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00171
ltr,6
Ir ! /— I l a(Row [ OOIINI'Y D>�Al1�iP OF HF•ALTH �
Dlvl.i.a.f L9.vkoataaeafal Be" Seevloea. Carsel. N.Y.1RS11 >� a PravWo taasit
a CERTNICATE OF COMPLIANCE
CONgllDGliON�L,ZR�M'fI' I,r101< SEWAGE DISPOSAL SYSTEM
L.eaad at '�l To" 1,�
Stibdivbsiaa Nt Sulail_. loot r Ts: MaP�B{odl � t,
Renewal_❑ Rertaien ❑
owsedAplRtwat Nam � j�l i 71 T%��r
Date of Previous Approved
Matias Addr... Get l �G ?DAtD Towa b1 r:sj" ./f fT//N a"!
Date Subdivision ADDrOVed Fee Enclosed ❑ Amnt,nt
fi
BWWIng Typs gel 117 L] r1, T! Lot Area l !/ FillSecdonowy Dpth vaum.
Ntlabsr s[ Be�uoats De.IRe Flow G P D 6 e O nPC�HD NodBmdm is Realab'ed Wbsa FM 4 oorarpi.ad
S.ptraa Sa+«.p 5�.. a osasi.t at �� GaBw Ssptk Task sad -5d�7 1::r= � C 14 L S
To be ooasfrwead by �1 n Addles
Wsar Supply: Pulak Supply then Address
an L passe Supply Drilled by _Address
Otis Rrqutom.ats
1 represent that I am wholly and completely responWo for the design and location of the proposed system(s); 1) that the separate sews"-diva system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regulattons o ham
County Department of Health, and that On completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of Heslthwili
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the buiktor, that sold bulkier will
place in good operating condition any part, of aid sewage disposal system during the period of two (2) years mmetliately following thedate of the Imu•
some of the approval of the Certificate of Construction Compliance of the iginal system or any repairs t o; 2) t t the drilled well described above
wile M bested at shown on the approved plan and that YW well will W Instal n accortlanp with t stendar rules d r ns of the Putnam
County Ospartment of Health.
Date 5 - fo igned PRE. R.A.
Atltlnss ` C U me No
APPROVED FOR CONSTRUCTION. This approval expires two years from the ate issued unless construction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by mmistioner of Health. Any change or alteration of construction
Re V .
require$ • se
w permit. Approved for disposal of domestic sanitary wage, 1 only.
5 /
1��88 Oats /�/ �` g� _ Title
r
DEPARTMENT OF HEALTH (
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509r
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Street Address Town Villp�ge C ty Tax Grid Number
eG 1 (� /"t G - -<-
WELL OWNER
Name Mailing Address
/-/ S wo'�'%L - S J�'° -S 7 G
4Wrivate
O Public
USE OF WELL
1 - primary
2 - secondary
❑ RESIDENTIAL OPUBLIC SUPPLY OAIR /COND /HEAT PUMP
O BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY
40ANDONED
O OTHER (specify
. O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE. gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY O TEST /OBSERVATION Ll. ADDITIONAL SUPPLY
O NEW SUPPLY (NEW DWELLING) 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
6
i2 /d `;
WELL TYPE
❑DRILLED
DRIVEN UG
OGRAVEL
OTHER
IS WELL SITE SUBJECT TO FLOODING? YES (GNU
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
MATER WELL CONTRACTOR: Name 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
O ON SEPARATE SHEET
(date)
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 too degrade or otherwise ontami urface or oundwater.
Date of Issue: 19 /
Date of Expirati 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509 �D 7
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Stet Address Town/Village/City Tax Grid Nu5ber
WELL OWNER G
P�mWd2'f� G Address
13 Publice
USE OF WELL
1 - primary
2 - secondary
RESIDENTIAL ❑ PUBLIC SUPPLY
O BUSINESS ❑ FARM
0 INDUSTRIAL M INSTITUTIONAL
Q AIR /COND /HEAT PUMP
❑ TEST /OBSERVATION
❑ STAND -BY
❑ ABANDONED
❑ OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT_ gpm /# PEOPLE
SERVED 'Z /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION 12-ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING EI DEEPEN EXISTING WELL
DETAILED_S�
REASON FOR
DRILLING
WELL TYPE
®DRILLED DRIVEN
ODUG
DGRAVEL
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 -`.0 Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: ja TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
RON SEPARATE SHEET
(date) ignature)
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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: _19 _(
Date of Exp' tion 19._`y 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:., . A ., :.. - - -
PU11" CODIr!'t DEPAVNIUt! OF ®MLM
.1i �� I � DIVYiN U[ lEbeaETh'Seevbs. Cnse1. N.Y:1ixSU B�Yssr fa± P�lae Pa�It R . � t� qq
CZnnWATB
COMTMX
7MPW POR, WWAGB"DIWO_ SAL SYSI®1[ Q h �i q 6
Sia6ivYw Naato c.ra Let R Ter= Map � Block � it �J'
o...dA�ik,..e �17 7_ f TOLAe
/� Date of P.etdo eAApproval
W�IB A"os 6b . J1. Town KI �Tt IU�►'t�L
Date Subdivision Approved Fee Enclosed emn„nt
�++rs hPe (� rfv� V Lot Area l 1w Secfber:0a4 Depth Vehloe
Tlemili t Dosip Flow G P D idO O ]?CEO Nomidim b Required Wi m P® d almosood
SWrah S@..WW SYWM to eta filet eti OD (iaB.. Saplle Tam ...t
To bwe...te.ee.a by 7M t? Adam,.. _
WaMr S'W* - Ftlbie Sop* From Address
on Sig ob Mee by Ad6ims
OIMr Rilnsasnts .
1 represefnY:that 1 am "oily and completely responsible for the design and location of the proposed system(s)1 1) that :the toper at* sewage disposal . stem
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules all rigTi�ant OT
1� Funam
County Department of : Health, and that on completion thereof a "Certificate of Construction compliance•• satisfactory to tea Commissioner of Hesltnwill
be submitted to the Department, and a .written guarantee will be furnished the owner, his successors. hairs or assigns by the builder, that said bulkW will
Wct' in goo0,.operstinii condition, any pert of Said swage disposal system during the per od of two (2) yens mmediately following the"to of the isau-
afica., of, fire approval of fM Certificate of Construction Compliance of Me ginal system or any repairs t o. 2) t t the drilled .wail defamed above
well be'.ktcated es ahmen'bn the spprovee plan and that laid well will be instal n accordance with t stands r rules r ns of the . Putnam
County Department of HIM-
ealth.
Date fined P.E. R A:
Address tt =tl S JUMUMc 1 44V L�, Lime No
APPROVED FOR CONSTRUCTION: This approval expires two years from the cats_ issued unless ,construction of the building ,has been undertaken and is
revocable for cause or may be amended or rnodified when consider -ad necessary b mmissioner of Hearth. Any change or alteration of construction
3ev. .
'"uhes a w permit.. Approved for disposal of domestic sanitary sewage, only.
_--
LO/88 Date �' ! B�,r Title L
DEPARTMENT OF HEALTH TC`�/N�
Division of Environmental Health Services
4 Geneva Road, Brewster, New.York 10509 ,�
(914) 278 -6130 r �� v�y"�6
v_
APPLICATION TO CONSTRUCT A WATER WELL —p
PCHD PERMIT #
WELL LOCATION
Street Address / Town Village C y Tax Grid Number
WELL OWNER
Name Mailing Address
rJ ,wdi�'
4rivate
0 Public
USE OF WELL
1 - primary
2- secondary
41- Aw
O RESIDENTIAL OPUBLIC SUPPLY QAIR /COND /HEAT PUMP
0 BUSINESS O FARM O TEST /OBSERVATION
0 INDUSTRIAL U INSTITUTIONAL O STAND -BY
BANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__gal
O REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION M ADDITIONAL SUPPLY
❑ NEW SUPPLY (NEW DwELLLNGI 0 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
.e ,5 / 4'
`G-
WELL TYPE
13DRILLED
DRIVEN OUG []GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY:
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION
O ON SEPARATE SHEET
(date)
TOWN /VIL /CITY
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 ontami urface or oundwater.
Date of Issue: 19 /
Date of Expirati 19� Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130 (,�l 41-71-,16
APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT #
WELL LOCATION
Stet Address Town/Village/City T
Grid Nuer
WELL OWNER
D
Mr�7� C_ Address
I I
®Private
O Public
E OF WELL
1 - primary
2- secondary
RESIDE TIAL O PUBLIC SUPPLY
D BUSINESS O FARM
0 INDUSTRIAL O INSTITUTIONAL
O AIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
D ABANDONED
O OTHER (specify
O
AMOUNT OF USE
le
YIELD SOUGHT _ gpm /# PEOPLE SERVED i -Z /EST. OF DAILY USAGE �po0 gal
)A REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION Q ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
n �,
WELL TYPE
®DRILLED
DRIVEN
ODUG
GRAVEL
11 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 'MV Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO
NAME OF PUBLIC WATER SUPPLY: M 1A TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: �A /A-
LOCATION SKETCH & SOURCES OF CONTAMINATION
[-ON SEPARATE SHEET
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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19
Date of Exp' tion 19 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 cowrY DEPART r OF. HEALTH
DIVISION OF ENVIRONM�L HEALTH SERVICES
DESIGN DATA SHEEET- SUBSUFACE
SEWAGE DISPOSAL SYSTEM
FILE NO.
owner P Xi 17jZ[(4
TES 1N�dress
0N
D
HAM E-TOM
crO `�� ZZ II TzkA
/ f i
17
Located at (Street) r'C` f
f i Lf�i�`D
Sec.
. Block
f Lot
(indicate
nearest
dross street)
Municipality 'V,/\J r y� C 001_q
Watershed Cep
SOIL PERCOLATION TEST DATA.REQUIRSD TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking
Date of Percolation Test
t5 • { �- -Gf (�,
HOLE
NUMBER CLOCK TIME
PERCOLA'T'ION
PERCOLATION
Run Elapse
Depth
to Water From Water. Level
No. Time
Ground Surface
In Inches
Soil Rate
Start -Stop Min.
Start
Stop
Drop In
Min /In Drop
Inches
Inches
Inches
¢.'/ .
PT "f 2 �
.3
I
--
5
Z2
3
4
5
1 -
2
._
3
4
5
NOTES: I. Tests to be repeated at same depth .until.approximately.equal_ soil -rates
are obtained at each percolation test hole. All data to be.submitted
for review:
2. Depth measurements to be made frcm top of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF 'SOILS ENCIXJN'I'ER.ED IN TEST HOLES
DEPTH HOLE NO. HOLE NO. �i HOLE NO.'
G.L.
o„ 5!51 L-
21 51L S-\. tA V SIB
3'
4, _
5'
6'
7'
8'
9'
10'
12'
13'
14'
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENMUNTERED
DEEP HOLE OBSERVATIONS MADE 'BY:- DATE:
DESIGN
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided
No.. of Bedrooms Septic Tank Capacity gals.' Type
Absorption Area Provided By 4DZ) L.F. x.24" width ' trench
Other
Name +1I , X111: �Q Signature
k�•L.
Addres �L ����F �r-,NI F— SEAL %
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
PUTN�f C=TTY D EPARTMZNT OF HEALTH
DzVZ51oN OF ENVI OINiENTAL, HEALTH SERVICES -
Tate Jt'_ -_U�
Re: Property o£...�. -
.�.00dt ®d at i>1FZGl�_- 1 -� -1LL ��• � __' - --
(T) PT"rSd SectsQn ,Block I,ot
Subdivision of '
Subdv. Lot # —Filed Map # AAte
Gei.tl'tmen :
This letter is to authorize—ILA E1�2 4VL__s 1_7 e7,
a duly licensed .-prof essi_or .:k! ex,.Uineer or reVistered 1Mrchjt4dt
C7.z�d�.os�te
to a 'P3)1Y :tor a Cons tx'uct' on VCT-Em .t fox' � Men crate sewage -system' to
7erve the above rioted pr.opert�4 �.r, wccordan4re vi.th the Standards, x-ules
or re�cul.ations as promu_7_a`ai:ed by the Cor=l_,ss;oxxer oi. tae Putnam County
Department o_C Health,. and to all x.•x.ecessary papers ori. my b0half a4k
conn.ect;-o.n, i.Ti..tlh this mat ter a,-ld tcj sups -rv_j rc the oo:13tZCL0tk0ri or sa7_S
system or s }'stem i�z, conform �y �,i.th. the prov�s�.oz�s of Article 145 or
147, Educatj,on
Pitbl_a_c i4ea.i_th La-w, and the Putnam Cousity SanJ.--
taxy Code. r'^,,�,�!riicG�,�•�
No. 1124
NV
'Very t
S1`:Led
Addr°eat3
A3dxesra
`�UK71
Xc .
Ritnarn County Depart•rit'm t or !{e al th
pivleion of Cnvirarr". %snto1 Sa„itatiOn
AFFIDAVIT C6RPO?,4TZ 0x47NZR APPLICATION
kOR PERMIT, APPLICtiT ION SUBMT TTED TO
,F1J3:NAM COUNTY HEALTH pEPARTMENT ;
TO: Cornmissionex, of xealth In the matter Of application for
represent'.
that .1 am an officer or emPtioyee of the corporation and &m; su01ox,i2ed
to aQt for. ,� -.�'_
(name of corporatTon)
havin g offices at
Whose officers -are
-,0
'aar e ana Address)
Vice 'F. ^esi. en
(Name and Address)'
' (!lame and Address )r '
Treaszarer' _ ,
.....-..._ ._.',.........�
.(Name and Addre+5l�)i
and t�ie,t 1, 2m•and W�11 be :.ndividua? ly responszble fon any' or all ,aFt'p
of, the- corporation vith. respect to the approval regLie5tgd and Fill sUb
segve�t: acts 'relating .thereto, r
Sworn' 1-0 before he this ciao, Signed
7 W-rl
Title O
No fix y N io
r .
IDAMS
RM MOM
C-13A RM PA Durem
Z
Corpor4te Seat,
t
I�
:SCRIPTION OF WORK TO BE PERFORMED:
DATE: .r -� (v SIGNATURE: ����t/A'� -�� jt:�
This permit, to abandon one water well as set forth above, is granted under provisions of
Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that:
Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that the information delineated on the
application for this permit has been completed.
DATE OF ISSUE PERMIT ISSUING OFFICIAL
STREET ADDRESS
TOWN /VILLAGE /CITY
TAX GRID N0.
'ELL LOCATION:
ELL OWNER:
NAME P'�U��Si/CIOr'�TN 'E(� -( �S .�j� ADDRESS
� PRIVATE
PUBLIC
c Z -Z S
ELL TYPE:
DRILLED
DRIVEN .)4, DUG GRAVEL
OTHER.
EPTH DATA:
WELL DEPTH ft
STATIC WATER LEVEL r ft
DATE MEASURED
SE OF WELL:
RESIDENTIAL _
PUBLIC SUPPLY _ AIR /COND /HEAT PUMP
_ ABANDONED
primary
_ BUSINESS _
FARM _ TEST /OBSERVATION
_ OTHER(specify)
-secondary
_ INDUSTRIAL _
INSTITUTIONAL _ STANDBY
NAME
ADDRESS
kTER WELL
)NTRACTOR:
I75)
:ASON FOR
%mss R�Pi�cl iL TAD CI-dS� TGjC15�1 f��� �Uf�
1/� /ILL ,
3ANDONMENT:
:SCRIPTION OF WORK TO BE PERFORMED:
DATE: .r -� (v SIGNATURE: ����t/A'� -�� jt:�
This permit, to abandon one water well as set forth above, is granted under provisions of
Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that:
Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that the information delineated on the
application for this permit has been completed.
DATE OF ISSUE PERMIT ISSUING OFFICIAL
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FA)O 278 -2658
HARRY W. NICHOLS JR., P.E. N1 CONSULTING SITE ENGINEERS
May 24, 1996
Putnam County Department of Health
4 Geneva Road
Brewster, NY 10509
ATT: Mr. William Hedges
RE: Proposed SSDS Repair
Birch Hill Road
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing SS -1 "Proposed SSDS Repair ",, dated 5- 24 -96.
2. "Application For Approval of Plans For a Wastewater Disposal System ".
3. "Construction Permit for Sewage Disposal System ", dated 5- 24 -96.
4. "Application to Construct a Water Well ", dated 5- 24 -96.
5. "Design Data Sheet ".
6. "Letter of Authorization ", dated 5- 24 -96.
7. "Corporate Affidavit ", dated 5- 24 -96.
8. "Application to Abandon a Water Well ", dated 5- 24 -96.
Please review the enclosures and issue the repair construction permit at your earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. Nicho , Jr., P.E.
HWN:TR:bd
96027
cc: S. Pizzitola
�C_> YJ '7C I- .A. M C CD 'CJ 1 '" -C -Sr 7D )a: P ,C� R ,)' -r (D )F )E_l DE
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
Name and Address bf. Applicant ATr5 iN c
-T7 2'
2. Name. of Project: PRG'OSI`1� St25 et�-CAJIQ_ !3.._._Location T/V /C:
4. Project Engineer: �14�9Tt N1r-.h17J S a f_e 5. Address: Millbrooke Office Centi
r
Brewster, NY 1CF509
License Number: Phone: (914) 278 -6108
6. TYDe of Project:
Private /Residential Food.Ser.vice ....Cor�-,iercial ,
Apartments Institutional H6bile Home Park
Office Building - Realty Subdivision Other (specify)
?. Is this project subject*to State Env ironmental.Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt
Type II. Unlisted.
8. is a Draft Environmental Impact Statement (DEIS) required? h(�
9. Has DEIS been completed and found acceptable by Lead Agency? ...........
10. N an, e of Lead Agency
i. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ......... .................... .I.......... r,
2. If so, have plans been .'sucmitted to such. author .sties ?•. ........:.........
3. Has prel in, inary approval beep 'granted by such authorities ? Date Granted: N
_. Type of Sewage Disposal: System Discharge...... Surface Water Ground Waters
5. If surface water discharge, what is the stream class designation ?........ 1Jr//,a,
Waters index number (surface)_
Ts project located near a public water supply system? ..................
If yes, name or water supply Ll 1A Distance to water supply --- _j�A11�_
Is project,
site near a
public sewage collection
or disposal syste-i ?.....
t�ar,e of
sewage system
�A
Distance .., sewage
system
Date observed:
23. Name of Health Inspector: j','�>✓t�5 _._.__-
roject desi5n flc; (gallons per day).........
2.
25. Is State Pollutant Discharge Elimination'System '(SPDES)'Pern.it required ?.._ 1J Q
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 ? .................... .............. ..................I............ o
i
23. Wetland ID Number ........................ ...............................
29. Js Wetland Permit- required?' .............. ...............................
Has application been made to Town or Local DEC Office ?,............ ........ I-A 1A
30. Does project require a DEC Stream Disturbance Pe tit? i10
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 or NO
32. Is project located within 1,000-feet of e'x istence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge.disposal site or
any other potential known source of contamination? .............,.YES or NO G7
DESCRIBE:
33. Is there a local master plan or fife.-with the Town or- Yilla'ge? ......
34. Are co:--iiunity water, sewer facilities planned to be developed within 15 years? �Id
35. Are any sewage. disposal areas in excess of 15; slope? ................._
pxP +1O N S ► cs-
36. Tax Nap ID Number .............................. .......................
A
37. Approved Plank are to be: returned to:. ............... . . pp �licant 'Engineer
_�' g
EF the application`is signed by a person other than the applicant shown in Item .1, the.
°pplication must be - accompanied by y-a Letter of Authorization: Failure to comply with this
Drovision may be grounds for the rejection:of any submission.
I hereby affirm, under penalty of perjury;• that information provided on this
,
fo is true to the best -of my knoule -lye and bet ief. Fa Ise sta'te;-,ents "made
herein are pun ishab Ie as a Class A Hisde,,eenor pursu2- t to Section 210.45 of
the Pena 1 Law. 1 4 f n n
1GNATURES & OFFICIAL TITLES:
!`lillbroo!-%VOffice Centre r%
`%T L I NG ADDRESS: Brewster, NY 10509
.b
Rl�-CAI�-
i
i
M �
lUTNAM COUNT! DEPARTMElff OF HEALTH c�
DMdm of BnkrualaW Hetidb Seevlees. Cum@L N.Y. 14512 Ensh I r to Ptrsvlds Peter r R
CONSTRUCTION PEW= FOR SEWAGE DWOSAL SYSTEM
Localsd at►'1 11,E
a CERTIFICATE OF COMPUANI c
Pstlalt
Town or Ter: Map�Htoet 1 fd 0,5
SrabWvlisa Ntlao Subil. Lot r
Otr�sr /Apprcant Na�.� l�l 7 7_ I T7%I�k
Ci
Rooew.l_❑ Rev4ise
❑
Date of Prevbas1'Appproval
2
M.Sh,R AdB.aa "JJ (JN �G� D D
ro.►n by T fT�y /( (/= –�
C�
r, i j "!
Date Subdivision Avvroved
Fee Enclosed ❑ Amn,,,nt-
p�� n
eS F r(�.�rT_ G
fi
! �
�s Type _g Lot Area •
FM Section Oety Depth
valaoe
NtWbsc st Heirtsas Dealp Flow G P D a O
PCHD Not clarion Is Regabed Wben FM Is coaplsted
S"W"AB seweap Sy"M to ago" of ���{G.6e. Sepik Tent .
W �OD Lr=
C 14 L S
To be esrfrsKbd 67 J r% 1
Addmse
Water S"WI1 . Pink Sstp* Free Address
an Z- Pd ltie setpply Dow by 1 _ Add—.
Orbs Rogdnaeab
1 represent that 1 am wholly and completely responsible for the design and location of the proposed tystem(s); 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regulations o
County Department of Health. and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of HMlthwill
be submitted to the Department. and a written guaranis* will be furnished the owner. his successors, heirs or assigns by the builder, that said builder will
Woke M good operating condition any part of said swrags disposal system during the period of two (2) yeas mmedlately following tMGts Of the {m-
anoe of the approval of the Certificate of Construction Compile nce of the iginal system or any repairs t o; 2) t t the tlrilled well described above
w!! M located as shown on the approved plan and that said well will be Install n accordance with t stsnGr rules d r ns Of the Putnam
County Department of Health.
D_ ate 5 .� »n.tl
P.E. R A.
Addrea ` It — No
APPROVED FOR CONSTRUCTION: This approval expires two years from the Jet* issued unless construction of in* building has been undertaken and is
revocable for cause or may be amerlded or modified when considered necessary b mmissi*ner of Health. Any change or alteration of construction
require$ a w Permit . Approved for disposal of domestic unitary sewage , 1 onl .
lev .
LO/88 Da"
` e
NZ
DEPARTMENT OF HEALTH Tj & — la
A_. 6A lei Or m� Q-
Division of Environmental Health Services*
4 Geneva Road, Brewster, New York 10509p
(914) 278 -6130
a APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT 0
WELL LOCATION
Street Address
OF (7/
Town Villll ge C. y Tax
/_' L
Grid Number
-<—
WELL OWNER
Name Mailing
1".5 �°��%L
Address /
- S T°S �7 G
4Private
O Public
USE OF WELL
1 - primary
2- secondary
❑ RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP
O FARM O TEST /OBSERVATION
O INSTITUTIONAL O STAND -BY
*�BANDONED
O OTHER (specify
Q
AMOUNT OF USE
YIELD SOUGHT
gpm /#
PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
❑ REPLACE EXISTING SUPPLY
❑ NEW SUPPLY (NEW DWELLING)
O TEST /OBSERVATION 12 ADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
.v .6
WELL TYPE
13DRILLED
DRIVEN
UG DGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name 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
ON SEPARATE SHEET
(date)
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 too degrade or otherwise ontami urface or oundwater.
Date of Issue: 4:V-3 19 / A"
Date of Expirati 19� /Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division of Environmental Health Services I
4 Geneva Road Brewster, New York 10509 (D
(914) 278 -6130
a APPLICATION TO CONSTRUCT A WATER WELL
PCHD PERMIT # / t
WELL LOCATION
Street Address Town/Village/City Tax Grid ji u I ber
+4 1L - I -
WELL OWNER
C
P-Q"- - 2 �c,M r C_ Address
®Private
O Public
E OF WELL
1 - primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP
O BUSINESS O FARM O TEST /OBSERVATION
O INDUSTRIAL O INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify,
O
AMOUNT OF USE
YIELD SOUGHT gpm /# PEOPLE SERVED 1 -7i /EST. OF DAILY USAGE ?p gal
REPLACE EXISTING SUPPLY O TEST /OBSERVATION D. ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING 13DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
®DRILLED EDDRIVEN
QDUG
[]GRAVEL
C] 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 —M-0 . Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES A NO
NAME OF PUBLIC WATER SUPPLY.-- tA TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: ^
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
RON SEPARATE SHEET
(date3� � � ignature)
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 manner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19
Date of Exp' tion 19� Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
o / Il \ \ 1 / / I �,• H
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