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HomeMy WebLinkAbout2783DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -1 -55 BOX 23 frA Ll ., om .� 02783 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH .SERVICES. . CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE E:I— MATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 09- ° - j �� Located at S' 1��- if0W,-0Vq -DAD Town or Vill V/4H. -W Owner /Applicant Name Formerly. GA"W Ha OAHr.�9-0 Tax Map G i Block Lot 65 Subdivision Name wr 13 EP- Subd. Lot # . Mailing Address ,i 0 -+5 -1 ltit P.UA®G �0%-GIlrl�'�j �� Zip Date Construction Permit Issued by PCHD �f- Separate Sewerage System built by PM coo I'1—ti Address 110 45 � � �' Iw U i+ VKL i 4 Consisting of Gallon Septic Tank and A L-' 05 1 KHM Other Requirements: 2" r•'I LA- Water Suonly: Public Supply From, Address or: K Private Supply Drilled by 1+Eb I M' 60yp Addressi46-q �L-l' 52 r Buildin Ty e 9-613 '� -U5: Has ero. _ on cont. of been comWet Number of Bedrooms Has garbage grinder been installed? ND I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulation of the Putnam County epartment of Health. h Date: (1 ` 0 Certified by D 44 �� -- - P.E. X R.A. Address 1,060 S4, Q.E>^� 1 (D ' n P -rQf Tonal) Gv o License # Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation, modification or change is necessary. I'u6Iic. By: Title: ke- 4-A �,�g;ac�� Date: 14 It 1,D3 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 le l Win: »t.�n Street A 3 :ys 1... Town/Villag 1 Map . Block Lot(s) Well Owner: Name: Ju� Address: Use of Well: I- primary 2-secondary Residential Public Supply it 6ond/heat`piinfp Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment __V,_ Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing X 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 _,X Threaded _ Other Seal: , 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 Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air IX Hours Yield,2p 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 ste�ie analyses -, .. are available, please attach. ➢De th From Surfface- Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 439 Y Pump Type SAJ., Capacity Depth I go Model jq_!= j 1641 2 Voltage 2-30 HP I Tank Type Ujx -302- Volume I (} / 14 26 Date Well Completed Putnam County Certification No. M3 Date of Report - -D ell Dri er. (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be prov- on a separate sheet/plan. Well Drillees Name �° Address: Signature: Date: / /D White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Harry W. Nichols Jr., P.E. Dear Joe: In response to your March 19, 2003 comment letter, we note the following: 1. There is a vertical separation of 24" + between the installed water line -� and effluent line crossing. Ch✓�"'"' 2. The separation distance'between the well and effluent line is 25 + which is allowed when the pipe is below frost line and has tight joints. The r►�i .. „ _ SDR -35 utilized.in this installation . is a pressurQ'. with rubber -t .._: �_�_ ._�•_;�;_ ..__._._ .._ ... •gasketeci joints:..._. -_ 3:. Ties to end of trenches and junction boxes resmeasured from fixed points A and B. 4. House has been survey located and offsets added to plan. 5. Two (2) additional cleanouts located and added to plan. . 6. Tax Map number verified. Reflecting the above, enclosed are five (5).prints of Drawing S -2 "As -Built SSTS - Lot # 2 ", rev. 04- 04 -03. o. - tG LOIEETTA MOLINARI -R.N., M.S.N. Acting Public Health Director Director of Patient Services March 19, 2003 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 �7q -�47 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive V Re: Construction Compliance - Danford 83 Bell Hollow Road, (T) Putnam Valley TM# 62 -1 -55 This office has received and reviewed the most recent set of plans for the above mentioned project. We would like to offer the following comments for your review and consideration. 1. An 18" vertical separation distance is required when a water line and effluent line are crossing The separation distance between a well and effluent line is a minimum of 50 feet. 3. The distances necessary to locate the junction boxes and the end of the trenches need to be from two fixed points. Based on the submitted plans, points C and D don't appear to be fixed points. Please clarify. 4. The house needs to be survey located with respect to the property lines. 5. According to field notes from the final inspection, two more cleanouts were required according to approved plans. It doesn't appear the provided tax map number exists. Please verify this with the town. This office will continue its review upon consideration ofthe above mentioned comments. Please feel free to contact me at ext. 2157 if any questions arise. Very truly yours, Joseph S. Paravati, Jr. Assistant Public Health Engineer JSP: cj �7p •567 a � ,r LOPE TA MOI.INAAB AN, M.B.N. ROBERT J. BONDI Aa ft Awk rr.a6A D&.r Cor4e, Awmh. Dbm 4/ Pah w S ,+— DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 JNVI. ueonl Bubb (843)276.6138 IaU(84s)ne -7921 Nam S—km (843)278 -6336 WIC (945)278.6678 F.(643)278.6883 "ratn4a UWfte4mael (843)278.6084 Fa(645)278 -6648 March 19,2M Han), Nichols, PE Patterson Park, Suite 106 2050 Route 22 v Brewster, New York 10509 Ra: Constiuction Compliance - Danford 83 Bell Hollow Road, ('C) Putnam Valley TM# 62 -1 -55 Dear .'&. Nichols: This office has received and reviewed the most recent set of plane for the above mentioned project. We would like to offer the following comments for your review and consideration. 1. An 18` vertical separation distance is required when a waterline and effluent be are crossing each other. 2. The separation distance between a wall and effluent line is a minimum of 50 feet. 3. The distmlces necessary to Iowa the junction boxes and the grid of the trenches need to be from two fixed points. Based on the submitted plans, points C and D don't appear to be fixed point& Please clatify. 4. The house needs to be survey located with respect to the property Laos. 3. According to field notes from the final inspection, two more rAcanouts were required according to approved plans. 6. it doesn't appear the provided tax map number exists. Please verity this with the town. This office will contimse Its review uponconsideration ofthe above mentioned comments. Pleasefeel flee to contact me at at 2157 if eny questions arise. Very Uy yours. Joseph S. Parevati, Jr. Assistant Public Health Engineer J5P:cj "Q &UNSNVE1 UMr100a SMOM do sJHd ZSUI q x0 : ED Apt 700 : 9£:TT 6Z -HVK : T/T : L9SV6LZ6 : SITI sx scow swls assam swls UVIS saf)Vd sNOHd TZ6L- 8LZ -Sb8 UL HZTVMH dO SNHGZ1HVc1da XJ&MOD KVNInd : MMN LE:TT JVS £OOZ -6Z -M Sstia KOIZMN00 ONIMS 1� 71 1-117 11 Ines. IS ji✓eGl Ae - )? Cf' 7 A iN —tK-ecJs- -5-o -fw,* rftkm tol'r) aCo-CJU/ 914 279 4567 P. ­MBRUCE IL FOL9Y.. W. _ ..: r K•: , ... 'IAAStTA LtQi,tNAkI RN, 64 S.N.:, :.... ' !r►lic Nr.16V 04rtw• • - .. •• .Aum(�t hllliC..K1ttFN L76tiw ...... " .... _. _... ......._� ... • •_.... DI�PAR'ITv1El�iT OR ' I�.Ar.TH . � r� .: ...:... . _..�. - 1 agneva Road _. Bnvnw, New York I009 _.._._. _.. ... U*"Mttd ROM (111)711.600 ftm4)1n -ml Nwang.80*0 14)VI.011 .WIC 014111."?? .Ha01A t1{•f0e7 .. - t�dlTwwmaYa'Rig11t'•i011 Mu>�►pl1)711i0t7 lat/ihtit•eMl ' E211 ADDRESS V .R� I�ALON FORM OWNERS NAME: _GAP -01 1 HO PAWFO LD TAX jVMKp NVMBER:. �p �"` ) _..... ' .............. . ... E911 ADDRESS. AV- TEORIZLp TOWN. -OF ICIALLC 'DAT.E: Tho Putnam County Department of Healtb will not issue a Certificate. of Construetfou Compl{atnee unless the above form 6 completed, i.e., a legal E911 address Is #ssiened by an authorked town off1clal, TV3 form- Is to be submitted _ with the. application for a.Certificate of Construction CoMpLance: •;., .. MAR -03 -2003 11:07 AM HARRY W NICHOLS tol'r) aCo-CJU/ 914 279 4567 P. ­MBRUCE IL FOL9Y.. W. _ ..: r K•: , ... 'IAAStTA LtQi,tNAkI RN, 64 S.N.:, :.... ' !r►lic Nr.16V 04rtw• • - .. •• .Aum(�t hllliC..K1ttFN L76tiw ...... " .... _. _... ......._� ... • •_.... DI�PAR'ITv1El�iT OR ' I�.Ar.TH . � r� .: ...:... . _..�. - 1 agneva Road _. Bnvnw, New York I009 _.._._. _.. ... U*"Mttd ROM (111)711.600 ftm4)1n -ml Nwang.80*0 14)VI.011 .WIC 014111."?? .Ha01A t1{•f0e7 .. - t�dlTwwmaYa'Rig11t'•i011 Mu>�►pl1)711i0t7 lat/ihtit•eMl ' E211 ADDRESS V .R� I�ALON FORM OWNERS NAME: _GAP -01 1 HO PAWFO LD TAX jVMKp NVMBER:. �p �"` ) _..... ' .............. . ... E911 ADDRESS. AV- TEORIZLp TOWN. -OF ICIALLC 'DAT.E: Tho Putnam County Department of Healtb will not issue a Certificate. of Construetfou Compl{atnee unless the above form 6 completed, i.e., a legal E911 address Is #ssiened by an authorked town off1clal, TV3 form- Is to be submitted _ with the. application for a.Certificate of Construction CoMpLance: •;., .. E'/ 4'F r,, j, 3 r�. ',F aF , '� �'4 ( H �"a.�t ry i 't .,..:b_..•- _•c..a... .o ..., ., ,� ,..•o .,..w a.._.ti•� -,. � .� ..: ., ..., .. _,. ..� -.�. :.._. a.::ws'w" .w;< .. �f- .,.... � .. • ., ,. ... � .`.; n'..•. e• -... .. .. GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM C,A94 V) HiF. .PAH Fo �-D Owner or Purchaser of Building P)\- � C-0 i__4 Building Constructed by ,;,b B6�- P-aW Location - Street T Building Type Gee 1 1545 Tax Map Block Lot TownNillage EF BER- Subdivision Name 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 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. 12, Dated: Month Day Year �� General Contractor (IOwn &) - Signature . PM c� H HC" Corporation Name (if corporation) Signature: V-17 Title: Corporation Name (if corporation) Address: M Address: llQ 5 j`�" R-G Ru. FO.K_k4A"� State Zip � State Zip Form GS -97 JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET STAMFORD, CONNECTICUT o6905 NELAC, CT and NY Stole Certified Environmentol Laboratory Mailing Information: Collector's Information: Name: Boyd Artesian Well Co. Client: PMCON Name: John N Address: 1054 Rte 52 Address of site: Lot # i2 Bell Hollow Rd City: Carmel City: Putnam Valley State: NY Zip: 10512 State: NY Zip: Telephone: 845-225-3196 Fax: 845-225-8420 Telephone: Sample's Information: Site: kitchen tap Date Collected: 1/29/03 Date Received: 1/30/03 Preservative: HNO3 Time Collected: 16:00 Time Received: 13:20 Temperature: . <4C Lab No.: J030481 Date Analyzed Test Name Result MCL Method 1/30/03 15:00 1/30/2003 1/31/2003 1/31/2003 1/31/2003 1/31/2003 1/31/2003 1/31/2003 1/31/2003 1/31/03 12:00 1/31/2003 1/31/2003 1/31/2003 1/31!2003 Total .Coliform Chlorine Free Residual Color Odor Iron Manganese Sodium Chloride H.arltnF`ss:�._ Nitrate Nitrite pH Sulfate Turbidity Lead Absent Absent SMWW 9222B <0.1 mg /L N/A SMWW 4500CIG ND 15 Units SMWW 2120 B ND 3 TONs SMWW 2150 B 0.047 mg /L 0.3 mg /L SMWW 3111 B 0.02 mg /L 0.3 mg /L SMWW 3111 B 16.3 mg /L . N/A SMWW 3111 B 20.0 mg /L 250 mg /L SMWW 4500 Cl C : -- "`?'' rrig /L -• - .... _. �l/A _. „ m .. ;. - S!`A�1�Nli 23�J.C.. 1.13 mg /L 10 mg /L SMWW 4500 NO3E <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 6.62 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 15.8 mg /L 250 mg /L SMWW 4500 SO4F 1.26 NTU 5 NTUs SMWW 2130 B 1.14 ug /L 15 ug /L SMWti ^J 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable S.U.= Standard Unit MCL- Max. Contaminant Level ug /L- micrograms per Liter Signature: Michael Lapman President mg /L- milligrams per Liter NTU- Nephelometric Turbidity Unit TON- Threshold Odor Number ND- None Detected State #: PH -0218 ELAP #: 11715 Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 - Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 March 03, 2003 Mr. Joseph Paravati Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance - Danford 83 Bell Hollow Road Town of Putnam Valley T.M. # 62.4-55 Dear Joseph: Enclosed are the following: 1. Five (5) prints of Drawing S -2, "As -Built SSTS," dated 03/03/03. 2. "Certificate of Construction Compliance for Sewage Disposal System," dated 03/03/03. 3. Three copies of "Guarantee of Subsurface Sewage Disposal System," dated -03 /03/03. _ - -- 4. Laboratory Report, dated 01/30/03. 5. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 6. "E -911 Address Verification Form," dated 03/03/03. 7. "Well Completion Report," dated 01/10/03. If there are any questions concerning the enclosed, please call. Very truly yours, Hang W. hol1r, E. HWN:JM:gav 02- 018.02 Street Location PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION a. STS area located-as per approved plans ... .. .................... :.. b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil.not stripped... ................................................ d.. Stone, brush, etc., greater than 15' from STS area.......... e.. 100' from water course /wetlands.. H. Sewage System 7 a. Septic tank size - 1,000 ......... 1125 0. ........ other ...............: b. Septic tank installed level ................ .....:.............. ..........:. c. 10' minimum from foundation.. . ..... ................... ............. d. gistribluio, o 1. All outlets at elm s - evation -water tested ................. 2. Protected -b6 ow frost .................. ............... ................. 3. Mhulli'um 2 ft.Original soil.between box & trenches Junction 13 - properly set , L ........ .............:........:...:.... 1. engtFi required �'l/i�ength installed 2. Distance to .watercourse measured 3. Installed according to plan .... ............................... 4.. Slope of trench acceptable 1/16 -1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 %...... .. .................. 8. Size of gravel 3/4 -1' /z" diameter clean .................... 9. Depth of gravel in trench 12" minimum... :.......... ....::.:.....::::: „;;: . .................. g. rump or liosea bystema 1. Size ot pump c am e . ............... ............................... 2. Overflow tank... ............................ 3. Alarm, vis audio ......................... . .......................... 4. Pump a ily accessible, manhole to grade ................. 5. F sC iox baffled........ .....:.......... ............................... ycle witnessed by H.D.estimated flow /cycle........... III. H6useBuildin . a. House locat&d per approved plans...... _. ..Date.:. 1/1.o/c. ilspecieci by: _ Owner:�yt�� Permit # IV. a. WeU Well located as per approved plans ........................ ... b. Distance from STS area measured ft.:l:W,iz c. Casing 18” above grade..... ............... 54- d. Surface drainage around well acceptable ....................... V. Overall Workmanship .a. Boxes properly grouted ................... ...... :........................ b. All pipes partially backfilled ........... ................:.............. c. 'All pipes flush with inside of box ... ..............................: d. Backfill material contains stones <4" diameter .............. e. . Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from.STS area............... h. Surface water protection adequate ... ............................... L Erosion control provided ................. ............................... Rev. 1/97 Subdivision Lot # Form JAN -02 -2003 04 :56 PM. HARRY W NICHOLS 914 279 4567 P.01 AL ll i PUTNAM COUNTY DEPARTMENT OF HEALTH DWISION OF ENVM0N1V'lENTAL HEALTH SERVICES. &EMMU P „�M MI= For: Pill -- Date: .._J. -..32& �� _.... Trenches 4��. PCHD Construction Permit # Located: MO., M260Q (T) (`) VA LIE Owner /Applicant Dame: LIP E I W E2” TM 61, Block ,A Lot � Formerly: Subdivision Dame: WE WL r,a�® Subdivision Lot # 3 Is 'systet$ fill completed? N system complete? Its Is system constructed as per plans? 2 c Is well drilled? �,r����rr �n Its Is well located as per.plans? Are erosion control measures in place? `. Date: _ bate: a� o?--e� Date: _ )mr- e a,& -lea 1 certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PdHD Construction Permit and approved plans and the Standards, Mules and Regulations of the Putnam County Department of FIea)th. Dale: Ag? oz 0 , Certified by: 46, PE Z-► 'RA . Desi rofessional Address..... 2050 zx 62%g -bosh Al 10509 Lic. # S'Clz4 Coamients: Vl v`no� �✓ i / AnA. (it ! !�!� 60 c(vUl i FOR: 11 ADAM 041914 3 Y �„ I.Q Form Flit -99 r. ,, PUTNAM COUNTY DEPARTMENT OF HEALTH WPM : DIVISION OF ENVIRONMENTAL HEALTH _SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # 3,� Located at f4O"N FLOAD Town or Village Pv� NAM •�(AI. -1—E� Subdivision name W E fr--R— Subd. Lot # Date Subdivision Approved G) /00 Owner /Applicant Name GA?-O,"' I N G pa`W FO �-p Mailing Address ) 10 4A-P 2-6 Amount of Fee Enclosed A(J o0 Tax Map &l-, Block I Lot 6r7 Renewal Revision Date of Previous Approval r—oP-ejqol- H • Y Zip Building Type Lot Area x•00 )�LNo. of Bedrooms 4 Design Flow GPD g C)O Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of j fl-�H( 14 IBC) gallon septic tank and 500 L4�- AG6 Other Requirements: �� Pll"L- To be constructed by T60 Address Water Supply: Public Supply From a Private Supply Drilled by Address T NY -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 a stem 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. i< R.A. Date '5) 191 n- Address )-050 6WW51 o— 1 Dezol License # 5611.' 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 when considered n essary by the Public Health Director. Any revision or alteration of the approved plan requires a new ,p rmit. pproved r discharge o domes 'c sanitary, se ge *only. G 3 2 By. � �- Title. Date: 'White copy - HD File . Yell w opy - Building Inspector; Pink copge copy - Design Professional Form CP -97 PUT NAM COUNTY DEPARTMENT OF HEALTH DAqSION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL � please print or type PCHD Yermlt # J V--) J S d WeR Location: Street Address: Town/Village Tax Grid # W • WNW VAH -,2Y Map r2- Block Lot(s) 56 Well owner: Name: t- R�1�11 Olq4F60 Address: 110 -4 -71 READ RgE6 t4l! O, NV 11'j I* Use of Well: 7( Residential Public Supply Air /Cond/Heat Pump Irrigation I- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought _5i� gpm # People Served 1-y Est. of Daily Usage � gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling' New Supply (new dwelling) Deepen Existing Well DetaiRed Reason for D ril ing Well Type A Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision Lot No. /2- Water Well Contractor: T$9 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 o be provided on separ a sh et/plan. I %,. Applicant. Sip,. o the `� �1�,i I J, . _ _ Al . % �.J LI 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 wat9t well driller certified by Putnam County. Date of Issue �2 Permit Iss g Official: Date of Expiration z _ Title: Permit is lion -Tina® ffe>r>rable White copy - HD file; Yellow copy - Building Inspector; Pink copy - OWmer; Orange copy - Well driller Form WP -97 Harry W. Nichols Jr., P.E. Patterson Panic, Suite. 106 . .... . .. . _... � ....... . - ;r.;:. ..- .viii: L Brewster, NY 16509 Telephone (845) 2794003 02— Fax (845) 2794567 To: - -- - Attention: 6EW ?O(W4 Date: 4 1 1 J Da- Job No.: C)9,- OW oL Project Gentlemen: We enclose ( ) copies of B/W Prints Reproducibles Reports Tracings Specifications -- Memorandum Copy of letter Description: - Revision/Date No. x Sent Via: �Our Messenger Your Messenger - Blueprinter Hand Delivery First Class Mail . Special Delivery Copy to Very yours, l �4 Ha . Nichols Jr., P.E. BRUCE R. FOLEY Public Health Director April 1, 2002 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: Re: Proposed SSTS - Danford, Bell Hollow Road (T) Putnam Valley, TM# 62.4-56, Lot # 2 Review of ans and other supporting documents submitted at this time relative to the above regard project has been completed. Comments are offered as follows: l House plans submitted are considered to be a five (5) bedroom residence, revise The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Sincerely, Shawn Rogan Public Health Technician SR:cj PROJECT LA MUM -If'j' Appenift vivo'. state Envk6misn'tal Quallty. fw** 7 SNORT ENVIRONMENTAL ASSESSMENT' - fQf W. ... .... For UNUMP 410MON8 PART I,-PROJECT INFORMATION (ro be completed by Appllo.at or Pmjeci soqnw 1. AMCANTAPONSOR VA44rP 0 I.- MONOT NM97-. . . ....... o. -r L Munwpamy own-ty kLijow .BELL S. IS PROPOSED ACTM '8N#w _0 ft*4W_ 6. MONSE PROJECT ORIPLY$ 7. AMOUNT OFLANDAFFECTO wiay uldmo_* acm 8. WILL. poopo$WAMM=MYWMV"loZo?MNCoR4MfApm LM U86 REBTWOT10N8t: Vy" ENW, -0 Na d"0w bwly Mcdcuitwo 0 Pwwwostft. *am 10. DOE$ AMWWWW1 A APPROVAL. OR FUNOING, NOW OR ULTIMATELY FROM ANY OTHER Q0VVL4 CY PuvvL, 13y" 'I9 No 11Y% OR 4QwwM WA wwuwmaw C1098 A NY AVW 0 u. AS A RESULT. OF PRO AM= 0.q Oi I.-OWN 710T TM INFOWYM PW go W4.18 TM M RIT w W1010ka* !�'�R� .. , N ► °r:+o , JR= 'E ' .. �� -rt'.. a I i I o 2 ApvucanvaPor►aar AA na<rlac 'If the ; 440 a.- -.6*1# In ft.0cal'tal.Ares, and you are a state agency, oompleter-tho Coastal -Assessment Form before proceedIng with'thle assessment PART 11 ;- ENVIRONMENTAL'ASSLRSMENT'(TO be'cornpleted by Agency) _ A. 000 ACTION ExOW ANY TYn I THRESHOW IN ® NYOM PART $17,4 7' II yea, voordinaty' lhv revlvw prcoss8 tln4 ussiha 6�Ill �: e•.,' . J e. WILL ACTION R CEIYE COOROiNATEO.RBYICIN MVIpE®FOfl UNU#TE® ACTIONS IN 9 NYC PAN 91y.a? It N ®- nsgseNe deelsrotlon may Do super by on )OW.InvAlved igslwy C. COVLo ACTION RESULT. IN ANY ADV911149 gYFE®Ta,ASSMAT90 WITH THE FOLLOWING; (Anatirere raeoy 00 her'dwrUten,1' Ieel0le) Cl. Ealapng. r euallty, -: rfa0® or ®roundww1w awAly Or quatntlyr, nolao level$, oweling Irolltm 1>8 .vall� areate ,�go0ustlon -or disposal, - pot ©Waal ler c>roalon, drelr►9®e Or Iloodln® pl'oWeaaal P p6a31r• Imlellyt ' C1. nostnottc, ogrlcultural, ar01189010glCai, historic, or other acturel or cultural resoumeo; or community W neighborhood charsct0r? tsxpl8ln wielly: CJ. Vogotatlon or launa, Ilah, 6mullah of wpdille apowee, algnlliml habllatl, or thrwtenod or 0081190r0 opee1009 bpleln txlvlly: - Ca, a eornrrtunity'a vxlating plate 0f goase sS ® IY edople d, of a chsngo In use Or Intenallty of u90 o1.lt! or.ottwr ncterltl.r0 rceisT.Ea<Rlsin brl0lJ;r Cs. orovAn, auoao¢uent ombopment, of related aetivitiee likely to bo M0004 by 'ho propoew 00tior19 Qxplam twielly, C$. tong term, $hart term, 6uareWaatbe, Or Otter 0110669 nat Identified In C1457 Explain brolly. V. 01nor Impacts (Including ohengea In use of 011her ®ulanuty or type of energy)? Explain wlefiy, , G 41 ` r -'' r •'1� �3i;•°°• • :: °s :oiv eBa�A�-e Cr6a ie6F "�81f1�J:ai4ltA11G1tm 6beAia7wrftasiayii TitA$ a3A� lt3TASt.'o$NMtoPr� ®R WA �" w ❑ Yoe p ...... . 4 E is THERE, 98 13-thEN UKELY TO 64 OOKXVER3Y-RELAT TO POTENTIAL ACVERSE EIIVIROHIM&NTAI, IMPACTS? 0 Yva A. ILYva, �axplalri brletly .. , . "" 0i ART III — DETERMINATION OF SIONIFICANCL (To be completed by'Agency) -- - INSTRUCTIONS, For each Over".#JIM ldsntlfled above, dotermins whether It If substantlal, Iar ®e, Important or otherwise slpnlflcant. . Each effect should be assesaTad in oonnsotlon with Its settlna. �.e.' lllt�tn or furalk..(f kpMba�lllty . ®f .00 4ttttta �o�.0unilon;'(d) Irreveralblllty;'(v) eeopraiphl0 as w, and M mapnitwfe..It.neoeas'' add eltsoloonte or mfitenco eupponing ma<terlals.' Enstir9. thal• ; explanation$ contain su1f101ent d#WI to QW 11hal all relevant ady" Impaa;'te 4" taeen tdentlfled.agd adequately oddreeaed. II question D of Paan 11 was oha>WW yea, the determination artd sign111danc® must evtaluate the polontlal linpact Of the proposed action on the envlronm ®ntaal characteristics -of the CFA. 0 Check this box If you have Identified one or more tentlally large or slgnifloont adver :6 impacts which -;NAY "' occur. Then proceed directly to the FULL EAF an of prepare a positive declarstlom . heck thlo box. II.you'have. det®rminedrr1LI0 on tbO 1111190 ltion 4nd• malysis above and .any- suppon.Ing documentation,, that the proposed action NOT result' In .any SIGnIfIdanI adverse environmental IM pacts ` AND provide on atta¢hMonte as n eaaa , the reasons supporting this dotermination. _ p or Typq Nam 'firm R logwy if w—w—w 91 oplow Imm er PUTNAi41 COUNTY DEPARTME \T OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH UDnM)UAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT _ gkmE OF UC�1� k'. ° .. J STREET LOCATION: , P Z" REVIENED BY: RIK OR, AS, ATE: TAX MAPS: (CQYFff ED) N' N DOCL'`iE \TS PER. IIT APPLICATION LZJUWELLPER`fIT ORPWS LETTER (v(__)P C -97 (�(JLETTER OF AUTHORIZATION ()(DESIGN DATA SHEET (DDS) UUCORPORATE RESOLUTION C!Uka T E_AF U S- E - '0 SETS U ST SUBDIVISION (-)LE GAL SUBDIVISION U�USUBDIVISION APPROVAL CHECKED (,:f�PERC RATE ^,42 . UUFILLREQUIRED a DEPTH (_)(QCURTAL\ DRARi REQUIRED GE, `'ERAL U( ATED Lei NYC WAJERSMD UUPLANS TO DEP JD(_) GATED TOP. _ EP APPROVAL, IF REQ'D L DEEP TEST HOLES OBSERVED Lz��PERCS TO BE W11-tiESSED (�JEX- APPROVAL SSDS ADJ, LOTS L J(� TLAh"DS (T O WN/DEC PERbUT RE Q'D ?)' - ((_-)DATA ON DDS PLANS & PER�11T SAIYIE UL,& 'RE 1969 NEIGHBORNOTIFICATION L j(J�LETTER Bl/ZBA (J( z: jtg0.YR :FI,O:OD.ELE ATION_WII200' , :- =( .jtE-` ESIM- 0iS> YEARS OLD E IED D SON S (� SYST EM PLAN - (NORTH ARROW) SRAULIC PROFILE GFLOW • Lfj(_JCONSTRUCTION NOTES 1 -15 _ L,-,:5L-)DESIGN DATA: PERC & DEEP RESULTS (d'�2' CONTOURS_EXISTI`iG & PROPOSED U TMUM (, 2i C_)USDA SOIL TYPE BOUNDARIES • (���TTTLE BLOCK; OWNERS NAME ADDRESS TM9, PEMA; NAbIE, ADDRESS, PHONE" �DATE OF DRAWI`iG/REVLSION (DATUM REFERENCE OF WATERCOURSES, PONDS. LAKES,WETLANDS WITHIN 200' OF P.L. (_}PROPOSED FINISH FLOOR AND BASENIEN'T ELEVATIONS WELLS & SSDS'S W/IN 200' OF SSTS L b1ETES 4 BOUNDS COMMINTS: I (REVSHEm ('y (REQUIRED DETAILS ON PLANS CONT'D) HOUSE SEWER - Y1' FT. 4 "0'; TYPE PIPE CAST IRON (=NO BENDS; NLAX BENDS 451 W /CLEANOUT RENEWALS UUSTTE\ 60 CHANGE) FILL SYSTEM x,10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE (,FILL SPECS/ FILL NOTES +-S (--lC.-)FILL PROFILE & DZQBM13S (:= UFILL IN EXPANSION AREA FILL GREATER TFI.42 2 FEET UU CLAk BARRIER NO / y ()LJFILL C ICAT NOTE ©,.�5� a-v UUD' GAU UUVOL. 0 ' FOR RO.B., UNCLASSIFIED & �IPERVIOUS L)LJSEP ATION DISTANCE FR0 TOE OF SLOPE NC (, __)LF TRENCH PROVIDED OLD % 60FT MAX. ((PARALLEL TO CONTOURS �100% EXPANSION PROVIDED. ) DETAIIMUST FREE CRUSHED STONE OR WASHED GRAVEL (�GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS UU10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL U i L�20' TO FOUNDATION WALLS )'100' TO WELL, 200' IY DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. ezpan) TO CATCH BASIN, 35' STORNIDRAIN, PIPED WATER �U10' TO WATERLI \�k: lts• ?20' , �. ..�_._....._. _........._.:......:_ (_0' L�ITER,`YIIl`�1T DRAIYAGE COURSE - (, J200'1500' RESERVOIR, ETC._ 150' GALLEY SYSTEMS ( _)10' MRN TO LEDGE OUTCROP SEPTIC TANK �ZU10' FROM FOUNDATION; 50' TO WELL WELL (� DIINMNSIONS TO PROPERTY LINES - ( ELOCATION OF SERVICE CONNECTION _ MIN15'TOPROPERTYLVE ' SLOPE USLOPF.IN SSTS AREA JC (520 %) (_J NMGRADEDTO15 %,IFREQUIRED DOSE/PUMI? SYSTEMS (_}( }PUti1P NOTES (_)(DOSE " , OF E OLUIVIE/DOSE VOLUME NOTED UUDETAIL 0 0 E MAIN, (PIPE TYPE, ETC.) L-)LjPTT AND BOX HOWN & DETAILED UUl DA 0 ABOVE ALARM CURTAIN DRAIN U(_JSTAND , S�'BOTB SIDES, DETAIL UU15' blDi CDS= >5 %, 20' -4 %, 25' -3Yo, 35' -1 °!0,100 °!0 -<1% L.-)L�20' NI o /DISCHARGE/100' with 182 cons day discharge UU10' b to NON - PERFORATED PIPE PUTNAM COUNTY DEPARTMENT OF HEALTH - r r y E LETTER OF AUTHORIZATION RE: Property of 4-1, 12ANF0 9 -0 Located at 144- � PVJ P-OAD TN Pi J NhH OW-el' Tax Map # Block 1 Lot Subdivision-of- -\145 - Subdivision Lot # Filed Map # 2- 44- Date Filed cl °Q Gentlemen: This letter -is to authorize HAW VJ, N U t- DM, JiL, fE5 _. _....._ _ duly licensed Professional Engineer X or Registered Architect to apply for the required ,.�,astewater treatment and/or water supply permit(s) to serve the above -noted property in accordance I'Vith the standards, rules or regulations as promulgated by the Public Health Director of the Putman, County Health Department, and to sign all necessary papers'on my behalf in connection with this marter and to supervise:the.construction of said wastewater tretment.__.dlo,:vate.r s1;} nLn�i;_::___..__ - o rMITY W-T. i to 6ns of"Artic"fe'l4�Y_ind1or °14'1 of the Education Law, the Public Heal:", ': aw, and the Putnam.0 uaty. Sanitary Code. 1� N E: �.0 CN 0 R NI Very truly yours, Countersigned: P.E., R.A., # ' 56324. N'lailing Address State N` Signed: b a j (owncr of Prgperty) ' Mailing Address: 116-45 111 Zip ( 0W Telephone: H1 i—� State �! : _Zip Telephone: /bl D( tl 6 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 _ ... - Route 22 , �. ......_ . Brewsier� i�iY'i 0509' ZZ Telephone (845) 2794003 Fax (845) 2794567 March 19, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Weber Subdivision, Lot #2 Bell Hollow Road (T) Putnam Valley, T.M.# 62. -1 -55 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -2, "Proposed SSTS," dated 3/19/02. 2. Short EAF. 3. "Application for Approval of Plans for a Wastewater Disposal System," dated 3/.19/02. 4. "Construction Permit for Sewage Disposal System," dated 3/19/02. 5 "Applicafion.to Construct_ a Water Well," dated 3/19/02. _ ------ , ._..- ..._.,;,..:.:..:._...,._. d° 6: - : -- -`• LGSIY,ci ata S lftL *" ...._ ....._. _.. ......._. _.._: �..._ _ - -- • .� _... 7. "Letter of Authorization." 8. Two {2)- copies of residence floor Plan(s), - - 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. Nic is Jr., P.E. HWN:JM:jmm 02 -017.02 .. .P: UTNAM. COUNTY DEPARTMENT ♦ OF THE EC AT�i1 T7H TY.� �JW5 VTJ1 O ^ iili �NKLk y.,!!.�- tA.b±l,.r,.i•.:., 1�, ^.115:�.,._'le +T. S.�= .+..�� DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner GHQ o W H P.NH EOi -9 Address Iii ' �'S 'I 1 ¢�R� 9-0 Located at. Street . R'D i �' ' Tax Map Block""' (indicate nearest cross stre Municipality Watershed SOIL PERCOLATION TEST DATA•; Date of-Pre- soaking Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained a4gh •percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted -for review. 2. Depth measurements to be made from top of hole. Form DD -97 Hole 'N Run No Time Start $top Eta of . ime Min:) D�eptb to''V1!ater From Grpund -S.urface (Inches) Start <Stop Water Levelercolati�(:` Dro In pp finches Rate MI. nch 2 3 Lsfl �� 1i2 2',� 4 .26�I�I• 2�i�_. . �2 . l �o� ��° �a tip_ (o�ZJ � . • 2 I.�r� �QrL 4� V4 '2`IL IYL 1241 •3o�t3� �0 . 2A 2'11; lilt �..�,j. �.._ ._.:.. 4 -r-7. a rr 4 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained a4gh •percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted -for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH. HOLE.NO....... HOLE NO. HOLE NO. 3 G.L. 1.0' 1.51 2.0 SL S� 5��►p� 2.5' . ... P -�r�r� _ ..SRS► `� ... � , ��N : ; ...... . 3.5' 4.0. i 5.0' oUl _... Om t .6.5' 7.0 LN 4 7.5' 8.5 ' _.._ 10.0' o snn Indicate level at which groundwater is encountered Indicate level..at which. mottling is observed NA c4� -' 7i. m Indicate level to which water level rises after being encountered A �; Deep hole observations made by: ADAM � ii; EU�► ��'�� �'. Date Y_ Design Professional Naive: 'W W W,, kC/R0,,S j 30- FE Address: 2pSl) ZZ. -t%E W NIC o G7o °I Signature: _ a� �p No.'S6124 OA % Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH • ' DIVISION OF ENVIRONMENTAL'.HEALTH,SERV-I.-ES' pER.OVA N s'.3<'D?' - TT A ..A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: G 'q Ir1 I-AF, P #<H R. �—p .. N .: �:L•- .?���`: >• ,;., :,; .� x.. 2. Name of project: Location iM' 4-.,-- Design W"� iii(, O LA J�L, 5. Address: �660 4 Z� 6. Drainage Basin: 7. Type of Proiect: Private/Residential Food Service Commercial - -_ Apartments.. Institutional Mobile-Home'Park Office Building Realty Subdivision. Other (specify) 8. Is this Proiect sub'ect.to State Environmental uali Review SE R s. Type Status (check »one).. ......... ....... ...:....:...... ' .Type I empt Type IL,: - :.: : Unlisted-' X, . -9. Is a Draft Environmental Impact Statement DEIS required? No 10: -Has DEIS been completed and found acceptable by Lead Agency? ...........::. I I ;-Nary a of Lead Agency N A. 12 Is..this project in an..area under the control of local plaruiing;.?�ning; or.other b _ ,, x - b ~:omciafis ;'ordinanes ?�::...: ... ,•_. .......................................................... ... 7.:.. _ ..,....... 13:' :If so, have plans been,submitted to such authorities?, :...... ............................... q 14 Has preliminary , approval been granted by such.authorities? h o Date`granted: 15. Type of Sewage Treatment System Discharge...... ............ surface water Xi groundwater 16.. • If surface water discharge, -what is the stream class designation? 17; • Water's •index number (surface) .........:.......:. V N h ° a ....... 18. Is project - located near a public water supply system? .. ............................... - NO 19. If yes, name —water supply NP .Distance to water. supplyo .4 h, 20. Is project site near -a publie"sewage collection'or•treatment ' ? ... system .:....:.:...... - 21. Name of sewage system N� Distance'to`sewage syterYi `NW 22.` Date test holes observed 1 j )24(gq 23. Name of Health Inspector ADAM 51'Ir�EU Nra $ 24. Project design flow (gallons per day) 6 d s,r 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... NO 26. Has SPDES Application been submitted to local DEC office? ......................... N A Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? 28 Wetlands ID Number. _ s_.. .... ........................... - - — 29. Is Wetlands Permit required? ....- - F4 Has application been made to Town or Local DEC office? ............................... P A 30. Does project require a DEC Stream Disturbance Permit? N 0 2 31. 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"�o_... 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? ............................... DESCRIBE: Yes/No'o 33. Is there a local master plan,on file with the Town or Village? ......................... ` s' 34. Are community.water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site. ................ rs o 35. -Are any sewage treatment areas in excess of 15% slope? 36.. Tax Map ID Number ........................:. ............................... Map G2 Block' ,......Lot 55 37. Approved plans are to be returned to ..... Applicant_ Design Professional- NOTE:.All appl iQat; am , for review--and »Yrro al. ofa ��a W 33 T S to be located within the N YC 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, underpenally 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. Sect'on 210.45 of the Fena . ATZURES & OFFICIAL TITLES. a W H I c;+ -rot, �E P; kei4 Address: ................................... p (Z'r Cr- a- 3 o DIMENSION CHART (in feet) Number A B WELL 45 119 SERTANK 1 21 5b cool 46 104 Coat 66 149 COa3 154 216 COn4 215 276 0085 253 311 2 279 336 5 285 341 4 291 346 5 2% 351 6 301 355 7 306 359 B 311 364 9 316 369 10 921 373 11 326 377 12 256 306 13 261 310 14 266 314 15 272 319 16 276 322 17 281 326 IB 286 330 19 290 334 i G, t7 O NOTES THIS IS TO CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM WAS CONSTRUCTED AS INDICATED ON THIS PLAN AND THAT THE SYSTEM WAS INSPECTED BY ME BEFORE IT WAS COVERED OVER. DIMENSION CHART (in feet) Number A B 20 294 337 21 299 340 22 291 350 I Exls' WELI 156.00' 516 °4T 28' W° THE SYSTEM WAS CONSTRUCTED IN ACCORDANCE CNO WELLS/ 5515 vJIrNIN Zooms WITH ALL STANDARD RULES AND REGULATIONS OF THE DEPARTMENT Of F.jAAI.TH AND TH NEYd,YQI2K.,z,•�.�:._o -... ..; :.y..,..�.,- .......x.,.r.��....•<,... :.- .�..... ». ... .._ ..... aif ;Y�E•IIBPfcRTM�IVT:OPHEALTI'i;: -,_ . _.: .. _ .:. ..... ...........- ._....._ _ �... ..._ ._ .. ._ _ ,_ ... _. .. SURVEY INFORMATION FROM SURVEY PREPAREDBY TERRY BERGENDORFF COLLINS, L.S. K12A a A,, ._a_ 0 170.06 522*10128"W PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROTENT ENT HEALTH SERVICES. APPROVED AS NOTED FOR CONFORMANCE WITH APPLICABLE RULES AND REGULATIONS OF THE PU AM COUNTY HEALTH DEPARTMENT. /SJONATURE & TITLE DA 99.61 U tu r- 5' L CotiNGM ............. SITE LOCATION PL, SCALE: V'= ZOOO' PROPERTY SHOWN ON TOWN OF PUTNAM TAX MAP'. 4Z.-I-55 —1 ^A n-1 PROJECT: PROPOSED 5575 WEBER SUBDIVISION LOT N27— BELL HOLLOW ROAD PUTNAM VALLEY NEW 1Y CLIENT: CAROLI HE S. DANFORD 110-45 71 ROAD 2C. FOREST HILLS NEW V Harry W. Nichols Jr., Suite 106, Patterson P 2050 Route 22 Brewster, NY 10509 (645) 279-4003, Fax 279-4 CONSULTING SITE ENGIN DRAWING. TITLE AS-SWLT S575 L0'r Ne 2 SCALE 30, NEW DATE : 0.3-rA--