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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.19 -1 -13 BOX 2 oil �{ .: L 6 91 111:: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Town Village City Tax Grid Number WELL OWNER Name Mailing Address OPrivate O Public SE OF WELL 1 primary - secondary ® RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0 ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHT �j gpm /# PEOPLE SERVED /EST. OF DAILY USAGE DD al fl REPLACE EXISTING SUPPLY O TEST/ OBSERVATION Q ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING 0 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN DDUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES / NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name L' Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES ✓NO NAME OF PUBLIC WATER SUPPLY: Q. /A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: W/k LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED�j L6 ®ON SEPARATE SHEET (date) gnature PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: Date of Expiration 19_�j Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller m to ,),88 PVrMAM COUffff DEFAMMERr OF EMIMTH DIVIIII011111 d iv- hl Be" ill - - CammL N.Y. IIS12 � to Pas- peff" PER= MR SWAM 2---- NUM , lost III miCUMIMATEOFLOMM"CE To" .x"01 TM Map -22 Block I W ReuvwWL-0—ROVISIM-0 Daft of Pir"Ime Approval Mmftg Adifiless Town patp, Fee Enclosed Subdivision ApRroved Amniinf Dliit T2100 t., Am soedmo* " Depth—whials, Number 49 Bad Dw4p Flow G P D PCHD Noliftedais is RaMbed Wbm FM In calmisted swoub S*WMW SY@N= Is call" ed SOP&Tmits" z9rFE Al2.-5g 1 of,3 To be -by Ad6ves Water &**. —P&& &W* Fliress Ad&e.. on t/ —M.,ft So* DOW by ---Ad&. n,, I represent'that I Orin wholly ano'compietety responsible,fo► the design and location of the proposed system(s). 1) that the abave described will be constructed as shown on the approved amendment there to and in accordance with the standards. ruleAMA'g—M.M. 34TV'0513. -County Department of " . Ith. and that on completion thereof a --cenificate, of construction Compliance" satisfactory to the Commissioner of Heafthwill be submitted to the Department, and a written guarantee will be furnished the owner, his succamors, heirs or assigns by the bulkier, that said builder will place in good. operating condition any part of old saws" disposal system during the period of two (2) yews Immediately following thedets'of the Iseu- lipce of the approval of the Certificate of Construction Compliance original system or any 6 It at*. 2) " the well described a6olre `ontheappoov plan that mid we laXino 00 of the put will be located as 81 - it will st in accordance with t=: &Vonz nam County Department of Health. hl;� = Date Signed WE- '25 License -5 Address. No APPROVED FOR CONSTRUCTION: This approval exPW*g two years from the date Wed - unless construction of the building has been undertaken and is revocable for cause or may be' amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction Muires a =rWpormit.. Approved for disposal of domestic unitary *"a, and/or private water supply only. -1 Gets - I -- Title LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 RANDOLPH W. LAURENT, PE. (914) 278-6108-(FAX) 278.2658 HARRY W.NICHOLS, JR., PE. CONSULTING SITE ENGINEERS July 21, 1993 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS North Street Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -1 "Proposed SSDS ", dated 7- 21 -93. 2. "Application For Approval of Plans For A Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 7- 21 -93. 4. "Design Data Sheet ". 5. "Letter of Authorization ", dated 7- 21 -93. 6. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 7. Check in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. H rry W. ichols, Jr., P.E. HWN:bd 93036 enc. cc: Mr. T. McGlasson w /enc. 16'X 40' Unfinished SP-.. �d Floor • 640 Sq. Second Floor 1 AR`1'1E'PIT OF HEALTH STANDARD NEWFOUNDLAND FEATURES • Luxurious First Floor Master Suite • Fireplace Options Available • Compartmentalized First Floor Bath with • Consult an Authorized V'Jestchester Builder Two Separate Vanities for a Complete List of Options • Formal Entry Foyer • Arist's renderings and Floor Plan Dir-,lensions are • Formal Dining Room approxim, ate. All srecl5cazions must t,-, wrinen in J ContracL No oral conc.kjons. • Formal Living Room • Spacious Eat -in Kitchen ESTCHESTER ODULAR OMES, INC. Reagan's Mill Road • Wingdale, NY 12594 .� 9141832 -9400 • 8001 832 -3888 PAO --, �0� 1 Firs[ Floor �; t i -{; • ti � I 1 _ . � DINING ROOK KITCHEN 1E• -O• X IJ' -G' � IE•• E•X IS' -O' : , IV Z CCSiJNT I)E� !! BEDROOPd GU —F EDR40MS — I4ASTER BEDROOM ISM -1' X 13• -G• -�r\ j'�✓ L(VIHG R0014 I <• 'XI i'f2.:r ' UP > AR`1'1E'PIT OF HEALTH STANDARD NEWFOUNDLAND FEATURES • Luxurious First Floor Master Suite • Fireplace Options Available • Compartmentalized First Floor Bath with • Consult an Authorized V'Jestchester Builder Two Separate Vanities for a Complete List of Options • Formal Entry Foyer • Arist's renderings and Floor Plan Dir-,lensions are • Formal Dining Room approxim, ate. All srecl5cazions must t,-, wrinen in J ContracL No oral conc.kjons. • Formal Living Room • Spacious Eat -in Kitchen ESTCHESTER ODULAR OMES, INC. Reagan's Mill Road • Wingdale, NY 12594 .� 9141832 -9400 • 8001 832 -3888 PAO --, To: Putnam County Health Dept. 4 Geneva Road Brewster, NY 10509 Atienlion: Mr. William Hedges Gentlemen: We enclose ( ) copies of: O B/W Prints O Reproducibles O Specifications O Memorandum Description: Job No.: 93036 Project: Proposed SSDS North Street Patterson, N.Y. • Reports O Tracings • Copy of Letter O Certified Mail receipts Copies of Neighbor Notification Letters Letter from Patterson Building Inspector Sent Via: :3 Our Messenger O Blueprinter 3 Your Messenger M Hand Delivery :�opyto: Mr. T.'McGlasson Revision /Dote No: 7 -30 -93 8 -5 -93 O First Class Mail O Special Delivery O Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: Jr Harry W. Nichol s- Jr.. LAURENT ENGINEERING ASSOCIATES, P.C. /j 73 FAIRFIELD DRIVE PATTERSON. NEW YORK 12563 914.278.6108 CONSULTING SITE ENGINEERS Date: 8 -10 -93 To: Putnam County Health Dept. 4 Geneva Road Brewster, NY 10509 Atienlion: Mr. William Hedges Gentlemen: We enclose ( ) copies of: O B/W Prints O Reproducibles O Specifications O Memorandum Description: Job No.: 93036 Project: Proposed SSDS North Street Patterson, N.Y. • Reports O Tracings • Copy of Letter O Certified Mail receipts Copies of Neighbor Notification Letters Letter from Patterson Building Inspector Sent Via: :3 Our Messenger O Blueprinter 3 Your Messenger M Hand Delivery :�opyto: Mr. T.'McGlasson Revision /Dote No: 7 -30 -93 8 -5 -93 O First Class Mail O Special Delivery O Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: Jr Harry W. Nichol s- Jr.. FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT Gail L. Harrison 3601 No. Jefferson Street Arlington, VA 22207 Dear Gail L. Harrison: Date 7 -30 -93 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: McGlasson Realty Address: North Street Town: Patterson, N.Y. Tax Map: 3.19 -1 -13 Rlease be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed,, fo,r. the captioned property has been made to the Putnam County Department of.Hea.lt.h. Attached please find a copy of the latest. site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you. may call: Mr. Hedges or Mr. Morris of the Health Department at 278 -6130. Very truly yours, By Title 2L mac,, RECEIVED BY: Address: Tax Map: JK;cj FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT William F. & Jean H. Smith P.O. Box.154 Patterson, NY 12563 Dear Mr. & Mrs. Smith: Date 7 -30 -93 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: McGlasson Realty Address: North Street Town: Patterson, N.Y. Tax Map: 3.19 -1 -13 P:lease be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed= fora the captioned property has been made to the Putnam County Department .of. Health. Attached. please. find a copy of the latest site plan.. If you have any questions, concerns or information which may bear on the. Health Department's review of this application, you may call: Mr. Hedges or Mr. Morris of the Health Department at 273 76130. Very truly yours, By z! jz Title RECEIVED BY: Address: Tax Map: JK;cj FORMAT Date 7 -30 -93 NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT Eugene Browne RE: Department of Health Review of 140 E. 72nd Street Proposed Sewage Disposal System New York, NY 10021 for property: Name: McGlasson Realty Address: North Street Town: Patterson, N.Y. Tax Map: 3.19 -1 -13 Dear Mr. Browne P:lease be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed; for: the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you raay ca1T Mr. Hedges or Mr. Morris of the Health Department at 278 -6130. Very truly yours,. By (;�/,Juz Title 24 -e , RECEIVED BY: Address: Tax Map: JK;cj A FORMAT NEIGHBOR NOTIFICATION CONSTRUCTION PERMIT William & Dorothy Lawson North Street Patterson, NY 12563 Dear Mr. & Mrs.'Lawson: Date 7 -30 -93 RE: Department of Health Review of Proposed Sewage Disposal System for property: Name: McGlasson Realty Address: North Street Town: Patterson, N.Y. Tax Map: 3.19 -1 -13 Please be advised that an application for a Construction Permit relative to the construction of a sewage system and /or well proposed, for the captioned property has been made to the Putnam County Department of Health. Attached please find a copy of the latest site plan. If you have any questions, concerns or information which may bear on the Health Department's review of this application, you may call: Mr. Hedges or Mr. Morris of the Health Department at 278 76;00. Very truly yours, By Title,, RECEIVED BY: Address: Tax Map: JK;.cj !jQ :l ;t P/0 3.19 1 -4 4 14.1 AC. 976 9b 129.13 srQrE 113.91 A i 22 O , 120.00 28.4 xj7 ti N i g 21 �tcl t .15 - $_ r / 7 163.89 17 o 14 104.90 = xoz.zz $ J 4n zoe.63 X 6 6 / 209.01 u a N- 18 ° 13 g cZ5 8 E 8 8 �_ xs s F. ' 8 199.12 8 - 201.45 /I 125.00 tot% 12 s 8 �{ 19 ' 8 / 1 19 8 9 $ . 206.68 b 107.09 a m 2 _ g -Z $ /r r"n 5 AL. CAL. $ L20., 125.00 .� 10 �qt 4 ° 1ol.%e BUSH ROAD ( SUGAR 110.40 toz.r 29 180.00 J °rJ 30 a 31 , 114.33 xoz $ ' 28 ' s 0 3.19.1-13' P/0 3.19.1.14 s 8 29009!1 s M1`� P/0 3.15 -.I -2 :aa P/0 3.IS 1 31 P/0 3.15031- 30 _ /03.15 1 4 Z 140.0 47.5 �. toz 24 1 n r r 6 S . 201 141 23 g . 12 7992 a 21 22 79.03 2.50 AC. 65 II g o J° 106.0! '- •� $, r 10 0 136.0 N 20 a „9.16 r 19 a JOHN N. CALBO Building Inspector TOWN OF PATTERSON PUTNAM COUNTY PATTERSON. NEW YORK 12563 August 5, 1993 Mr. William Hedges Putnam County Health Department Rt. 312 Geneva Road Brewster, New York 10509 RE: TM - 3.19 -1 -13 (125' x 180'/22,500 sq.ft.) North Street Patterson, New York Dear Mr. Hedges, This is to inform you that the above.noted tax parcel constitutes .a single building lot in the Town of Patterson. If you have any questions, please do not hesitate to contact this office. Very truly yours, .-- , Frank Blas' Temporary Building Inspector cs cc: Mr. H. Nichols ENCLOSURE Telephone 878 -6319 ..:u.,:�,. u: lluJCt'LLCt10Il. § 154 -46. Application for permit to rebuild. Application for permit to rebuild or restore the damaged portion of any building damaged or destroyed as set forth in 154 -45 above shall be filed within six (6) months of the day of -..' . such damage and shall be accompanied by plans for recon- - st ^action which, as to such portion, shall comply with the - provisions of this chapter in all respects save as the use- of the 5^•.` r � building or structure. • 47 Completion of rebuilding. § n g If a permit for such rebuilding or restoration is granted, it shall lapse twelve (12) months thereafter unless the permitted con- : struction is completed within such period, except that the " ilding Inspector in his discretion may grant one (1) six-month extension thereof if construction has been delayed by cir cumstances beyond the control of the permit holder. § 154 -48. Buildings on nonconforming lots. No provision of this chapter pertaining to minimum lot area and �.; .:c minimum lot width shall prevent the construction of an otherwise permitted building or the establishment of an otherwise permitted use on a lot owned separately from any adjoining lot at the ef- fective date of adoption of any such provision, provided that the building will have the minimum yard requirements specified in = this chapter and will not exceed the. maximum specified lot coverage. 15441 - F '•r ' '`4 1661 aunt •008E: wJOJ Scl _P1 326- 770 655 Receipt f®r Certified Mail No Insurance Coverage Provided Do not u.se, f,_,r !n+lc,, nat;oria; Maii (See Reverse) ej.VC,-V 4 1 L P- 326 770 656 V 0., §UVe and ZIP Code Receipt f ®r R 32.,6-770 654 Cartified Postage Receipt fOT t No nsuranc,�.- Provided Do not use I Certified MaN Certified Fee %-.-.�ational Maiil (S,--e Revers�!. No insurance Coverage Prov ided for International Mail Looe—, Do not use (See Reverse) `ice Special Delivery Fee Street .id N Jo'. -700E� Sent I r ri-so, n Restricted Delivery Fee State a a zip c W o Street and No n M Postage $.7 late and IP Code •0 Certified Fee Postage $ j C =3 Special Delivery Fee Certified Fee QQ Restricted Delivery Fee Special Delivery Fee 0) Q.) Return Receipt Showing to Whom & Date Deli, ed Restricted Delivery Fee 4) r- 3 Return Recei ho It Date. and dres 's -A ss Return Receipt Showing Whom & Date Delivered C; TOTAL P & Fees to Return Receipt Show-'j 00 Postmarl pc, Rte .a sCDate, and Addressee' t e TOTAL PCs ag 0 tv C, & Fees Postmark or D t 0?0 08 > LL V) 'N CL E 0 U- V) 0 M . it r- 0 5? "Aso -0 T E 0 > h. O.0 C3 0 U CIS qs�e r— CD C 4) > a) 0 ru C ID (D I= L ) 0 o Z 0 L 0 W d M, 0 nD ai c E c M E 0 —i N E 1661 aunt •008E: wJOJ Scl _P1 326- 770 655 Receipt f®r Certified Mail No Insurance Coverage Provided Do not u.se, f,_,r !n+lc,, nat;oria; Maii (See Reverse) ej.VC,-V 4 1 L 0 LL Cn 0- reef anU I.Sq V 0., §UVe and ZIP Code Postage Certified Fee 00 Special Delivery Fee Restricted Delivery Fee Return Receipt Showing M to Whom & Date Delivered •0 Return Receipt Showing to Whom, C =3 Date. and Address r Q TOTAL Postage Fees 74 0 0 D Postmark or M C14 E 0 LL Cn 0- a JOHN N. CALBO Building Inspector TOWN OF PATTERSON Telephone PUTNAM COUNTY 878-6319 PATTERSON, NEW YORK 12563 Mr. William Hedges Putnam County Health Department Rt. 312 Geneva Road Brewster, New York 10509 August 5, 1993 RE: TM - 3.19 -1 -13 (125' x 180'/22,500 sq.ft.) North Street Patterson, New York Dear Mr. Hedges, This is to inform you that the above noted tax parcel constitutes a single building lot in the Town of Patterson. If you have any questions, please do not hesitate to contact this office. Very truly yours, Frank Blas Temporary Building Inspector cs cc: Mr. H. Nichols ENCLOSURE I ' 1 § 15446. Application for permit to rebuild. Application for permit to rebuild or restore the damaged portion of any building damaged or destroyed as set forth in § 154 -45 above shall be filed within six (6) months of the day of such damage and shall be accompanied by plans for recon- struction which, as to such. portion, shah comply with the provisions of this chapter in all respects save as the use of the building or structure. § 15447. Completion of rebuilding. If a permit for such rebuilding or restoration is granted, it shall lapse twelve (12) months thereafter unless the permitted con- struction is completed within such period, except that the ilding Inspector in his discretion may grant one (1) six -month extension thereof if construction has been delayed by cir- cumstances beyond the control of the permit holder. § 154 -48. Buildings on nonconforming lots. No provision of this chapter pertaining to minimum lot area and minimum lot width shall prevent the construction of an otherwise permitted building or the establishment of an otherwise permitted use on a lot owned separately from any adjoining lot at the ef- fective date of adoption of any such provision, provided that the building will have the minimum yard requirements specified in this chapter and will not exceed the maximum specified lot coverage. 15441 Y r: Y•i t _ ti 1} � t 1� •' ''Ai W 1D•.• • � ti Offiorn of WIiMM H. H RI)KK a perir t of Highwzys August 19, 1993 Bill Hedges Putnam County Department of Health 4 Geneva Road Brewster, NY 10509 RE: Ted McGlasson Parcel - Tax Xap No..�3.19 -1 -1 North Street Town of .Patterson Dear Mr. Hedges: r As you know, you recently contacted me regarding your review subsurface sewage disposal system (SSDS) on the above -noted parcel You indicated that poor drainage existed on the lot and would likely result in ponding in the proposed SSDS .area. You also indicated that you would like to request that the applicant specify fill in this area of the lot to promote better surface drainage. However, you recognize that this may cause drainage problems on North Street, a Town road. As requested., I have evaluated the matter by visiting the site with a representative of the Town Engineer's office to determine the effects that placing fill on the lot would have on surface drainage patterns and the road drainage. Based on our visit, it was determined that the proposed filling and regrading would not be found objectionable, as long as some drainage improvements to pick up the added runoff were provided along the road frontage at the applicant's expense. The additional improvements should consist of a new catch basin installed along the frontage with a pipe crossing the street to tie into a new catch basin installed in an existing 18" diameter CMP drainage line on the east side of the road. Specifically, these basins should have flat tops with grates and be set just off the road so that the inside edge of the basin coincides with the existing edge of the pavement. Such basins should be precast concrete (manufactured by A &R Concrete or equivalent) and certified to meet H -20 loading requirements. The frames and grates should be cast 'iron (Campbell Foundary Pattern No. 3407 or equivalent) and also certified to meet H -20 loading. The basins should have a 3' deep sump and be connected with 15" Ted McGlasson Parcel August 19, 1993 Town of Patterson Page 2 diameter corrugated polyethylene pipe (ADS N -12 or equivalent). This pair of basins should be situated 140' south of an existing flat -top catch basin which is located on the west side of the road on the frontage of Tax Map Parcel No. 3.15 -1 -4 (generally across from Sugar Bush Road). The area immediately around the installed basins should be graded to drain to the top of the basin. I hope that this information is sufficient for your needs. I would appreciate it if you could forward a set of any plot plan approved by your department for this property. I would likely make these drainage improvements a condition of any driveway permit I would issue for the lot. If you have any questions, please do not hesitate to contact me. Very truly yours, WILLIAM H. BURDICK Highway Superintendent WHB /dsm cc: Slayton, Gainer, Wilbur Consulting Engineers, P.C. Planning Board Town Board 9177 \081993.1tr pUTN•AM COUN"T'SZ" DEP.A.R'TMEI�7'Z' O&' I= 3CLALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1 . Name and Address of Applicant: N Po. G,A n t5 2. Name of Project: 5VG�,f2 3.._, Location&)V /C: 17�t� -y4L 4. Project Engineer: #(_AiT__.Z- 5, Address: ,572 License Number: Phone :12:7 b G10b 6. Type of Project: �: _ .• +/ Private /Residential Food .Service ....Commercial , Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject* to State Environmental-Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted - ) 8. Is a Draft Environmental Impact Statement,(DEIS) required? ............. ,n 9. Has DEIS been completed and. found acceptable by.Lead Agency? 10... Name of Lead Agency wil A- 11. Is this project in an area under the control of -local planning, zoning, or other officials, ordinances? .... ... ............................... On .2. If so, have plans been. submitted to such:. author .s ties? ..................... _ 13. Has preliminary approval* been' granted by such authorities? Date Granted: /A 4. Type of Sewage Disposal: System Discharge...... Surface Water L--` Ground Waters t5. If surface water discharge, what is the stream class designation ?........ 6. Waters index number (surface) ........... ............................... _ �N11_ 7. Is project located near a public water supply system? .................. U0 3. If yes, name of water supply Distance.to water supply 9. Is project site near a public sewage collection or disposal system ?..... )�D )• Name of sewage system I- Date observed: Distance to sewage system - =71=— 23. Name of Health Inspector: UJ� Project design flow (gallons per day) ...... ............................... _o 25. Is State Pollutant Discharge Elimination..System (SPDES) Permit require 26. Has SPDES Application been submitted to local DEC Office? ............ 27. Is any portion of this project located within a designated Town or Sta wetland ? .............................................................. 28. Wetland ID Number ........................ ............................... iJ /Q 29.-Is Wetland Permit• required? ............................................. �In Has application been made to Town or Local DEC Office? .................. �J /Q 30. Does project require a DEC Stream Disturbance Permit? ................... dln 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste disposal;".. " landfilling, sludge application or industrial activity? ........ YES: or, NO 32. Is project located-within 1;000'feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? .....'...._....YES or NO DESCRIBE: 33. Is. there a local master plan or file with the Town or Village? 3.4: Are community water, sewer facilities planned to be developed within 15 years? _ din 35. Are any sewage disposal areas in excess of 15% slope? ........................ �i 36. Tax Hap ID Number ........................................................ 'x•1`1 �.-�� 37. Approved Plans are to''be returned to: Applicant Engineer :f the application is signed by a person other than the applicant shown in Item the. application must be•accompanied by -a Letter of Authorization: Failure to comply with this )rovision 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 Crass A Misdemeanor pursuant to Section 210.45 of the Pena 1 Law. ;IGNATURES & OFFICIAL TITLES:_ H_/ ,tom /,a,,� ,, L . :AILING ADDRESS: 9 3 PUI1, M OCUNTY DEPAR24ERr OF HEALTH r DIVISION OF HEALTH SERVICES: DESIGN DATA SHEET- SUBSUFACE SEEIWAGE DISPOSAL SYSTEM FILE. NO_ traner M -��4 N Address Located at (street) Sec. Block _ 1 Lot 1 � (indi to near cross street) t-tnicipalIty CA:41 E rho IJ . Watershed G 1o'ro� SOIL PERCOrATICN TEST DNM RDQ(7= TO BE SUBMI= WITH A.PPLICMICNS Fite of Pre- Soaking 25 - 1,7 ) , -�'7 Date of Percolation Test rj HOLE NL'=M C1= PERCOLATION 11ERCOLATION Run Elapse Depth to Water Fran Water Level No. Tug Ground Surface In Inches Soil Rate Start -Stop Min_ Start Stop :Drop In Min /in Drop Inches Inches Inches 2 a 2,4 2 2t1 ! 12� 4 12: SL 1 �o !Z4 2 1 3 11Z:0 -_ IS:51 ' 1Pio �4 24 !9�1- Z Ile «. d S 1 2 3 4 5 0 NOIES: l.• Tests to be repeated• at sari depth until approximately equal: soil rates are* obtained at each percolation test hole.. All data to' be :knitted for review. 2. Depth measure- eats to be made fran top of hole. rev. 9/85. ; TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION � DESCRIPTION OF SOILS E9COUNTERM IN TEST HOLES DEPTH HOLE NO. HOLE NO_ HOLE NO_ G.L. 1' 21 3' 4' 5' 6' 7' 8' 9` 10' 11' 12' 13` 14' INDICATE LEVEL AT WHICH GROUND'rM= IS ETKMNTERE.D INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTEF2 BEING ENCOUNTERED DEEP BOLE OBSERVATIONS MADE BY: a w I PA ^ M 14 -ebEf� DATE: . DESIGN Soil Rate Used 12 Min /1" Drop: S.D. Usable Area Provided _ No. of Bedrooms �2 Septic Tank Capacity leg-no` ,;i�tio O � � e_. Absorption Area Provided By L.F. x 24" width.tr Other - r Nam Signature— O l Address '—(�25 r,—A SEAL Al THIS SPACE FOR USE BY 'HEALTH DEPARnMTE ONLY: Soil Rate Approved sq.ft /gal. Checked ,1?1' Data_ PUTN_ COUNTY DEPARTTiENT - OF HEAL DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date 2 Re: Property Located at Di'LT ��� � �i Tjr_f'4r%0 �j (T) C A� &A Section Block Lot Subdivision of Subdv. Lot R4 _ Filed flap # Date Gentlemen: This letter is to authorize -{�}� `� y,J , — 4-. % 1 a duly licensed professional engineer I/ or.register.ed architect (Indicate) to apply for a Construction Permit for a separate sewage systern, to serve'.the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the, Public health Law, and the Putnam County Sani- tary Code � 24 � Counter I,* �@ R I ass o P� P.E. , R.A. , # 2z�- Addre s 2"jh Glo�� Telephone Very truly yours, Signed Otaner of Property PD f30x >� Address Tdw-n Telephone IM OF &lPBN9Ctd HOW DOPRDW P. 0. BOC 445 RMPOTi, MW M91256 4445 91 7,q S Office of VUU. AM H. EDIQZ Syerir t of Highways August 19, 1993 Bill Hedges Putnam County Department of Health 4 Geneva Road Brewster, NY 10509 RE: Ted McGlasson Parcel - Tax Map No. 3.19 -1 -13 North Street Town of Patterson Dear Mr. Hedges: As you know, you recently contacted me regarding your review of a subsurface sewage disposal system (SSDS) on the above -noted p4rcel. You indicated that poor drainage existed on the lot and would likely result in ponding in the proposed SSDS area. You also indicated that you would like to request that the applicant specify fill in this area of the lot to promote better surface drainage. However, you recognize that this may cause drainage problems on North Street, a Town road. As requested, I have evaluated the matter by visiting the site with a representative of the Town Engineer's office to determine the effects that placing fill on the lot would have on surface drainage patterns and the road drainage. Based on our visit, if was determined that the proposed filling and regrading would not be found objectionable, as long as some drainage improvements to pick up the added runoff were provided along the road frontage at the applicant's expense. The additional improvements should consist of a new catch basin installed along the frontage with a pipe crossing the street to tie into a new catch basin installed in an existing 18" diameter CMP drainage line on the east side of the road. Specifically, these basins should have flat tops with grates and be set just off the road so that the inside edge of the basin coincides with the existing edge of the pavement. Such basins should be precast concrete (manufactured by A &R Concrete or equivalent) and certified to meet H -20 loading requirements. The frames and grates should be cast iron (Campbell Foundary Pattern No. 3407 or equivalent) and also certified' -to meet H -20 loading. The basins should have a 3' deep sump and.-be connected with 15" Ted McGlasson Parcel August 19, 1993 Town of-Patterson Page 2 diameter corrugated polyethylene pipe (ADS N -12 or equivalent) . This pair of basins should be situated 140' south of an existing flat =top catch basin which is located on the west side of the road on the frontage of Tax Map Parcel No. 3.15 -1 -4 (generally ,across from Sugar Bush Road). The area immediately around the installed basins should be graded to drain to the top of the basin. I hope that this information is sufficient for your needs. I would appreciate it if you could forward a set of any plot plan approved .by your department for this property. I would likely make these drainage improvements a condition of any driveway permit I would issue for the lot. If you have any questions, please do not hesitate to contact me. Very truly yours, WILLIAM H. BURDICK Highway Superintendent WHB /dsm cc: Slayton, Gainer, Wilbur Consulting Engineers, P.C. Planning Board Town Board 9177 \081993.1tr 1 - w, vd, • _ - -- aq 2.0 I I M<N. �Fr'101✓NG� U0� ��. S rxt�ING o 4" ;1 d 1'r. � ✓It7�NG� I too CIA,. — �4 ✓wTv, �i�tJK Z a MIN. 7 fP.) ;3",6T(P.) �\ (vGG�F7YF) IoO.GCfYP.) q_Z \ °�z PT2 -rI .4 ccLtn I'J.G C1YF) \p N royI°i /i a /� Y �y �10raT9i .1o1>zf�tY 0 es dci2-� R- 8O \e -en a 4 .dll l�l SITE LOCATION PL SCALE : I"- 20001 PROPERTY SHOWN ON TOWN 1✓/�Tfti�aON TAX MAP : 3.1.1 SSDS DESIGN DA7 DESIGN FLOW - RE5IDENTIA 3 t3EDROOMS ®2O0 G.P. D. = !,De SOIL RATE USED: 11_IJ�IMIN./ I° APPLICATION RATE: 0-15 G.P.P. ABSORPTION TRENCH REQUIRED : 315 V f. PROVIDED '37& L.f TEST PIT DE5GRIPTI, HOLE a I 0 _ 1 -0" rpP�✓olL, O" :*ANO P, Gq(zAVf� NOI � n 2 : G5AML M7 Aq�ovg . I U. L. n L . F01 .0 F� �XI'AN�i1GN p.rfCA �' � 4 0 ell I S � 1 too Gl�.l.. (v'G G itYe) to n.G CTYP.) q Z \ o Arl�WrrTlcN � � Pt2 7.K'I A °4'GiG'�1D f°JIiCIYPi A 1 � 4110 Wo>2T11 6TT9�f,i ° 80 ' ( d5-2 k owl ',V \ls+. Ak SITE LOCATION PLA SGA LE : j", ,L0001 PROPERTY SHOWN ON TOWN G TAX MAP 3.1°I SSDS DESIGN DATA DESIGN FLOW — RESIDENTIAL 7j OEDROOMS 0 2Ii0 GRO. SOIL RATE USED: N- 11iMiN.� 1° D! APPLICATION RATE : O.b G.F.D. /' A55ORPTIOW TRENCH REQUIRED : �)75 1,r. PROVIDED 3i6- L.r' TEST PIT DE5CRIPTIC HOLE a I 9 _ 1��0" :-Vjj%oIL ✓44.1' VOAM :*ANO GII' vel W H01Lr 2 : 1,AMr- Ah AV0,10, . CONSIM i FviNAM COONI'Y DEPARTMENT OF HEALTH Divisloe et[ BbvMmeefd Hedlh Swirloeo. Carmel. N.Y. IGS12 Ruginearteprovw0ptintafto I PERK' FOR SEWAGE DISPOSAL SYSTEM Su6dlvlds� Hams ��- Lat / � w CERTICE OF COMPIIANCB Peok l t% _ :��, . l�J% Town dr VMMP Tax MOP Block 1 —Let 7�%y SSGJV Reaewd_6� Revhlom__p Ownw/ApplicsltNave i�fcCif D .2L-41 5 Date d Frovloae Approved MullIng Adze a �, 0, T.W.— L)Jbeln 'Z�L 22p Date Subdivision Annroved Fee Enclosed ❑ Amnttnt '- Building Type Lot Area 9242 - �G Fm section Only Depth Telam Naaber of Bedrooan / Dmlp Flow G E D 600 PCHD Notmcadoo V Required When FM Is completed Sepaeaos Sewerep Syd m to eoeslat of GO o GAB= Smile Teak and Z- S C To be oeeetreeted by / J!� V Addreeo Water Supply Piddle Supply Feoo -rte n Address an ftftte Supply DrMW by T �! 4ddnm Odwr Redahemmts 1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(%); 1) that the separate Iowa" disposal system above described will be constructed. as shown on the approved amendment there to and in accordance with the standards, rules an regu '.ions of • Y nom County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of H•althwill be submitted to the D•partmant, and a written guarantee will be. furnished the owner, his successors, heirs or assigns by the builder, that mid builds will glace in good operating condition any pert of said saweg• disposal system during the period of two (2) s immediately followlny the date of the !$$Y- anew of the approval of the Cartific:ate of Construction Corn plianca of orpinal system any rapair et ; 2) that the drilled well described above will be located as shm an the approved plan and that mid well will be Inst I in actor nc• h the st rd rubs d reguMTro f oof the Putnam County Oepertmsest of Health. ./ Dot • (/p /O. Sgnod p.E.!� R.A. Address �r r —License No. APPROVED FOR CONSTRUCTION: This approval expires two year m the oat slued unless construction the building .has been undertaken and Is revocable for cause or may be amended or modified when consider n mry by a Co ssioner of Health. Any change or •Iteration of construction requires a no Per 'it. Approve 0 for disposal of domestic Unit y age, and /or pr' a water supply only. Rev. / 10/88 Oate TT_ By Title —1�-- DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # P *`38 "�� WELL LOCATION Street Address T wn Village City f4 S �5 OA) Tax Grid Number 1q - /-/ WELL OWNER Name Mailing Address %Private C C S.SO PO DO 6l e) c- a' O Public JS E OF WELL - primary 2 - secondary 13 RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP I3 ABANDONED 0 BUSINESS O FARM O TEST /OBSERVATION [0 OTHER (specify 0 INDUSTRIAL M INSTITUTIONAL O STAND -BY 13 AMOUNT OF USE YIELD SOUGHT Jam' gpm /# PEOPLE SERVE10.5 /EST. D REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION UNEW SUPPLY NEW DWELLING L3 DEEPEN EXISTING WELL OF DAILY USAGE gal Q ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING Q�S /D�nJG _ WELL TYPE DRILLED DRIVEN DUG OGRAVEI. OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name 7-50 Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED / OON SEPARATE SHEET (date) (s gnature PERMIT TO CONSTRUCT A WATER This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health provided by the Putnam County Health Department. During all well drilling operations, the applicant any and all water or waste products from such well property and in c a manner as not to degrade o Date of Issue: L� 19� Date of Expiration 19�_ shall take appropriate action to assure that drill operations be containi�d on this r su oth� ami9pte surface or groundwater. Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES- Date Re: Property of Located atO (T) pG�j�j��/'SO Section 3 .I� Block % 71ot: /�D n Subdivision of Subdv. Lot # — Filed Map Gentlemen: 1 This letter is to authorize %% C�� /V �(� 4 aL � r - a duly licensed -prof essional engineer or registered architect (Indicate) to apply for a Construction Permit for a separate sewage -syst.em, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of. the Putnam County Department of Health,. and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law; the Public Health Law, and the Putnam County Sani- tary Code. �0� PJCt�i Q " � W Ci� W No. 66124 Countersigned.- P.E. , -R:A. , Address �r ©SQ !'elephon<: Very. truly yo s Signed O er o Property f• '/) , 6/0 Address Town Telephone a LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E.. CONSULTING SITE ENGINEERS June 10, 1997 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS - Renewal McGlasson North Street Patterson, N.Y. Dear Robert: Enclosed are the following: 1. Four (4) prints of SS -1 "Proposed SSDS ", revised 3- 25 -97. 2. "Construction Permit for Sewage Disposal System ", dated 6- 10 -97. 3. "Application to Construct a Water Well ", dated 6- 10 -97. 4. "Letter of Authorization ", dated 6- 10 -97. We would appreciate your review, approval and issuance of the renewal Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. 1 Harry W. Nichols , P.E. HWN:TR:bd 93036 cc: T. McGlasson LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road . %A Brewster. New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FA)O 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS October 18, 1995 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Renewal Permit #P -38 -93 North Street Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -1 "Proposed SSDS ", revised 10- 13 -95. 2. "Application For Approval of Plans For a Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 10- 18 -95. 4.. "Application to Construct a Water Well ", dated 10- 18 -95. 5. "Design Data Sheet ". 6. "Letter of Authorization ", dated 7- 21 -93. 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichol Jr., P.E. HWN:bd 93036 enc. cc: Mr. T. McGlasson w /enc. pUTN.A.M C��CTNT SZ" DEPARTMENT C>)F ; I �EAL.TX� APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEH 1 . Name and Address of Applicant: D . �DX• �, I b 2. Name of Project: 025 L� C-,,5D`� 3.. _Location�TJV /C: 1�:1`"�ef'� -�n� 4. Project Engineer: 5. Address: �? �FI>vt G�izisi License Number: i Phone: 6. Type of Project: Private/Residential• Food .Service ...Commercial , Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject•to State Environmental-Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted LLI 8. Is a Draft Environmental Impact Statement (DEIS) required? 11vn 9. Has DEIS been completed and found acceptable by Lead Agency? _ 10.- Name of Lead Agency till A- 11. Is this project in an area under the control of -local planning, zoning, or other officials, ordinances? ......... ............................... :p}n f2. If so, have plans been.submitted to such:. author .s ties? ..................... _ s 13. Has preliminary approval been granted by such authorities? Date Granted:��A :4. Type of Sewage Disposal; System Discharge...... Surface Water ►-' Ground Waters (5. If surface water discharge, what is the stream class designation ?........ '6.. Waters index number (surface) ........... ............................... 7. Is project located near a public water supply system? .................. _ Q o S., If yes, name of water supply Distance to water suf)ply 9. Is project site near a public sewage collection or disposal system ?..... �)o 0. Name of sewage system I. Date observed: Distance to sewage system T 23. , Name of Health Inspector: 4 . Project design flow (gallons per day) ...... _ G-�o _ 2. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.._ Qn 26. Has SPDES Application been submitted to local DEC Office? ............... 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... N n 28. .Wetland ID Number ........................ ............................... WA 29. -Is Wetland Permit. -required? ............ Ian Has application been made to Town or Local DEC Office? .................. t��Q 30. Does project require a DEC Stream Disturbance Permit? ................... 43�� 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste disposal;}'` ` landfilling,'sludge application or industrial activity? ........ YES. or NO 32. Is project located-within i;000-feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known-source of contamination? .............. YES . or No fl» DESCRIBE: 33. Is there a local master plan or file with the Town or Village? ........... - - Ye 34. Are community water, sewer facilities planned to be developed within 15 years ? — 35. Are any sewage disposal areas in excess of 15% slope? ........................ _ 36. Tax Hap ID Number �,.1�1 IA- 37. Approved Plans are to' be: returned to: App-licant t/ Engineer :f the application is signed by a person other than the applicant shown in Item.1, the. application must be-accompanied by-a Letter of Authorization: Failure to comply with this )rovision may be grounds for the rejection of any submission. I hereby affirm, under pena7ty of perjury;- that information provided on this form is true to the best of my knowledge and belief. False statements mado herein are punishable as a Crass A Misdemeanor pursuant to Section 210.45 of the Pena 7 Lair. J GNATURES & OFFICIAL TITLES: :AILING ADDRESS: `b FUMAM COUNTY DSPARTNE NT OF HEALTH Dhhlw d SnM@ asnW Hem Sambre. Cassel. N.Y. 10512 shear to rmwe Feesk e !ElOM FOR SWAGS DEPOSAL SYSTEM �w Name Bbd. Lot Y an C8g1MATS OF COMPLIANCE Pelf ° er VMMBO Tor: Map 3 49 Siock _ —Ia 1, 3 Rawwai .®' Revidon__o Ow�erYAppYaat Name �� �� % >t.���,ni Date of Previous Approval %�i� T Mdit Addles , %/i Town i'a..s.Re j/° —ZIP Matp, Subdivision Approved Fee Enclosed ❑ Amniint guNdlian Tmw _!`- i. <42d 4/ 7-141— Let Area r2 - J• i 4 �' Ac, FMM Sectloat Oalp Depth Voh ww Nmber of Bedroom a Ded@I Flow G P D �C7t a �PCHD NolfBlstlon h Regahed When 3.�fU h completed Separate Sewe ns" System to csadd d Gdbu Septic Took sod . Y �i c� 4- %rf�ar l C To be consheded by / 4 '� Address Water Stlpp*: PI> & Supply From Addtoea on k Pdvate Sup* Darted by rte_ ---Addross Other Reotdremeaq 1 reprsYnt'.thot 1 am wholly and completely responsible for the d•sion and location of the proposed systern(a)o 1) that the separate ;sway disposal system above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu of O • norm County Department of Health, and that On Completion thereof a - Certificate of Construction Compliance" satisfactory to the Cominisslon•r of H•olthwill b• wbmitted to the Department, and a written guarantee will be furnished the owner. his successors, half$ or assigns by the bulklaq, that said builder: will place In good operating condition any part of said saws" disposal system during the period of two (2) years modlat•ly following the "to of the iau- once of the approval of the Certificate of Construction Compliance oft • original system Or an repairs tlle► n--2) that the drilled well described above well be located as'shoarll on the approved plan and that Yid well will tN lost 1 in accordan with t slander rule an •gY tins of the Putnam County Deportm•frt of Health. Date Signed P.E,k- R.A. ; () '-' /� "�S Address s% % 7 � APPROVED FOR CONSTRUCTION: This app►eval expires two years from the date issued unless construction of the building has been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any charge or alteration Of"tonstructkrn Rev. requires a now p rmit. Approved for • disposal of domestic sanitary saw a F p ' e afa Ifl only.. By '�-�� Title 10/88 D•t• DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PF RM ?T $ P_�Vq WELL LOCATION Stree Address. <� Village City Tax Grid Number 9✓ ;1 . �'CJ,1 WELL OWNER Name Mailing Address APrivate i,: // . !a A13' O Public USE OF WELL RESIDENTIAL 0 PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP ❑ ABANDONED - primary O BUSINESS D FARM p TEST /OBSERVATION 0 OTHER (specify 2- secondary O INDUSTRIAL O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT _gpm /# PEOPLE SERVED.,'•- y /EST. OF DAILY USAGE al REASON FOR REPLACE EXISTING SUPPLY O TEST /OBSERVATION 13- ADDITIONAL SUPPLY DRILLING EI NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN DUG GRAVEL OTHER IS WELL SITE SUBJECT.TO FLOODING? YES _ Y NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name - r3p Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY. DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED SON SEPARATE SHEET (date) ( Qnature) PERMIT TO CONSTRUCT A WATER WELL 'This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt; (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: 19 51 5— Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange cope: Well Driller DESIGN DATA SHEY-T- SUBSUFACE SEWAGE DLSPOSAL SYSTEM FILE NO. TSi dress ?OwneY 6(o jZM GL N .`f 105 !ice Located at (street) u/9V, fa ST12m::� Sec. �-�.Jj Block _ti Lot 42 Undicaltd near t cross street) municipality CA=ffV--20Q Watershed SOIL P&RCOLATICN TEST IIATA REQUIRED TO BE SU& II'rI'ID WI'TFi APPLICATICNS Date of Pre - Soaking �j - 2) , �j �j Date of Percolation Test r HOLE _ v - Ntt r—R CI= TDE "1 3 1 ol, PERCOLATION P1mC0=C11q Run Elapse Depth to Water Fran Water Level- No. Time Ground Surface In Inches Soil- Rate Start -Stop Min_ Start Stop Drop In Min /In Drop 2 :G Inches Inches Inches 1 2 _ v 2 V ( . "1 3 1 ol, _:2 (4 ;�p 5 2 :G _ 2 2V �v ' 3 2 2- 7 5 1 2 3 0 4 5 NOTES: 1.' 'bests to be repeated' at same depth until appraximately equal: soil rates are "obtained at each percolation test hole. All data to'be submitted for review. 2. Depth mPirements to be made from top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WI'3.'9 APPLICATION DESCR 'ION OF SOBS ENCOURIERED IN 1 2 HOLES DEP'T'H HOLE NO. HOLE NO_ HOLE NO. G. L. _= f�Y (�� "` /i 011 2' ) 3' 4' 5' 6' I v S 7' 8' 9' 10' 11' 12' 13' 14, INDICATE LEVEL AT WHICH GROONDRATER IS ENCOUNTERED WIA INDICATE LEVEL TO WHICH YMER LEVEL RISES AFTER BEING ENCIOUNTERED DEEP HOLE OBSERVATIONS MADE BY: a1J I NA ^ M } b j, ' DATE: . DESIR4 Soil Rate Used �_(ri Min/1" Drop: S.D. Usable Area Provided _ No. of Bedroans d2 Septic Tank Capacity d y� ^ +icyo O e Absorption Area Provided By ,!I(/ _ L.F. x 24" width.tr Other 1 i � J, Nu Nam ,� G o Signature..A Nr l Address IE- L I> p P2111 SEAL THIS SPACE FOR USE BY 'BFALTH DEPARLMEM ONLY: Soil Rate Approved sq.ft /gal. Checked by Date 3 C) /\ -ru • lizu 16'X 40' Unfinished S,--.. -id-Floor.- 640 Sq- Second Floor ME -ST-C H-E -ST E-RM -OD -UL -AR-H-oMES, INC. Reagan's Mill Road • W-ingdale, NY 12594 (914) 832-9400 • (800) 832-3888 PUTN- COUNTY DEPARTMENT • OF, HEt `> DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re: Property of j�. �� j�/jl �xLAv� Located at er y� yew ' (T) �� 4744 Section 3r /g Block Subdivision of Subdv. Lot Filed Map 4 Gentlemen: Lot Date This letter is to authorize {��`( �ti� , }�JG� �nl—�� �� •. T a duly licensed professional engineer or,register.ed architect (Indicate) to apply for a Construction Permit for a separate sewage system, to serve.'.the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers'on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Las., the, Public Health Lai, *, and the Putnam Comity Sani tary Corr.; a, v/ Counterg,,i @ 1P., R�`F,�SS�O � P.E. , R.A. , 12 Address � � 2 O Telepho �ne Very truly yours, .� Signed 0i.*ner of Property SAD. r'!-nx Address l OSr"11 Telephone I fee. GO,_,- 7 — , M AI. r- —r, ne.wC,e I10U o � U.L. �. � +a9 0 s - V3 qI'y G.I.Q. — ¢ 1 coo qa.t.. � ^� %EPiIG �j4�IK . I T. g m � � jt1'Y'iO��TfoN �(�ENGHFh C(-fP).� Z411,1) wor2TH 6112 1✓Y tLz ��1�1uG7 e� 4�I -1 R -40 i T �5 SITE LOCATION PLAN SCALE: FWFEZTY SHOWN ON TOWN OF t��Tr�i� -yaN TAX MAP : 3.1`1 SSDS DESIGN DATA DESIGN FLOW — RESIDENTIAL ,5 OEDROOMS Q 2OD G.PD. _ loOO G.PP. SOIL RATE USED: 11 _ Ici MIN./ 1° DROP APPLICATION RATE: O Pi G.P. D. /S.F. ABSORPTION TRENCH REQUIRED 375 V.F. PROvIDED: 1>7& 14. TEST PIT . DE5CRIPTIONS HOLE a I : 0 _ 1'.0" : CpPg01L NGI.� � 2 : LAME; ALA A4�o�B