwill be subrmRted to the DooarbrAnt, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, mat said builder will place in good *MAIN coo dillon, My part Of Old swrap disposal system Owing the period of two (2) years knowdlately following thedate of the Issu- O W of the apdrenal of the Certificate of Construction Compliance of the original system Or any repasts tOWWO1 Z) that the drilled well dowitled above WIN be' I N *Wen on the apprewd plan and that Old well will led nee with he rds, rules a r s of the Putnam Comely Deportmem Of "nah. (�, j {� Oats _ ® 5 PL / RIT APPROVED FOR CONSTRUCTION: This appro%al expires two s from the date' I unless construction of-the building has been undertaken and Is (evocable for cause or may be anna11ds or modified when eon ry by t emmissionor of Haalth. Any change or alteration of Construction Revi, pp feduirse a JJnow per Q�JILLQAr'p�proved for dispoOl of domost y a ate water SWIV only. G,�^ j��� �O� V V Onto L © T l �! Ov Title .J�� I� Ti t.p DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APErLIC:iti T10N `1'U ' CONS'i'ROC'r A WArt`E R WELL— _.- PCHD PERMIT # WELL LOCATION o Street Address To Village City Tax Grid Number WELL OWNER Name JOH YAro Mailing Address 'Private 9 C° iA FZV 9 ®o Al ywi #, IV, O Public USE OF WELL (lam- primary secondary kfRESIDENTIAL ® BUSINESS ® INDUSTRIAL 0PUBLIC SUPPLY ®AIR /COND /HEAT PUMP 13 ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify 0 INSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE`_gal ® REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 13. ADDITIONAL SUPPLY ANEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING ell &�7e6 WELL TYPE CMDRILLED ®DRIVEN ®DUG OGRAVEL OOTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: W owoao M Lot No. HATER WELL CONTRACTOR: Name Toole loereflHilyeo Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __ArNO NAME OF PUBLIC WATER SUPPLY: /V 14 TOWN /VIL /CITY . Dj.C1rA .CE TO PROPERTY FRO M _ N 44 F:cT WATER, 11ATN : Al 1A R LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 9 - 2-5 ° ON SEPARATE SHEET , -_9,r,, (date) (si ture) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of 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 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 attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall any and all water or waste products from such well drill property and in such a n er as not to eg�de or othe Date of Issue: 19 L4 ff Date of Expiration 2P19� Permit _______W take appropriate action to assure that 4 operations be ntained on this se contaminpte -face or grqundwater. Issuing Off. Permit is Non - Transferr b e White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller i F DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPL1CA`1`TUM"TU CONSTRUCT- A' - WATER -WELL' PCHD PERMIT # WELL LOCATION Street Add ,ess o Village /��JJCity Tax Grid Number WELL OWNER Name, °U Ma ij ing Adr s � � m(IISL rivat e 0Public OF WELL 1- 'primary 2- secondary RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL JI O PUBLIC SUPPLY /HEAT. PUMP Q AUSE O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# . PEOPLE SERVED /EST. OF DAILY USAGE gal 0 REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 12 ADDITIONAL SUPPLY NEW SUPPLY N DWELLING) [3 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR 'DRILLING new Kenia4eAce_ WELL TYPE DRILLED DRIVEN QDUG []GRAVEL. C1 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: /.(JIM a)o6 l' is �!_ J Lot No.' 1 WATER WELL CONTRACTOR: Name `tom �G GlE�'/�l n L° Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: j'ij �- TOWN /VIL /CITY _ OTSa CF T : jPR0P_17TTX .F..ROMi..NjclAn 4ifl WATER:.1K9Y',-;:�`1(Y,; LOCATION SKETCH & SOURCES OF CONTAMINATION PRO ON SEPARATE SHEET (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of 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 shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health provided by the Putnam County Health Department. During all well drilling operations, the applicant shall any and all water or waste products from such well drill property and in such a manner as not to degrade or oth Date of Issue: 19 qD Date of Expiration r 19 Permit take appropriate action to assure that ng operations be contained on this ise contarAnate surface or groundwater. 11 4 oe d/A _AJ I-M A" LA Issuine!( Of Permit is Non - Transferrable White copy: HD Filel mink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller YIIl'LVHP1 WUltlll LL' Ct[tli•L.yt va. a• •+.0 _ INDIVIDUAL WATER SUPPLY & SUBSURFACE SEUdM DISPOSAL SYSTEMS REVIEW SHEET - CONSTRUCTION PERMIT. DATE REVIEWED: BY: /�� Permit Application _ Corporate Resolution Plans - Three sets Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) 30" Perc Hole Other House Plans - Two sets If PWS - Letter Variance Request REQUIRED DETAILS ON PLANS Sewage Systen Plan Sewage Systen Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box Detail Septic Tank - Size, Detail Well Detail, Service Line if PqS,_ Trench /Gallery Pump Pit Two -Foot Contours Existing & Proposed Slopes for Driveway Cuts Footing /Gutter Curtain Drains Perc & Deep Holes Located Representative of Sewage & Expansion Area Expansion Area; shown; gravity flow If Puntped Pit & D Box Shown & Detailed House - No. of Bedrooms Property Metes & Bounds House Setback Necessary House Sewer - 1/4 " /ft. 4 "0; pipe pipe No Bends; Max. Bends 450 w /cleanout. SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains- Curtain,Stonn,Leader,Footing 25' to Catch Basin 10' to Water Line (pits -201) Septic Tanks 10' fran Foundation 50' to Well 15' Well to PL GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same W1LP CP 6% 0 > CANTILEVEP, Op lyZ4LTjj COUATT' 'f)CTSl PLITIJAI' PUN' CO'L-oi�,,-24,PCPROVED f put? (7 'Ila 7 UD a. FL 7Z�7" -30 SG 3 0 5 UP so L.J • f Z6 3. �: u lo, 1'' C) , -7 oc, EEI C, 12co � 30 is -5044 4vLI2 ,' ` Si 50'-.4!/,Z '314EA.-T"o'l(m I> 2 PIZAAE 32 a. FL 7Z�7" -30 SG 3 0 5 UP so L.J • f Z6 3. �: u lo, 1'' C) , -7 oc, EEI C, 12co � 30 is -5044 4vLI2 ,' ` Si fll'unam County Departn,^nt of 9fealt1l DiVisiOn Of blvironmcntal Sani va Lion AYFIDAVIT — CORPORATE WNER. APPLICATION FOR �PERI, T "APPI. CAT•10 N SllBriTT.TED-TO _ ., TO: Commissioner of Health - In the matter of application for ' I► lC // ..�.._,._ " "�._����+ represent. that .I Am an officer or employee of the corporation and am authorized' to act for, J� o Z-/w i) j1F,4oP1f4 P,a. i name of corporation) having offices at _33 Whose officers -are President _ ("kr'ri�o%c 0 (��� / r i`/� 3 ?/ (3/ ASA< dwx /x/,�: /O 5900 I'Name an2Y A'd- Sress) Vice - President ' ����ame and Address} Seerdtar-Y i� %el°�su2ex /((� � PA-rt-x 33 oemga�/4��'!& t r .... r r ... •� .-. v ti .�. ��.. .-. ..+,• /w r r +'•• r. (Name and Address)y , Treawirer ,Name and Address)w �-- -ei ' - = 3Ix.•A=a,�d -i 'I:i°`cie 3ntix i u lly responsible fort any or X11 a t6 of the- corporation With respect to the approval reques:trid and -all .sub= eeque�t acts relating thereto. c `- " Q S 47 worn' to 'beefore me s day Signed of -�c? N C 1990 Title No ary blie ANTHONY R. INGLESE • . NOTARY PUBLIC, STATE OF NEW YORK No. 60.1923075 Qualified In WeatdINSWCM14 comminloo EVUU 7/J �y0 LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE .-W Z;m e: 7,E a (914) 278-6108 -(FAX) 278-2658 RANDOLPH W. LAURENT PE: HARRY W. NICHOLS, JR., PE. CONSULTING SITE ENGINEERS June 26, 1990 Putnam County Department of Health 110 Old Route Six Center Carmel, NY 10512 Att: Mike Budzinski, P.E. RE: Proposed SSDS Richard Motta Oscawana Lake Road Putnam Valley, NY Dear Mike: Enclosed are the following relative to the above referenced SSDS: 1. Four (4) prints of Drawing SS-1, "Proposed SSDS" dated 6-22-90. 2. "Construction Permit for Sewage Disposal System", dated 6-12-90. 3. "Design Data Sheet ". 4. "Letter of Authorization", dated 5-9-90. 5. Two copies (2) of Residence Floor Plan(s). for r-co.,k. -Cwi --a u.v�tl�-ft -Y 6. "Application to Construct a Water Well", dated 6-12--90. 7. $150.00 Money Order for review fee. 8. "Corporate Affidavit". We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Randolph W. Laurent, P.E. 90012/map cc: Mr. R. Motta wl encl.