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HomeMy WebLinkAbout0263DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 5. -1 -28 BOX 3 o . " � �h.. AN A ti MAN , � ,.i A. I.J i .�; AN A i �; lA t� LAN A r -ti■ AN 00072 c�- � ` PUTNAM COUNTY DEPARTMENT - OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL �O please print or type PCHD PERMIT #ht'V' Well Location: • Address: TownNillage Tax Grid # 8) Rr_N 010, P A O Ph-rr0_60 H Map 61 Block I Lot(s) 2� Well Owner: Name: Address: lu h t NAB tA� '61 A °�� f� i 22 �3iZl; wS r�7Z N lv�yoi Well Type: X Drilled Driven . Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned I- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: Contractor: Reason For E'A 6 tru GMTHA5 J E"90 bi? iKVS N6Lt -1; 9VJA 06 MA44VD Abandonment: A+•+isy oosw kk' s gcaNlti CWAT'JVM my A MEN fScLl- WiN, b 0 440 To Description of Work To Be Performed: %9 6a Mu c-q wi C-VNrJ C -C11\0 ! W6- CMkW1 \ l y 6jc�0�1 = 1P115�1 �P�G "I„ Date:. Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. , Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 1 �% _ � �' A _ ^./i[ / \/ Q� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FO ATMENT SYSTEM PCHD CONSTRUCTION PERMIT # P I - a y- Located at C049 N - 61 PLB I'll I-L- R-o /�P Owner /Applicant Name i4-6HNET" Formerly. gTc Town or Village Tax Map 95 Subdivision Name Subd. Lot # pmrM N Block Lot -� Mailing Address PA_ 21-1 9P- 1=_\JJ6T6iP— 1-4� Zip 101-0 Date Construction Permit Issued by PCHD 9 12s 1 991 Separate Sewerage System built by KE�4H40 5-TP(bE . Consisting of Gallon Septic Tank and Other Requirements: Address 4I'L O kW "L W i 015 09 Fro ° '- r h b 1; 'Tv- eHw Water Supply: Public Supply From Address ors X Private Supply Drilled by %\\w Address 75 PVMP'� � Building Typed 1 �l;�L� Has erosion control been completed? Number of Bedrooms Has garbage grinder been installed? Ht I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam County Department of Health. Date: °� j'L'11 �� Certified by P. E. R.A. Design Professional) Address �o M � ". 10� 0 k" 5�-- W, I9 �°� License # C-1 W'� -� 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 subject to modification or change when, in the judgment of the Public Health Director, such revocatiXkfl n mo icati r change is necessary. By: `�--- Title: % %/6' Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 ALUMBS NORT HEAST LABORATORY OF DANBURY CT Cert: PH -0404 39 MILL PLAIN ROAD - DANBURY, CT 06811 NY Cert: 11471 (203) 748 -7903 - FAX (203) 748 -0652 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: MILL DRILLING, INC. 75 PUTNAM AVENUE BREWSTER, N.Y. 10509 SAMPLE SI'Z'E: SAMPLING POINT: SOURCE: TREATMENT: DATE SAMPLE COLLECTED: 9/8/99 & 11/1/99 & 11/15/99 TIME COLLECTED: 3:00 P.M. & 5:00 P.M. COLLECTED BY: ROB & RUSS DATE RECEIVED @ LAB: 9/8/99 & 11/1/99 & 11/16/99 TESTED BY: LAB# 11471 REPORT DATE: 11 /17/99 KENNY STABE, 649 NO. BIRCH HILL ROAD, PATTERSON, N.Y. TANK -HOSE BIB WELL NONE TEST PERFORMED RESULT: MAXIMUM CONTAMINANT LEVEL BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml PHYSICALS: Color 0 15 Odor ND .3 Units 11/1/99 - pH 6.34 no designated limit Turbidity 1.6 NTUs 5 NTUs CHEMISTRY: Nitrite N <0.005 mg/L as N. 1 mg/L as N Nitrate N <0.20 mg/L as N 10 mg/L as N Alkalinity 27.0 mg/L no designated limits Hardness 36.0 mg/L no designated limits 11/16/99 - Iron 0.053 mg/L 0.30 mg/L Manganese 0.067 mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 7.6 mg/L 20 mg/L ** Lead 0.002 mg/L 0.015*** m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTED: 9/8/99 & 11/1/99 & 11/16/99 SAMPLE, AS TESTED ABOVE: MOTABLE or �NOT —POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) Q� 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM { _E H J-j L=_-VIA -"7T_ P� b� Owner or Purchaser of Building }_E 1-4 �_A �A Building Constructed by Location - Street 3 , Z� Tax Map Block Lot PA,-rrl; lP-60 1-4 TownNillage 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 hvo 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 fiirther 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 Days Year �' Signature: �► .�?i Title: General Contractor (Owner) - Signature Corporation Name (if corporation) Address: \J� 95TH '-- State }`�� Zip j Q �� Corporation Name (if corporation) Address: PT_ State NY. Zip 'l l� Form GS -97 Y t - ^+. J NORTHEAST LABORATORY OF DANBURY CT Cert: PH -0404 39 MILL PLAIN ROAD - DANBURY, CT 06811 (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: MILL DRILLING, INC. 75 PUTNAM AVENUE BREWSTER, N.Y. 10509 SAMPLE SITE: SAMPLING POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: Total Coliform (Bacteria) PHYSICALS: Color Odor pH Turbidity CHEMISTRY: DATE SAMPLE COLLECTED: 9/8/99 TIME COLLECTED: 3:00 P.M. COLLECTED BY: ROB DATE RECEIVED @ LAB: 9/8/99 TESTED BY: LAB #11471 REPORT DATE: 9/22/99 KENNY STABE, 649 NO. BIRCH HILL ROAD, PATTERSON, N.Y. TANK -HOSE BIB WELL NONE RESULT: MAXIMUM CONTAMINANT LEVEL 0 per 100 ml 0 per 100 ml 0 15 ND 3 Units 6.12 no designated limit 1.6 NTUs 5 NTUs , Nitrite N <0.005 mg/L as N 1 mg/L as N Nitrate N <0.20 mg/L as N 10 mg/L as N Alkalinity 27.0 mg/L no designated limits Hardness 36.0 mg/L no designated limits Iron 0.722 mg/L 0.30 mg/L Manganese 0.067 mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 0.067 mg/L 20 mg/L ** Lead 0.002 mg/L 0.015*** m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTED:9 /8/99 SAMPLE, AS TESTED ABOVE: ❑ OTABLE or a OT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) t 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: North Brrch Hill Road Town/Village: Patterson Tax Grid # Map �. Block Lot(s) �r, Well Owner: Name: Address: Kenny Stabe Rte. 22, Brewster, NY Use of Well: 1- primary 2- secondary xxx Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Xx Compressed air percussion Other (specify) Well Type Screened Open end casing X_ Open hole in bedrock Other Casing Details Total length _4_ft. Length below grade 40 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: Xx Steel _ Plastic _ Other Joints: _ Welded xx Threaded _ Other Seal: _ Cement grout Xx Bentonite Other• Drive shoe: xX Yes No Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped XX Compressed Air Hours 6 F Yield150+ gpm Depth Data Measure from land surface- static (specify ft) 30 During yield test(ft) 180 Depth of completed well in feet 225 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 5 Sandy soil 5 20 1 Sandy gr. a e l 20 225 Medium to hard . bedrock If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information. 225 .150+ Pump Typesu mersi 46fpacity Depth 120 Model 1 OGS07.412 Voltage 230 HP 3/4 Tank Type _d_i aphragpVolume 62 qal , Date Well Completed .4/7/99 Putnam County Certification No. 2 Date of Report 4/7/99 We gnatur) • NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's N L DRILLI G Mtm Address75 Putn.am..AVe., Brewster, NY Signature: Date: .4122199 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 pp�� Z0.0N R00 I I SURUE'1ED R5 py-P, INDICATED P055E5510M I I 1 N Z4. OS'44 "E I I 430. so Sck. I. a / wu\.L NOLE MUnlg- FENCE N I I o N I o s TOT0.L RMA = S.ZOS RCRES d �; m � t i wo S 24. 0 S'44 "W ]Oq .OD' I I I I r r � FSSUMFA CENTE�I-L \NE N AT T CAOIE L'RSEML.N"L _o` WE0.111N6 �� UNOC'0.L.flUUNO — — SIGN POST CP[4LE I I I I I I N � F RAV E.SON � I LISM \223 PFGCIGG I SEE FILED MAP ND. 2093 I I ( I I I uf� PNGE 194 ' I I f I I I I _ I I' I I mmsE 1 26 X S4 3, 33A 21 LGT 1 A LOT l6 I 1^ 2.300 "� I N SEE FM to. ZS \q �r I COTTA GE ; I Z L ' I C3 , i d OA I "E id Oa S 61 '1LS'16 2 40T \E UYIS II t/ SLS`Dl'LS "W 30.00' 119.00 % � CWkL9 -ZTf- M?1RVW1 STS 4y,.SZ.•Vy' N�\ - aQ}�� FKN _STRGE CORCk1 ilOf\➢ U7\L \11 10.00 SE"[ POLE SENDER: V ■ Complete items 1 and/or 2 for additional services. I also wish to receive the ■Complete items 1 and/or 2 for additional services. ■Complete items 3, 4a, and 4b. following services (for an ID s Print your name and address on the reverse of this form so that we can return this extra fee): extra fee): card to you. ■Attach this form to the front of the mailpiece, or on the back if space does not 1. ❑ Addressee's Address SCE 3 permit. ■ Write'Retum Receipt Requested' on the maiipiece below the article number. 2. 11 Restricted Delivery 41 ■The Return Receipt will show to whom the article was delivered and the date C delivered. Consult postmaster for fee. 0 a 3. Article Addressed to: 4a. Ar c(a Number '►) �`� � � & I C) `'�5 see PaN/250 (� 4b. Service Type E w Sd a0C',Y, r �� t1 t\ ❑ Registered Certified co cPd�� �'� �� 9, N a �6 3 �r1 Express Mail ❑ nsured WrIke Receipt for Merchandise ❑COD o z D of elivery w1 p 5. Received By: (Print Name) r 0. Addressee's Address (Only if requested d /ee is paid) c 6. Signa re: dr A en a� X PS Form 3811, December 1994 102595 -97 -B -0179 Domestic Return Receipt m SENDER: 3. Article Addressed to: 1'.�ber� �2�c1,j11 P)0 sS�.Cook ■Complete items 1 and/or 2 for additional services. 1 also wish to receive the o ■Complete items 3, 4a, and 4b. following services (for an 4D ■ Print your name and address on the reverse of this form so that we can return this extra fee): .. card to you. SCE 3 ■Attach this forth to the front of the mailpiece, or on the back if space does not 1. ❑ Addressee's Address permit. Write'Retum Receipt Requested' on the mailpiece below the article number. 2. ❑ Restricted Delivery $■ The Return Receipt will show to whom the article was delivered and the date 7. Date of Delivery c delivered. Consult postmaster for fee. 6 3. Article Addressed to: 1'.�ber� �2�c1,j11 P)0 sS�.Cook 4a. Article Number � 1 ' CL E v 4b. Service Type ❑ Registered A Certified t SCE 3 ❑ Epfess Mail ❑ Insured eturn Receipt for Merchandise ❑ COD a z 7. Date of Delivery 5. Received By: (Print Name) S. Addressee's Address (Only if requested and fee is paid) 1 g 6. Si at (Addres ee or Agent) a°. X 0 PS Form , December 1994 , 16259s97- 13-0179 ' Doomestic Return Receipt SENDER: following services (for an V ■Complete items 1 and/or 2 for additional services. I also wish to receive the m ■Complete items 3, 4a, and 4b. following services (for an permit. Receipt Requested' on the mailpiece below the article number. y ■ in ■ Print your name and address on the reverse of this form so that we can return this extra fee): ■The Return Receipt will show to whom the article was delivered and the date j card to you. ■Attach this form to the front of the mailpiece, or on the back if space does not 1. ❑ Addressee's Address y 2 permit. � d ■ Write'Rstum Receipt Requested' on the mailpiece below the article number. 2. ❑ Restricted Delivery 4) .t. ■The Return Receipt will show to whom the article was delivered and the date r 4b. Service Type delivered. Consult postmaster for fee. d c 3. Article Addressed to: 4a. Article Number c E p .�j j_ ©x a 4b. Service Type w Q���Q�n N i as63 ❑ Registered Certified ❑ Express Mail ❑ Insured G G m Meiv e By:. riot Name) etur Receipt for Merchandise ❑ COD w Q t 7 S ivery Z, o M ec ived y: (Print Name) 8. Addressee's Address (Only i /requested Y and fee is paid) m Si natur : (Addressee or Agent) 0 rn X PS For, 3811, December 1994 102595 -97 -B -0179 Domestic Return Receipt d SENDER: I also wish to receive the :P ■Complete items tand/or 2 for additional services. 0 ■Complete items 3, 4a, and 4b. following services (for an d ■ Print your name and address on the reverse of this forth so that we can return this 2 extra fee): card to you. d■Attacc Attach forth to the front of the mailpiece, or on the back if space does not 1. 11 Addressee's Address ai , permit. Receipt Requested' on the mailpiece below the article number. y ■ 2. ❑ Restricted Delivery N ■The Return Receipt will show to whom the article was delivered and the date u delivered. Consult postmaster for fee. 3. Article Addressed to: 4a. ArticNumber�� cc C ✓ (� /� v 4b. Service Type d cc U) W ��-- �- e.s'so n N� � �5 6 3 ❑ Registered Certified ❑ Express Mail ❑ Insured Cr �, M Return eceipt fo Merchandise ❑ COD ` a 7. D 0 /De' 0 G m Meiv e By:. riot Name) 8. Addr see' Address (Only if requested w and fee is paid) t Signature: (Addressee orAaent) H T X N PS Form 3811, December 1994 102595 -97- 8-0179 Domestic Return LAURENT ENGINEERING - 'j- 1 �T OP. AD J0 I N IN G+ PP- �P7= R-'i` �WIJ�J�j ASSOCIATES, P.C. / MILLBROOKE OFFICE CENTRE Fp-.o pew _, Tµ. t�._ Route 22 & Milltown Road Brewster, New York 10509 j \ (914)278 -6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS PAWL DUTCHESS CO. PUTNAM CO. -- 31 a • � � 1. 16.94 AC. CAL. 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NY I'1V4�9 Scar' A C*IHAP-�H> �ou d A' b {FAN E4 ILP-D• PATTER- `- °NIt`►� iz T14 o i� Jbu �T 50 aW A- V4 -- WILL 9-0• F#Tr0L5bN, W )"I- CC h-l'3"1 DF. 1" �GI- FIL.7RoBT.-�.Goof- I.NEI -I ?SA .. 6�X Cow ._PTr�.P�oH, kY l�jCo9j LAURENT ENGINEERING - 'j- 1 �T OP. AD J0 I N IN G+ PP- �P7= R-'i` �WIJ�J�j ASSOCIATES, P.C. / MILLBROOKE OFFICE CENTRE Fp-.o pew _, Tµ. t�._ Route 22 & Milltown Road Brewster, New York 10509 j \ (914)278 -6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS I \" \\ � \� � - \�. 2101 WEW- 4Z � t-r, ,NOTE" FXl',Th44 SEPTIC TANK TO �F- p,14 4) AIP F-LLrio wl I I — PER rv.Y9.e•4.0 Iy 4'0 pvt srA�,jFl, 41 7. i iZGH HILL C, AKA F-A 0) IN. To BE AWD �,W--ep 1w N I PL.6 -3r. ELL TO ,t RE MOYED A34Y F, AS-F."4W M , Fay =F,A16TlNC, PVEA4pr-e4 TAI FROM PUTNAM COUNTY DEPARTMENT OF HEALTH SION OF ENVIRONMENTAL HEALTH SERVICES q a► CONSTRUCTION PERMIT F _ PERMI _ I -1 Located at Subdivision name Subd. Lot # Date Subdivision Approved TREATMENT SYSTEM Town or Village Tax Map Block Lot_ Renewal Revision Owner /Applicant Name �+'ti�E�� ' Date of Previous Approval Mailing Address �-j �� Zip Amount of Fee Enclosed Building Type R4'J WC�Nt C" Lot Area Ai %)) No. of Bedrooms 7 Design Flow GPD Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Q gallon septic tank and � Ce 4,F A-85 Other Requirements: To be constructed by 1--8- 0; Address Water Supply: Public Supply From, or: Private Supply Drilled by Address 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: P.E. R.A. Date Address 9 a�? l O`U g License #. UA 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 n considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p t Approv r discharge of domestic sanitary se a only. By: Title: <i Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAG NATMENT SYSTEM PERMIT # Located at D1 I CAN H 44- iO Ap To P rr c ���'� Subdivision name Subd. Lot # - Date Subdivision Approved Tax Map Block 1 Lot 1-8 Renewal Revision Owner /Applicant Name �N�TH µJ�II.� �r�'` Date of Previous Approval Mailing Address raj rk 1'.-j- SPz-W rDrVP-- N Amount of Fee Enclosed 4 P))00 Building Type Zip 10601 Lot Area 5• °?� ' No. of Bedrooms Design Flow GPD 600 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1000 TRENc-H Other Requirements: To be constructed by Water Supuly• ,r-bv. . Public Supply From or: % Private Supply Drilled by T,B,P, gallon septic tank and P90'0 la' *46 Address Address 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: P.E. R.A. Date �� 7`��4L �'d:'✓i�S Rp- �L''r7f�R- NY 1 ��ia `I License # 6GI f,� APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved for discharge of domestic sanitary sewage only. Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 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: TownNillage Tax Grid # W-Jn44 H&L P-0 FINTTIEF-60N Map fl. Block l Lot(s) Well Owner: Name: Address: 9E4 + I.iMLE y r*0 2i 2!L },, p0W,i'TL : /Z- N).,/ 1 G tIo `i Use of Well: 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 .4- gpm # People Served -9; -* Est. of Daily Usage ?ecti gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type ): Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes No X Name of subdivision Lot No. , Water Well Contractor: T -(;• i2, Address: Is Public Water Supply available to site? .................................. ............................... Yes No A Name of Public Water Supply: °-- Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: i m 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 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 well driller certified by Putnam County. , Date of Issue r1-4 k Permit Iss g- Offici Date of Expiratio Title: Permit is Non-TransWra-bld White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 G�- � C ` PUTNAM COUNTY DEPARTMENT OF HEALTH � DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL /O PCHD PERMIT# j%uU / 0 please print or type Well Location: reet Address: TownNillage Tax Grid # B)P-CH f410. PNO P1� IFIz off Map 6, Block I Lot(s) 2� IN Well Owner: ame: KM I- Nara 6r .400 Address: fzr 22 Si?-OW51Z�IL N/ Iv off Well Type: ?C Drilled Driven . Dug Gravel Other Depth Data: Well Depth ft Static Water Level ft Date Measured Use of Well: I Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial. Institutional Standby Water Well Name: Address: Contractor: - 9 9` Reason For�r~� i:CjTP�► +vr��x►1S ycl�fEO �� ?K�5 uEbt -1� iaiEt�tn O�M'�1tir0 Abandonment: A,mEY DVS6 ►t*xkS. 6E%hkx cca o M.AO f, MFFN h4;51-1 W%w %F 0044'0 'To ��S awe ►.�,�LL• Description of Work To Be Performed: To III-' ^rt A&A 4+Pb `t Date: �'��'�� Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. / 11A q12 r Aj, Date of Issue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION 73115 Date: Street Loc tion Cam'` �I f`'�' Owner S��spected by: S� Town Permit # - K -y 1� TM 9 _S �- a Subdivision Lot #. 1. Sewage Svstem 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 1 5' from STS area......... e. 100' from water coursehvetlands ..... ............................... II. Sewage System a. Septic tank size - 1,000 ......CI,J25 .. ......other .............. b. Septic tank installed level .............. ............................... c. 10' minimum from foundation ........ ............................... d. Distribution Box All outlets at same elevation - water tested ................ 2. Protected below frost ................ ............................... 3. Minimum 2 ft.Original soil between box & trenche e. Junction Box - properly set ........... ............................... f. I renc es . . t 71ength required � Length installed - IS)L 2 Distance to watercourse measured j- Ft.ow� Offistalled according to plan ....... ............................... 4. Slope of trench acceptable 1/16 - 1 /32 " /fo t........ 5. 10 ft. from property line - 20 ft.- foundat .... 6. Depth of trench <30 inc es r surface...... ...... 7. Room allowed for expan ' 00° ....... .E.......... 8. Size of gravel 3/4 - 1 %" di eter cl 9. Depth of gravel en 12 minim ........... 10. Pipe ends capped .. ....... .................... g. Pump or Dosed Sv Size ot pump 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/Buildin a. House located per approved plans .................. b. Number of bedrooms ............................... .... IV. Well a. Well located as per approved plans ............................. b. Distance from STS area measured `i- ft. /-9 c. Casing 18" above grade ................ ............................... d. Surface drainage around well acceptable .................... V. Overall Workmanship a. Boxes properly grouted ................ ............................... b. All pipes partially backfilled ........ ............................... All pipes flush with inside of box ............................... d. Backfill material contains stones <4" diameter.........;. e. Curtain drain & standpipes installed according to pla f. Curtain drain outfall protected & dir.to exist watercoi g. Footing drains discharge away from STS area............ h. Surface water protection adequate .............................. �SA ,. U' ' R NN S- EP C�TIONN For. Fill Trenches PCHD Construction Permit Located (L�9C# _ (T (V) SQ Owner /Applicant Name iviL 'T � % TM WBIock La: O Formerly '— G Ca*# 000Subdivision Name Is system fill completed? Date~ 3 9 S Is system complete? Date — Is P Is system constructed as per plans? Is well drilled? WFY - Date Is well located as per plans Are erosion control measures in lace' ?. I certify that the s} stems), as Iisted, at the zi ove premises has been constructed and I have inspected and verified their completion in accords � e issued PCHD Construction Permit and approved plans and the Standards, Rule: a e Putnam County Department 2 of Health. �i:� 'Mt t_ 4- Date:` 2- 3 Certi fled by: Address Comments: s Form FIR -99 TOTAL P.01 r r, l* y y ra P► ° �o PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address B i R < k Located at (Street) 5�-,a ���,,��N ?i?�, Tax Map !�" Block �_ Lot (indicate nearest cross street) Municipality ,#TTE �,N Watershed SOIL PERCOLATION TEST DATA Date of Pre - soakings / I % Date of Percolation Test . .. . ... Y T�neIa s se Time S Y L LV1.Y■ 1 1 ti.•f MVffi ♦lVi[- Mart :StopM�n.) S 2 3 ' 't3- a a 0 025 l l 4 X X 5 1 / /U, 06 - i0: 56 c c � �33� -� 0 0r d d 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. Fonn DD -97 TEST PIT PROFILES �.�77"T�rc'soN CC Hole # �_ Lot # �- Hole # vZ Lot # ---- -- Hole # Lot # Depth to water �- 3 " Depth to water. 5 '- 6 " Depth to water 'Depth to mottling ,V& v Depth to mottling A/0 K e Depth to mottling Depth to..rock/imp. 4/& ti e Depth to rock/imp. mpo F Depth to rock/imp. G.L. G.L. 16, G.L. 0.5 10 70�'� ° 0.5 0.5 1.0 1.0 1.0 a G oGvH �o-Y'1c Zx�Yow 2.0 14ed. 2.0 2.0 3.0 u r 3.0 L"1 3.0 4.0 4.0 4.0 5.0 5.0 5.0 ... tv4 Ter sa - 6.0 u.af�r Ltr/' 6.0 6.0 7.0 7.0 7 7.0 8.0 a 0vW�� 7' -v "8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 Hole # Lot # Hole # Lot # Hole # Lot # Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L. t G.L. 0.5 0.5 0.5 1.0 1.0 1:0 2.0 2.0 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 4, r .,� --.4 a -4 ,, y` 3 F a v '. t.a t -,y y.., , r t -� t o �' t s r :" vtr'�` y f 3* � ,-K { i _ x f _`'✓ AM �, '� }.,+�; Y ss { .,'3,4 '�� z - k�:. 5 -> 4{' a r�' a.. r� .� 1` {tEk' - a • -, = - ', --, :r .a� '.�° », Sl�ect _o,- : � �' t _ t •' YT * F ' PUTNAM COUNTY DEPARTMENT OFhHEAI:TfI DIVISION OF ENVIRONMENTAL IiEATLII SERVICES ` ��'tIi` �j0�'� v a- - TIELD ACTIVITY REPORT f - k _ 11 11 n .�...;.. ..,K. -r..„ -VV "., v.. `5. ..af'r s - 7..k, '...; } t� s a t,, x. t. �.. a l vs, _ rrj� 3� a "a a` _ n _ , , ;: � 1 ,i n ,/ ,r��J k 9D1�Ii .. I I r� h r/1l��� f(rXi 'f GC E'YSc ✓! z x � 3 i P Street ra a< Towri State - Zip F ,�. 4. ' x s 'xf, ,3'`- �! 'y z,y e 0' �C _ 1: H . ; ;g '� ,� r' w �*. s - PE.RSON IN CHARGE • t r °F " ' il- ,'Q TmTFRy,m-W,F1Y T)atP - Name= and Title i r a TYPE OF FACILITY; �c�l e "� a►' ' l i J b v `� C, , �,`r -� `' r ? t s r T-' z :.r • 1. �. _. .,... "i *` -..e .> t , .s ` r `a .-�,X ias 3a m. v ' y FI NDI NGS': 4 j r c� l !�^ .,e , , - , ♦ �_ � �E° Gtj y ,� N I. - a' 9a t i X X : , YP e Y a 8 4 ...c : .: ..4? j ' d _ 3 _ _ __ roc .v 4Z '!4 _. .g, .- if - p to 3 F•i�^ `u.; S, -'S- x+^e >z. :�.- +tj _ _ Y)IC s 9 r r +z.. r 's �} a o-5 7 < u .� a r F ...: Fy a. }+' sy 2 T b 3 :y 3 - F. w`7r *•1 wg'z• .. .. •„i -.-ro I"• a #5 to 4 :t x+L. - F ray .viz s -,ry z i 17 } k § 7, r , a s- r o- H I r "•} > q� ash �"�. _ M € _ 0 a ; c p .. , . ._E- v, o-,. f ia'f s - ,a.. �.r 5 ' < �r s .w r ESL <' fi s a r {£ -` 5 s +„ i 4- y, 'a - .yt - Lt -h- 5y S �.. _, A -4 '(' �, 3. _ a- s > s Kr xs' m y uc - a '�' z . fir. m�f, ` °' :� w �- e- '- 1 y a ? a - _ rC t.. ,c&. ;a e a>t is '�r #cd ?, d a �i c -�� s a o t ` 4 _ , 1 - �.A...t.n z, s z - ... - _ - .. '�"Zx' S .. s £ 4 5 �a e d 9 b TN4 ,. cw-! 3 ' TFt k f 11 y - ay d -,� z - r� E ,Signature and , , l , rt= ,, 3 x ' � �y � x a B 11 R�'FTVFT) RY•' ., } I acknowledge:receipt ofths report "SIGNATURE• f1� h . _ 02:%96 Title; {Ya F s:� <Rev LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Brewster. New 11York 0509 j\\ (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS List of Abutters RE: Kenneth Stabe Birch Hill Road (T) Patterson 1. TM #5 -1 -27 2. TM #5 -1 -29.1 3. TM #5 -1 -30 4. TM #5 -1 -37 Casarella, Vito & Dora Et Al . - RT2 Box 32 Patterson, NY 12563 Halkett, Scott & Catherine Box 3 1 A N. Birch Hill Rd. Patterson, NY 12563 Raveson, Thomas & Janet 50 Quaker Hill Rd. Patterson, NY 12563 Demchuil, Robert & Cook, Melissa P.O. Box 658 Patterson, NY 12563 0 0 V 0 0 .0 C C a r f L t C ( Z 391 341 8.82 US Postal Service Receipt for Certified Mail NO Insurance "Move' aye rwvn.c..• Do not use for International Mail See reverse Sent to " f^f s S eet & Number O x 3 a P st office, State, & ZIP Code _ 3 k ^s d /., Postage $ Certified Fee Postage Special Delivery Fee P t Office, State, & ZIP Cod Restricted Delivery Fee l Return Receipt Showing to Whom & Date Delivered Special Delivery Fee Return Receipt Showing to Whom, Date, & Addressee's Address , d TOTAL Postage & Fees r $ a Postmark or Date i 0 q$0O� Z 391 341 884 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for Internatinnal Mail /.Saa rauarcal Z 391 341 885 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International mall oee reverse Sent to t'5. RogVe,Sa 11 ("Id;sSc; ccv Street & Number \ O (!qj'z- C 4• k Post Office, State, & ZIP Code Postage $ '70 P t Office, State, & ZIP Cod Certified Fee l $ Special Delivery Fee $ O U3 Restricted Delivery Fee Certified Fee ' Special Delivery Fee Return Receipt Showing to 10 V) Whom & Date Delivered Return Receipt Showing to o Return Receipt Showing to Whom, •— Whom & Date Delivered Q Date, & Addressee's Address Q Return Receipt Showing to Whom, DTOTAL Postage & Fees Is ` a Postmark or Date E $ 0 LL Postmark or Date V) EL or Date Z 391 341 885 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International mall oee reverse Sentto 0106+ t U(%c Ji 14 ("Id;sSc; ccv Street &Num .a, Nox G S P st Office, State, & ZIP Code P t Office, State, & ZIP Cod Postage $ Postage $ O U3 3 Certified Fee ' Special Delivery Fee Restricted Delivery Fee Restricted Delivery Fee V) Return Receipt Showing to rn ' L •— Whom & Date Delivered Whom & Date Delivered Q Return Receipt Showing to Whom, Return Receipt Showing to Whom, Q Date, & Addressee's Address Date, & Addressee's Address O TOTAL Postage & Fees co $ J 3L Postmark or Date EPostmark or Date 0 u_ U- U) CL RPeoi� Z 391 341 883 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not usA fnr Internatinnal PA.ir /Cm .a,..,. i Sent to Street & Number X�No 1 N. P t Office, State, & ZIP Cod �- rs -, (as63 Postage $ O U3 Certified Fee ` Special Delivery Fee Restricted Delivery Fee V) rn Return Receipt Showing to Whom & Date Delivered Return Receipt Showing to Whom, Date, & Addressee's Address 0 TOTAL Postage & Fees $ EPostmark or Date 0 u_ 14.164 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEOR v Appendix C State Environmental Ouality Review SHORT, ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant. or Project sponsor) 1 . APPLICANT /SPONSOR KF_NNa-i I1 2. PROJECT NAME, jNDIvIDUAtl— 05tP11�5 3. PROJECT LOCATION: PAT F—P—.6Oi4 NAI'1 Municipality I County' 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: lot New ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: LON''ai WJ Gil ON 0 � �?iMGtL -E i�'MiL{ ��S►iT�t —tr.� � vd�t.L i- ts`���j 7. AMOUNT OF LAND AFFECTED: Initially 15, acres Ultimately ti'� acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? C9 Yes O No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? C Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: Lo%4 fftAla 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes N No If yes, list agency(s) and permlvapprovais 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ® No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes ® No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /sponsor name: hAW � A('SkT" Date: 2LL�z Signature: _j (J If the action Is in the Coastal Area, and you are a state agency, complete' the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? if yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No S. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible) Ct. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly • c r; J t:, C C5. Growth, subsequent development, or related activities likely to be induced.by the proposed action? Explain briefly. C-D —i C6. Long term, short term, cumulative, or other effects not identified In CI-CS? Explain briefly. C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It is substantial, large, important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed. ❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. ❑ Check this box If you have determined, based on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Print or Type Name of Responsible Officer in Lead Agency Signature of Responsible Officer in Lead Agency Name of Lead Agency Date F Title of Responsible officer Signature of Preparer (If different from responsible officer) 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: KaNN 5�rH {" N i ''`F &rA. ga F— w 2. Name of project: 3. Location TN: PATraR.enoN 4. Design Professional: kAP-9 10' +�1'�° ,,�-� t'�' 5. Address: U Mil-LTOWA ?-CRD . 6. Drainage Basin: pmr is P-At4c H 6R y.,yrep. Hy i o`ioei 7. Type of Project: A Private/Residential Apartments Office Building Food Service Institutional 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 _ Type..II. Unlisted x 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N A 11. Name of Lead Agency mp 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ...................... yc' 13. If so, have plans been submitted to such authorities? NO 14. Has preliminary approval been granted by such authorities? MO Date granted: CIA 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... IN 17. Waters index number (surface) ........................................... ............................... NA 18. Is project located near a public water supply system? h0 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ NQ 21. Name of sewage system Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) .................••• 600 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... o 26. Has SPDES Application been submitted to local DEC office? NA Form PC -97 27. Is any portion of this project located within a designated Town or State wetland? HO 28. Wetlands ID Number .......................................................... ............................... 29. Is Wetlands Permit required? ............................. .....:....... ... ............................. N Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 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 DESCRIBE: An Rt ND NO 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 15 years in or adjacent to project site? ................................ ............................... No 35. Are any sewage treatment areas in excess of 15% slope? . ............................... N0 E 36. Tax Map ID Number .......................... ............................... Map Block ► Lot '�-% 37. Approved plans are to be returned to ..... Applicants 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 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 X210.45 of the Penal Laws SIGNATURES & OFFICIAL TITLES. 14 A5 AC40t�4;r Mailing Address :.... ............................... PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner kEAIAIFrN ZN414E STW19E Address Row?- �dQ� Gv�,T "ie /V Located at (Street) _gi i /�. R019C) Tax Map Block Lot (indicate nearest cross street) Municipality D,4TT�%�SD®✓ Drainage Basinst"i ?-NON' SOIL PERCOLATION TEST DATA Date of Pre - soaking $— //— `3 ir Date of Percolation Test IF- /a- 9S - Hole No. Run No. Time Start - Stop Elapse Time (pli Iin.) De th.to Water k�rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 1 /o;0; — /,P %, go 5 17 2 3o 30. 3 4 ia:l� 3a ayc�' as'' `y '' 30. 5 i 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are octaineo aL raI-u 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 2 27. Is any portion of this project located within a designated Town or State wetland? Ho 28. Wetlands ID Number ........................................... ................................................. iy 29. Is Wetlands Permit required? ......................................:....... ... ............................. No Has application been made to Town or Local DEC office? AV 30'. Does project require a DEC Stream Disturbance Permit? 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? .........................I... Yes/.No N9 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 No 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 15 years in or adjacent to project site? ................................ ............................... Nb 35. Are any sewage treatment areas in excess of 15% slope? 'N0 36. Tax Map ID Number .......................... ............................... Map �- Block 1 Lot a-�O' 37. Approved plans are to be returned to ..... Applicant x 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 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 ;10.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: Maili ......j .... �.....�.!..... J........ ng Address: .' t:Ot�i'o 9-0 mi%' "f'o Wig R-0 big -Eh► 6-wp-- my i o 5 a 9 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of ANN NTH + i4 "-a 6-1_AEiF- Located at 15112tH HILL ROAD T/V PAT_r1E960 J Tax Map # Subdivision of Subdivision Lot # Gentlemen: 6o Filed Map # Block L Lot This letter is to authorize j+AQ -R_4 W • NiLHo 1-51J�- PrS Date Filed 9-S 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 of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putna;k = %% y Code. Countersigned: P.E., R.A., # Mailing Address 44 Very truly yours, , Y Signed: Alp (Owner of Property) Mailing Address: P-OV' E S1 State �4 y Zip 10150 State BILa W sr- Pa N� Zip 10601 Telephone: (oil 4) 2n'6, - Com Telephone: ($1) /L n- 04q� Form LA -97 i yt. h *` a