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HomeMy WebLinkAbout0259DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 5. -1 -23 BOX 3 ti . .;q ' .` J' T� V PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO Y ,P ; _ ° ATMENT SYSTEM PCHD CONSTRUCTION PERMIT #_ Located at ZC) t) �A 0 P— *D Town or Village �` ® Owner /Applicant Name e4vi 0IN-3 -A pa r_ Formerly Mailing Address ter, Tax Map 5 Block i t Lot � Subdivision Name BPD P-4 Subd. Lot # Date Construction Permit Issued by PCHD Separate Sewerage System built by . n-0-..r% 1 Zip i0�Q� D955 NH UP-i W- 9J Address F4 N)04 C N0&fA k5« Consisting of t Gallon Septic Tank and Other Requirements: -)t cJ�T-pe'o 0 �-NkM Water Sunnly: Public Supply From or: X Private Supply Drilled by Building Type pL �i0EHLIE Address Address' PLTOP AUG W--�J� �'L Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed? Ho I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved b plans and the standards, rules and regulations of the Putnam County Department of Health. Date: '��'"' ®Q Certified by 1, '�ld- P. - P.E. R.A. Address -jii k4�1 License #5 L' 7 Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer .becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocation o ification change is necessary. By: Title: P'����%��' Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM. COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building 6UY k Q19I- HA PEL. Building Constructed by Location - Street Tax Map Block Lot PrAl� 60 H TownNillage -off P yko Subdivision Name Building Type 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 _4�5' Day / Year�� General Contractor (Owner) - Signature Corporation Name (if corporation) Address: / f State N (/ Zip Signature: Title: 0­3 tC �&, ku Qql� / Corporations Name corporation) Address: �f 0 - ` ai' -,? �_3 State z Zip 14L_," Z Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 30 Bridle Ridge Road Town/Village: Patterson Tax Grid # Map 5, Block Lot(s) 0) Well Owner: Name: Address: Guy & Diana Delbene, 26 Overlook Lane Brewster NY 10509 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 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: X Steel _ Plastic _ Other Joints: _ Welded X 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 L gpm Depth Data Measure from land surface- static (specify ft) 30' During yield test(ft) 445' Depth of completed well in feet 485' Well Log If more detailed Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. information descriptions or sieve analyses are available, please attach. Land Surface 17 Drilling in overburden clay and boulders 17 Hit rock at 17' 17 32 Drillin in rocki set casing, routed 32 485 Drilli in rock ani e If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type sub Capacity 5a9m Depth 440' Model 5GS10412 Voltage 230 UP 1 Tank Type M51 Vol um 1. Date Well Completed 3/7/00 Putnam County Certification No. 002 Date of Report 4/4/00 Well ri r MBeal NOTE: Exact location of well with distance to A A ast two permanent landmarks to be pro eo6 on a separate sheet/plan. 4 Putnam Avenue Well Driller's Name ons, T r. Address: Brewster, NY 10509 Signature: Date: 4/4/00 Perry White copy: HD Fill Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 NE /JL *n NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 LABS (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: P.F. BEAL & SONS DATE SAMPLE COLLECTED: 5/17/2000 4 PUTNAM AVENUE TIME COLLECTED: NOT STATED BREWSTER, N.Y. 10509 COLLECTED BY: PLB DATE RECEIVED @ LAB: 5/17/2000 TESTED BY: LAB #11471 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) PHYSICALS: Color CHEMISTRY: Odor pH Turbidity Nitrite N Nitrate N Alkalinity Hardness Iron Manganese Sodium Lead 1 14-IZ07 718 DIN I DMUMP11I1111 DELBENE, 30 BRIDLE RIDGE ROAD, PATTERSON, N.Y. FAUCET WELL NONE RESULT: 5- ORGANIC 7.63 0.32 <0.005 <0.20 54.0 46.0 0.057 <0.01 11.6 0.001 ml = milliliter mg/L = milligrams per Liter * *Notification Level ** *Action Level MAXIMUM CONTAMINANT LEVEL per 100 ml 0 per 100 ml 15 3 Units no designated limit NTUs 5 NTUs 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 SUBMITTED: 5/17/2000 SAMPLE, AS TESTED ABOVE: MOTABLE or AMNOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) 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 ri q pM 4,, . 0 ROO �Rp e ONC q C.1-P 4, . - - JZ50 GA� K // %� -rya ?� ' — x it � \I \1 11\ v ` 1�QgypP, E• �l lV'Vbv 0- f 0 0 v I L 4f 1.11 091 r S 88 °5757 ",E 0 w N DIMENSION CHART (in ft.). No. A / 13' 3 ¢ 83 111 6 8 q6 q l30' l6%' /0 /45' 16 7' 70" 12 l3 /3/ 161' 14 /34' 162. 15 / 3.6' l6 3 16 /39" 164" 17. .142 l8 55, 61' l9 2/ 40' 22 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 E911 ADDRESS VERIFICATION FORM OWNERS NAME: GU`j + Dt d -HA PF_L TAX MAP NUMBER:' _ E911 ADDRESS: �p 0 -4 Q�_4 ?L-1DL,a P-0�fl TOWN: i'ATT-F_PL- tDoi-4 AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 017/ 1,5-- OC9 o The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the applicafion for a Certificate of Construction Compliance. (E911 VERFRM) Harry W. Nichols Jr., P.E. 311 Clock Tower Commons Route 22 Brewster, NY 10509 Telephone (914) 279 -4003 Fax (914) 279 -4567 May 26, 2000 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 RE: Individual SSTS Compliance Bridle Ridge Estates, Lot #4 30 Bridle Ridge Road Town of Patterson Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As -Built Plan," dated 5- 15 -00. 2.. "Certificate of Construction Compliance for a Sewage Disposal System," dated 5 -22- 00. 3. "Three copies of "Guarantee of Subsurface Sewage Disposal System," dated 5- 16 -00. 4. Well Completion Report, dated 4 -4 -00. 5. Laboratory Report, dated 5- 17 -00. 6. E -911 Address Verification form dated 5- 18 -00. 7. Application Fee in the amount of $200.00 payable to Putnam County Health Department. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic ols Jr., P.E. HWN:JM:his 00- 008.00 Re —.. '4 V. 571la/0 ® PUTNAM COUNTY DEPARTMENT OF HEALTH Gu /'-t 00" D r- i K 15 t.o v er ed o ve DIVISION OF ENVIRONMENTAL HEALTH SERVICES 5/26 J00 u 5c4 prv6c� FINAL SITE INSPECTION '�" ` "''f/ 7 :fo d Date: :�' t ` h Inspecte y: 4, p-,57,5 r> . Street Location /$2/D/ -e Owner -bEz.8jFA/E Town P,,4-rr�-_X s o^i Permit # p -- 4 - 9, TM # 5- — Z _ 2 a Subdivision Lot # !f 1. Sewage System Area a. STS area located as per approved plans ................::......... b. Fill section date of placement 3:1 barrier Lgth. Width Avg.Dpth c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... — e. 100' from water course/ wetlands ...... ............................... II. Sewage System a. Septic tank size - 1,000 ........ ,,25 .........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. _Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost ................................................. 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly �set ........... ............................... f. Trenches `°7®& T. Eength required Length installed Z 2. Distance to watercourse measured t Zoo Ft.......... 3. Installed according to plan .......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ......:...... 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface... ............... 7. Room allowed for expansion, 100 % .................. ..:. 8. Size of gravel 3/4 - 1' /2" diameter clean .............� 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems 1. Size o pump chamber ................ ............................... 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/Buildin a. House located per approved plans.. b. Number of bedrooms ...............:... $rat..................... IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured ©© 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,cil f. Curtain drain outfall protected & dinto exist Ovate e g. Footing drains discharge away from STS area............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 6/97 rorm 1 -s '? I� MM Imm lOm Imm Imm INE Imm Imm IC=I���J� ICMWlfr7ii� ICe�i. Id! inn rorm 1 -s '? BRUCE R. FOLEY Public Health Director' DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 Date: !n;'.//0 1e e; To: 11.4 K R-1 ail /c//e2C -5 From: Gene D. Reed Putnam County Department of Health For your information For your review As discussed Fag #: ;2 7 9 •- -6 i 8 No.. Pages �z (Including cover sheet) ✓ Please respond Attached as requested Please call Notes/Messages S `-' �n O. k % cJ Z3i 'c A �IG� G 0/ij /21 EN 7�5; �/ r ♦ .� D ✓ L �G Tizl G /_ /.� /. S . 7r//0 /®© % G X 7- >'4N.S / oi✓ /? l� 7'c4w5 SNowlN! 7"/X4---A(G H t ocXTIa V 5 In the event of transmission /reception difficulties, please contact this office at +,qp 5:1 (914) 278 -6130 ext. 2261. WE 5` P.01 MHY -04 -2000 08:32 PM PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES R 4t= EORFINAL INSPECTION For: Fill* Date: 0.4 ' Q Trenches PCHD Construction Permit # Located: SO P-t0615 (T) M �p40 N. Owner /App4cant Name: ALW *' DIANA DEL 8e�e TM. Block � Lot Formerly: PA O Mtr Subdivision Name: B�Lk - 114m%g Subdivision Lot # is system fill completed? Is system complete? Is system constructed as per plans? Is well drilled? Is well located as per plans? . M Are erosion control measures in place? �ff2 1 certify that the system(s), as listed, at the above premises and verified their completion in accordance with approved plans and the Standards, Rules and Keg Health. Date: 61 w Certified by: Address: 3l1 C,Q Date: Date: Date: P� tiK ta;wa Comments: LtiK OP-AAM iNsT.W FOR: ❑ ADAM ,GENE ❑ (NAME) icted and i have inspected Construction Permit and A County Department of PE X RA Form FIR -99 s 2 VA IYI}t11f� r• c ` PUWN FOR UWAM Ilk I+1T!TUM COMM DEPAR220 M1' OF EM"M DIaYw of Da�rla�whll% ebb Sttitrloio. Cassel. N.Y. t�dt? tai PwwNr Fw�lt 1 �f.OM�f/.�AiO AO McItN ■'mar /iQ' tot Diirs TRW ' tot A. • t' .� Fm seatbia polo . Vdasse Nazis of Podwleae Delp Flow G P D � PCHD Nolmotlaa 1s Yega4ed Wbee F61s o�pialeJ Sops ssile Seneesse sy m U el�tiot of �� QeBw Salads Teak r Tg be andzsi ed by Addreog Webs S"** PIYa Sep* Fenn Addireq oil �Pe web Sup* DrEW by �.u.M.. Oleo 1 represent -that I am wholly and completely responsible for the design and location of the proposed system($); 11 that the separate saw disposal stem above described will be constructed es.shoixn on the approved amendmsmt there to and in accordance with the standards, rules a rpu ns o ne County Department of MaaRh, and that on compwion thereof a ••Certificate of Construction Compoaner' satisfactory to the Commissioner of Mulliiwill M submitted to the Department, and a written guarantee will be furnished the owner, his successors.. heirs or assigns _by the bIWider. that aid builder will VIM in good Operating "adkiorl iigy "ft , of laid aswaga disposal system during the period of two (2) yeas immediately following tledete Of the 19111- 'elm Of the approval of the Certificate of Construction Compliance of the original system or any repbk M►eto: 2) that the drilled wall described. s6oye WN be located as Wcoi on the approved plan and that said wall will be Inst 1 in accordance with the at runes and fall io s of the Putnam County Department Of MNRh. Date ' , 2 i Signed P.E. PA. - AddreM license No APPROVED FOR CONSTRUCTION: This approval expires two years from the. date sued unless construction of the building has been undertaken and is revocable for. cause or may be amended o► modified when considered•h a misiioner of Health. Any charge or alteration of construction feeuires a w per it. A rowed for disposal of domestic unitary eve / ate ater supply only. 2 /� r88 Oato 4.2 Title PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION + S WAGE TREATMENT SYSTEM PERMIT # P-4- 6- j %� Located at ��--ifl �-�Q°''�F Town or Village PA-rMF-60H Subdivision name 6P-M -L- N%tE E6WO? Subd. Lot # 4 Tax Map 6 Block ) Lot Date Subdivision Approved 1-1IPk �A Owner /Applicant Name Mailing Address S'5 0P-C'h!�Ffl DP -i"iF- Amount of Fee Enclosed n�oo Building Type A— -'' X N6,r-- Renewal X Revision Date of Previous Approval pC)dkh jb0N(n, Hj - �I�,gigG Zip 199'0 Lot Area f) -4-`r No. of Bedrooms A Design Flow GPD $ou Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of _ Other Requirements: To be constructed by Water Supply: Public Supply From a��Q gallon septic tank and Address Address or: 1(i Private Supply Drilled by -F # Q), 0 Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. - Signed: cam,.. LA P.E. R.A. Date 19 f Address �-o i'a L— OW M P ,+ 050 License # G 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 pprove r discharge of domestic sanitary se jonly. By: Title: ).� �` Date: * j o' White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 s r`• k s r LL � I HOUSE PLA*'SS APPROVED FOR BEDROOM COUNT ONLY; ( GARAGE EDl C' ]0- ..20 -0 ECK ignature & Ate — 13RKFST. ° of BRKFSo KITCHEN <' ,.DINING/ UTIL. GREAT RM. u -o. N -6 I I r..1.<. "0 FAMILY RM. FOYER PORCH Design 09668 ueslgn oy First Floor: 1,254 square feet Donald A. Second Floor: 1,060 square feet Gardner, Total: 2,314 square feet Architect, Inc. ® This stylish Counts• farmhouse shows off its good looks both front and rear. A wraparound porch allows . sheltered access to all first -level areas along with a covered breezeway to the garage. On the first floor, the spacious, Open layout ha, all the latest features, The master bedroom on the second level has a fireplace, large walk -in closet and a master bath with shower, whirlpool tub and double -bowl vanity. Three addi- tional bedrooms share a full bath with double -bowl, vanity. �► Is 111 Y� 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 # faz WELL LOCATION Street Address Town/ Tax Grid Number ` WELL OWNER Name )mailing Ad re' 9v rr D OPrivate �� , O Public �SE OF WELL primary 2- secondary 10 RESID N IAL [3 PUBLIC SUPPLY ❑ AIR/ OND /HEA PUMP O ABANDONED 13 BUSINESS O FARM O TEST /OBSERVATION 0 OTHER (specify, 0 INDUSTRIAL 0 INSTITUTIONAL O STAND -BY O .AMOUNT OF USE YIELD SOUGHT 6� gpm /# PEOPLE SERVED /EST. OF DAILY USAGE_ &eJ gal ❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 12-ADDITIONAL SUPPLY JINEW SUPPLY NEW DWELLING ) Cl DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED DRIVEN E]DUG GRAVEL. 0 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: Na me 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 N JaON SEPARATE SHEET (date) (signature) 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 third, (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:-, ,j �� 19e 7,::: --- -i - - - - Date of Expiration 19� Permit Issuing Official Permit is Non - Transferrable White copy: Hb''File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller 121 LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. Nq CONSULTING SITE ENGINEERS January 12, 1996 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Bridle Ridge Estates Lot #4 Bridle Ridge Rd. Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -5 "Proposed SSDS - Lot #4 ", dated 1- 12 -96. 2. "Application For Approval of Plans For a Wastewater Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 1- 12 -96. 4. "Application to Construct a Water Well ", dated 1- 12 -96. 5. "Letter of Authorization ", dated 1 -10 -96 6. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 7. Moneyk rder in the amount of $300.00, review fee. 8. See original submission for precolation rates and test pit data. 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. Nic oH' ls, Jr., P.E. HWN:bd 96006 enc. cc: Mr. & Mrs. D. Wool w /enc. p'C_7TN,A.i� COiJXV -T'S� T�JEPA.RTL���TT O� HE,A.L'T� APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of Applicant: ff 2. Name of Project: i�i'LUPD��t� �r'Zb5 3.•_•_Location�'V /C:'��� 4. Project Engineer: W. ILND��� _. 5. Address: G -f 'Z4 'f oft.)' °wo row . License Number: 3 1�12 Phone: Z'1 _ C�Iol3 6. T e of Project: Private /Residential Food- Service - ....Commercial Apartments Institutional Mobile Home Park Office Building: Realty...Subd1vision Other (specify) 7. Is this project subject'to State Environmental-Quality Review (SEQR)? TyQe Status (Check One) Type I.. Exempt Type II. Unlisted. - 8. Is a Draft Environmental Impact Statement (DEIS) required? 9. Has DEIS been completed and found acceptable by Lead Agency? �J /A 0, Name of Lead Agency rJ /a 1. Is this project in an area under the control of -local planning, zoning, or other officials, ordinances? K)d 2. If so, have plans been - submitted to such: author .sties ? ..................... r��Q J 3. Has preliminary approval been :granted by such authorities? Nil Date Granted: 4. Type of Sewage Disposal; System Discharge ......• Surface Water v Ground Waters 5. If surface water discharge, what is the strewn class designation ?........ O/A _ >. Waters index number (surface) ............................ Kj4L - Is project located near a public water supply system? .................. Ala If yes, name of water supply 4A /A Distance to "water supply , Is project site near a public sewage collection or disposal system ?..... 1Jo Name of sewage system Q/A Distance to sewage system, Date observed: 23. Name of Health Inspector: Project design flow (gallons per day) ..................... 25. Is State Pollutant Discharge Elimination'System ( SPDES) Permit required ?.. 00 26. Has SPDES Application been submitted to local DEC Office. �11A 27. Is any portion of this project located within a designated Town or State wetland ? .................... ............. ............................... f\) 0 28. Wetland ID Number ......................... ............................... �/,d 29.-Is Wetland Permit required? . .............................. ............. Has 'application been made to Town or Local. DEC Office? k\/ 30. Does project require a DEC Stream Disturbance Permit? fJ D 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 r.)v 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 -K) (J DESCRIBE: 33. Is there a local master plan or file -with the Town or Village? 34.'A.re community water, sewer facilities planned to be developed within 15 years? uNI:f OJAOQ 35. Are any sewage disposal areas in.excess of 151"U' slope? ..................'..... 0 36. Tax Hap ID Number ............ .:............................. ... 37. Approved Plans are' to''ba. returned to: ................ App-licant Y_ Engineer If the application is signed. by a person other than the applicant shown in Item.1, the. application must be-accompanied by y-a Letter of Authorization: Failure to comply with this Provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury,- that information provided on this form is true to the best of my knowledge and be 1 ief. Fa lse statements made herein are punishable as a Class A Hisde!reanor pursuant to Section .210.45 of - the Pena 1 Lair. SIGNATURES & OFFICIAL TITLES: krT 11�3t�o �tl� I�NT MAILING ADDRESS:j{Ws rL rJ 1p50�1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES. Date 1 / I o Re: Property of Located at pp, IV Section Block Lot 2� Subdivision of Subdv. Lot # �. Filed Map # a� �d Date Gentlemen: This letter is to authorize CZVv �u V1 �C, J a duly .licensed•professional engineer !_ or registered 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, Educatiy�ty the Public Health Law, and the Putnam County Sani— tart' Very truly yo S, 3 4� Signed �J�. +Io. X124 4 by Owner of Prop rty Countersi Fl SS1-- o P . E . $ • , � �D I Z 1 �is %�i�l �%� �i P. Address ►�! 1!�l. OW-9101MMOVEM •.. Telephone Telephone 0 - PUTNAM COUNM DEPARTMENT OF HEALTH DIVISION OF ENVIRONM�AL HEALTH SERVICES DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. owner Address f� c,F cLq nir ' .�2 + ; �hiC'F��.sr -nr? ti' ) Located at (Street) (Wjo v Sec. T.�' Block Lot i dicate n rt'&os street) Municipality p Watershed SOIL PERCOLATION TEST DATA-REQUIRED TO BE SUEVMITTED WITH APPLICATIONS Date of Pre - Soaking Date of Percolation Test HOLE NUMBER CLOCK TIME PERCOLATION 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 2 NOTES: 1. 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. rev. 9/85 _ TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCO=ERED IN TEST'HOLES DEPTH HOLE NO.. HOLE NO. ex HOLE NO.' G. L. 2` 3'� 4, _ 5' 6' ?' . 8' . - 91 10' 12' 13' 14' INDICA'T'E LEVEL AT j-TKCH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED 6 �j 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 v Absorption Area Provided By L.F. x 24" width trench Other f 0 NEW y Name f� r fiber Signature Address SEAL s• No. 56124 D D ARpFES& 1414 ��j . THIS SPACE VOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ftfgal. Checked by Date LAURENT ENGINEERING jASSOCIATES, P.C. \ MILLBROOKE OFFICE CENTRE Ro$Ae 22 6 Milltown Road Brewster, New York 10509 ` \ (914)278 -0108 • (FAX) 27 8-2858 CONSULTING SITE ENGINEERS To: Attenlion: G1fro /F��� S Genllemen: We enclose ,® B/W Prints O Specifications Descripfion: copies of: O Reproducibles O Memorandum Date: 2� /i - Job No.: Project: O Reports O Tracings O Copy of Letter ❑ Sent Via: O Our Messenger O Blueprinler O Your Messenger L>v Hand Delivery G' t ,' Copy to: ;r( O First Class Mail 5 Revision /Date No. O Special Delivery Very truly yours. LAURENT ENGI ' EERING ASSOCIATES,P.C. Per: LAURENT ENGINEERING j\ ASSOCIATES, P.C. \ MILLBROOKE OFFICE CENTRE / \ Route 22 6 Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 HARRY W. NI LS JR., P.E. \ CONSULTING SITE ENGINEERS November 19, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Proposed SSTS. Wool Bridle Ridge Road Town of Patterson I Dear Mr. Morris: In response to your review letters dated November 12, 1998, we offer the following: 1 Curtain Drain has been extended. We trust the above adequately addresses your concerns and request the issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. ichols, Jr., P.E. HWN:JM:hs IS •�:.� Yew DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Jeff Moore Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Dear Mr. Moore: November 12, 1998 Re: Proposed SSTS: Wool Bridle Ridge Road (T) Patterson, TM# 5. -1 -23 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) Curtain drain is to be extended the minimum of 10 feet to fully protect the SSTS. The curtain drain can be proposed within the 100 foot well arc. Upon receipt of a submission,. revised to reflect that above comments, this application_ will be considered further. RM:tn Ve ruly /yours, Robert Morris, P.E. Public Health Engineer 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 # foi c i§ L15 *PKTI��L6Qi-\ Map 15 Block Lot(s) Well Owner: Name: Address: Use of Well: A Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 67D+ gpm # People Served Est. of Daily Usage b2� gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling X, New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type >G Drilled Driven Gravel Other Is well site subject to flooding? ............................................:.... ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes .K No Name of subdivision S-u'- �=`��� 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 contaminat"tobe ovided on separ a sheet/plan. ��`%b��% Signature: Date: Applicant I /' 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 inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water a driller certified by Putnam County. , A I A4 Date of Issue Permit Is g Offici . ���� --- Date of Expiration _ Title: c Permit is Non- Transferrbblet f/ White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION REVIEWED BY RM, GR, AS, MB, BH Y N DOCUMENTS PERMIT APPLICATION PC -1 WELL PERMIT_ PWS LETTER LETTER 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 Y. GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME 7 PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMITS) REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) ' PS HYDRAULIC PROFILE GRAVITY FLOW PNSTRUCTION NOTES I ` DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME,ADDRESS' 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: NAME OF OWNER DATE 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 HOUSE - NO.OF BEDROOMS )WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° 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 WILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED TAX MAP # ON PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL ?O' TO FOUNDATION WALLS _15'WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER M TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE Z00' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' - <1% ZO'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50'170 WELL WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION October 30, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: . Individual SSDS Daniel and Brooke Wool Lot 4 -30 Bridle Ridge Road Town of Patterson Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -4 "Proposed SSDS," dated 10/30/98 2. • "Short EAF," dated 10/30/98. 3. "Application for Approval of Plans For a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 10/30/98 5. "Application to Construct a. Water Well," dated 10/30/98 6. "Design Data Sheet" 7.. "Letter of Authorization.:' 8. Two (2) copies of Residence Floor Plan(s), For Bedroom Count Only." 9. Review Fee in the amount of $300.00. Very truly yours, LA NT ENGINEERING ASSOCIATES, P.C. Harry W. Nie ols, Jr., P.E. HWN:JM:hs 96006 N LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road HARRY W. NICHOLS JR.. P.E. j \ Brewster, New York 10509 (914)278-6108 - (FAX) 278-2658 CONSULTING SITE ENGINEERS October 30, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: . Individual SSDS Daniel and Brooke Wool Lot 4 -30 Bridle Ridge Road Town of Patterson Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -4 "Proposed SSDS," dated 10/30/98 2. • "Short EAF," dated 10/30/98. 3. "Application for Approval of Plans For a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 10/30/98 5. "Application to Construct a. Water Well," dated 10/30/98 6. "Design Data Sheet" 7.. "Letter of Authorization.:' 8. Two (2) copies of Residence Floor Plan(s), For Bedroom Count Only." 9. Review Fee in the amount of $300.00. Very truly yours, LA NT ENGINEERING ASSOCIATES, P.C. Harry W. Nie ols, Jr., P.E. HWN:JM:hs 96006 N 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only 'art 1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR: � ���.).- jNQ 12. PROJECT NAME: INpry (pJi�L 3. PROJECT LOCATION: �p Municipality rT�� County Rr� NMl 4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map) 5. PROPOSED ACTION IS: KNew ❑Expansion ❑Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: IND)y OVAL 5�_ Tb 7. AMOUNT OF LAND AFFECTED: Initially 124-C acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? K eS ONo If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential 0Industrial__ OCojMcpercial ❑Agricultural OPark /Forest /Open space OOther Describe: A)j"'j4L FWtL�? 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY ((FEDERAL, STATE OR LOCAL)? OYes KNO If yes, list agency(s) name and permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? OYes Ao If yes, list agency(s) name and permit /approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? I2Yes 2.�Wo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE f nay[X�-O_ VJ ` � l P'5 • A }( Date- ]a1U� ii If the action is in a Coastal Area, and you are a.state agency, complete a I'• Coastal Assessm6rrt Form before proceeding with this assessmer;; {I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: DAHII�-L- Vii! 5 \0001- - '9 6 09-WAM 2. Name of project: 0�4 liA0NiDU 1-- Av--5T6 3. Location TN: 4. Design Professional: I }AW W' Mc• 016 J- PC 5. Address: 0-0 6. Drainage Basin: $c�N 7. Type of Project: A Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt X Type II Unlisted _ 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... NO 10. Has DEIS been completed and found acceptable by Lead Agency? N A 11. Name of Lead Agency NIN 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ..................... ................................ ............................... 11c5 13. If so, have plans been submitted to such authorities? ........ ............................... No 14.. Has preliminary approval been granted by such authorities? 1-JQ Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water ik groundwater 16. If surface water discharge, what is the stream class designation? .................... �► 17. Waters index number (surface) ........................................... ............................... N A 18. Is project located near a public water supply system? 19. If yes, name of water supply! Distance to water supply rJ� 20. Is project site near a public sewage collection or treatment system? ................ N� 21 22 Name of sewage system 0 A Distance to sewage system �R Date test holes observed �� ° I'� • `G 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................ ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... goo N�? Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? N 28. Wetlands ID Number ................................... .......................................................... N P 29. Is Wetlands Permit required? (X 0 Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? N� 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No 0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within A 15 years in or adjacent to project site? ................................ ............................... _ 35. Are any sewage treatment areas in excess of 15% slope? .. ..............................Q 36. Tax Map ID Number .......................... ............................... Map 'E) Block Lot 37. Approved plans are to be returned to ..... Applicant A Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penally 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 X10.45 of the Penal IV&w;, SIGNATURES & OFFICIAL TITLES: i+AXP, VV �11Cfloi,6: J�-• (G, A� fltat:Ni Mailing Address. -1-0 M ►L-L� jo'If RAP F jl� /5 ia- )-t'f l Q �1-0 � PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - /SUBSURFACE SEWAGE TREATMENT SYSTEM Owner. �iq/V %FG �c .l % (/1���% L- Address l F S/PT %!� Located at (Street) %di�'pGE �d9� Tax Map Block Lot (indicate nearest cross street) ,, — %— 1 3 Municipality M SO Drainage Basin E �j(�RNfit� Date of Pre-soaking �0 ' /'-�� Date of Percolation Test A/)- 3a —9 8i Hole No. Run No. Time Start - Stop Ela se Time (i Iin.) Dep th to Water )From Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 1 9, 3v —,o;o0 3o a3 �� a43 1-7 2 0,,fo1— /01'3 1 3 101#3A-11,'0A 30 93 4 5 1 q,�33 —/0"0-3 3 o 0-? z 2 �a ;off -10,3 3 /0:310- 11:0(� 30 �c� a�3 /01 9 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 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 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. Indicate level at which groundwater is encountered g, Indicate level at which mottling is observed 6� S Indicate level to which water level rises after being encountered Deep hole observations made by: AA ljeh'oG Date / —2 I Design Professional Name: FIv6li18 'y6 i9550c::4T. � Address: ",,� o� a F 114CC e��� F hEi Signature: Design`Professional'sSesl ,�� ° v ro NICyO� 9� w C17 tv%.J'c�` No. 56124 .� OF W0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of PA P I F- J_ t �P—Ov F WOO � Located at T/V PA1 -1" o H Tax Map # Block 1 Lot Subdivision of P -10 -F-i P Pe4V_ �`� I A,­rF_:�� Subdivision Lot # Gentlemen: Filed Map # $'�) Date Filed 2• �A- M This letter is to authorize HAP—' W ' 1� I i�o �A a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. F NFI�Y rP } Very truly yours n i CH Countersigned: , T .� Signed: P.E., R.A., # /� (Owner of Property) Tj Mailin Address: Mailin Address R�l+�f�� OR fyt A9�FE I�NA gR— v pauC�4t.UP A State N `� Zip [06 State ' Zip I? -70 Telephone: 914 11 b - Co 10 b Telephone: Form LA -97 SECOND FLO.0 R 4828 = ••1344SF KITCHEN jif) 1 war .DINING ROOM p MORNING ROOM 12' 0" • 12'•0.. L_ w I N _ OPEN ABOVE 1 LIVING ROOM u. FAMILY ROOM 13'.0 ** x 1•'.p.. 13'0" • 17. 0" FOYER �- FIRST FLOOR r 4828 BATH` �, U • r...- BEDROOM 4 �.J� �1 5i'•8" : 12.0.. llll���� ORE:SSING- BEDROOM 3 . WALK' 13' -0" x 10' -0 ': —I IN t CLOSET . _•._ -ter a MASTER BEDROOM BEDROOM 2 - OPEN ,. 17•-0 R t6'•8" 11' O' x 15'•8' i — — . z -A• se; IN SECOND FLO.0 R 4828 = ••1344SF KITCHEN jif) 1 war .DINING ROOM p MORNING ROOM 12' 0" • 12'•0.. L_ w I N _ OPEN ABOVE 1 LIVING ROOM u. FAMILY ROOM 13'.0 ** x 1•'.p.. 13'0" • 17. 0" FOYER �- FIRST FLOOR r 4828 r; MA VX �-v OXP% 3 „ � PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner j4laoi_ Address 131Z i °DLE: pt n & E �„t, Located at (Street) 31RCtl NlL[. ?OAI> Tax Map Block l Lot (indicate nearest cross street) Municipality PATT, =1e6atj Watershed gA�5T j37ZAA(GN SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 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 Time hla se Time Surface (Inches stop Dropp In Rate MtnJIneh Hole No Run Na Start SiopIfn) Start Ihehes 2 1Q'O I - le; 31 <f--> d- __3 — 3 4 5 %X* j/ f, a 2 X7 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 G U Akins 8 c i�nxnrax� F ES O . > i 64 of jB rook -✓ \) "/j L N MQy�te: /i 12563 22 ' * ` (Mendel Pond 164 �II 65 40 r i 1 �•, f� 1 Comers Now 411 L _ I o 2 ,- t urarutnar Lake l'fie Q Reinbeck ! Corners Lake ?I R harles d 22 W�,Que Area _ Mount Ebo Corporate 62 � � t HS I rOES a ` �I 0 W. Z z p I cy J 67 z e i 411 L _ I o 2 ,- t urarutnar Lake l'fie Q Reinbeck ! Corners Lake ?I R harles d 22 W�,Que Area _ Mount Ebo Corporate 62 � � t HS I rOES a ` �I 0 W. Z z p I cy J 67 z 0 TRW-REQI SCALE IN 1110 OF AN INCH 1 -800- 345 -7334 ' z 3 4 s R 981000 _ b4b1, WI I i � f i! I� i I I� i� Ic is I I I I i I_ i� Ia i I i Allis f61.01 i&r2 21.3 BREWSTER ( PA r 1 s r 1 24.36 AC. CAL. 42 40.70 AC. CA 1f1 G'+ m 43 i fa 1 5 AC. CAL.- 217.21 X1.11 � 0 6 ° n s Z09AC 27&93 yu J� sf RECORD OF PHONE CONVERSATION Time: -? If 41,7a Date: V2. ?/ Person calling rl i�f Phone k 9-7 6 " rJ � © 5 C4',Q v f PNt� Reason () Inspection: N Deeps and /or Peres: 11 11 Town.- Road /Street: 1-o L Tax Map #: 15�- =( a 3 Comments: I a&nowledgeTeceipt of t' is report SIGNATURE: �/'Af WO e; 02 / 96 Titl