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HomeMy WebLinkAbout0022DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3. -1 -23 BOX 1 ab 1 T 00022 \/ R 3 61,0 J PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # fic I'M D �' . 0x07 Located at 45C + %Hd.. Ill iA, P-4)AO Town or Village Owner /Applicant Name Tax Map Formerly Subdivision Name Subd. Lot # fIATrEP -6o0 Block i Lot PNPFOUT- tl��'� u4: `)- Mailing Address �' ` m 4pties iA(Li' PA —60tJ N� Zip 0- 6-1) Date Construction Permit Issued by PCHD o4) Phi 1D I V -pi Separate Sewerage System built by G ,I''- 01 CgW4 FOLk'K'"'''Address I'* (-1L'6H0AM 0� IM,71 Consisting of i Gallon Septic Tank and ')-`� % 7ILeL-IwA Other Requirements: Water Supply: Public Supply From Address or: Private Supply Drilled by G)4 6jAH6 Address Building Type K�- �m"Wr !' Pi %I O Number of Bedrooms Has erosion control been completed? �E� Has garbage grinder been installed? N � 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 Putnam County Devartment of Health. Date: _ Address P.E. 5( R.A. 1561-"1 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. By : Title: `-�o� Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design ro essional Form CC -97 Harry W. Nichols Jr.., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (844) 279 -4003 Fax (845) 279 =4567 November 17, 2003 Mr. William Hedges Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Re: Individual SSTS - As Built Addition Edelstein Patterson, NY Dear Bill: 9 Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As Built SSTS," dated 05/13/03. 2. "Certificate of Construction Compliance for SSTS, ". dated 11/17/03. We would appreciate your review, approval and issuance of the Permit at your earliest convenience. Very truly yours, Harry WnNicho Jr ., P.E. HWN:gav 03- 030.00 Exl3'i. WELL DIMENSI ®N CHART (in feet) Number A A 35 24 2 67 47 3 71 52 4 75 58 5 75 63 6 50 60 7 56 66 8 62 72 9 68 78 TTTTATA_TATBTTf TIITATATA�A- W7ATRT'WSATA7WTATTlTATATA /AT TTATATWTATw�v�v�a�w�ATA�WTWTW TAT7TW PUTNAM COUNTY HEALTH DEPT. 1 Geneva Road (845) 27 &6130' O `� Brewster, NY 10509 n r2 Date Received ofL� The Sum Of 1{wc.l!z:la'a' d Dollars $ 14 a ,0�6 For ��si 13 a/ -6 y5p V YO Y0p, THANK YOU! ❑ Cash. ❑ Check 5),. O. ❑ Credit Card By 0 a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at 45G HQVHe 141 -1- f2LOA D Town or Village Subdivision name PP�KOJi 11471 --LDgt - Subd. Lot # 6- Date Subdivision Approved 41 Owner /Applicant Name lob I \M MAC- nal.,6-j-5lH Mailing Address Amount of Fee Enclosed Building Type V-E605 U9 Tax Map 0 139 -03 A rM " Block l Lot V3 Renewal Revision . Date of Previous Approval FNT -Tf;R ,5oo , O (PFePO4 h rm) Lot Area 61 A No. of Bedrooms I Design Flow GPD �L©o Zip 0-609 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of D ©Q gallon septic tank and i P-F-�HU14 Other Requirements: To be constructed by "�� Address Water Supaly: Public Supply From Address or: Private Supply Drilled by G ,* 1 pair l l-4 W - Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address 0670 P.E. X R.A. Date 0 ,+1 1A I Arai H'� i D License # 25 L I J-q 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 necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. A�� - for,discharge of domestic sanitary sewage only. By: e" �'� --'' Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design ofess' al Form CP -97 1 L: =>':5TiNr, !N54' ==XTER!OR -FYP,-- 7— 7 �7' r 0 L5 X1. F- �;a W, FLAN SCALE: 1/4'= 1'-0' 01R, R.� 70N ;D ON PL=•NS CONTRACTOR TO PROVIDE sLocKlr'45' HANDLE.BAR5 AND -BATHIIZOOM NEW CFEN'C2, I i ACCESSORIES T'�'P..:SEE DE:rIll '-2- A] + hTNAM COUNTY DFPAMW OF MLLIS HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; F;FDROO,%a- =613 EXISTING 5 RTitle is I FOUNDATION. WALL o,/ER iV I'-10' X 10' PEEP POURED -.1 CONCRETE FOOTING Y NEwtuCCD SWN-SLE5 ROOF --- --- EXI57 G TYP. MA CH RAKE BOARD PR -LE WIT'- EX!5TING I II P05T 4 L CONTRACTOR TO 11.1f. 54TH EXACT'LOCATION OF MILE ;:L. ACCE55 DOORS TO A56URE FROPER CLEAFZANCE:r VJF C4G. HGT. 2)x8 c G. JT. 16, O.r-' A 77- RELOCATE EX15T:G FLOOR DRAIN '45 '.RE'Q'D 4x4 ------------------------- --- - I -- CONTRACTOR TOVAP: LUM4' ..... ---------- i i'lEr-HANICAL EN, FOR I nK'..CLEA"CE . t , cm 1 /8' TYPE 'W I . 60 GYPSUM -BOARD rINISP e.E>'ISTI'G SLO-E CLG. EXIST'G-FLAT'gL94' EACH SIDE E Of - WALL 7 r -------------- : 7- r irV O A14-:1 NSUL .C. --------------- 'RECREATION 7, WT. 8'-G' :, NEW WOOD FLOOR TO-MATCH 4� __- ______-I I EX'1571W-OVER 3/47 PLYWOC SUEFLOOR OVER PRESSURE TREATED 2 X. . !LEVEL) OvE GLAD jGONTRACTOR C WF hTNAM COUNTY DFPAMW OF MLLIS HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; F;FDROO,%a- =613 EXISTING 5 RTitle is I FOUNDATION. WALL o,/ER iV I'-10' X 10' PEEP POURED -.1 CONCRETE FOOTING Y NEwtuCCD SWN-SLE5 ROOF --- --- EXI57 G TYP. MA CH RAKE BOARD PR -LE WIT'- EX!5TING I II P05T 4 . 7- C4G. HGT. 2)x8 c G. JT. 16, O.r-' ------------------------- --- - I -- hTNAM COUNTY DFPAMW OF MLLIS HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY; F;FDROO,%a- =613 EXISTING 5 RTitle is I FOUNDATION. WALL o,/ER iV I'-10' X 10' PEEP POURED -.1 CONCRETE FOOTING Y NEwtuCCD SWN-SLE5 ROOF --- --- EXI57 G TYP. MA CH RAKE BOARD PR -LE WIT'- EX!5TING I Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 April 29, 2003 Mr. William Hedges Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSDS - Edelstein Addition 456 Mooney Hill Road Town of Patterson Dear Bill: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSDS ", dated 04/28/003. 2. "Short EAF ", dated 5/31/02. 3. "Application for Approval of Plans for a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 04/28/03. 5. "Design Data Sheet ". 6. "Letter of Authorization ". 7. Two (2) copies of Residence Floor Plan(s). 8. Review Fee in the amount of $100.00. We would appreciate your review, approval and issuance of the Permit at your earliest convenience. Very truly yours, H QTY W. Nir. P.E. HWN:JM:gav 03- 030.00 SS :iii -1d 6Z -'d °j Z'0 14.16.4 (9/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEQR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR / 2. PROJECT NAME 6,�7nv' 3. PROJECT LOCATION: Q i f�- Municipality °'"r C!® County v!P� 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) ''I—�� `� m "OCAK v ' V 1" `v m't 5. IS PROPOSED ACTION: ❑ New Expansion ❑ Modlfication /alteration 6. DESCRIBE PROJECT BRIEFLY: ih�TKU`19 0 0' 1 15�11r_► 1'0 °a-i —;RAZ, 00-1i is."Y91-ocm 7 AMOUNT OF LAND 1 t i : . , n L ! �g yT 1 , v acres Ultimately acres B. W PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ,&Yes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 19 Residential C3 Industrial El Commercial ❑Agriculture El Park/Forest/Open space ❑Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY.FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑Yes ['lo If yes, list agency(s) and permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes &41 If yes, list agency name and permit/approval 12. AS A RESULT Of PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes 4440, 1 CERTIFY THAT THE INFORMATION PROVIDED ABOV.)EE IS TRUE TO BEST OF KNOWLEDGE /THE � +MAY N �u ' b �� po Ruo d4I' �'0�''i ApplicanUspon o name: . Date: Signature: If the action is in the Coastal Area, and you are a. state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion; drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly. C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; -(c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer. in Lead Agency Signature o Preparer (if different from responsible officer) Date . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION-OF ENVIRONMENTAL HEALTH•.SERVICES``` APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM'._` 1. Name and address of applicant: M—A' 2. Name of project: �Sr -4 3. Location TN; P ° 4. Design Professional: RAW W `- �1�Ua�� ►�F�S.. Address: -0 co __...- . ,.. 6. Drainage Basin: _.G� � _... 7. Type of Pro' ct: Pr vate/Residential Food Service Commercial Apartments Institutional Mobile Home-Park, -. . Office Building Realty Subdivision __ . Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... NO 26. Has SPDES Application been submitted to local DEC office? ......................... Form R -97 Type Status (check one)... .................................................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... No 10. Has DEIS been completed and found acceptable by Lead Agency? 11. Name of Lead Agency A2 Is this project in an area under the control of local planning, zoning, .or other J :. . officials, ordinances? .................... . ............................... ..............- ............... 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has preliminary approval been granted by such authorities? OP Date granted: 15. Type of Sewage Treatment System Discharge. ..:............. surface water groundwater 16. If surface water discharge; what is the stream class designation? ....... :: :.:........ (U A 17. . Waters index number (surface) �% 4: 1.8.. Is project located near a public water supply system? ................... :................... . 19. If yes,. name of water supply Distance to Water: supply fly 20. Is project site near a public sewage collection or treatment system? ::....:........ 2 i . Name of sewage system N Distance:to. sewage system �fl 22. Date test -holes observed D jol 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................. ......................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... NO 26. Has SPDES Application been submitted to local DEC office? ......................... Form R -97 I 27. Is any portion: of this project. located within a designated Town or State wetland?. WD 28. Wetlands ID Number ....................... ........................... . ...... . ....... I .......................... � 2.9. Is Wetlands Permit required? ...................................................... :................... ... - .. -.. Has application been made to Town or Local DEC office? ...... ............ 30. Does project require a DEC Stream Disturbance.. Permit? .. ............................... I�Si 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 ti 0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and /or sewer facilities.planned to be developedwithin 15 years in or adjacent to project site? ............................................... ................ � 35. Are any sewage treatment areas in excess of 15% slope? . ............................... Q 36. Tax Map ID Number .......................... ............................... Map �J . Block I Lot 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be.sent to the Department, and need not be sent in duplicate to the DEP, although the project may require.DEP _approval of the-SS-TS 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 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 Lqw. 1 SIG:NA T URES -& OFFICIAL TITLES: Mailing Address: ............ ........ PUTNAM :COUNTY. DEPARTMENT OF. HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES -- DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner - F iE��T�:11 -i . Address 4-56 M0005i RM, R.; . Pl-irrg)-6N t�1 (Street) `�t�� A �fo Tax Map . ' ... Block 1 Lot.__.. �� . Located at Street ���, � .#3�II•L �� � (indicate nearest cross street) Municipality pNrrE5�--A>0H Watershed F N� rl BF-AH64A SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of- Percolation Test >Dtt roi 5 - 2 3 4 .................... . 5 NOTES: 1 Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e: 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 G.L. 0.5' 1.0' 1.5' 2.0` 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5. 1 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED .IN TEST HOLES. HOLE NO. HOLE NO. 2-, 0 � I 'a%f- No V'j- HOLE NO. Indicate level at which`groundwatefis encountered —Nod Indicate level at which. mottling is observed o Indicate level to which water level rises after being.encountered N� Deep hole observations made by: 3rP�- MM94 okwo) Date. 4/11.J Design Professional Name: W! NlUOot � e Address: V-�w'�5 �- , H,� , - j© 13 Signature: 6��l 's Seal ,of NEW C*� NICHO� W Uj �yd's, No. 56124 AROFESSe©��� 2 PUTNAM COUNTY DEPARTMENT OF HEALTH. DIVISION OF ENVIRONMENTAL HEALTH SERVICES.;:::,:.:::: LETTER OF AUTHORIZATION RE: Property of l;1)E1,?�b`p -1— ........ ... ;4 Located at OHE�? 14-1 LL, AND T/V �1 �-"�dN Tax Map # _ Block _Lot Subdivision of 1HWQ r4F-fti) Subdivision Lot # Filed Map # �0('' Date Filed_._. Gentlemen: This letter is to authorize - — - a duly licensed Professional Engineer or Registered Architect toMply for the. required wastewater treatment and/or water supply permit(s) to serve the above- noted.property m accordai ce ;: '-` with the standards, rules or regulations as promulgated by the Public Health Director of,tlie..Piitii' 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 Pu_blic Health Law, and the Putnam County Sanitary Code. Very truly yours, -- C.ountersigried: i Signed: � i P.E., R.A. # L (Owner of Property) Mailing Address Mailing Address: R1L K State �'`S Zip I Q5A0� Telephone: J('; �1 � a q:j UNTY DEPART�ENT F HALTH..` Permit CO w: i, DwrS/on of. Environmental Heath Services Carmel X 12 , 5 . � . ° 207Y � , CONSTRUCTION PERMIT :FOR_'SEWAOE DISPOSAL Tawn o► illage 0. 1 . Blo�k 1 Lot _.15 2 Located at Ni00n f{1 "Rd tax tvlap i °. Subd. -Lot N Renewal Revision x Q�� ai Subdivision —�' '.Owner /Address Susan :& ChiH es''Marka^ i an.- PattOrsah N_"_Y_ 3,0S Site, Of Prev]Ou8 Approval - i Passive Solar 27 G7.6" -Ac Fill 'Section, ❑ Building Type Lot Allrea y Number of Bedrooms Three Desig[i. Flow G /P /D UQO - - P C:,N. D. "t icatim, Required Separate" Sewerage System to consiit of jW' 0 .000 Gal Se` is Ta and vU. t 24" - W.. x.. 2n' ateral s" Dona�d 6 '_Luckett ._ ' — To be .constructed by Ad or, es Water ` Suppyy, - Public "Supply From i " _ X Private "Supply to be drilled by -7 Address'i Nj Other Requirements Ndne ? *400' T01�'E`1 was s?s; ? f7 'r = KitCh?gTL�IiIrC�rTW�Ctes 6Yepresent that l,am wholly and reompletely,'responsDfe for the design and location of 'the proposed systems) 'l) that fire separate sewage disposal system above described will be•.constiucted as'sho;wn'on the approved amendment thereto and in accordance with the standards, rules an .regu,a I=o e - u nam ' . County Department of Health, ',and that on completion thereof a ".Certificate of Construct "ion Compiianca "'satisfactory to the Commiss)onor of. Healthwill " be .iubmitted,to;tne, Department,, and _a written guarantee will'be'furnished the owner, his successors, heirs oi`issigns.by the;bdilder, that said builder will place in good operating' condition; any °part ofr said sewage "disposal system during :fhe period of tvvo,(2) years immediately following tliedatepf'the issii % once' of the ,approval` of 'the Certificate ` :of,..Construction';Compliance of the original system` :or any repairs thereto; 2) that the drilled well described above' " wilf be"located as shown on .the approved plan and that said well will De installed in accordance -,with the standards, rules and' regu regulations !of." the -Putnam County Department of Health. )6 Se tember.'1983 Date, P^ _ Signed ,_ PE:ii�i— R.A R0 #9: Fair St.: rme ^a9nF Address - 'License P � . APPROVED OR CONSTRUCTION This''approval ex- pires one" yearfrorti the date' = issued unless con5fruction -of the builtling has been undertaken and is revocable for :cause -or may, be be 'or' modified when eorisidered necessary' by -Wc Corp ionei "of, Health.. Any Change or aReration of Construction' _ requves a /nle�w2.Permit. 'Approved ffoi'disposal of domestic wag an /or'priv ty only. Date :.r/ Title 8y ..Rev. -9 -81 .,.. r. .. - .. - d FD: T,D 1A ST . Date: : - - Insp . by:-- � IT ?.T.TTA.L SS`1'1; Ii �hrr,1'T.OI: Yes No Cotntncnf.s ,Properly lines or corners found _ Can cstirste, house location . Will driveway need cut . . . . . . . . . . . -- Mu., ;t trees be removed -note these -_- Is deep hole representative'of entire SDS area Additional deep holes r_e-ec;ed. Sufficient SDS area available considering driveway cut, hou:;•e location, separation distances, etc. . . . . . . . . . . __._ - - - -- DEEP II0LE, DATA , D!!p• -h . .1-later elevation: Rock elevation: Soils descriAion: Date: W I'IN! A L SITJ T,kSP1 C`T'I. : Insp. tiy: - House Located vhere shot;n on 'approved plan • . SDS located where approved length of trcnc'1 measur•ed Width of trench ave r­�e Slope of the line and trench. acceptable . . . V _ Room allowed for expansion trenches . . . . . Over 50 ft. from m,a- miD. vat erc ours e . Fatural soil not . stripped or SDS area iu-n-iecleSsarily graded ... 10 ht. maintained from prop.line and z 20 ft. from house Sep,, ration of trench from house, Taal! -.—etc. - follows plan hTrilibcr of bedrooms chocks . . Stones, brush, • stun :ps, rubble, etc. greater than 15 ft . from necarest trench . . . . . . 15 I't. of peripheral soil horizontally from trench Jw -iAion boxes properly set CoiLld surface run off from driveway, roads, ground surface, etc. channel near SDS area. . . . . . . . . . . . . . Does lot dr. ainaE;e app—dar 0. K. :i.n a.rea. of SDS -- FINAL GIMIRG OF SITE ACCE11'.A= RAP W111- 134 • � r � W i� a ,q PUTNAM COUNTY DEPARTMENT OF HEALTH. DIVISION OF ENVIRONMENTAL HEALTH SERVICES COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512 DESIGN DATA SHEET- SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO. Owne r J :C 1*r* ✓jrQ s sue, 140 0 rl opY Located at (Street : Block j Lot / . �. ca e neares cross s 4.ee Municipality �•s ®n Watershed 5*o SOIL PERCOLATION TEST DATA REQVIRED TO BE SUBMITTED WITH APPLICATIONS Hole Number CLOCK TIME PERCOLATION PERCOLATION apse Deptft to Water 'Water ve No. Time From Ground Surface in Inches Soil Rate Start -Stop Min. Start Stop Drop in Min. /in drop Inches Inches Inches 5 FO 3 /C K I 1 2 — ®; 3� oV" . Notes: 1) Tests to be repeated at same depth until approximatelyy equal soil rates are obtained at each percolation test hole. All data to be submitted for review. 2) Depth measurements to be made from top of hole. DEPTH G. L. 6" TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS_ENCOUNTERED IN TEST HOLES HOLE NO. % HOLE NO 12" 18" 2411 3011 3 6 if 42" 4811 54 60" 66" 7211 7811 8411 A INDICATE LEVE INDICATE LEVE. TESTS MADE BY AT TO c a . .�6. WATER IS ENCOUNTERED Noae SVI�L IS S AFTER BEING ENCOUNTERED / jP24#Ys• ' &JOZ&O to 05 Soil Rate Used#fj'Iin/l "Drop: D GN S.D. Usable Area Provided No. of Bedrooms %�Se is Tank Capacit O s Gals, Type Absorption Area Provided Y width � L.F.x24it width trenc ¢M 1�a // trm � l� %IiCi �4►�►�► i' Other Name J r igrlq Address 9, FAIR ST t#A .. Y THIS SPACE FOR USE BY HEALTH DEPARTMENT ONL •Gy �o Soil Rate Approved Sq. Ft /Gal. Ch `F �b 2g2 °b �'` Late WELL COMPLETION REPORT PUTNAM COUNTY DEPARTMENT OF HEALTH 3/71 �� ° Division of Environmental Health Services r,� 7 COUNTY OFFICE BUILDING - CARMEL, NEW YORK This report is to be completed by well driller and submitted to County Health Department together with laboratory report of analysis of water sample indicating water is of satisfactory bacterial quality before certificate of construction compliance is issued. REPORT MUST BE SUBMITTED WITHIN 30 DAYS OF WELL COMPLETION OWNER NAME ADDRESS LOCATION OF WELL (No. & Street) (Town) (Lot Number) O.. PROPOSED USE OF WELL BUSINESS DOMESTIC ESTABLISHMENT ❑ FARM ❑ TEST WELL ❑ SUPPLY 11 INDUSTRIAL El CONDITIONING OTHER CONDITIONING (Specify) DRILLING EQUIPMENT COMPRESSED CABLE ❑ ROTARY ®A R PERCUSSION ❑ PERCUSSION (S(Specify) ER CASING DETAILS LENGTH (leaf)_ ��� DIAMETER(lnches), WEIGHT PER FOOT 1j ® THREADED WELDED YES O❑ NO I(A YES NG Ca$Q— GfiES?- U NO T ST j ( HOURS G.P.A. ❑ BAILED ❑ PUMPED 11 COMPRESSED AIR 81 YIELD (G.P.M.) WATER LEVEL MEASURE FROM LAND SURFACE —STATIC (Specify feet) Ian DURING YIELD TEST fleet) / Depth of Completed Well in feet below Land surface: 'y SCREEN MAKE LENGTH OPEN TO AQUIFER (feet) DETAILS. SLOT SIZE DIAMETER ( Inches) IF GRAVEL PACKED: Diameter of well including gravel pack (Inches): GRAVEL SIZE (inches) FROM (leaf) TO (feet) DEPTH FROM LAND SURFACE FORMATION DESCRIPTION Sketch exact location of well with distances, to at least two permanent landmarks. FEET to FEET If yield was tested at different depths during drilling, list below FEET GALLONS PER MINUTE DATE WELL COMPL ED 87 DATE OF REPOR o- iy- 8 WELL DRILLER (Signature) OF Susan _&Charles la arkar t an Owner or Purchaser or Building Road Building Constructed by T. Patterson Location - Street Plass ive S01 ar Building Type T. Patterson Municipality f Section r5.2 Block Lot GUARANTY OF SEPARATE SEWAGE-SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that it 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 guaranty to the owner, his succes- sors, 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 initial use of the sewage disposal 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive. the de- termination of the Director of the Division of Environmental Health Ser- vices 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 s s em. Dated this da 4N� T of October l9 84 Sianatur Title Owner If corporation, give name and address) THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health Susan & Charles Markarian Owner or Purchaser of Building Building Constructed.by Mooney Hill Road Location - Street T. Patterson Municipality Passive Solar Building Type 1 Section: Block 15.2 Lot Subdivision Name Subdv. Lot # GUARANTEE OF SEPARATE SEWAGE SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and that. it 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 success- ors, 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 initial use of the sewage disposal 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 occu- pant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determin- ation of the Director of the Division of Environmental Health Services of the Putnam County Department of Health as to whether or not the fail- ure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated. this day of, Qct04ar 19-84 Signature Title Contractor Corporation Name if corp.) Maple Ave., Patterson, N. Y. 1,2563 Address THREE (3) COPIES ARE REQUIRED WITH THREE (3) COPIES OF FINAL PLANS BEFORE CERTIFICATE OF COMPLETION WILL BE ISSUED. GUARANTOR IS REQUIRED TO FILE NOTICE OF DATE OF FIRST USE OF SYSTEM. Division of Environmental Health Services, Putnam County Department of Health YORKTOWN MEDICAL LABORATORY INC. P.O. Box 99 321 Kear Street Yorktown Heights; N.Y. 10598 245 -3203 LOCATIONS: ❑ 321 KEAR ST., YORKTOWN HEIGHTS, N.Y. 10598 245.3203 ❑ 201 BUTTONWOOD AVE., PEEKSKILL, N.Y. 10566 737.8777 ❑ 495 MAIN ST.. MT. KISCO, N.Y. 10549 666.3335 9�STONELEIGH AVE. (NEAR HOSPITAL), CARMEL, N. Y. 10512 278.9 LAB # DATE TAKEN: DATE RECEIVED: Z/t 'dl° ` S- 3v DATE REPORTED: SAMPLE SOURCE: REFERRED BY: COLLECTED BY: L —1 LAPORATORY REPORT i mg /L ❑ ACIDITY ............................ ............................... ❑.ALUMINUM ................................ ............................... ❑ ALKALINITY ............... ........ /...................... ❑ANTIMONY .............................................. `�J ACTERIA. TOTAUrn .......... ............................... ❑ ARSENIC .................................... ............................... BOO, 5 DAY ............................ ............................... ❑ BARIUM ....................................... ............................... ❑ BROMIDE ............................ ............................... ❑ BERYLLIUM ................................ ............................... ❑ CARBON DIOXIDE, FREE ........ ............................... ❑ BISMUTH .................................... ............................... ❑ CHLORIDE ............................ ............................... ❑ BORON ........................................ ............................... ❑ CHLORINE ............................ ............................... ❑ CADMIUM .................................... ............................... ❑ COD ..................................... .......... ...................... . ❑ CALCIUM .................................... ............................... ❑ COLOR ............. ............................... ............... ❑ CHROMIUM (tot.) ............................ ............................... ❑ CYANIDE ........ ...............:............... ❑ CHROMIUM (hexavalent) .................... ............................... ❑ DETERGENT, ANIONIC ............. ......................•........ ❑ COBALT .................................... ............................... ❑ FLUOR.inF ............................ ............................... O COPPER .................................... ............................... ❑ HARDNESS ............................ ............................... ❑ GOLD ........................................ ............................... ❑ M?bL=LIFORM COUNT/ 100 ml ................................ ❑ IRON ........................................ ............................... TCOLIFORM COUNT/ 100 ml ........Q .................. ❑ LEAD ..................................... ............................... ❑ CONFIRMATORY TEST ............. ............................... ❑ LITHIUM .................................... ............................... ❑ NITROGEN, AMMONIA ............ ............................... ❑ MAGNESIUM ................................ ............................... ❑ NITROGEN, KJELDAHL ............ ............................... ❑ MANGANESE ................................ ............................... ❑ NITROGEN, NITRATE ............ ............................... ❑ MERCURY .................................... ............................... ❑ NITROGEN, ORGANIC ❑.NICKEL ❑ ODOR ................................ ............................... ❑ PALLADIUM ................................ ............................... ❑ OIL & GREASE ............................................ :............ ❑ POTASSIUM ................................ ............................... ❑ PH .................................... ............................... ❑ RHODIUM .................................... ............................... ❑ PHENOL ................................ ............................... ❑ SELENIUM .................................... ............................... ❑ PHOSPHATE (ortho) ................ ............................... ❑ SILICON .................................... ............................... ❑ PHOSPHATE (condensed) ............ ............................... ❑ SILVER ........................................ ............................... ❑ PHOSPHATE (total) ................ ............................... ❑ SODIUM ........................................ ............................... ❑ SOLIDS, SETTLEABLE, ml /L .... ............................... ❑ TIN ............................................ ............................... ❑.SOLIDS, SUSPENDED ............. ...........................:... ❑ ZINC ............................................ ............................... ❑ SOLIDS, DISSOLVED .......................... . ........;..... ❑ .................................................... ............................... ❑ SOLIDS, TOTAL ......:.............. ............................... ❑ ................. ............................... ........................... .r... ❑ SOLIDS. VOLATILE ................. ..................... ...... ...... ❑ REMARKS:..................................... ......:........................ ❑ SPECIFIC CONDUCTANCE ......... ............................... ❑ . y.. ............................... .. ❑ SULFATE ............................. ............................... ❑ .. .......3s'4.1��1rt�.::STrs..... J1.g.R.Laz`co. ❑ SULFIDE ............................. ............................... ❑ .................................................... ............................... ❑ SULFITE ............................. ............................... ❑ .................................................... ............................... ❑ SURFACTANTS ............::.. .............................:: ❑ .................................................... ............................... ❑ TURBIDITY ......................... ............................... ❑ .................................................... ............................... THESE RESULTS INDICATE THAT THE WATER WAS \-119-)� OF A SATISFACTORY SANITARY QUALITY WI1E?4 THE SAMPLE WAS COLLECTED. �TyHHEESEpRKESgULTS INDICATE THAT THE WATER DID MEET THE SATISFACTORY CHEMICAL QUALITY 01' �ORYPRARAMETEADMINISTRATIVE ST RULES & REGULATIONS, DRINKING WATER STANDARDS (PART 72). ALBERT H. PADOVANI M.T. (ASCP). DIRECTOR :, Z'- I poo c� A L'• Prm cr T 4• ° +hnla V" "I� rs C�TvJ " (T.i lebs) rur,-nolJ poxes -rYh, - It) Ze=n A L%it t =_lQv 0. o• tip ybe ti o!Y w� e ,a, �0 0 �yq,�z �rogo�9 • w o q ti: I 4 AobYea ^. ti AS BUILT' QAATA Structure _located from survey by surveyor,ndtgd- beldr% Well located by.:;Surveyars sur.veY" - ® Well drillers.. oport Enp'inaprs.mesuremenYs•p_•_ _ _ Tank, boxes, pits, galleries a 14terdis.lo•ca;Lesl by - onLnccton . 'En9•tneer�` He4lth dada F Field inspection by: Health dept ® ddt.e/� =_ Engineer ® date NOTES: TvItGT TvT'AL lrGl��it{-� �'� �I�l:t>y . - G G– �zlJ/iL� 270 –e- ;? . tol LeTy . K IONA A- B T A - C -C ■oZ1 m. A Er1_'Q! lJ$_� i1B -. E' =zi li .P2 _ Ali A - F =�Z2��UB - F A - G °,emu A H �t21T x L�_Dlu - 4 _Y '- N ■1r,1 0p - �[�It A - K daZ-u' ---B K SANITA Y S Y51EMQE �J N °AS BUI LI , OWIN*R h tv c LC,� �HAtzKA .&Z LOCATION Streit _ N1oo1�G– �,f�il,L .wAp'� Town:,l�?T�vrh CopntY:�/>,I"1 State _ SD.BDIVISIOl N "]oY1 if �R pT�� Al_RLv( Lhl�vtar<G soFESSioni[ Map -- — v PR Fpc� Mack•. — i _ LOT' Ns I cam, Z y`r'OO�r N• E,yryfR� Builder: Q�,_Ci —�••. -- - — �_ Surveyor,, _M! tlp — — -- -- * ;y Drawn: Datet tool ?: 4 1; Job N! lam• �A, °r:= 14 - .:I . . Icw . tia.ryto�� Ot JOHN H PRENTISS RE \r CONSULTING ENGINEER 10 - -- y