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a
\, f . PUTNAM COUNTY DEPARTMENT OF HEALTH
4
EN
CERTIFICATE OF CONSTRUCTION COMPLIANCE SEWA, TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # /may ;Z7 -0l
Located atO,ylr����� Town or Village
Owner /Applicant Name 17%C17 �/ C�. ace/4 Tax Map _ 74 Block / Lot
Formerly Subdivision Name
Subd. Lott #
Mailing Address 27-33 ZL50re XV Zip /off i
Date Construction Permit Issued by PCHD /a/ -,/ /
Separate Sewerage System built by 67�16W `vim Cv��' Address Aoi3 -I-r Alva
Consisting of %o a y Gallon Septic Tank and �d ,�� 2 ,4
41 e, fr
Other Requirements: % / C
Water Supply:
Public Supply From
Address
or: % Private Supply Drilled by1,�rr �,� /�a/j Address /
c� -
Number of Bedrooms Has garbage grinder been installed?
.lel
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putn Department of Health.
OF N
Date: &.-I ell & .7-, Certified by � P, i y P.E. k*" R.A.
,LIJ
Address 2— ,:7,,
Any pe n occupying premises se a by the above
* I License # �'- y �1� --s✓
take such action as may be necessary
to secure the correction of any unsanitary conditions resuliuch 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
revocatio , modification r change is necessary.
By: Title: r Date: {'
White copy -.HD I, Ye o copy - Building Inspector; Pink copy wn , range copy - Design Professional
Form CC -97
PUTNAM (COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL IE1<IEAILTIH[ SERVICES
WJELL_COM ><, 0 ! -
Well Location
Str t Address: �67-7:?
lla e•
"
Tax Grid #
Map, Block Lot(s)
Well Owner:
e: I Address:
v� N 4&L
Use off Well:
fl- primary
2= secondlary
esidential Public Supply Air cond /heat pump Irrig tion
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
?t Rotary Cable percussion Compressed air percussion Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock _ Other
Casing Details
Total length / 3 S ft.
Length below grade 43k. J
Diameter in.
Weight per foot alb /ft.
Materials: Steel _ Plastic _ Other
Joints: _ Welded X Threaded _ Other
Seal: jam. Cement grout _ Bentonite Other
Drive shoe: -'21-, Yes No
Liner:_ <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%
v
Yield O p
Depth Data
Measure from land surface- static (specify ft)
During yield test(ft)
_
Depth of completed well in feet
gg �
Jed
Well Log
If more detailed
information
descriptions or
ev "atiaiyses
are available,
please attach.
Depth Fr
Surface
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
Pump Type Capacity
Depth A 22i Mode`
Voltage O HPY
'Tank" 0 Y Vol me -2 _ /"7
Date Well Completed
9/6 71
Putnam County Certification No.
11
Date of Report
Zo —
.
Well Driller (signature)
i;NUX E�Exact location of well witn instances to at Least two permanent iramarxs to or pruviucu uu a bupata« aiI" F all.
i,
Well Driller's Name ,g"ZrAe-j— �� ' Address */• /
Signature: _ �,�, -- a -- Date:
White copy: HD File; Yellow copy - Building. Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
I
� YML ENVIRONMENTAL SERVICES
321 Kear Street
Yor k ' --
Albert H. Padovani, Director �
LAB #: 32.202564 CLIENT #: 55375 NON STAT PROC PAGE 1
~~~~~~~~~~~~~~~~~~~~~~~~~~~~-�~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
�
MCCORMACK, RICH ' 74~�-- �� � DATE/TIME TAKEN: 04/08,02 11:30A
23 STEPHAN SMITH DR DATE/TIME REC'D: 04/08/02 1200P PUTNAM VALLEY, NY 10579 REPORT DATE: 04/16/02
PHONE: (845)-528-1491
SAMPLING SITE: 273 BARGER ST,PUT VALLEY,NY SAMPLE TYPE..: POTABLE
: TANK , PRESERVATIVES: NONE
COL'D BY: SARAH ANDERSON TEMPERATURE..:
NOTES...: COLIFORM METH: N/A
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE
PUTNAM CNTY
PROFILE
04/08/02
MF T. COLIFORM
04/08/02
LEAD (IMS)
04/08/02
NITRATE NITROG
04/08/02
NITRITE NITROG
04/08/02
IRON (Fe)
04/08/02
MANGANESE (Mn)
04/06/02
SODIUM (Na)
04/08/02
pH
04/08/02
HARDNESS,TOTAL
04/08/02
ALKALINITY (AS
~ � 04/08/02
. '.TURBIDITY ITUR,
RESULT NORMAL - RANGE
ABSENT /100 ML
10.5 ppb
<0.2 MG/L
<0.01 MG/L
<0.060 MG/L
0.010 MG/L
3.75 MG/L
6.4 UNITS
48.0 MG/L
48.0 MG/L
'- <1^NTU
ABSENT
0-15 ppb
0 - 10
N/A
0-0.3 mg/l
O-0.3 mg/l
N/A
6.5-8.5
N/A
N/A
0-5 NTU`
COMMENTS:
BACT THESE RESULTS INDICATE THAT THE WAT WAS NOT) OF A
SATISFACTORY bHNl|AKY QUALITY ACCORD E NEW YORK STATE
AND EPA FEDERAL DRINKING WATER STAND OR 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 ale 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 /L of Sodium
METHOD
1008
9101
9139
2037
2037
9043
YML ENVIRONMENTAL SERVICES
321 Kear Street
(914) 245-2800
� Albert H. Padovani, Director
LAB #: 32.202564 CLIENT #: 55375 NON STAT PROC PAGE 2
MCCORMACK, RICH DATE/TIME TAKEN: 04/08/02 11:30A
23 STEPHAN SMITH DR DATE/TIME REC'D: 04/08/02 12:10P
PUTNAM VALLEY, NY 10579 REPORT DATE: 04/16/02
PHONE: (845)-528-1491
SAMPLING SITE: 273 BARGER ST,PUT VALLEY,NY SAMPLE TYPE..: POTABLE
: TANK PRESERVATIVES: NONE
COL'D BY: SARAH ANDERSON TEMPERATURE..:
NOTES...: COLIFORM METH: N/A
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD
is suggested.
.pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF
THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY.
WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND
FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5.
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 O TO HUNDREDS OF MG/L, DEPENDS ON THE
SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED.
�R��Fk��I�W
MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER
| HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) |
SUBMITTED BY: -
Albert 44~Padovanfl M.T.(ASCP)
Director ELAP# 10323
P UTNAM CO UNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIROr�MENTAL HEALTH SERVICES..... _
.:S ..
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner or Purchaser of Building, Tax Map Block Lot
Building Constructed by
Location - Street
Building Type
TownNillage /
sd��l�s q-,R,d /���sSE�
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
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 5_Day_Z,5 Year
) - Signature
Corporation corn
on Name if co oran
a
tio}
/8
Address: _ va, " e �'(
State ���, Zip /D
Si g nature• �4n^'./
Title: Dwr? e.-i^
Corporation Name (if corporation
Address: f `
State Zip
Form GS -91
Public Hecith, Director
. 4
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
I Geneva' Road
Brewster, New York. 10509
Environmental Health (914) 278.6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 . Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278.6082 Fax (914) 278 ! 6648
E911 ADDRESS VERIFICATION FORM
TAX NIAP'NUMBER:
E911 ADDRESS:
A . RIZ W
110ED TON OFFICLAL
UT
(Signature)
.. . . . .........
The Putnam County Department of Health will not issue A-0e r0da-t-6--b-f
Compliance unless the above form is completed, 1.9.9 glegal E91-1-...
assigned by an authorized town official. This form As-to--bd.subm.itted----
Ni-itb the application for a Cirfific'ate of Co ns tructio n C om a c&'.
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PUTNAM COUNTY DEPARTMENT OF 1IEALT11
:.�.. :..- .xDIViCiON_ .F� k:NVT.RONMENTAL,
4 FIELD ACTIVITY REPORT
A'nn'RRCC:_ 13,#1ZC957Z 52: . IL9LL 6y AXY,
Street Town State Zip
PERSON IN CHARGE
1
a
OF
PUMP TEST [j DOSE TEST
nI- /fl
I.
03
O m O O
\
I
I
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. 6-//6 /o-)- -/l/
REQUIRED GALLONS
Signature and Title
DEPORT RRC`.RTVF.T) RV.
I acknowledge receipt of this report: SIGNATURE:
02/96
Rpm-
Title:
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONIAENTAL HEALTH SERVICES .
FINAL SITE D6PECTION S /G�o� �,4�1
Date: 3 //_ o� .sop e� (ebele�g
Steef Location
5AK6� 5T2s_"c-- Owner
Town _� iiMA& Permit 4 ?V-
TM r 7 (2. Subdivision Lot 4 �
I. Sewage Svstem Area YES � CO1� MENTS
a. STS area located as per approved plans ...........................s Q
b. Fill section = date of placement
3:1 barrier Lgth. Width Avg.Dpth 1,51
c `Natural soil not stripped ........................ ....:....................
.
d. Stone; brush, etc., greater than 15' from STS area..........
C. 100' from N ater course- wetlandsy,, ......... - .— --
II:-_S ewicre Svstem � , @-- - g�y� nor per
peptic tan�_si .. ::
X1,400: -� 1;20. other.
b. Septic tanki evel ................ ...............................
c. 10' minimum from foundation�..................................
, � � , 3 • r .� s = -, .�" �io r .� - �.-..,�- �
T1 'ATl out DeTiit,s ame elevton w ested ::
2. Protected below frost .................. ...............................
3. Minimum 2 ft.Original soil between box & trenches
e. Junction Boxx - properly set ........... ...............................
f. rent ches
Length required 5 Length installed 5
2. Distance to watercourse measured-71- /00 Ft.......... '
3. Installed according to plan ......... ............................... . '
4. Slope of trench acceptable 1 /16 -1/32" /foot .............
5. 10 ft. from property line - 20 ft.- foundations..........
6. Depth of trench <30 inches from surface ........ :.........
7. Room allowed for expansion, 100% .........................
8. Size of gravel 3/4 -1 %2" diameter clean. - -
_ _.- .�.E..�1i ttth grK.
ends capped . _
:urn Dok&Sv 5�k
e;g pump c aim er '
2. Overflow tank .. .........................:.:.... .......... -,6- X _ate _.7a,i.. cor.
3. Alarm; visuaVaudio .................... ...............................
4. Pump easily accessible, manhole to grade .................
5. First box baffled .......................... ..............::...............
6. Cycle witnessed by H.D.esfunated flow /cycle.......:...
III. ouse/Buildin
a house located per approved plans...
b ?lumber of bedro ms ° a /� a3m,�Q- °
-
-"
a7-Well located as per approved plans .............................
b. Distance from STS area measured r/ oo ft .........:.
c. Casing 18" above grade
dam: S ce drat a aio4t� uid well acceptable:. =� kn TiY►�� Y . ' '
g //
V. Overall "i�Vorkmansliin / �`;` °'�P;�r��t */� Jn °'o.'srea'`�
a. Boxes properly grouted ................... ...............................
b. All pipes partially backfilled ........... ...............................
c. All pipes flush with inside of box ... ..:............................
d Backfill matenal contains"stones <4" diameter .-
e K CUrtaui drains &_stant Ape`s'installed ac oidtng
f u-'rtain drain outfall protected & dir.to exist waterco^ se
g� Footing drams discharge away from STS area
Er ce waterprotectionadequate
h Surfs - '
r
i onion co t l provided ......: fi
03/13/2002 12:38 9149624248 JOSEPH SULLIVAN .. . PAGE .. 01. --,- —
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
ATTENTION 13 ADAM GENE
REQ=j FOR FINAL INS 1JCTION For: Fill
All information must be fully completed prior to any Trenches _JZ
inspections being made.
PCHD Construction Permit
Located: if
.4 e4f (1) (V) /�4—wa lov—klalle-
Owner/Applicant Name: .r e~.& /< TM 710 • Block Lot
Formerly: Subdivision Name:— ;2
Subdivision Lot # - -1
Is system fill completed? Y-4�4, Date:
Is system complete? of o Date:
Is system constructed as per plaa4f Vr—,o -
Is Well"drilled? /( Date:
Is well located as per Pima?
Are erosion control• measures in place!'
I certify that the system(s), as listed, at the above premises has been coakructed, and I have inspected
and verified their completion in accordance with the issued PCHD Construction Permit and
Me V1,11e -put im-&-Coud� -D�
Health.
Date: Certified b y: PE — BRA
Design Professional
Address:
Comments:
Form FIR-99
AO
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M1 ML I^M
0
OV
74.09
74.13
---- - - - - --
P/0 63-3 -51
AL JL 35
..t—oo - - —� 4
AL 38.29 AC
BRYANT
PO/V,9
74.06
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74.10 It
4.14
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RYAN
POND
PON D
4 60
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LT3 A
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it
407.39
9
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4.78 C. C L
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POND
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4 60
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All
_.P ."•,a c ". �_;y".'.. .. i's�'sxi.�.c•�r•i'" R<i .%•.,�w:..�- _:rr :W:�.3 s•R �.r:`•�.:.m.r�. �. :r
BRUCE R- FOLEY
Public Health Director
March 19, 2002
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
LORETTA MOLINARI R.N., M.S.N.
Associate Public Health Director
Director of Patient Services
Environmental Health (845)278-6130 Fax(845)278-7921
Nursing Services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085
Early Intervention (845)278-6014 Fax(845)278-6648
. Preschool (845)228-5912 Fax(845)228-6113
Frank Sullivan, PE
2972 Femcrest Drive
Yorktown Heights, New York 10598
Re: Field Inspection - McCormick
Barger Street, (T) Putnam Valley
Lot # 1, TM# 74 -1 -6
Dear Mr. Sullivan:
The following comments must be corrected in the field.
1. Expose comers of the septic tank and pump tank.
2. A pump test needs to be witnessed by this Department once the electrical inspection has
n) i f16 tift a. � ecyl S "t)1�rr1.; �:d. ±- Ahl i;c
3. Stand pipes need to be installed as per the approved plan.
4. Silt fence needs to be installed downgrade from the well.
5. All silt fence must be properly installed in the ground, as per the approved plan.
If you have any further questions, please contact me at. (845) 278 -6130 ext. 2261.
GDR:cj
Very truly yours,
/- 0�2
Gene D. Reed
Environmental Health Engineering Aide
BRUCE" k. - 'r`Gi EY
Public Health Director
�LOI'c�'17A �MOLINA�" -kN' ., M.S.N.
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845)278-6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648
March 19, 2002 preschool (845) 228 - 5912 Fax (845) 228 - 6113
Frank Sullivan, PE
2972 Ferncrest Drive
Yorktown Heights, New York 10598
Re: Field Inspection - McCormick
Barger Street, (T) Putnam Valley
Lot # 1, TM# 74 -1 -6
Dear Mr. Sullivan:
The following items are in violation of Article III, Section 2C of the Putnam County Sanitary
Code:
1. Silt fence has not been installed below the well. A trench was constructed allowing silt
and tailings to enter the adjoining stream.
Please note that all silt fence must be properly installed as per the approved plan prior to the start
of any construction.
A formal notice of hearing may be issued if the violation is not corrected within 5 days. It is truly
hoped that the above violations are corrected without having to take legal action.
GDR:cj
cc: Norman Anderson
Richard McCormick
Very truly yours,
RIP 5-11f
Gene D. Reed
Environmental Health Engineering Aide
SMMG-CONRUM.-T, N
DATE : MAR-20-2002 WED 00:09
NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH
TEL 845-278-7921
PHONE
: 919149624248
PAGES
: 2/2
START TIME
: MAR-20 00:08
ELAPSED TIME
: 00'55"
MODE
: ECM
RESULTS
: OK
FIRST PAGE OF RECENT DOCUMENT TRANSMITTED...
BRUCE R. F01" 1A)RMA MOLWAJU R.N. M.S.N.
A—d.* ft&. h.." Dfts tar
M.00, -f Pa w,#
DEPARTMENT OF HEALTH
I Ckmeva Road
Brewator, Now yoft losog
11-ft(us)2111.600 F-MS)271-11111
Wj*; a. (145)27A-6Sn sec (WS)27a -6679 9.(645)2711-4W
X" Tftrwa#-p W278.$014 Ra(1545)2701-601
n"dwd(WS)U8-"12 Fas(041)228-6113
March 19, 2002
2972 Famorest Drive
Yorktown Heights, New York 10598
Re: Field Inspection - McCormick
Berger Street, M Pumsm Valley
Lot # 1, TX# 74-1-6
Dca Mr. Sullivan:
The following comments must he corrected in the field,
1. Exposo oomers of the septic tank and pump tank.
2. A pomp test needslo be witnessed by this Depairtniont once the electrical inspection bas
bam completed and notification of such has been submitted to this Department.
3. Stand pipes need to be installed as per the approved plan.
4. ce Silt fenneeds to be installed downgrade from the well.
5. All silt fence must be properly installed in the ground, as per the approved plan.
if you have any fiather qucstiom please comw me at (845) 278-6130 ext. 2261.
Very truly yours,
A-1111,
Deno D. Rood
GDR:oj' Environmental Health Enginoming Aide
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From: RICHARD MCCORM,Fax: +1(645)526.7436 To: gone reid Fax: (845)2767921 Page 1 of 2 Monday, May 13,2002 10:32AM
0
q '., ._ ;c_:w. ti�:��.. _.�... .•e'C �-- °,_- -rc.3 �- ,""^Ue.c _i. � .. .. �'- r.�.cu...y� -ti" .....,. "1i� �l'�rtFv�s -:. ":"i`"s'-•, -. ...ar.� -... r�,R
�0 o gene reid
Phone
F &u Phone (845)2787921
IDate: Monday, May 13, 2002
Pages including cover sheet: 2
From.-
RICHARD MCCORMACK
23 STEPHEN SMITH DRIVE
PUTNAM VALLEY
NEW YORK 10579
Phone
+1(845)528 -1940
Fax Phone
+1(845)528 -7436
_77P_70�1
KIOMC - PI ITKiom rni 6.ITV I)CP0QTMrkIT fll= P 1
o�
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF M
ENVIRONENTAL HEALTH SERVICES
•.�::• - .e.:q.:.al�`7ri =: . _ .. - - _ .. oz air° � cj° ^.,_ ...
---!7m -7 ..�: .. :�.ae Z" -;4!^ F ..
CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # loll-t9-1-0t d
%G►Y 1 / �jL!"� �'%'� Town or Village X���
Located at $ g � ,Vw4y
Subdivision name Subd. Lot # . % Tax Map Block % Lot
Date Subdivision Approved 1fd57 Renewal Revision
Owner /Applicant Name 9111c4e'j I%C� rr� l��i Date of Previous Approval
Mailing Address ;23 y e,& Zip
Amount of Fee Enclosed 23 C7 ey
Building Type Lot Area 3 - ;2 &No. of Bedrooms 3 Design Flow GPD o o
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
sv tem to consist of
Other Requirements:
To be constructed by
a gallon septic tank and .mod
��.� .2 ' rev /� �• %�
Address
Water Supply: Public Supply From Address
or:--i7 .. - Private Supply Drilled by _ �? U i� ^` "--Addre'ss' `% -5
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. �1
pF NEW yo
Signed: ~P ANC /S `rG �� E. R.A. Date V13
Address ;2 f % 7— ��� W License # ;-2 'V "Y"
�jf�i� 248
APPROVIA FOR ONSTRUCTIO ires two years from the date issued unless construction of the
sewage treatment system has been complete 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 perroNt. Appro ed fo Wcge domestic sanitary sew only.
By: Title: (ior, Date: 101
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professio al
Form CP -97
PU NAMI COUNTY DEPARTMENT 07 HEALTH
DRWSRON OF IEN VERONMIIENTAL HEALTH H S ERVR CIES
-
APPLICATION TO CONSTRUCT A W. AT ER WELL
please print or type MhIJ Pirifiii
We11 ILocatnone
Street Address: TownNillage Tax Grid #
,� el �a , Map ?* Block / Lot(s)
Weal (Dwnein
Nam :
Address-
Use off WeRI:
Aesidential Public Supply Air /Cond/Heat Pump Irrigatio
I- pirimairy
Business Farm Test/Monitoring Other (specify)
2- semmdlan y
Industrial Institutional Standby
Annnma mt of Use
Yield Sought �r gpm # People Served Est. of Daily Usage e, al .
IBeasolm ffoa•
Replace Existing Supply Test/Observation Additional Supply
IlDn!uJiiig
I,-New Supply (new dwelling) Deepen Existing Well
DetsMedl Reason
ffo>r Pniflkg
WeB Type
Drilled Driven Gravel Other
Is will site subject to flooding? ................................................. ............................... Yes No A,-'
Is W11 located in a realty subdivision? ...................................... ............................... Yes X.- No
Nane of subdivision Lot No. p
Warr Well Contractor: A 1--,Vel b Address:
Is IPiblic Water Supply available to site? .................................. ............................... Yes No A,-
Name of Public Water Supply: TownNillage
Disgrace to property from nearest water main:
IProesed well location & sources of contamination to be provided on separate sheet/plan.
iialica At. Sigr4Vare
PERMIT IT TO CONSTRUCT A WATER WELL
Tb6permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
IEAarn County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
ithawithin thirty (30) days of the completion of water well construction, the applicant or their designated
rersentative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
retirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
P "ded by the Putnam County Health Department. During all well drilling operations, the applicant and/or
wr driller shall take appropriate action to assure that any and all water and waste products from such
wj drilling operations be contained on this property and in such a manner as not to degrade or otherwise
coaininate surface or groundwater.
.&JIROV EID.IFOR CONSTRUCTION: This approval expires two years from the date issued unless
c4naction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
ceded or modified when considered necessary by the Public Health Director. Any revision or alteration
<u-te approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam
Y.
�; of Issue (oil S °i Permit Issuin Official: a4 R
jCy, of Expiration 1:71,0 Title:
]P-omil b Non- Traansfer>rabIl
106,e copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WP -97
PUTNAM COUNTY ]DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
RE: Property of
Located at
Jf
T/V _r =� -9 ; Tax Map # 7 Block �_ Lot 6
Subdivision of e'n
Subdivision Lot #
Filed Map # 2- 3 3,4 Date Filed 7
Gentlemen:
This letter is to authorize dv-.s �hL! /��
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 I.�aw, the PubLic.Health.
Countersigned:
Mailing
State 2.�-
i 1e�✓'Z
Telephone:-
Very truly yours,
Signed:
(Owner of Property)
Mailing Address:
V/.
State /., U Zip
Telephone: � �� �'� �' / , e
Form LA -97
Goulds
Huhn
r �y
-.. , ' .. nA ,a.&..u.,a.+6owr......�Lrarww+a �lw, / i � •
N{tfiGW pro eri k mum smovFujim, ors ;t :� ,��i�.r�tcE rontulutlEa� y=
h. t_ 7� PrwV1!'!0 . i!i s I ter u!
d l +. f, . `' 11 }1 +3Lr "iii3illy �a 4`ti<:t lilt rt %1i (l t}L
p8tif'i I' 'si0,nr.dfc''thc ¢ 'Snai., threaded: 4�l +i
tt1iitl4Vl[e.s, , i4 11 . d r�c7!lYoS�.Ipi)fv('.aflt�
• r3;r SsUS1 mew, 0 , duty W1 17('itr111
�
Btiiiings: ;N teal Ag` !ype �...;( 1 tifCiiJil��;1!C'Efi }` (rv,lEttU(1r`UCf,
i >Wr courts f I )we! 21; r" ' t I J 1�9 f �44�St'iii�ls� a� .�i't3iiuty� �
- . i;c tv�i1 . rdtari; i 1e(yywrtld ��J &tGr re6s(St 11, ,
s.Yt C47, Y Yl'tltbr °.2Rd
, Ij ,- ?: fr �.. s_,7 ,�IY_:t',e.;Pt �,�.,y � t t �
+r th,s �walla,,le,, y r
t;t�;�OM E T SWON pMvide secondary moisture
11,du5ir, StOglp phone! .- f;,�l''iOW _+ rsiU fi^v5. .a�1r?ii3r'rl 1cw'0 Gf oSr lF1'*'k "i
I $ r- i ' t 6 and rl HP i v.� ,,J -01 4. h 1.1: •: , , � 1t , r ( ' .•,
E flu("' �. syst�.rns � n gel r:,:tt,. p. t:', alnag, and is preu ht "D
wQM 117 V or 280 v Me �iri��, ,s t,'.ast0i� ere,, wicking;
> �+Agep yrp��,11 1y�k�Migg��e� profl.g lUWg. t ey A
V1 CR i.p,RSi'i1U+7941'478E�Y _ so! r[ 1 P —' U So) ':0111 Y1
� c�t�iili` ��i,'l l'r air. �1 .tiJr,?l.ii'l Yom:.. 1d'�iEE�� muls po—SR* i 9
F'UITit1 Lire leads. "1uirliE � ', UB? r 1116 Ir C SeallfYa.agaEt�5t L'tiRt�]friino is
* ] %i�i!?u I'.PlEtill1 C2h atJl iui3t:: T tiros ,'3liiiSi : rL ' r i ,aw nui n thme and 9,i (etikt:Rr .
21% HP— 10 STC pme nu ds to aua(u
060mwe sit NPT. 40h bare lr;,,S On OSA agshm conpunerd dw;Vle AGENCY LIST9MQS
•'t ir• M1J t I 1 . rrli?r p :•n� r. ..«+�+...,�.. s
Capaciba; up to 1 �tt3 GPwi t•, d n10 eIG - 210 fna- r .;ct , i I t,s ..�,�ii..l , a
!? Gan,, ^,t ?:aye Sta rlISardsAnar.ralttrtl
Total heads: up W 123 feet drt J;i? a,! I'�,i?l and ST'y't'" a 1An4•Iir 4illd 'Lib 'l'vs �c iri Ji
'•D#1, aw Wrllw -d. t`,gi) gf; d `ibine oil for f
sHdl; -silicon ;rd ofi;tNl,Jl °iE f CJ:,Iruttm LiWratoff 0 t'
i;arhi! +8'�t� tsr���t'Sili�gr; FEATUAt _ transiFr �;
a•lllipl�.l1%'f_ {.,.YSI ?CUR 3E ?1111- � r`1G' :i�iit" fl,!5.�.�.siifI'Ee� .....
series s air0esis steel matai (. Operation; r t ';+? t rl ary
n 1:7r1, 11Df1-C1�7g i'1✓iff? f)Ellli;!- '��! t t:a_iLlt, .
�1at u, DUNG. -N elastoaiiur` - 41I.It Vanes , lfd I r?CCi10r;1 rn S$Kll WAN :; t max r1�i!'°lll�sower�s
a Temperature: I
pla ecton. Balanced for
eI1Ue4 Vviking limits,
104cF (40 °C )
continuous
14WF (60°C) intermittent. METEA3 PUT E
v rastarlers: 300 series coi `__ -.. -. _ _.; ......�
NOW So , '
., , t. vil�'
- �!p abie of running diy =�' 30 r 1 I ".
ts
i
_ I
Whou1 darn age to
1
Single phase: i wrnrrr r `;�. ``.,, . I i ! I .. ,
RPM; � 1
1��1, I
Hwy_
>ly 3�O
��J .�P, f �' , ^t
ii HP- 1'i;:HP, 230 V,
i)
Built-in overload wlti I , �' --- �:....>e,..,s�"''"��...�;.,. '�.. � �.I � I..�'"'�;w, •�..;, i .,�_
autonlotrc
r
tiltlSv g lf151+iOUr ?. \ ( r I ; i , ~�''- "'7 �= 1 •ti.,, e
"`h:t�e Phase" iLr ( ' ; �;.��..`,, ' ._.�,.'.,,,�.� 1 I r
f r i 1
�Jry �{ i
IA' HP —111 H11 20012 0! u` t .. {-., I 1..
460 V 60 H�, 3500 ApNI. 10 20 30 wo o din. ;.�
Class irESUlatic�n......___� r
_ _.._ ...���.___._.- _-- __.__.._.__._. __.._ _ - _.....w
Io i e 20
CAPACITY
11905 MOUIs Pumps, Wc, F:f19DtIV,�.iV�B
��IIt�. •.... ....,
- ' "_ ... ..-.'. ..:. ... .� .�r. -, ':.� -... it :,. .:, ,:'....'�_.. '.. -:.: ..., .:w. .. ::. . �r.r. ».:.::.'"• .,. wU .. '• �•.�„'�iyn.vr+cra:'iF.`a.��•"'� - .
r c n
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
- "PLICArI ION F6' "AP'PiWVAi OE I'LANS7FOR -.
A WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant:
2. Name of project:
4. Design Professional:�5���� vp�
6. Drainage Basin: 130
7. Type of Project:
Private/Residential
Apartments
Office Building
3. Location
5. Address:
Food Service
Institutional
Realty Subdivision
Commercial
Mobile Home Park
Other (specify)
8. Is this project subject to State Environmental Quality Review (SEQR)?
Type Status (check one) ....................... .... ............................ Type I Exempt
Type II Unlisted
9. Is a Draft Environmental Impact Statement (DEIS) required? ..........:.............. �Y'o
10. Has DEIS been completed and found acceptable by Lead Agency? ...............
11. Name of Lead Agency
_...tisaajcl:in an. t.tic',er'�.:cc�ntro .o . oel a�aig,:�ni�g,
_...._ :1:. f1 ail'
officials, ordinances? ............. ............................... ......... ...............................
13. If so, have plans been submitted to such authorities.
14. Has preliminary approval been granted by such authorities? _ Date granted:
15. Type of Sewage Treatment System Discharge ................. surface water Y' groundwater
16. If surface water discharge, what is the stream class designation? ...:...... ....:...... --�
17. Waters index.number (surface) ..........................:
18. Is project located near a public water supply system? ....... ............................... --
19. If yes, name of water supply Distance to water supply
20. Is project site near a public sewage collection or treatment system? ................ Ie
21. Name of sewage system Distance.to sew ge system
22. Date test holes observed" 1y10 23. Name of Health Inspector AM .
24. Project design flow (gallons per day) G °O
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.:. A/'a
26. Has SPDES Application been submitted to local DEC office?
.. Form PC -97
F
27. Is any portion of this project located within a designated Town or State wetland? Ale)
28. Wetlands ID Number ..... ...............................
_ .. �4. Is'Netlanus Yeririit required ......................... ............. �
Has application been made to Town or Local DEC office?
30. Does project require a DEC Stream Disturbance Permit? A/'v
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
32. Is project located within 1,000 feet of existing or abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or any
other potentially known source of contamination? ............................... Yes/No w
DESCRIBE:
33. Is there a local master plan on file with the Town or Tillage? ......................... Alel
34. Are community water and/or sewer facilities planned to be developed within
•�
15 years in or adjacent to project site? ................................ .........:.................:...
35. Are any sewage treatment areas in excess of 15% slope? . ............................... Ive
36. Tax Map ID Number .......................... ............................... Map Block ) Lot Z
37. Approved plans are to be returned to ..... Applicant e,' Design Professional
NOTE:,All applications for review.and approwal of a new S$T'1to b
= 1ra�sc 'the-be aftftfeK neea 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 storrnwater 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 1.,the application must
be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision
may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this form is true
to the best of my knowledge and belief. False statements made herein are punishable as
a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
�-y
SIGNATURES & OFFICIAL TITLES:
Mailing Address: ........................... ��
T� i
PUTNAM, COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1AsT,61q!'D TA SHEET SUBSURFACE SEWAGE TREATMENT SYSTEM
�'a Address
Owner--/' leAn,,1,111 V. IV
Located at (Street) l a, rq &e- 15f- Tax Map 7* Block Lot
(indicate nearest cross street)
Municipality b2c, �vvj le, q Watershed
SOIL PERCOLATION TEST DATA
Date of Pre-soaking 'T I I,, I C91 Date of Percolation Test — q1 1 -7 101
fy
3
4
5
9
0
I I
I
—2-
-2
N
1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at ea(
percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD-)
.........
Depth to Water'
' V
From Ground
tevel
ercd- I I
a p
t
T'. e:..
.. ...... ..... .
E I 1"Me
_4ps� 1
Surface (Inches)
'Start Stop'...:,f'..
Q
ypp
4Awhe S
A
2e 21
2
pie
30
�U ;?-/
3
,& &
3a
4
5
fy
3
4
5
9
0
I I
I
—2-
-2
N
1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at ea(
percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD-)
a
TEST PIT DATA 2
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
HOLE NO. � HOLE NO ~ R HOLE NO
v
G.L.
0.5'
1.0' _
13 �arr �ov ate, �dr2
3.0' ti 1
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
7.5'
8.0'
8.5'
10.0'
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed
71
Indicate level to which water level rises after being encountered Sari
Deep hole observations made by: %,/ Dater
Design Professional Name:
Address: >,r7,-'—
Signature:
Design Professional's Seal
1. 1 A
4 ,
A Kd 11. 1 tel't I !" 0 8
tine.
t.j
E u s s t-N- n s
Pump
lain maxi,-wim.
Dis-hargri siz.e: 21" NPT.
L -, .- 0 ipac ijp to 126C
Total h•adG: up to 123 i06t
a Overload
proviW,, iv, ter w!iti
threaded. 41,T
staIr,!@s,,3 steoi,
and lowor.
Siagle, phe.-sq.,
and' HP - 1 -IV3 S,
M - 2'0 V Three
th 115 V oi
wo.O.g plug.
%i- *1 ' i HP - STO. 'v.dth
bare leads-
Three phasw
i"11111i HP-1414 GTO
-with bare On CSA
!ts'ked modes -- 20 fooi
SJ11N -md ST VV
aria
N P 7
- SILIC.ON
Stai r, !a .;-'rIel r�!Aal, P;v Is,
BU,".41A.`,1
r
stainle::. -, Threaded
Olase nlv,-A S to nard
ar '11 1
Ca:1 uwailluously
v4tijoul,
a geatiaUs: Upo6r and
lvnur he:!Rvy dully ball hehring
mms"l-Uckion.
a Plawortable! S�vq.m. %duty
ratan, end water resistant.
Fpoxy ,,,eaf on motor end
provides secordarj moisture
bar-vier ;;n cue of outer jkkel
damagr. and 'L'v prevent Oil
wi&ng,
P. Assures positive
seaiing against contaminants •
?,:-id oil leakhga.
AGENCY LISTINQS.
ri CAA; P , SIA n lards Asoctallun
'tine oil for
-iutiro , . . . �� heet (UL) vi"ISPA(rit5riLOMWIV&
14! anid officler
S801: silicon
carbida-rotary seaVsHicon. FEATURES transfer
C 31.W il.1,1--l�--11
e steel meta! a W Operatim Ptur,l) ratings, avo,
,,,pan, non -Oog with Pump- 1, 1
earls, BUINA-N elastormirs, within th� �%:jtor fra, U�Oclute:"S
out vanes for mechanical seal
Temperature: recon-,,:eoded working limits,
Protection. Balarwed for
104 c,F 4011C) continuous
40 I
' (60°C) intermittent.
L F
mvcm rEFT
Fastanerts: 300 series
20
J SEHO"! 38a.,-,
r-"J .
:steel.
C;, i p a b i 6: runm;ng diy R.' M VA A 10 US
'"N! EV I
J1.
W.MOU! dafn�lge to
7 WOO
,.
2',)
Mato,
A
lip, 1-5 V., 200 V, 2so v
60
`0 -0 RPM HP,
i, Hz, I '7,�
'Iz, 3,� 00 q Phil; >
115 V0 , 6
Hp- 1 .;.t -G, P 2 3 0 V,
10l- WIZEvirl. ..1....L.-4 .... ... ...
6 0 .4 7, 3.600 RVA
Built-in ovprload w1fl. 4- -
q 'r, ..e, �a lQ" p.�r +,,.,1 j ..., _ '_ .� �_`� -• —I ,....i!�,.,ti�,.ti � .� ,.�....l...y,� „,..., ...r_' :
Gass B
T
A Th.,
et
H r — V,,d� HP-4.00/2301;
7 •
460 V, N Hz, 3500 RPM. 0 0 M GO 7;j 80 'j0 1 QQ 1 0 120 'W'ORM
• Olass B h!.,iulation.
10 20 30 n13/h
CAPACITY
1 80r4 Gaul &. pumv&, hie, effeefiva May;A OdB.-:•
-A=-tr . . . . . . . . . . . .
09/17/2001 13:27 9149624248
o ... JOSEPH SULLIVAN PAGE 01
A `?`:--°114 SAT C 19 Ail F11.1 -44 �T-f EM' 11q,k TH P A I h!'0. i514"N M
ri
BRUCE R. FOLLY � LOIM TA MOLINAM RX. 342-N,
Public Heafrh Diroa or A610090 Mile M$011k Dir®ewr
Mrwiof of Mimi Sarvtear
DEPAR.`rMENT CAF HEALTH
I Geneve Road
Browmer, New York M04
0 My
A'i R :N'i 10N*. A,tiX S'l''JEB ELAING 0 GM RPRD
All Worrnation below must be 1& completed prior to any sekeduling. DAM
I✓NGINCER OW FIRM: ado � _ _ � ml r #:. ' °
REASON:
IDEEM. FERCS: n KIN1P TEST: o
RO A,flb /URNET.
SUBDIVISION. LOTO:
OWNER-
.. —� vN•..�— �r��. .nr - -mow .� —
0_.09� .�. _ _r� .,�,.,..
YES NO
u Proposed SSTS within the dtainage basin of West Brach or Ji Oyd§ COMW MOSCrvoirs,
wit'. i:t St►!a.trx }. Q11Q resxrvoic.,'tos®¢voir stcu or Control ltb�.
Propoffied r9S'C w ttiiit'oQ It4t bf 6
Proposed SETS clesign slow greater than 1000 gallons /day or MRS Permit required- r
Cl Proposed SS'T's for it Commericid Project.
It is the responsibility of the design pro(essio,na1 to provide the. abovo information prior to sail testing.
This 0epal-talient wiU o+terenine the NYCJRIw'P praiect status (Joint or Delegated) bitted on the
redponse. If yqu b1L91 ered,k= to any of the questions, NYCDTP must wvilmss the Boilt46ting. T116
Department vtall coordin4te a inutually suitable tent for r1eld testing with the PCDOH, the Dedgn
Professional slid NYCDEP,
If a project has been deterrtdned to be delegated based on the above rciponse aad t'het, subaequttit
informatioa joidicates WCDEP is required to witncss the soli testing, it w 1fi be the sole r+espocasibilit:y
ofthr desiput p)•ofessional to schedule of the soil testing with NYCDEP.
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