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HomeMy WebLinkAbout0172DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4. -1 -70 BOX 2 J as '{ I or It 1 ' %6 � - ' ; , 00172 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM IQ PERMIT # Located at LC'i� Town or Village �4r� =r -SGT✓' Subdivision name C Subd. Lot # Tax Map Block Lot 70 Date Subdivision Approved Owner /Applicant Name k 6 gi � N--d ` V Mailing Address % �,, LVL- J � I- Renewal Revision Date of Previous Approval wl�o, %j y Zip 0 J Amount of Fee Enclosed ff Building Type vL' Lot Area N of Bedrooms Y— Design Flow GPD �y Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 12-:50 gallon septic tank and Other Requirements: To be constructed by NIC-S&AI Address Aj Water Sunnly: Public Supply From Address or: Y, Private Supply Drilled by Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the sepazate sewage treatment s, sy tem 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 R.A. Date ///V[ License # J 3 Z7 7 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe t. pprove discharge of domestic sanitary gs g only. Y• B Title: Date: /0 /(o White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 271811 x 44'e 2464 24'x ICS' family room* 384 ToW 28 8 First Floor PUTNAM COUNTY DEPARTMENT OF HEAkTH N PLANS APPROVED FOR WESTCHESTER MO DU L A R H 0 N, I B S M I COUNT ONLY; Second Floor 1; i7nature &Title 0 1) t,)V:A tj is *&P )6+*A4 WWAWMr ML S% 1146MAW610 IWIP art, LI UL I, loam a No BEID00CM 4 saga ms Date VOW 0 Lr4NGPWM WANG ROOM [Xta F14'JIoX1T1' FAWLY R0014 11EMACCM 2 0 1) t,)V:A tj is *&P )6+*A4 i � ' /1,10,<7D Al -P-A 4 -i.4 i—j -7 /-7 C us A/ F 7 r— 7 le WRYCMTER NOM f@VM M 'vw York 1 Z594 (800) 832 -3M • (914) 832-9400 I 1110- T O UL I, loam a No BEID00CM 4 saga ms Date VOW 0 11EMACCM 2 i � ' /1,10,<7D Al -P-A 4 -i.4 i—j -7 /-7 C us A/ F 7 r— 7 le WRYCMTER NOM f@VM M 'vw York 1 Z594 (800) 832 -3M • (914) 832-9400 I 1110- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Well Location: Street Address:. Town/Village Tax Grid # Map Block Lots) 7o Well Owner: Name: Address: 7 0 1\1 & ffl 165, Use of Well: Residential Public Supply Air /Cond/Heat Pump Irfigaiton 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage dal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason Lk for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... . Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. `- Water Well Contractor: Address: Is Public Water Supply available to site? .......................................................... :...... Yes No Name of Public Water Supply: Town/Village '�-- Distance to property from nearest water main: Proposed well location & sources of contamination be rovide n separate sheet/plan. Date: Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED _FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well. has been completed and inspectedby the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate 11 driller certified by Putnam County. Date of Issue Ia % q•me. Permit I i - Official• Date of Expiration Title: Permit is Non- Transfe ab e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 il SOIL SURVEY OF ' PUTNAM AND WESTCHESTER COUNTIES, NEW YORK - SHEET NUMBER 7 3000 FEET 500 0 .25 .50 MILES � nnn ..CTC OC 5IN1 nn � � � • • n nnn �n ....... -a 13 27.8„ e 44'e 2464 Sq. Ft. 241 X 16' fey room* 384 S . Ft. ToW 2-848 Sq. Ft. First Floor Y 4 OSWAKFASr lvw%tT1- FANKY ROOM D 'J' XI R t47'1, 1 166 -X73' - gfto 4 -0. ml LMNG ROOM Vr0Ixlrw 211 \� \• , � i WESTCHESTER MODULAR Ho L'S Second Floor wa emaoo�e 4 �! see i phoUt am P�132 wks�e elmowi n ? °. ! i� lt,IeA272) Al �3i �'G/`f 11/L L /cif P477�o1,1 L'7 -) -Txd-,W-- 4 -1 -70 ..j u t-l- f NJ � /C .I/- t, 4 ( z l c u S t-}-mf^) Ra . PA7-7-Ek -5oN� 9 7 r ! y • L' , Fcacurv� Atxleeaoa le : � mS ?t3 Rr!appSS MM Rd • 14sn dge, New York 12594 (800) 832 -WS • t914) 832 -94W 27t8l$ X 440 0 2 / . L Sq. t. W E S T C H E S T E R M O D U L A R Ho Nm i s 24' x 16''' family room* `384 S . Ft. Second Floor TOW 2848 Sq. Ft. .�..�.,__... 0 1 I _ S ttV4L 'd M'f �C 4tZ0'� t� � �Ietts�r*Cxitil„ sEtti " i � � LMN'G R'O• O ewF1raIrx� rvr am�s r a- ' ao r o► Mr ' s •i�tti m 7ti Yls First Floor , - BEDQOOt 7 wwwmmr CPK 2 s FAWLY ROOM DRBNG R001A • �IV /19h1z7D N l ° i IGIACH A/L� --Xo/f �. P/f 77 0A-1 C7)- TM#� 4-1 -70 (Z-1 C U.Si-M-s / A.4� P, 7--So 9i,{- F 7 r-_ 17 r' f Fcantcv Arxksraa c1 Rte; vAns.140 Rd. • 14u>gcla,z, N. York !2 >9u, (800) 83u -3&AS • (914) 8329 W14►4• uAYrk!a Inr. n�M�.S�� .-.�- • DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 John Karell, Jr. Tel. (914) 278 - 6130 Fax (914) 278 - 7921 P.O. Box. 644 Carmel NY 10512 RE: Morton Birch Hill Road (T) Patterson Reservoir Basin Dear Mr. Karell: BRUCE R. FOLEY Public Health Director November 19, 1998 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on November 16, 1998 is complete. The Department will notify you by December 9, 1998 of its determination. The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. El Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 166. Ve truly yours X��Vv & Robert Morris, PE RM:tn Public Health Engineer STREET LOCATION PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER REVIEWED BI RNI, GR, AS, MB, BH DATE TAX NIAP # Y N/ DOCUNIENTS PERMIT APPLICATION. -1 V,WELL PERMIT _ PWS LETTER 71LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS - THREE SETS HOUSE PLANS - TWO SETS VARIANCE REQUEST FEE SUBDIVISION LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL OCATED IN NYC WATERSHED q7ZDEEP LANS SUBMITTED TO DEP 15ELEGATED TO PCHD EP APPROVAL, IF REQ'D TEST HOLES OBSERVED PERCS TO BE WITNESSED X- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERIMIT(S) WAGE SYSTEM PLAN - (NORTH ARROW) DS HYDRAULIC PROFILE AVITY FLOW Y N EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED WELLS & DS'S W 260' OF PROPOSED SYS. PROPER Y ME BOUNDS PIOUS CK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 450 W /CLEANOUT FILL SYSTEMS LAY BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME ILL IN EXPANSION AREA LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSTS le-I TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 0' TO FOUNDATION WALLS _15'WELL TO PL 0' TO WELL, 200' IN DLOD, 150' PITS 1 0' TO STREAM WATERCOURSE LAKE (inc. expan) TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 'TO WATER LINE (pits -20') 0' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS CPNI STRUCTION NOTES 'MIN to CDS= >5 %,10'- 4 0/o,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <1% DESIGN DATA: PERC & DEEP RESULTS 20'MIN to CD discharge /100'with 182 cons day discharge Z' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT SEPTIC TANK E150' FROM FOUNDATION; 50' TO WELL FOOTING /GUTTER /CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES DIMENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS FALOCATION OF SERVICE CONNECTION TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: / 'WLE BRUCE R. FOLEY 1 \ � Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York .10509 Tel. (914) 278-6130 Fax (914) 278-7921 November 19, 1998 John Karell, Jr. P.O. Box 644 Carmel NY 10512 Re: Proposed SSTS: Morton Birch Hill Road (T) Patterson, TM# 4 -1 -70 Dear Mr. Karell: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1) The plan shove is within the no% jurisdictional subdivision titled "Roesch" approved by the Putnam County Department of Health on August 6, 1997. However, the" plan submitted does not reflect the approved subdivision. Please clarify this discrepancy. 2) Remove all notes and details on the plan, not applicable to this submission. 3) Minimum scale is V = 30'. 4) It is noted the parcel is 144 acres, however, all current codes and guidelines are applicable. Review Bulletin ST -19 and revise accordingly. Upon receipt of a submission, revised to reflect that above comments, this application will be considered further. RM:tn V eq truly yours, Robert Morris, P.E. Public Health Engineer 6- • DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road - Brewster, New York 10509 Tel. (914) 278-6130 Far (914) 278-7921 December 8, 1998 Jack Karell. 121 Cushman Road Patterson NY 12563 Re: Proposed SSTS: Morton Birch Hill Road (T) Patterson, TM# 4 -1 -70 Dear Mr. Karell: BRUCE R FOLEY Public Health Director Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental on this lot, percolation tests must be witnessed by a representative of this Department. 1) Erosion control measures for the well is to be shown. 6 2) Dosing volume has not been shown. Dose Iq be 75% of pipe volume. 3) Basement elevation has not been provided. / 4) Property metes and bounds have not been provided. / 5) USDA soil survey boundaries are to be shown for the entire prope lU 6) Water service line from the house to be well has not been shown. 7) Dimensions from the well to the property lines has not been noted. 8) Remove all details not of relevant to this and fill section. 9) Septic tank detail and septic tank sizing chart do not cone ate. 10) Minimum scale is 1 " =30'./ 11) Remove or. cross out fill notes. . Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve t y yours, Robert Morris, P.E. Public Health Engineer RM:tn PC -1 r pUTNAM COUNTY DEPARTMENT OF HEAD' —rJ= APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM . i/f 1. Name and Address of Applicant: 64 0427z) 2. Name of Project: 3. Location T/V /C:740�" 4. Project Engineer: J3Z t46) KA72_" - 5. Address: 12-1 c Vii /N% Al Aozl-V License Number: S_ 2 Phone: 6. Type of Project: =.—Private/Residential Food Service Ccrrmercial Acartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 7. Is this project subject to State Environmental Quality Review (SEAR)? Tvoe Status (Check One) Type I.. Exempt Type II. Unlisted K_ 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. S' ias DEIS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .... .....I ............................... 12. If so, have plans been submitted to such authorities? 13. Has preliminary approval been granted by such authorities? --Date Granted: 14. Type of Sewage Disposal System'Discharge...... Surface Water Ground Wate - x 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index number (surface) ........... ............................... 17. Is project located near a public water supply system? 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... y '.0. Name of sewage system � Distance to sewage system !1. 0 ate observed: �J- 23. Name of Health Inspector: '.4. Project design flow (gallons per day) ..... ..............................Z 2. 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. A,1 0 kd. 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 V 28. Wetland ID Number ........................ ............................... I---- 29. Is Wetland Permit required? .............................................. Has application been made to Town or Local DEC Office? .................. �- 30. Does project require a DEC Stream Disturbance Permit? ................... Q 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal,f� 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 N DESCRIBE: . Is there a local master plan or file with the Town or Village? ........... 34. Are community water, sewer facilities planned to be developed within 15 years? A/ D 35. Are any sewage disposal areas in excess of 15% slope? ........................ /-)o 36. Tax Map ID Number ...... .................... ............................... q- 37. Approved Plans are to be returned to: Applicant _)<- Engineer 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. Failure to comply with this provision may be grounds for the rejection of any submission. F 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 Pena 1 Law. SIGNATURES & OFFICIAL TITLES: MrT'_ING ADDRESS: PUTNAM COUNT' DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of IW6 Located at [9 ( TN �Leplxs_41 W . LETTER OF AUTHORIZATION ILc- A/� Tax Map # Block l - Lot 76 Subdivision of . Subdivision Lot # Filed Map n Date Filed Gentlemen: This letter is to authorize a duly licensed Professional Engineer or R to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Bducation Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned: f P.E., R.A., #' 32 7~7 Mailing Address 12� 64 14 State . ' VVY +'�.' Very truly ursi Signed: ( wncr of Property) Mailing Address: Vae Ta State Telephone: y/ Zip =- l , -t v � �s .a.�a.A.'c3 r n _ � y... a 4 -.r.� J`r �rs•�. 14.16.4 12107) —Toz( 12 PnOJECT I.D. NUMOEn G 17.21 SEC Appendix C Stnto Envlronmonlal Ouniny noviow SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPUCANT /SPONSOR ��%�� //VV11 2. PROJECT NAME .S s '61.� J. PROJECT LOCAT1011n !,•� / Municipality d County A. PRECISE LOCATION ( and road Intersections, prominent landmarks, ate., or provide map) (SStreettaaddrass 5. IS PROPOSED ACTION: (p`New ❑ Expansion ❑ Modl /1ea1101/alle1allon 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAnNG AFFECTED: Initially r� acres Ultimately acres a. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING On OTHER EXISTING LAND USE RESTRICTIONS7 R!�Kos ❑ No 11 No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 6ostdonlial ❑ Industrial 0 Commercial ❑ Agriculture ❑ Pork/Forosl /Opon space 0 Other Ooscrlba: S 2 jo;_O �e' ee�l� %:•P f (- h4, -A'cJ 1o. DOES ACTION INVOLVE A PERMIT APPROVAL. Oft FUNOING. NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL STATE OR LOCAL)? 0 Yes gi aMo It yes. list agency(s) and permlllapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Cl Yos &No it yna, list agency name and pormiilapproval l \ . 12. AS A RESULT ROPOSED ACTION WILL EXISTING PEF11611TIAPPROVAL REQUIRE MODIFICATION7 kN1 C] Yes o 1 CEnTIFY`TAT THE INFOnMATiON PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE r `�✓ rr `- l�.�G Dato rl (f ` eO Applicant /sponsor nomo: G'. Slanotura: 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 FA. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCAR. PART 617.127 11 yes, coordinate the tavlow procass and use the FULL EAF. ❑ Yes ❑ No a. WILL ACTION RECEIVE COORDINATED REVIEW. AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 It 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, It legible) Cl. 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. Aeslhclic, agrlcullural, archaeological, Itlstoric, or other natural or cultural resourcas; or community or neighborhood cheraclo(1 Explain brlolly: C3. Vegetation or fauna, list, shcllllsh or wildlife species; signlfltanl habllats, or threatened or endangered species? Explain brlelly: Ca. A community's existing plans or goals as olfaclally adopted, or a change in use di Intensity of use of land Of olner natural reaourees? Explain brio C5. Growth, suuso.quent dovolopmont, or rolalod activities Ilkaly to be Induced by tno propasod action? Explain brlally. C6. Long farm, short term, cumulative, or other effects not Identified In CI-05? Explain briefly. C7. Olhor Impacts (Including changes In use of eltne( quantity or typo of oncrgy)? Explain t:riolly. D. IS THERE, OR IS THERE LIKELY TO EIE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yos ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANdE (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.a. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (1) magnitude. If necessary, add attachments or relerenca supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have boon Identified and adoqualely addressed. ❑ Chock this box It you have Identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to tho'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 documontatlon, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: I'e is m rytv.. s �7071r In I a.n AMwe'y Signature of Responsible 011icul in Lea Al;cncy Nama of Lead A;:cncy Daft N w, � ilrfiw�na' u Puf ignalurc of riapucs.(Il different hom tesponsihic officer) i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA HEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address VC /� �✓ /� s Located at (Street) i�L Tax Map E— Block Lot _76 (indicate n crest cross street) I� Municipality Pa Drainage Basin % �4 SOIL PERCOLATION TEST DATA Date of Pre - soaking I Date of Percolation Test Hole No. Run No. Start - Stop Elapse Time De th to Water F rom Ground Surface (Inches) Water Level D nches Percolation Minn//Inch i 1 -0 1031 z r' 2 z��� 13/y 1 3 I l Z Z�j "3% J 3� 1 4 5 2 W Y O 111-V ;1-) ZZ.. I 3o 3 III rim �� 3d 4 5 1 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 r MR 11 q- TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. I G.L. —f-6 mD1 L. 0.5' i 1.0' C1 a da 1.5' 2.0' 2.5' .. Ol 3.0' 3.5' M 4.5' 5.0' 5.5' 6.0' , 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE NO. — HOLE NO. q L i Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level ris after beine encountered Deep hole observations made by: Date , d', Design Yrotessional Name: Address: Si Design Professional's Seal rr ,,, 0 01— U PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM mpg A1&' Owner Address Located at (Street) 21ECa H111 Tax Map Block Lot (in5icate nearest cross street Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test . ... .. .... .......................... . .. .... . ..... . ...... I . ... ... Depth t, Water ::::;:: F rom round. er Ave L I Hole '::N6.-. ... .. ..... ----:RunW6. ...... Time ... ...... S sj�- me Surface (Inches) 111.6es S Pr9p: In Inches Rate mi .. ..... .. 2 It ;07 �4- 25!,4 3� ( i 3 11 *,38 Y�— 4 5 2 10"q-0 Iwo 3 D 3 30 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each 10, percolation test hole. (i.e. s I min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-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' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. i > %D f' 20 f- # . a ._p hH aE 14 AV HOLE NO._�_ >7 HOLE NO. 3 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: Address: Signature: Design Professional's Seal I I r TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTI= G.L. 0.s' 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' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE NO. i > To? HOLE NO. 77 HOLE NO. 3 rol Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: Address: Signature: _ Design Professional's Seal old 1j1, 1 \ \\ \ 111 II III I I111I�.ji \' \ \ t l I 1 11 I I I I !III IIII . , :, , I , � ) / ; / / � , , :; � � � ,: , . , • , I � ' , ti • I I , 1 1 A \ \\ 1 1 1 1 I I IIII I (i l 1' I .,� •. !• I` l c 1 � j, II I I I 1 I � \ I I I(' I (• YY � � , ! J. I• � y . �C.r' / :I I I I I I I I 1 y��1�\ '�I �I.1 I I I I I I I I.I �I I i t f I r �:l : 1/ �-�i '• (. • I - 1. � I (;; � ,:I�\ ( •X,., � ^� .,' I I { I I I I 1 - '1 \,''b' ,` -' .J _t-I 7. i I 1 I J l r . 1 1 / �... x•_f� _ � 1 :' � , � I:.. M . � ` � � b I 1 � . !r Imo- \1_ _. { -�`I I I 1� 1 \ '•- . • � . I i • I I 11 / � r ' � 1 � /. �.., fv•.. - ,: 1;.::.; �- -� I ( 1` Qom. '' � ';+�`'�.._�: + '� .� \ (i Imo. 1 I. I i l J I I I I I I l ` I 'r ?I I :1 ' I I I I I 1 I �• IIII 'III i I -♦ �i I !:; I / �I I .y I I I Il; 1 I, II,I 1111 � I •1' ss`4: I.- •.:� \ / , 1 1 1 I ..�� I I I I I� 11 I• I' I I I l I !�'✓) / 1 1 I ( ° � � `- U � I �'1.A • \1 :# 1 / % / / /T,�:,•,' / / /.// / IF l ' I I 11\ ;I r / / / //% trI I i III_ I i I I \ \1\ 1 \ \`4�;I•II °v l / �a w` , / c I ! _� I I ' 8, .. r,;•:, o. .a / / �/ // ! r I l i Ir I `• , 1 III 1111, tll,,l { -� �.r;� zA ! "�. -, :.� -�'•lo.� :.> 8. ./ / % /)�: /�/ // I L I 1 I I i I tI 11 I I I I I I II 11 /.., li�s.�j�'! � �, A � ✓(1 IAy I �aZ�l itli r Y'YAO. I / /% /r � � I III 11 I 1 I I It I II // ''�. r �I 1 I � �L � I�° I 1 / •i -� / / / / % / I 1 ' 1. 1 I 1 I ! 1 I � �, / m _ •fir •j / - - I '' 1 I I ! j 1 111 /!1I 1111 1111 ;th yn r I -1_ `l /• ��' 1 ��I�; i'I I 1 1111 -D< II1 1 /IIII 1 I o{ I N ..t � I I �.., �:. '/ ... , % � I N 'I N ; � I I ! I I / I I I / I I I � 1 � ° <" 't> (. � I �• ' .. ' I '' ♦ ! � J I \ :: �' . I( l �I, I� - / ; �--,< ---- :.. ,� !� I' III � I I � � � 1 I I I I I I I + � � I I � "�-4., f � I I . I 1 • � :�, �, .,►"` �t�l 2 ! / / // III � I I Illl�tl ll I I I I I I .. 1 .,, 1• i I •. /, I Ma .... -.. . " f � �: : / // /';' ; / // 1 I I I 1 111 1111 it I II I I I i 1 , ! � I I ��I I ' I I � I --1 I • �, , H�S70x 11N RECORD OF PHONE CONVERSATION Time: % ; ego Date: 10/19. Person calling: rA,,�r— /<AIZL i G Phone #: e—'-;L1B— ;L O c3 7 Reason O Inspection: eeps d/ Peres Scheduled Field Meeting Time: Date: Y N Tentative/to be confirmed () ( ) Town: 2a'm/f— Road /Street: 8"r-r— h Tax Map #: y -- — r Comments: Owrn er — rZar7�&,d 1{ 1 •P 1 i CAkins it 1 i •y Jy `�`�CrenbenyMounf In'.,.-' - b 1 � ',Mldllfe'Maria_gameM:` ^' 7 CC firr/ ES � I, z, z( we 12563 i t1 liaviland 1 ollow z I) �'.,1 r lMmhl Pond / 184 65 P s a d .0 1 alnes Corners ~•l ' d ,4 p, ct a a e ",:�fc ✓ It - • . _. i/ �r Putne Lake mum U - \`Ig51 � g teinbeck Corners l harks t - -- 1 — $$ Q 8 �22 eF __ = M-WEGO \ r st + - --- ------ y coraorare In Ll : rs �. . 4. 10 a H 237.25 AC, CAL/ EXEMPT - SATE OF MEVI 4B K TOWN OF PATTERSON E5 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Birch Hill Road TownNillage: Patterson Tax Grid # ^7 Map Block Lots) / 0 Well Owner: Name: Qi�-To Address: Westc ester Modular Homes, Inc., Box 2910, Route 22, Patterson, NY 12563 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type . Screened Open end casing X Open hole in bedrock Other Casing Details Total length 74 ft. Length below grade 73 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel Plastic Other Joints: Welded g Threaded _ Other Seal: X Cement grout _ Bentonite Other, Drive shoe: X Yes No Liner _ Yes X No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed X Pumped X Compressed Air Hours 6 Yield 5 gpm Depth Data Measure from land surface- static (specify ft) 20' During yield test(ft) 440' Depth of completed well in feet 505' Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 59 Hit roc at 59' 59 74 Drillinc in rock set casincf, , grouted 74 505 Drillinc in rock granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5cj- Depth 460' Model 5GS07412 Voltage 230 HP ..3/4, Tank TypeWX302 Vol 86 cra Date Well Completed 2/ 26/99 Putnam County Certification No. 002 Date of Report 4/29/99 W Wfile6ii, n 3 Ma . a , Cr>� NOTE: Exact location of well with distances to are o permanent landmarks to be provided on a separate sheet/plan. 4 Putnam Avenue Well Driller's Name P F. & Son c. Address: Brewster, NY 10509 Signature: Date: 4/29/99 Malcolm T. Bea , Jr. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 EOD -F 70fM- 113 IAp too_.- ` t I, •� 1 O F r� �00 6 iy 100 Divisionam County Department on of Enviro�ental Of Realth Health Servioee p proved as noted for confo anoe with aDD ble Rule s and and Regulations CO Y Health De °� the Part eat. ienature 4 T.Itle� f Z� ' Doto -sac Std SvI2vlcY fon Mks �3ovvt� S '5/4,/99 "74S is. to certify that AS —BUILT the seaaga dis_oosatsysten was constructed as indicated•oh this plan and MEASUREMENTS that the system was by me before it was covered over. The system was constructed in accordance with all standard rules and regulations of the Putnam County Department of Health and w:., the w:., yore to Leoartnenk of Health.° NO A B Mkol: S'110`14W 404100 L+ (0 Du51NC� S�PNDN f�Z Iz.�rp�a.CoNG.;s'EplyGTIiNK � I . /(0 1••ll 46 12-14trK� l'o .•59 FS I b L- 65 to o • . W Rv- sEn7,-Mo0-mIJ q ewa 7ivy p1"+Ce MANaPA� Ny t!oS�f � REMARKS 1 ZSo(1- M PV C -TANK 4" fbtti TAt7- �3 5 6 l v,�c,, T�ks• r-d D T 1 FNn � 3 5 -- -G r-wD %:*8 A"VIL -Ir 11 1p z rte: vim. MOP,7W BIQC�lFiK:c.RD . WtUe50 xec a ce> Nl9KNL• 1t1 -3d I JOHNKARELL JR P.E 1 ro194 -- CU6h',l4N AvAP PAY7Ek5011 NY C11 14-87 9- 785%'1' rl 14 i3 15 11 t 5 I. 1(, W 11l ) � Rv- sEn7,-Mo0-mIJ q ewa 7ivy p1"+Ce MANaPA� Ny t!oS�f � REMARKS 1 ZSo(1- M PV C -TANK 4" fbtti TAt7- �3 5 6 l v,�c,, T�ks• r-d D T 1 FNn � 3 5 -- -G r-wD %:*8 A"VIL -Ir 11 1p z rte: vim. MOP,7W BIQC�lFiK:c.RD . WtUe50 xec a ce> Nl9KNL• 1t1 -3d I JOHNKARELL JR P.E 1 ro194 -- CU6h',l4N AvAP PAY7Ek5011 NY C11 14-87 9- 785%'1' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser ofBuilding f �c" Aj� I Building Constructed by Location - Street Building Type 3> Z �� X70 Z Tax Map Bl—o--c --k Lot TownNillage Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month 5- Day c�_f' Year 90�� 04-z— General Contractor wner) - ignature �e Corporation Name (if corporation) Address: of 5/ A7 2 - PC L // 0 State PU y Zip /2S6 Signature: Title: Corporation Name (if corporation) Address: C2�/a ZP � State /i Zip Z? Form GS -97 MAY -20 -1999 11:38 AM WESTCHESTER MODULAR H 9148787819 P.01 BRUCE R. FOLEY Public Health Director r John Karell, P.E. 121 Cushman Road Patterson NY 12563 Dear Mr. Karell: LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road " 19mweter, -New York 10509 Euvlroemeotal Health (914) 278.6130 Fax (914) 276 - M I Nursing Services (914)278-6558 fox(914)278-6085 Early Intervention (914) 278 - 6014 Fax (914) 279 - 6648 WIC(914)279-6672 Fox(914)278-60$S Re: Proposed Compliance Morton Birch Hill Road (T) Patterson May 20, 1999 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1) Erosion control measures have not been installed. 2) Full water analysis has not been submitted 3) SSTS Guarantee has not been submitted. 4) Plan is to reference source of survey, by note. 5) Mete and bounds have not been provided. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:tn V truly yo s, 1 Robert Morris, P.E. Senior Public Health Engineer NORTHEAST LABORATORY OF DANBURY 39 -3 MILL PLAIN ROAD - .DANBURY, CT 06811 (203) 748 -7903 - FAX (203) 748 -0652 CT Cert: PH -0404 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO• P.F. BEAL & SONS 4 PUTNAM AVENUE BREWSTER, N.Y. 10509 SAMPLE SITE:. SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED PHYSICALS: 5/25 -Color 5/25 -Odor pH 5/25- Turbidity CHEMISTRY: Nitrite N Preliminary- Nitrate N Alkalinity Hardness 5/25 -Iron Manganese Sodium Lead DATE SAMPLE COLLECTED: 5/20/99 & 5/25/99 TIME COLLECTED: 7:20 P.M. COLLECTED BY: A. BEAL & CHARLIE DATE RECEIVED @ LAB: 5/20/99 & 5/25/99 TESTED BY: LAB# 11471 REPORT DATE: 5/25/99 WESTCHESTER MODULARS, BIltCH HIL RD., PATTERSON, N.Y. HOSE BIB WELL -NEW NONE RESULT: MAXIMUM CONTAMINANT LEVEL ND 6.73 no designated limit 0.24 NTUs 5 NTUs <0.005 <0.50 122.0 116.0 0.061 0.120 5.2 0.003 ml = milliliter mg/L = milligrams per Liter * *Notification Level ** *Action Level mg/L as N 1 mg/L as N mg/L as N 10 mg/L as N mg/L no designated limits mg/L no designated limits mg/L 0.30 mg/L mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] mg/L 20 mg/L ** mg/L 0.015 * ** ND = none detected NTU =Units RESULTS BASED ON SAMPLES SUBMIT T Eir:5 /20/99. & 5/25/99 (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) .� Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 BRUCE R. FOLEY Public Health Director John Karell, P.E. 121 Cushman Road Patterson NY 12563 Dear Mr. Karell: LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Re: Proposed Compliance Morton Birch Hill Road (T) Patterson May 20, 1999 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1) Erosion control measures have not been installed. 2) Full water analysis has not been submitted 3) SSTS Guarantee has not been submitted. 4) Plan is to reference source of survey, by note. 5) Mete and bounds have not been provided. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. truly yo s, V Robert Morris, P.E. Senior Public Health Engineer RM:tn NORTHEAST LABORATORY OF DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 (203) 748 -7903 - FAX (203) 748 -0652 CT Cert: PH -0404 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: P.F. BEAL & SONS DATE SAMPLE COLLECTED: 4/20/99 4 PUTNAM AVENUE TIME COLLECTED: 2:00 P.M. BREWSTER, N.Y. 10509 COLLECTED BY: C. BEAL DATE RECEIVED rd. LAB: 4/20/99 DATE(S) TESTED: 4/20/99 TESTED BY: LAB #11471 REPORT DATE: 4/26/99 SAMPLE SITE: �VESTCHESTER M DULARS BIRCH HILL RD ., PATTE RSON, N .Y. SAMPLING POINT: KITCHEN SINK SOURCE: WELL TREATMENT: NONE TEST PERFORMED RESULT: RECOMMENDED LIMIT BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml CHEMISTRY: Chlorine Residual ND mg/L - - - -- Mal =milliliter mg/L = milligrams per Liter ND = none detected RESULTS BASED ON SAMPLES SUBMITTED: 4/20/99 SAMPLE, AS TESTED ABOVE: X or AMNOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH.SERVICES STANDARDS FOR POTABLE WATER) i Laboratory Director *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAI. STTF. IN'SPEC'TION Street Location TownE�T7SON TM # —/~ 7© 1. Sewage System Area a. STS area located as per approved plans ........................... b. Fill section,- date of placement 3:1 `barrier Loth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water coursehvetlands ...... ............................... II. Sewage Svstem a. eptic t size - 1,000 ... ..�..other ................ b. Septic tank installed. level ................ ............................... c.. 10' minimum from foundation .......... ............................... d. Distribtuion Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches Junction Box - roperly set ....................... ............................... engtlPrequired Length installed 2. Distance to watercourse measured4-,2 o O Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1116 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ........... :...... 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 -1 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum .................... 10. Pipe ends ed ........................ ............................... 9. Dos Svstems ize o ump c�er ................ ............................... 2. Overflow tank .........................:... ............................... 3. Alarm, visual / audio ................................................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Build' ld a. House located per approved plans. . ..............................: b. Number of bedrooms ................. ........ J?L........... IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured le-) o ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship - a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box .. ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercours g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... Date: _� / 3 9� Inspected by: �, Owner /Al or-7-0 IV Permit # Subdivision Lot # 2 % ©�� N �r < I•`�tt r• x/33 X ,3, 3 = 4(C2,� q01-11