The URL can be used to link to this page

Home My WebLink About0271DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 12. -4 -3 BOX 4 111:1 , ir 0.el R m IM h . 111:1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at 1/%41,/0,e X0,0 own r =geONOY-J Owner /Applicant Name &/0(�2ySQIC7.1 J Tax Map Block y Lot Zq Formerly �',0✓q10 Subdivision Name 14-1k i9W Subd. Lot # Mailing Address Zip /ate Date Construction Permit Issued by PCHD jam° t'• 6b,!90 Separate Sewerage System built by 1-361D d A13Z,EW71 -0X/ Address, ©' 4i PaOAI Consisting of Gallon Septic Tank and o}" �NiDr /�SnrGI �l1IGh/ Other Requirements: j -Q %? a t3 )tlU Water Supply: Public Supply From, Address or: ✓ Private Supply Drilled by it/IW 1DO L V4 /NG . Address �� jlj,5//�iYl N• , i0 Building Type 517,&1&z c- A2QA/x Has erosion control been completed? 5 Number of Bedrooms Has garbage grinder been installed? Aip 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 re 1 Iam County partment of Health. Date: te a a• 203 Certified by P.E. ✓ R.A. (Design Professional) Address r/TivA10- G/ �L�% C OIjJ c v1�' (v License # Q ka C -1�1�T I IV , !©,mil 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 revocat odificati r change is necessary. By: Title: z. Zo Date: , White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 r s. UTNAM NGINEERING, PLLC. Engineers and Architects SEPTIC SUBMISSION FORM TO: vd- / /y'7i912121S3 FE. DATE: 47` 179.07003 PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: (V VA IS 6led a-1,1V �piySI- R11GT/ON��T) %qT e% :N AI)4, Jo2 /?ou1) - l - 3) ENCLOSED, PLEASE FIND: IJ `� COPIES OF THE SSDS "AS- BUILT" PLAN a/ CONSTRUCTION COMPLIANCE CERTIFICATE WELL LOG HEALTH DEPARTMENT FEE ($200.00) L`7 WATER ANALYSIS 0 GUARANTEE FORMS - 3 ORIGINALS a E 911 ADDRESS FORM ❑ LETTER OF EXPLANATION ' REMARKS: COPIES TO: SIGNE] 4 OLD RouTE 6, BREWSTER, NEW YORK 10509 • (845) 279 -6789 • FAx (845) 279 -6769 • EMAIL: puteng @bestweb.net TTERSO 845 - 878 -2019 P.1 Feb 19 03 02:23p TOWN OF PR - P"1 C� { Gy B17=2 R FOLrY " s., -- r C ErTA MOLiNAPI- RN., M-S.N. Pubix Kea:th Dtrec:er ��'� i diaociata Pccbiie Heakh Dlracter Director of Paamt Somers MPARTIMENT OF HEALTH 1 Geneva Road Hrcwsecr, New York 10509 Taricoamutal Health (914)279-6130 F.c (914) 273 - 7921 INrslmq Sorvtea (9141 273 - 6.558 WIC (914) 273.5678 Fax (914) 278 .6083 Early Iatecyaattoa (914) 278 .6014 Preschool (914) 21"092 Fmc (9I4).78 - 6648 OVV NTIE RS ( AMI:: TAY ri.�P:NCI�IBE12: E911 ADDRESS: TOWN: ' : : i► e AUTHORIZED TOWN OFMCIAL: (Signature) DATE: v�? / '/W41�7 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 assinned by an authorized town official. This form is to be submitted -with the application for a Certificate of Construction Compliance. (19'.. 1'V EU3,M) JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET STAMFORD, CONNECTICUT o69o5 NELAC, CT and NY State Certified Environmental Laboratory Mailing Information: Name: Mill Drilling Co. Address: 75 Putnam Ave City: Brewster State: NY Telephone: Sample's Information: Site: water tank Preservative: HNO3 Temperature: <4C Client: Beno Construction Zip: 10509 Fax: 845 - 279 -5075 Date Collected: 10/30/02 Time Collected: 13:45 Date Analyzed Test Name Collector's Information: Name: Russ Mill * Bob Address of site: Manor Rd City: Patterson State: NY Zip: Telephone: Date Received: 10/31/02 Time Received: 12:00 Lab No.: Result MCL J024124/ *J024205 Method 10/31/02 15:00 Total Coliform Absent Absent SMWW 9222B 10/31/02 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 11/1/02 Color ND 15 Units SMWW 2120 B 11/1/02 Odor ND 3 TONs SMWW 2150 B 11/1/02 * Iron <0.03 mg /L 0.3 mg /L SMWW 3111B 11/1/02 Manganese 0.119 mg /L 0.3 mg /L SMWW 3111B 11/1/02 Sodium 3.00 mg /L N/A SMWW 3111B 11/1/02 Chloride 6.00 mg /L 250 mg /L SMWW 4500 Cl C 11/1/02 Hardness 88.0 mg /L N/A SMWW 2340 C 11/1/02 Nitrate 2.37 mg /L 10 mg /L SMWW 4500 NO3E 11/1/02 12:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 11/1/02 pH 6.61 S. U. 6.5 -8.5 S.U. SMWW 4500 H B 11/1/02 Sulfate 20.0 mg /L 250 mg /L SMWW 4500 SO4F 11/1/02 * Turbidity 0.73 NTU - 5 NTUs SMWW 2130 B 11/1/02 Lead <1.0 ug /L 15 ug /L SMWW 3113 B Comments: * Resampled on 11/4/02 at 4:00 pm At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Signature. "L- State #: PH -0218 Michael Lapman ELAP #: 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot Building Constructed by _ 33 HAA /v 2. Location - Street 1 F11, -/ A6 f P e S Building Type pog 7"7ew.A cr A-1 TownNillage Subdivision Name . z- 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 Day _ Year ,AmO Signature: Title: General Contractor (Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) Address: 1 ` t - Z Ck State /(,,, Y • Zip Q % _�; _ Address: j7.0 . ;L�C' k kG l j. State & '/""- Zip f2 Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONhIENTAL HEALTH SERVICES g FINAL SITE INSPECTION Date: 7 8 �•:... Inspecte y: Street Location /1 Aid TL Owner. GCJ 1141 S Town Permit # P - ( v -- cn ; - TM # /z-- •- - 3 Subdivision Lot # :;7- . 1. II SeNvage System Area Y 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 ...... ............................... . Sewage System a. Septic tank size -1,000 ........ ;1,250 .:::.....other ................ b. Septic tank installed level .............. ............................... c. 10' minimum from foundation .......... ............................... A d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches y e. Junction Box properly set .............. f. Trenches cries -- ........................... engt required 6- 7G Length installed 5- 7� 2. Distance to watercourse measured- /o o Ft.......... -- 3. Installed according to plan ..................................... R 4. Slope of trench acceptable 1/16- 1132"/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. PumD or Dosed Svstems - Sizeot pump c am 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. �iouseBuildin - a. ouse ocated per approved plans......... ? ............... b. Number of bedrooms ..................... ?4....5; ............. . IV. Well a. Well located as per approved plans ........................... b. Distance from STS area measured 4- / o o ft........... c. Casing 18" above grade ............. ............................... . d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .......... I ...............:........ i. Erosion control provided ........... :..................................... COMMENTS 08/28/2002 10:56 FAX 845 2796769 PUTNAM ENGINEERING PUT CO HEALTH Q002/002 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION 0 ADAM GENE REQUEST FOR FINAL INSPECTION For: Fill All information must be fully completed prior to any . Trenches inspections being made. PCHD Construction Permit # P- e2 0 Located: M ,, 0 '1 40-(z s,o' Owner /Applicant Name; �1 5:21✓9-1 i Z_ Block _L_ Lot _Ll Formerly: Subdivision Name: f'1-7 1P- ZI t 0 1411Ao2 Subdivision Lot # Is system fill completed? e Y Date: 2.8 A 2 Is system complete? �_ Date:. 25 Ada o z Is system constructed as per plans? e Is well drilled? 1► e 5 Date: A✓ j v Is well located as per plans? �/ Are erosion control measures in place? I certify that the systems), as listed, at the above premises has been constructed and I have inspected and verified their completion in aceordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of Utwn=am Department of Health. Date: 2 Certified by: 7Z' RA Design Address: /� ��Lriv S,Qf.� /'dam -- Lic. # /2/ 7VVC Comments: Form FIR -99 0 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 (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 September 3, 2002 Paul Lynch Putnam Engineering 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Covais Manor Road, (T) Patterson Dear Mr. Lynch: The following comments must be corrected in the field. 1. End, caps must be installed at the end of each lateral. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR:cj Environmental Health Engineering Aide a SENDING CONFIRMATION DATE • SEP -3 -2002 TUE 09:17 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE :.92796769 PAGES 1/1 START TIME : SEP -03 09:16 ELAPSED TIME : 00'20" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED.. a BRUCE ," 00.dear �' I.ORBTIA MOL►NARI B.N. M.S.N. Aslaafpe P.bae HnIrA Db.o1x D4rrnv � PcfkN .rbrY[rr DEPARTMENT OF HEALTH l Geneva ltorA Brewster, New York 10509 1..Ire,r W Brut (641)778.6130 I-(84J)27a -7921 Naraq Beaks (a47)27t -6331 WIC (843)276.6678 Vm (845)271 -6081 11-11J Lhrw.t Wffl a 6-1 (645) 278.6014 118, (343) 271. 6"1 September 3, 2002 Paul Lynch Putnam Engineering 4 Old Route 6 Brewster, New York 10509 Re: Field Inspection - Covais Manor Road, (Tj Patterson Dcar Mr. Lynch: The fo4owing cammeats must be corrected in the field. I 1. End caps asst be installed at the end of each lateral. If you have any (httbcr questions, please comaet me at (945) 278 -6130 e#. 2261. I Sincerely, Gene D. Reed ODR.oj Environmental Health Engineering Aide rJ 1 :r I•d CS AW I 1 � T y }'I.A It •i. l ' l� .. - ' . ,..�: ,,'.n -0 2': d ti �4 ' � 1. t` l :7 - �r � U\ Q) 51'ON� PIANSP, OW) NOd L. POOP O.N 51ON� 5SP5 O r rrG T44W Kl 4 {: AMA— 4,069 AC--t .. as Iti "r Y .n� 7 ky¢1S ids S 76 59, G�W�L nplV� r' W C, 130X IPutnam County Department of Health / i / / / ! /Qy t'• Division of Environmental Health servioes Appro noted for oonformanee with ., appli b Rules jqnd Regulations.of the p; Co t ealth Department Signature i Title e , N 7C,. 5 trench Add me jtjohaj requirents: J'9 fILL Z011 I 4 Xt �s .AS -BUILT MEA%I;MMENT5 ( IN FEET ) 2 3 4 5 6 7 8 q 1 II 12 15 14 15 16 J7 A 2.77 _ 283 207 294 299 304 310 315 321 2 t 297 302 308 313 310 323 326 3 31 323 328 333 337 342 348 352 357 3 6 340 54/a 3� 35� 3(� 5 370 3 EVISIONS N0. i -. �: N6fNEERlN6. �cc h` ENGINE'ER5 - ARCHITECTS 4.. 4 OLD': ROUTE 6, BREMTER, NEW YORK 10509 . (845) 84 FAX (845) ?'Y9 -6769 4ti ®PUTNAM ENGINEERING PLLC'2003 -,_:, tf .. ��T.. .. ._e..P��'E >�e.,a, r�Y�. .. .. :r3 �.,.L•:.�._-�.�.k.�L:- �t+.un .. .. _ _ _ _._. I EVISIONS N0. 16 /7 18 19 22 21 22 23 -4_ 25- 2& 27 323 326 334 M 3or. Sao 29,4 277 2-7! 2, l 5 370 374 344 336 332 327 322 C1.7 31 f 306o 300 7/G TAi]k A 52 DEL L 8 77 G 33 '. AS -BUILT PLAN PREPARED FOR: DESCRIPTION BENO GON5MOTION CORP. :. (FORMERLY GOVA15) FAIRVIEK MANOR; LOT #2 16 MMM ROA0 `t�0 067446 t t TAX MAP 12, BLOCK I, LOT 3 TOWN OF PATTERSON %��f #Ftv�r��+.y"f. .�'E.s[$.v'.Yf_. F•*' �""."""w'^ "r -,�`. �''x" -$�-," '�' "U, 0 -` ��PU,TNAm COUN�T1(= L DEPT H _ 018 71 -� k �Ba s er f�1f9f1�4�)5 &6130 WUE � 'ter K �� -� _ �'.,YY' C��' w•�.��^`.6"�LL��i �•��5: N ^R"�- ..Y"��,�'$�„�� f,�rf.Fi ,�„� s� ��~"�'. _„0. t »� _ °li � `!� . ^�'�5 �'C�.. ;: R�< 7 s+�. ��..,•;.. �ss"�"+k"+.; 3,.,, �`r' -LC'� �, -�.xw •,d`"�' `�.�`F"� '�� +�is'� - r�� -��-.. .>,x, �-..r � r. Received � �''•a,,,.�" 'aR^a.,^�`�.' is��' +�"^,- `� -_�� {�� '�"c. - +-'t��„� ��yc��`��t-"�� r �"^+ -^c set,? �The;Surn «�'Of� :k. �• � r�� j-�-- -��, � �°�. oilars � ,� � � � finrw I=gjtv + aY. ':.a"' ......� -.J. ""'y ^C ..�-N ,�aa`z^`"` * s""K -✓ mow« t FF�^'' -kf+. •C. ,F k�„��i s�.t��''6`+�'^j� +''�*'• yCs i .l�^,s -c- °*,�"%"'7�`�yk•s- .`^3.. �,,.,,,s. �'i•� a r ^'-�. x"• �'_ - '-"'�F rc� ��+' "C•. .�'.�� c N� ��•� ! ',�`�- �''£�x' -� � r; -x •w.$• °'.r sc �" �� M.: -. .� �. � a��.�,';, x�"ti -fib �� /} ,.�s �,�s•.:,wc• x"� ..�- c � .v $v 3�ww�� '"' k+ Vt x•�;;�• r'v�i -��' �tr'�t, �� '�4t "� � }7 '•zf�� c'"Y''" r^ ,,,, ?-^` �.a...'.�r. � �G �- �`�''.m,�C y� �.G't G,�, •�F. F -s% ...yrf"�'.,y.. ^wYet' �..5,..,,G f '., �. `k ❑ M 4C7 Cash heclt OCI CretlFt Carci,By t i t x'•Y �. rr F t -t k' r � � � �4k ro. {I ,y "}"`.� Cj `� '� 3 � v r a?a k z ;'++�sxte i ♦y. � � s t ( (�s._.e� ^��? i a_ ,. ��.t�. »,, .:�r 3."„= ,.ui:�.�: ".� � wit:: y'v� ^' ^`' k ,. .�, �� i'Sr��C+ 1... .�`i,.¢�'l( } t:•� r�,R.f��... b:}'.k'•i.''° 3 0 a PUTNAM COUNTY DEPARTMENT OF HEALTH N DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM �1 D PERMIT # --(oO- 8 t b� Located at P oe- , Town or Village PA 1 FL-YLSG Subdivision name FA12V)&U PV�X(L Subd. Lot # Tax Map 12- Block I Lot _ Date Subdivision Approved rJ l i3 80 Renewal '><— Revision Owner /Applicant Name Date of Previous Approval )1 I )s b Mailing Address 44 46JTW q9 vet t! 64emeL Ell 16c? 12- zip S)6 1 L Amount of Fee EnclosedC�G . w Building Type Lot Area44 - o 18 No. of Bedrooms Design Flow GPD 803 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of r- Zi Other Requirements: gallon septic tank and 5-7 � GF 0 2a 6 C1 Lc, (44-O G .t� I To be constructed by lb 66 pi5Tby- K ine_ Address 'j Water Sunnly: Public Supply From r;g Address or: _ Private Supply Drilled by 'jj LE D (5-Tt;iLtl 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 treatments sy tern 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. Address R.A. Date I I a 7 0 License # ac APPROVED FOR CONSTRUCTIOk 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 whe sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe t. A roved fo scharge of domestic sanitary seewae only. By: Title: JYA-�- D ate: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 i j. BRUCE BRUCE R. FOLEY Public Health Director MEMO LORETTA MOLINARI R.N., M.S.N. Associate Public Health - Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road -' Brewster, lsTew .York. 105.09 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 - wIc (914) 278 - 6678 Fax (914) 278 - 6085 To: All Design Professionals, Builders and Property Owners From: Robert Morris, P.E., Senior Public Health Engineer Subject: Partial Submissions/Revisions Date: February 12, 1999 the review of Tans and the return of comments if warranted was constantly ahead of the P Y time frame allotted by the New York City Department of Environmental Protection Watershed Agreement. The Department is still striving to improve the time frame involved for permit review and approvals. Some improvements are: 1) Additional personnel in the program. 2) New York City Department of Environmental Protection faxing - comments /approvals- , (saving mailing time). 3). Reviewing the. neighbor notification requirement to make the requirement less stringent. 4) Updating the filing system. = - - - = -- However, it -is -also the--design professional, -= builders- and -property.. owners responsibility submit- - -- - = =- _. documents.with all pertinent information provided. A cover sheet must be attached.to.11 documents - not submitted with an initial complete application for a construction permit. The cover sheet must include the following formation for each project. . A) Owners name. B) Project address, municipality and tax map number. C) Document status, i.e., revision or requested additional information. The required cover sheet with assist in reducing the review and approval time frame. An example cover sheet has been enclosed. Your compliance with this requirement is appreciated. RM:tn { . -t BRUCE R. FOLEY Public Health. Director LORETTA MOLINARI RN., M.S.N Associate Public Health Director Director of .Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085. Early Intervention (914) 278 4014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 COVER SHEET t/B"iQi 0 ��rc � p arU , OS 0 K1ul,,Q. PROJECT (OivnersName): ICI C4N X72- 770 k hr1C. ------- '-CCA!,tS STREET: I m r2 i2O� NIUNICIPALITY: f' 077c 9('P /LI TAX MAP NUMBER: 12 3 CO Cr- 107 #9 DESIGN PROFESSIONAL: H 1 11Ft L WC/l/ DATE: d �T ;� • (�� . _ 11 REVISION - - -- -._ .. . ......... .. . - -- --- - - - - - -- - --- REQUESTED ADDITIONAL I iFORIIATION �Vo a - OTHER UTNAM E NGINEERING, PLLC Engineers and Architects SEPTIC SUBMISSION FORM TO: t-la " -a4 r'-G> DATE: PUTNAM COUNTY HEALTH DEPARTMENT PROJECT: AM� C)sAS FA1406i/J MAC ()(—' Vb-aAi T -L"-- P .._ (po `8 ) ENCLOSED, PLEASE FIND: v1 d, 5 COPIES OF THE SSDS PLAN ❑ 2 COPIES OF THE HOUSE PLANS CONSTRUCTION PERMIT APPLICATION CJ WELL PERMIT APPLICATION�� HEALTH DEPARTMENT FEE ($ ) ❑ SHORT EAF ❑ DESIGN DATA FORM LETTER OF AUTHORIZATION APPLICATION FOR WASTEWATER TREATMENT (PC -97) LETTER OF EXPLAINATION REMARKS: COPIES TO: SIGNED: 4 OLD RouTE 6, BREWSTER, NEW YORK 10509 - (845) 279 -6789 - FAX (845) 279 -6769 - EMAIL: puteng @bestweb.net PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER. WELL "p— please print or type PCHD Permit # (�y Well Location: Street Address: Town/Village Tax Grid # ' " A ' p/AZ) IPA*ef' b � Map % Block Lot(s) 115 Well Owner: Name: Address: (1 Am-y COV/�1S qL1 aN � bri Ve- CA LL A)Y 1a%2- Use of Well: X 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 MW 5 gpm # People Served j=AM Est. of Daily Usage ZCQ gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _�K New Supply (new dwelling) Deepen Existing Well Detailed Reason A&W RCS; L- Gvpph/ for Drilling Well Type_ Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No �C Is well located in a realty subdivision? ...................................... ............................... Yes i4 No Name of subdivision rA19,VlEin11/kN01f, Lot No. 2_ Water Well Contractor: -7o- /3e- Le4ermir7ed Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: /VIA Town/Village Distance to property from nearest water main: GrAk--r1h"% Jat91 e, Proposed well location & sources of contamination to C_pr_v' n _ aF to si-ieftl�p an. Date: Ik Islao 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 1 driller certified by Putnam County. Date of Issue d b i Permit Issuing Or�ial: Date of Expiration Title: Permit is Non- Transferra le IV 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 SERVICES LETTER OF AUTHORIZATION RE: Property of C'3\f/�1 S Located at Iyl a� }0.� T/V Tax Map # I2 Block Lot Subdivision of FA) Ry 1 EW AIA-NOR, Subdivision Lot # ;11 Filed Map # 22.E q Date Filed '1 '3A- " ' Gentlemen: This letter is to authorize 70f/\A�EA) G)A�k1Pj e7 a duly licensed Professional Engineer X or Registered Architect to apply for the requirec 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 Pumarr. 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 pro f ions of Article 145 and/or 147 of the Education Law, the Public Heattl: Law, and the PuT/a'm' I"u' h' jury Code. Counte"rgigni P.E., R.A., # Mailing Addressti22juC State A)&A� Vw—Y, Zip �saq Telephone: Very truly yours,. Signed: 02i r (Owner of Pro em) - Mailing. Address: 4q ken4wnocl Dry ve State Zip 0 �� a Telephone: o� d S- 7 to '70 _ Engineers and Architects SEPTIC SUBMISSION FORM TO: i rs DATE: PUTNAM COUNTY HEALTH bEPARTMENT PROJECT: SS TS Ve N:eyjAL - (�--o VA is �cYL a ENCLOSED, PLEASE FIND: COPIES OF THE SSDS PLAN ❑ COPIES OF THE HOUSE PLANS CONSTRUCTION PERMIT APPLICATION (Revised) ❑ WELL PERMIT APPLICATION ❑ HEALTH DEPARTMENT FEE ($150.00) ❑ SHORT EAF ❑ DESIGN DATA FORM ❑ LETTER OF AUTHORIZATION ❑ APPLICATION FOR WASTEWATER TREATMENT (PC -97) ❑ LETTER OF EXPLANATION w9m eto it �CGAACe w COPIES T0: SIGNED: j 4 OLD ROUTE 6, BREWSTER, NEW YORK 10509 - (845) 279 -6789 - Fax (845) 279 -6769 - EMAIL: puteng @bestweb.net BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 . Geneva Road Brewster, New York 10509 LORETTA MOLWARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 NVIC (845) 278 - 6678 Fax (845) 278 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Paul Lynch' Putnam Engineering 4 Old Route 6 Brewster NY 10509 Re: Proposed SSTS: Covais Manor Road, Lot 92 (T) Patterson, TM# 12 -1 -3 Dear Mr. Lynch: November 14, 2000 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. 1. The SSTS as designed (split system) is norpermissible in Putnam County due to a high rate of failures. Please revise accordingly. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:tn Very truly yours, L fi4me . , Robert Morris, P.E. Senior Public Health Engineer UTNAM COUNTY DEPARTMENT OF HEALTH ISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM /PERMIT # (0 ©" Located at M A&(0 (2 P -i-CAD Town or Village Pfd TIEF -S -0/) �,411z1� 1 Subdivision name ,/�f Subd. Lot # Tax Ma p I Block Lot Date Subdivision Approved 1 3 { Renewal Revision ri Owner /Applicant Name A lyt V CZ14Q 5 ` Date of Previous Approval a� Mailing Address 44 e, T—wcoD 7w=1 V cAa mF=L AL,� Zip 10S-1 Amount of Fee Enclosed r®° Building Typj nC }�vc�, Lot Area ,0 o. of Bedrooms Design Flow GPD� Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 125-0 gallon septic tank and 5°76 L, F &L 27 ' 141I D9 Other Requirements: `1' To be constructed by 16 `13 IZ-- ` orT;E v 'l LA60 Address Water Supply: Public Supply From W Address or: _ Private Supply Drilled by •Z Br -t�,� «1ED Address 40 6 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 Pe issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs theretq._ �_ Signed: P.E. b.� R.A. Date 'F��lRi� ft4Uroel -t^M-3 Address la-4- 6L-q- Z.QA AJr C.A-aw►g;:i- KW. License # GCP -744 (0 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 wheqeon idered necessary by the Public Health Director. Any revis' n or alteration of the approved plan requires a new perm; . oved f ischarge of domestic sanitary s e only. r By: 1 Title: � Date: l� White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 ;1 I ij r e a { t // �1`� // ..(.:. /'"' l!.' •.. - - � � II I I ter/ I -jI A� O O pp 11 1�U LlJ v o ro F S N� Uz �w QN �rQO NSQ v mok oxa �v- i= � Via? I UTN4M Epwm NGINEERING,PLLC. Engineers and Planners October 26, 1998 Mr. Robert Morris, P.E. Putnam County Health Department Geneva Road Brewster, NY 10509 RE: Covais Fairview Manor Lot 2 Manor Road Patterson TM #12-1-3 Dear Mr. Morris: Our client is currently looking at the option of merging Fairview Manor lots 2 & 3, and orienting the property lines differently. Lot #3 septic and well locations would not be affected by the proposed lot line adjustment. Enclosed are revised plans for lot 2, which would need a different septic layout plan than the currently approved plans. The Town of Patterson will not entertain revising the lot lines until Putnam County Health Department approves the proposed septic areas. Please feel free to contact this office should you have any questions or comments. Very truly yours, PUTNAM ENGINEERING, PLLC By: KH:I Enclosure (File 980532) 102 GLENEIDA AVENUE, CARMEL, NEW YORK 10512 -PHONE (914)225 - 3060 -FAX (914) 225 -2955 �� A 1rCA�'` I r � �� RECORD OF PHONE CONVERSATION Time: Date: //'3 Person calling: [< ',P4 41y r jV Phone #: l Reason () Inspection: () Deeps and/ eres: .' Scheduled Field Meeting Time'- i C7 Date: Y N Tentative /to be confirmed () ( ) Town: Road /Street: Tax Map #: Comments: � %1 RECORD OF PHONE CONVERSATION Time: 2 4 1 Date: Z-3 z � Person calling: C/ V' Phone #: Reason () Inspection: eep and/ eres: _ Scheduled Field Meeting' Tim Date: Y N Tentative /to be confirmed ( ) ( ) Town:,¢ Road /Street: Tax Map #: Denton, Lake tnes� 292 ('Solomon Lake 12531 S.C. 0 52 84' May, Com Tow 311 18 46 45 "P 63 Akins 311 ......... .... Sta ('EtE AI) TOWN ES 311 12,963 I? ell � yf, F6 I sir ) T R if (Mendel Pond ISd a nes Corners !11� 22 viland plow . N qriwnu m A. 'R P A � 4Li I �_ L IIILOD 'h: A% _ , CMTT -s COQ 5.69 AC_ f0 39 A($Y 4.7 5i ail( 42.57 AC. CAL -g. CAL y � 2.92 ++ tl 4 16.00 AC. CAL. 4 &33 , AC. CAL. C. 43 A ' 42 a AL. \,J 3B X92 9no: 8.92 4C.• 25.25A( CAL. 37 •a,. CAL. x _ ty 11.55 AC. 7.29 48 $ 3 62 Z CAL. .75 O 4.89 AC. W aN y1.M I I " � P D�PIR[i i° J MP a• + 17.97 A( + +d9 i :2 • ax DAP.NF� <EDIPS.E , ,,� Tya 2.26 AC. � e fil 1 .Q4 TfC.- xsxos 52 60 - �+¢ + 9.03 ssse CA 77.20 AC. . ' 5.21 AC 1.86 C. CAL � 6 'i \ '4 1' L' a .K 4C. _ x 9•w 5 ,1 I.9z A 5 � A�v� sseT6Taa 22 .9s + 33 .� ° �y Mass 5T s 17 219 K. [ - '� .84 ACS 59.57 AC. 2; 29 25 X2.60 A[. G .5 • 771 dt IvasT Y rn.vs 8 s C 27.08 AC. 26.78 AC. 3 > 62.60 19 r+ V. e'f ? .AC. \. �• V' X9.57 AG 1 1 �oluD i34 BB 2.68 Ac 1 ;7v79 1 90 O s i 2,77 A afv , 91 12.18 AC. CAL. 5.25 AC CAL a4 /\ `'.92' 93� FOR AS PUFPOSES ONLT REVISIONS SPECIAL DISTRICT INFORMATION NOT TO BE USED FOR CONVEYANCES JAMES W. SEWPLL COMPANY 147 CENTER STREET, OLD TOWN, MAINE 1 N. • e ss..e..n.n eti. re. waa .. arum vlswl vt ...Iwel ssa.n i� -- trM �I�uaN w 9 vr! IK _ rNIAM nmrs9nsula -� 1 T1i Dnttt ;1 y 72 S '. y R 73 M M1 CIj l� y� a q�scE 6 j _ s�\y. 6v9g'AC. �'.0 $ w 20.96 AC. 7 y aN 30.75 AC. CAL. a` ,6.60 AC. n . lxa y Ilasl 4i\ „T.x 74 i F 9231 PC. f y Nsn 3.15 -W� MA1 -T 3. 19 3.20 . LE NO PREL rtnuvs usz m sssea TOWN OF �nxnlm - IxIW 4 6 • olsAnla I�.cAUs wvutm wu ° 12 13 14 d PUTNAM COD' - sua unllmle x n -_- Nm exDCs 311 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Q �� Well Location: Street Address: Town/Village Tax Grid # WNW ROAP ,4TrF_Pej6/V Map /a. Block/ Lot(s)3 Well Owner: Name: CoAts Address: 14 k .AMY 4 t gy- Use of Well: k 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 MLg Sgpm # People Served FPM Est. of Daily Usage UQ al. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling __V— New Supply (new dwelling Deepen Existing Well Detailed Reason ,e"t, E ' ;p lax - , for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yeses_ No Name of subdivision VA / 2 V i 0 W M /-1 NO PI Lot No. �L Water Well Contractor: -rc> B E_ )2EMEp_jy6 e_15j)kddress: Is Public Water Supply available to site? .................................. ............................... Yes No _ Name of Public Water Supply: &-A Town/Village Distance to property from nearest water main: 6 rud e o- 'Th 4-A( / M1 L- E_ Proposed well location & sources of contamination to be r n s e sheet/plan. Date: Applicant Signature: lk 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 w driller certified by Putnam County. ' -1 1A . Date of Issue Permit I g fficj.: J _/ /Y� 97X f1ty,- Date of Expiration 77 'Lyod Title: Permit is Non- Transfefrabl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM ENGINEERING, PLLC 102 Gleneida Avenue Carmel, NY 10512 914 - 225 -3060 Fax: 914- 225 -2955 TO: RLfge=l— 'Mofegi5 a LETTER OF TRANSMITTAL Date: RE: t C)\/o I S MA-llloie &4p LQtoa p47t�,?64AZ (TM) 1s -1-3 We are sending you attached under separate cover, the following items: Shop drawings Prints Specifications Copy of letter Plans Other: No. of Copies Descrintion I.c/• LL 1lY �h, .� ,v�d `I-1 0M 1Nl If nib These are transmitted: _ For approval _ Approved as submitted For your use _ Approved as noted As requested _ Returned for corrections For review /comment _ Resubmit copies for approval Submit _ copies for distribution REMARKS: Copies to: SIGNED: Z16 z If enclosures are not as noted, kindly notify this office. €¢1:h Ud 61 100 86 SODS HJ**1i�JH AN AINn. 03 WVNind OV I333 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEN'T'AL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of C_ ot! A (s Located at UA • ►o' T/V Tax Map # I �)__ Block L Lot -3 Subdivision of j A- y t/ i F \z,/ Subdivision Lot # Filed Map # a--;134 Date Filed f/1-3 f3 Gentlemen: This letter is to authorize'p a, �- tgeCr �L . a duly licensed Professional Engineer �G _ 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 Departmenf= aridjolsign all necessary papers on my behalf in connection with this matter and to super/ sq, t q, - C..onstrucf o�n of said wastewater treatment and/or water supply systems <,;�r in conformity with lie rovisions o'Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putty, mrCounty`S.an`itary Code. ra Countersigned: P.E., R.A., # CIP-744 to Very truly 7//x Signed: - (Owner of Pr pertv) Mailing Address Fu) wij&AF Mailing Addre s: State yet 4 . Zip l OS1 o)— Telephone: +t y 148 6 f 1:00 $6 SOME H 11V311 AN3 ,k,Nnap wvNind 03AI93'11U State - &kw Zip �o Telephone:. �ZZ� ' -;&^70 (qaj Form LA -97 a" �S of , if xt, G PUTNAM COUNTY-DEPARTMENT OF HEALTH � DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner e ®G7? Vt N E Address 1-JA Flo x Pg d o �l 3 Located at (Street) 6415 -H '?A& Z©AD Tax Map - jft Block _ Lot (indicate nearest cross street) Municipality p 4 Drainage Basin BAs; 6mW-g SOIL PERCOLATION TEST DATA Date of Pre-soaking 7 4L3 /5?e Date of Percolation Test 7 b4 f9A_ Hole No: Run No. Time Start - Stop Ela se Time i Iin.) Depth to Water rom Ground Surface (Inches) Start Stop Water Level Dro In Incles Percolation Rate Min/Inch 3 8,3 2 3' - g, 3 911,12 0- 214 56 30 4 5 2 - :s �O'� - ;z3y 3 3 is -1 ;07 aoya -a3' 3 2 4 :08 20' ti 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are ontamea aL eOcn 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 119 CONSTRU�TIQN PERMIT FOR SEWAGE ' PERMIT# P- 60 _S? Located at M ANo ► ... -. _ Town • - .b . Date Subdivision Approved �S-/ 13 Aq a \ 1 Renewal Revision v Owner /Applicant Name A N1 V 60111115 Date of Previous Approval Cl Mailing Address 44 Dn'',Ve - CA;ani1Fj-- 14.ti. JOB? a Zip /05- 1 �- Amount of Fee Enclosed Building Type 6AIc & Lot Area Zql No. of Bedrooms A Design Flow GPDR Fill Section Only Depth Volume 1 PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of z gallon septic tank and � '7 f� l i7 —c�- AB pr;p l .-riz la Aj (- q Other Requirements: To be constructed by lb BE- 'P�F T. Address Water Supply: Public Supply From Address or:-Y-, Private Supply Drilled by 'T Q '?� !E�- Vf,- 1 • 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 ere, . Signed P.E. R.A. Date/A//t,/?P, License # 1) b-74460 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 whencmsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. proved r ischarge of domestic sanitary asew only. By: Title: �lLL Date: to 14y White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 14-164 (2J87) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR 4 Appendix C State Environmental Quality Review SHORT .ENVIRONMENTAL ASSESSMENT FORM _. For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (ro be completed by Applicant.or Project sponsor) 1 P (CANT /SPONSO &f A �N ,l ^i'ej 2. � PRO JE �i NAME. 3. PROJECT LOCATION Municipality County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) -30 �o /0S U /A 60 N-C i-f V4% 2a' 4-0 W a -"o 5. IS PROPOSED ACTION: ew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY:: _cl 0N 7. AMOUNT OF LAN DJ1j FFECTED: Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? `[ryes ❑ No If No, describe briefly 9. WH T IS PRESENT LAND USE IN VICINITY OF PROJECT? esidential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑ Yes .2�No If yes, list agency(s) and permif/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? ❑ Yes ;R-No If yes, list agency name and permitlapproval 12. AS A RESULT PROPOSED ACTION WILL EXISTING PERM171APPROVAL REQUIRE MODIFICATION? 13 Yes 9No I. CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE / 7`i 7 Applicant/sponsor name: Date: Signature: • �.` ` �` r� F r IV U J If the action Is In the Coas Area, and you are a state agency ;.complete the; t,cf 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 B. 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, It 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 brlefly 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 C5. Growth, subsequent development, or related activities Ilkely to be induced -by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1-05? 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 2 Title of Responsible Officer Signature of Preparer (if different from responsible officer) DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Date: .. _ J'AAZM �Ic 6'04 6AAI From: 6�0JV?5 h 2E iii Putnam County Environmental Health Notes/Messages BRUCE R. FOLEY Public Health Director Faxfr %73 —62 44 3 No. Pages 3 (Including cover sheet) T. At #- 3--I - I Z�p 1f, 3© 2C ��T//i/4.M -441 -.1A 4 In the event of transmission/reception difficulties, please contact this office ' s vBVI v/ 5 /OA/ Z-'q f0 �2'- 1ce� fi ep q�� j ✓ � j L 43 8.42 AC. CAL. z f W t20 Y rz 10 4a AC. rr 9 Is o 1.82 AC. C r 5 218 AC. C r 4 1.92 AC. f 3 2.13 AC. i � CO. ry 5 5.69 AC._ 40 CAL � ' I I,?, 2 y AC. I 42 r rrr AL \ \ \ 25.25 ,AC. CAL. Y ,) Y D STRICT r 12 •3290 : :o14r. s J o' SEi �pK 77.20 FOR ASSESSMENT PURPOSES ONLY REVISIONS SPECIAL DISTRICT INFORMATION NOT TO BE US=O FOR CONVEYANCES 1 .`1 .4..4 "� tnn. ... SCNYJL •SCN• CAMACL CEJRRAL SCHOOL DISTRICT — 3720D2 srA 7 t O—Z1a+•21 000w PAWLIND CENIM 5RI00L DISTRICT •.•134001 COC PREPARED 97 . 0u- u...... Ling ... TOn JAMES W. SEWALL COMPANY FIRE FRE PRDIE ION DIS 0.0 No. V1L BCC 147 CENTER STREET. OLD TOWN. MAINE ml 0RI ry 310 S vb c{, l- ofi J" viol: Denton We 5 k 0 4 % 292 X 63 Akins C (Solomon 4 311 m La ra. 311 Brewster' Pond ES 4 12531 1 - - `° ',� �' �� T94 S.C. 311 x 12563 so 52 84 MINIM LA M.." Ulff OW .-.Yn 164 414, May Corn Mendel P 164 Tlown 311 It I a ne Corners I -A (Corned — 1' � �f o viland Illow A o viland Illow BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 : August 25, 1998 Gary Tresch Putnam Engineering 102 Gleneida Avenue Carmel NY 1.0512 RE: Application to Construct a Subsurface Sewage Treatment System at Covais Manor Road, Lot #2 (T) Patterson, TM# 12 -1 -3 Dear Mr. Tresch: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on August 19, 1998 is incomplete. Please be advised that the following information is required before the Department may commence its review. • Construction permit has not been signed. • Well permit has not been signed. • Original Letter of Authorization has not been submitted. • Short EAF has not been signed. This is the second recent submission that has been submitted without the required signatures. Please review the applications prior to submission. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Dept. Of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (914) 278 -6130 ext. 166. RM:tn Ve tr ly yours, /&�4 obert Morris; P. E. Public Health Engineer 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: -j ` � %J Gveus . /0 5-1 ) O -2. Name of project: C:oS( Gi� 5 - S 5V j 3. Location TN: *?A TC E � r V/4 4. Design Professional: iUA-rr-� i�v .�c�. Address: 1 off- OAS a& Ay-e -, 6. Drainage Basin: .E. /5 T- 64 em r- L Oro-, --L 7. Type of Project: _ Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted _ 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... //0 10. Has DEIS been completed and found acceptable by Lead Agency? ............... IV IA 11. Name of Lead Agency W`!i 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... NO 13. If so, have plans been submitted to such authorities? ........ ............. ................... 411A 14. Has preliminary approval been granted by such authorities? Date granted: ILl4 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... 17. Waters index number (surface) ........................................... ............................... /V /A.. 18. Is project located near a public water supply system? ....... ............................... NO 19. If yes, name of water supply Distance to water supply-J::J�IAV J A41LF. 20. Is project site near a public sewage collection or treatment system? ................ NO 21. Name of sewage system Distance to s wage system� oMaP 23L(- 22. Date test holes observed ; �3 4� '�7 p c J �% 23. Name of Health Inspector ��1� �3 �1 24. Project design flow (gallons per day) ................................. ............................... UD 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... /1 C) 26. Has SPDES Application been submitted to local DEC office? ......................... A11A 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands -ID Number ........ ............................................................................... .... �A 29. Is Wetlands Permit required? .............................................. ............................... Has application been made to Town or Local DEC office? ............................... NIA 30. Does project require a DEC Stream Disturbance Permit? �JZ) 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&) O 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? ................................ YesA lqo 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? ............................................................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... No 36. Tax Map ID Number .......................... ............................... Map _l. z- Block I Lot 3 37. Approved plans are to be returned to ..... Applicant �_ 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 210.45 of the Penal Law. SIGNATURES do OFFICL4L TITLES. VUT/ M kM E-'Nct1tge w- a J-L ilk �h u2►-EY Mailing Address: ........... -3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner L OVA 1.5 T D fZ Address L- Located at (Street) MANOR ROAD Tax Map 12– Block /—Lot ? (indicate nearest cross street) Municipality ?A Drainage Basin AtILL �4 SOIL PERCOLATION TEST DATA Date of Pre - soaking. 3�9Q Date of Percolation Test Z (/v - NOTES: 1. Tests to be repeated at same depth until approximately equal percolation at s are ontainetgacn percolation test hole. (i.e. s 1 min for 1 -30 min/inch, :- 2 min for 31 -60 0� e � submitted for review. ESa 'QUFti 2. Depth measurements to be made from top of hole. Form DD -97 De th to Water rom Ground Water Level Percolation Hole No. Run No. Time Start - Stop Ela se Time Min.) Surface (Inches) Start Stop Drop In Inches Rate Min/Inch y - �76Y 2 1.,41- 2 / q °30 ; % 1.2- 4 5 2 3 e 6 4 a: oS - :, -7 6" -,23Y,;4" 5 2 i L 1r7 3 �_, wi l 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation at s are ontainetgacn percolation test hole. (i.e. s 1 min for 1 -30 min/inch, :- 2 min for 31 -60 0� e � submitted for review. ESa 'QUFti 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.51 1.01 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' 9.01 9.51 10.01 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. I I ' 2 HOLE NO. n 5 HOLE NO. Indicate level at which groundwater is encountered Indicate level at which mottling is observed �4ONE_ Indicate level to, 'which water level rises after being encountered Deep hole observations made 'by:. As Fl*�- Et Date 5/1722r Design Professional Name: wt - e- "w, L Address: f �. Am, SiPaWri JA . 1 , I,!" Design Professional's Seal SEOF NEMv, G, �� y��; iG�EAEt � rz 067446 pROFESS�� I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONNIELNTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PEPINIIT STREET LOCATION �' �' NAME OF OWNER REVIEWED BY 1 GR, AS, MB, BH DATE L TAX NIAP 4 Y . N DOCUMENTS PERMIT APPLICATION. PC -I 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 SUBDIVISIQN LEGAL SUBDIVISION SUBDIVISION APPROV KED PERC RATE 1' 4 b FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL ATED N NYC WATERSHED NS SUBMITTED TO DEP EGATED TO PCHD APPROVAL, IF REQ'D P TEST HOLES OBSERVED CS TO BE WITNESSED 1PPROVAL SSDS ADJ. LOTS ;TLANDS (TOWN/DEC PERMIT REQ'D ?) TA ON DDS PLANS & PERMIT SAME E 1969 NEIGHBOR NOTIFICATION ITER B1/ZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMIT(S) REOUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED AY '& SLOPES, CUT YGUTTER/CURTAIN DRAINS TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME,ADDRESS TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE 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. TY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) MOUSE SEWER -1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTENIS Y BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES CERTIFICATION NOTE 7H GAUGES PROFILE & DIMENSIONS N EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. 6fl PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED' ON PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS _15'WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. erpan) 50' TO CATCH BASIN, 35' STORMDRAN, PIPED WATER 10' TO WATER LINE (pits -20) 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MN to CDS= >5 %,10'- 4 0/o,25'- 3%,30' - 20/o,35' -I %,100' - <I% 20 'MN to CD discharge /I00'with 182 cons day discharge SEPTIC TANK 10' FROM FOUNDATION; 50' TO WELL :p WELL DIMENSIONS TO PROPERTY LINE LOCATION OF SERVICE CONNECTION LAP—]LOCATION. OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: _. ..: FQ1MA11[ COD[ITY DErAi111B6m OF• HEALTH �. �,�� DhMes a[ Endro mod Hod& Senloa. Geed. N.Y 15611 esr fe PeerNe Paalilf / 6' CSd1II+iCA18 OF CObIJAI!iC8 Co F� FOR UWAIN D MOSAL STUM Psee�k �.. ^' `Be PQTT &R :. " AOAD Town i.'.1e Sd.MWdm Ns.e FA /RW& t! MAAOR" Selid. [a# " 2 T. ]gyp / 1 .et 3 Dab a[ Ptevioa� Applrov�l �� / 7� g8 Mdft AlAhiu E D. Bc�C `j T6w, Mko_A YWOoD y' my Date- Subdivision Approved Fee Enclosed 0 Amn„nt- �s Type �ji�En/c lot Aran 'L- 9� >es Sectlon Depth valatab• Nobar d Beim �' Dealan F1ov G P D Boo PCHD Nollscstim IsRe ju6A Wb416 M Is oMplated Sspgnle Sewae V.S1apn b Oftg "d 2- 5UGpe. S TeOk.� 5'%� L.. AA PT /c?n/ 7RENGf4- Te be emakecbd by 7o 13H .DE Addiven Wsbr Shy: PdWk SW* Fkan Address oe: X 70 Be- 2&- Addrew 011MRiewd eafsb D /QTR /I3UT /ON �b�� J, )? aB F /LL 23b cze Yns 1 represent that 1 am wholly." completely' responsible for the. design and location of the proposed system(s); 1) that the separate se, - Ai ml stem above descriliid will be'cogstructed as shown on the approved amendment there to and in accordance with the standards, rules a rpu laxions of nam County Department of„ MMltl .' and tent oncompletionthireof a ••Certiffcat'e of Construction Comptlenee° satisfactory to the Commissioner Of Mealthwill be submitted to the * rtment, ands written quarintes will be furnished ten owner, his fill Mors. heirs or assilins.by the, bulkier.- that mid bulldw will Piece in good_ Operating condition any part of said se -s- disposal .system during the iod of two (2) .years Immediately following the date of the Hsu - o" of the appreoa of ten Certificate Of -Construction Compliance of. -the. original sy any repair hereto;2),that the drilled well. described a'hwe win be louted,as shoran on the approved plan'and that mid well Will be Installed -In with the it _ rds, rules and rpu ns "of ten Putnam County Department of .Mseltl+ Date �p > .G/ •:/ 7 �/}},,,,�� Signed 4 P.E. _P.A. .Address: /Y�/tJ( //V �0 2Z license No 0(9064:1 � APPROVED FOR CONSTRUCTIONS This approval expires two years from the N issued unless Construction Of the building has been "undertaken and if revocable for cause or may be anlende0 or modified when Considered necessary isVOner of.Meafth. Any - change or alteration of construction requires i JI permit, ` APwoved for ditpOml of domestk sanitary e, afar /or priva wpply Only. Rev. 7j!j 1088 Deb r 9 T above: dsscribaq,will.be constructed as shown on'the app►ovad'aniendmant tDere'to grid in'ai County Department of FINRIy „and that O completion tne►eof a'TG rttftcate .of. Constri. bpi w ed Dmitt to the Department, and a written guarantee `.will De furnish, the owner,' Platte in good operating Condition any part of 'aid `Iowaye disposal system during. the ante' Of the approval: of the .Certificate of. Construction ,Co npliance,'of the oiiginalsys will oe located as shorwn on the approved pian and that aid well, will be installed ' i accords County Di°lf��m1ent of Heal Dab Stgned Iz i AaArass C.�'�+•�'11n' /-��C.) ia"TL°u � Ric APPROVED FOR CONSTRUCT ION This approval.eiipues two years from the' gate Issuer revocable for cause orrnaY tie amended or nroddred'rrhen confider n” y py a Co ra iuiies a new'- it q[ w ad for dispoal Of domestic's. y :- a, / h i�/87 Date .. l 0.7 /Qr g rG Y -s. dance with the standards, rules a rregu 5wns o .T_ nam on'compliancel satisfactory to the Commissioner of. Hea@Qwill successors. heirs or assigns by thebuiWd, that said builder Will Wd of, two (2) ears immediately,followi g the date of the issu- or any ripe' hereto. 2) that the'Arillid well described above ith the ndards, -rubs -and, regu aT Mons of -the PUtnam' P.E. X R.A. �Srir- iGI.�LY License No 2l ooB lees$, construction ot'the building has.been undertaken anal is isfioner.Or, HaiKh. Any Change OraKeration Of.WnstlYttiOn ter bMy. _ Title 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 #X60-936 WELL LOCATION Street Address /�I+NOA 73c AD Town/Village/City Tax Grid Number 'PA E,- _5o /2,-/ -3 WELL OWNER Name Mailing Address Bew I oew NY -Private O Public USE OF WELL 1 - primary 2- secondary -RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL D PUBLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION M INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, O AMOUNT OF USE YIELD SOUGHTMiN. 5 gpm /# PEOPLE SERVED - FRM' /EST. OF DAILY USAGE GCO&al 13 REPLACE EXISTING SUPPLY O TEST /OBSERVATION Gl ADDITIONAL SUPPLY EW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING NEW WELL TYPE DRILLED DDRIVEN ODUG GRAVEL O OTHER IS WELL SITE SUBJECT TO FLOODING? YES _ X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: FAhS? v/E nt 11-4,08 Lot No. 2 WATER WELL CONTRACTOR: Name E.RMIAleD Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: lV / A-. TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: 47PF,+7-�t LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED O ON SEPARATE SHEET (date) IfsWdf ure) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt -y (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 s manner as not to degrade or otherwise contamina surface or groundwater. Date of Issue• 19 Date of Expiration Permit is Non - Transferrable 3/89 19 %` Permit Issuing Official White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller I represent that 1 am wholly and .completely resDonsible'foi the design and location 'of; the :proposed system(s); .,1) that Ue,'separste sewaye.disposal system above described wilt tie constructed as shown'on,the approved amendment there to-and in accordance with the standards; rules an repu_a :ons-o • . u nam, County Department .of health, -and that onxompletion'thereof i'!Certifitate of Construction Compliance" -sati faetory'to the Commissioner of Healthwill M wbmitted .to the Oepaitment, and: a: written guarantee* will be furnished the owner, his wceesso►s, hei►s,or assigris,by: the builder, that'Said'builder will place in good operating condition._any part of said sewage.disposal system.durinq the.pe►iod of two (2) years Immediately following thedate of the issu- once of .a .,the pproval of the Certificate of Construction Compliance of -the original system or any repairs thereto; 2) that the drilled well described above will be, looted as shown,on'theapprored plan and that sold well will be tnstilletl sin accordance with, the' standards, rules + / Atltlra . _iTTI r _ ..:• a nd ►ego a ons, oY f . he P utnam Coon lyOeWrtmentof.He�lth. RAPID 1 �gnOste 5 P E. R.A. y-/ OT..Baldvin &.Come!iLS, —iC , 6,Rt e.22;BeWSter,W10509. 'License No - 43791 APPROVED FOR CONSTRUCTION This approval expires two.years, from tAe date 'issued unless construction of the building has been - undertaken and 'is revocable for cause or may be amended or'nioditied when con ered,n Sfary by. the tCominissioner of Health.' Any change or alteration of, construction requires a new %Per tt.. APP - d for dispoiahof tlom'sii sa tar ' wa9 r D - �;,.pply ly. Rev. 87 Date�L!� e 13 Title m DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL" N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # WELL LOCATION Street Address Town/Village/City Tax Mooney Hill Road Patterson Grid Number WELL OWNER Name Mailing Address =Private H®mesite Associates, Inc., PO Box185, Thornwood,NY105940Public USE OF WELL 1 - primary 2- secondary Q RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 BUSINESS O FARM O TEST /OBSERVATION O INDUSTRIAL b INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT 5+ gpm /# PEOPLE SERVED 4 -5 /EST. OF DAILY USAGE 800 gal "REASON FOR DRILLING . NEW SUPPLY []PROVIDE ADDITIONAL SUPPLY OREPLACE EXISTING SUPPLY 0DEEPEN EXISTING WELL O TEST /OBSERVATION .DETAILED REASON FOR DRILLING New Residence WELL TYPE ODRILLED DRIVEN ODUG OGRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. 2 WATER WELL CONTRACTOR: Name (To be determined) Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES X NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: Over 1,000' LOCATION SKETCH.& SOURCES OF CONTAMINATION PROVIDED O ON REAR OF THIS APPLICATION ®ON EPARATE-S ET (See SSDS Plan) (date) PERMIT '(signature) TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Com letion Report on a form pro ided y t Putnam o n Health Departmen / Date of Issue: �7i t 19 mi Date of Expiration: 19 Issui ficia Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector 2/87 Pink Copy: Owner Orange copy: Well Driller .. PUMM OOURI'Y . DEPARR41 T . CF FiMTH DIVISION OF EWIPUIflWM HEALTH SEWICES DFSIGN DATA SHEET- S(JBSUFAICE SEWAGE ' DISPOSAL SYSTEM'.. FILE W. C finer' iAcrCS5 Address F'O. 130>. lay �iaow�awooU „^�Y T Located at .(Street) r—Att!o9— Sec: 'I Block I Lot 1`1 (1tu3.Lcate nearest cross street) Municipality- rTo,_1 •Watershed• Co,�,✓ SOIL PEROQLATICN TEST DATA ,R@WJIRED' TO EM SUMMIT= WITH APPLICATICVS Date of Pipe-Soaking 8• yZ : ee • Date of Percolation Test 8 z'3 Sa HOLE N IRM CLCCK TIME PEROOLATION PE b00LATI0N .. Run Elapse Depth to Water From Water. level ; No. ''Time Ground Surface In Inches Soil Rate Start Stop Min.. 'Start St6v ' Drop In Min/In Drop Inches Inches Inches • 2-1 3 ►y 9:2-1 •4S 24 2l 3 15 3 4 10:i5- 11103 _t6 2q 2-1 3 I(n 511 ".o3 - 1.8,10- 8,08 98 ZIA 21 1(0 4, o .q p .. 1 1. g ' 51. 24 2-1 3 5 - 2 4 ' ci i Tests to be repeated' at same depth until. ,approximately equal soil. rates • _ ! _ _ _ a i. .........1 �1 -i..�. 4 e�i• i,�� a n� i rind 4•n ib c1i}Tfll f t'iy TE�;T PIT DATA RMJIPM TO' BE 'SUMM= WITS APPLICATION DESCRIPTION OF SOUS ELKWN E= IN TEST HALES DEPTK HOLE • NO. HOLE NO. ' -Z HC LE NO. G.L. ! .•. 3' 4' 5. 61 •71 of 9' ' 10' 12.' 13' 141 INDICATE LEVEL AT WHICH GP=NDWATIM IS EN=JN1M= _ ' 1.1 a n! a INDICATE LEVEL TO WHICH. WATER LEVEL RISE$ AFTER BEING ENUJUNTEItID ,j /A DEEP' HOLE OBS&MTIONS MADE BY: LIATE! DESIGN Soil Rate Used • (o - 20 Mirv/1" Drop; 'S. D.. Usable Area •Provided• No . of Bedroams q Septic Tank . Capacity Z sa gals . Type ,moo -r 'Absorption Area Prove ded By 5-1 5 L.F. x 24" Miidth - trench other I R. O. i! ` 7.30 l t/; Name Slgnatd •!' Address z SEAL �..,•.. I�r ,r„ i �if��, NO 26��a nE�� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date` Re: Property of DC /Pare.,. �,JC. Located at n.�cx„� ��r I-1 i `� r'�.s ►��0 2 �,o (T). Section VS 1 Block 1 Lot t9 Subdivision of �s��RJI! r'1A,.iocZ Subdv. Lot # Z,. Filed Map.# Date Gentlemen: This letter is to authorize a duly,licensed professional engineer or registered architect (Indioate , to apply for a Construction Permit for a separate sewage system, to serve the-above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the-construction-of said. system or systems in conformity with the provisions of Article 145 or 147, Education Law, tart' Code. J Countersigned P.E. , R:A. , 0 the Public Health Law, and the Putnam County Sani- L- .�o.SN I �S�G� -TE 5t' �'• C • . Address QprJT� SZ C�M�J..�� 1JY Telephone Very truly - yours, Signed .Owner of Property Address 77tiaRNw0v � /U. n 9Li Town 5 2 ' ?f5e� Telephone Putnam County Department of Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE aVNER APPLICATION FOR PERT7IT APPL'ICA'TION SUBMITTED TO PUTNAM COUNTY llbt LTH DEPARTMtNT TO:.Commissioner of Health - In the matter of application for I, - - 1'V - e /-I_,om rre - ems - - - — - - - --- - -`' represent that I am an officer or employee of the.corporation and am authorized to act for _ — _ -- 1lMCSi ?C�50 «uS, iUl. - - - - - - - - - (name of corporation) having offices at _ /D— /loci wCw 6�0�. ��Q - Whose officers are ------------------ --- - - - - - -- President �%�v7iv�2 % • / iv��'c�rc cr - %4 /1oCetoft4aj/Lo(_ l�io►�w'c�=c'�c7c�y - --- - - -- - - - -= - -- - TName and Address) rcctcy -�3 _Plevr -_�1 �1.�,C_i�ve :c0osc�lti�:5/ _ _ (ivan�C aril Hddrzss) secretary --- ____ -_ _ __ (Name and Ad- dress) _ - - .Treasurer __ _ _ ___ --- _____ - - - - - - - (Name and Address) and that I;.am and will be individually responsible for any or all octs of 'the corpo- ration with respect to the approval requested and all siii�- sequent acts relating thereto. Sworn. to efore me this day ' ' Signed of • ? 19� Title �%ncS�rJ C��c/ L - NoTarv/ Hibiic KELLY H. WILSON NOTARY PUBLIC486EW ORK STATE QUALIFIED COMMISS ON EXPIRESS7 COUNTY 2119: Corporate Seal APPENDIX L PUTNAM COURI'Y DEPARTMENT OF HEALTH DIVISION OF ENVIROMWEAL HEALTH SERVICES DA'I'S: k RE: Property ofs¢/ I! /{,t�— ,t/�/J,c�pe-- z}/t�V1 —,�% NfG. I�o,� Es ► rE /�ss�c . Located at (T) Trh SLVI f Section ^�_ Block �_ Lot /9 Subdivision of �C'A/AZef� /VMAlOr- Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize X&I" y i 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 Ccanmissioner 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 thel provisions of Article 145 or 147, Education Law, the Public Health Law, and the Put= county Sanitary Code. Countersigned: Adriss �E ids a Pc ur' k> /4, .219- -///5 Te1.e ftone Very truly yours, Signed: ner of Property Address Telephone 19 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS (Name of Owner) COMMENTS LF trench provided required Z 60 ft. max./ Parellel toA REVIEW SHEET - CONSTRUCTION PERMIT 19 (Street Location) YES NO DOCLMa iSN�T Permit Application Corporate Resolution - WRPOMI fill notes r5MM ft. tr DATE REVIEWED: �) L BY: gineers Authorization !sign Data Sheet (DDS) Deep Hole Log Consistent Perc Results Perc Hole Depth SUBDIVISION Perc fie) (3) Fill / cd House Plans - Two sets Well ipermit; PWS letter Variance Request GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town /DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile - Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Purnp pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder rate) Design Data: perc and deep results Two -Foot Contours Existing & Proposed Driveway & Slopes Cut Footing/Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. size If Pwped Pit & D Box Shown & Detailed House - No. of Bedrooms Wells & SSDS's Win 200 ft. of Proposed Systems Property Metes & Bounds House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 1'0; Type pipe No Bends; Max. Bends 45° w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 35'to catch basin,stormdrain,piped watercourse 10' to Water Line (pits -201) 50' intermittent drainage course Septic Tanks 10' from Foundation; 50' to well 15' Well to PL 9 BALDWIN & CORNELIUS, P.C. Putnam Business Park RD 6 Rte. 22 BREWSTER, NEW YORK 10509 (924) 279-7115 TO P(I In a *i &. ,, �j Ike / ier I)er -t- //0 Old P-evk 5-1 Y, C -,, ca r rk-Le_ i /V y 10 1 .2- WE ARE SENDING YOU OJEUIREIM VF IMUSOMDUUM DATE 12-1 $7 JOB NO. ATTENTION RE: Ma-?of- P3' -3 161mv /C( o-7 5 + 4-61 ❑ Attached ❑ Under separate cover via the following items: q7 P I -.2 3 ❑ Shop drawings ❑ Prints ❑-ns 0alriples ❑ Specifications ❑ Copy of letter ❑ Change order 55 Q5 5 V b;41 (,;'S /011 COPIES DATE NO. DESCRIPTION -3 161mv /C( o-7 5 + 4-61 AC g2 ho in r'k4 C4 _rV, s /6,0 (V -P_, I I R° l/ co 4-/0" Ce "eo ,a lCe50 jL/ /a e THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ For your use ❑ As requested ❑ For review and comment ❑ FOR BIDS DUE REMARKS ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections 19 ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return -corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: First Floor FA^ILY Room I(o'-S•R 2J'-4'. WOOD DECK L-I BRARY 13REAKFA5T KITCHEN its O - /O1C 11' -v I4' x 13' 00 0 0 LIVING RDO FOYFK p1N1NGRom tJY GARAGE 2I' -2x 21' U DEPARTMENT OF HEALTH MOUSE PLANS APPF OVER FOR _ BE ROOM COUNT OP LYa =,} Second Floor t All room dimensions are approximate. Developer reserves the right to substitute materials of similar quality without notice. Fairview Manor • Money Hill Rd., RR 2, Box 348A • Patterson • N.Y. • 12563 -914. 878-4480 Exclusive Sales Agent: Resource Planning Concepts, Ltd. VJ AIDUTTMIX B (--MW r-r DER=E11T OF EIF-a-L-.F- - Dr JISICN OF ENV-IRCjNY_ENMrA_L D. U) (IRE N-A-= SUPPIZ & Z-UE-C:MFAC:E =V_A_=-, DI�SffMAL SYSTEMS RET_r;7r9 Cr_jNS=-=ICN PERMIT DA=- BY; Jt— --- of Cwnsr) — -------- C -2 1! E � Ti <_ 1--NO I DCC'2,A-T;-'\71'-Q Pe- -zit Appl ca t n I C--=rate Rlesclutticn :::�F-Pia'ris - Three F-hainear-s A_�_thcrI=_c_iCZII D--sL--n Data Si-'e✓ (7• C;s Ee Hole Lca ccr-c-stant Perc R=_SfLt_= Per= Hole Deoth SaDIii-- SICN. 31 F i i C_ Plans - Two Well E:ar-jut; V&:" L.Encs =-- 1 a A L. La=al. Sui-,c_iv-iSica Ex-_=corcval SS= We---', and (Tc-wn/DEC Pe- Ea-tz-1 C-,i ME Plans & &F.'raca systla-1 Plan F 1' 1 _1 P _- o f --' I e_ & D Limz r S i c n S VC- D cr J .-M-tic Tt-qk S- well cer=;-I Serv`ce L=ne iz c%,-_=:: C_-nstrLy&__ cashin associates, p.c. design professionals route 52 Carmel, new york 10512 Q / (914) 225 -8088 / TO i `�Tq*_ __1 un/T1— _`rev -r. of /7oL --rA ��E� —• fJ`f� to512 LETTER OF TRANSMITTAL DATE �j•1 •8 JOB. NO. ATTENTION RE: fi �tE I� -�a.WR L.oT' 2 9' 9 9g 4::�_ o T cJC'7- oA/ CQ M 1 T WE ARE SENDINGYOU IKAttached ❑ Under separate cover via ❑ Shop drawings X Prints ❑ Copy of letter ❑ Change order Plans the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION I 9' 9 9g 4::�_ o T cJC'7- oA/ CQ M 1 T 5 • 14 •8$ . EtL �B2 -NAT 4'IZ $8 A -r%otJ T'tt�?_ I 3 ' 1 ` 88 Pb2 �cttr �! tT �cs� Carl a T �• Zq . � � K X02 Svc, a© THESE ARE TRANSMITTED as checked below: 'I�Forapproval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ Folyour use ❑ Approved as noted ❑ Submit copies for distribution ❑ Asrequested ❑ Returned for corrections ❑ Return corrected prints ❑ FQ review and cornment Cl ❑ FER BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS��•SF 1Z�yl,/ b-i Your mss. -1ESr �oi�dEA/i�./G� "J COPY T©• .r SIGNED: If enclosures are not as noted, kindly notify us at once. DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT # ` ;WELL LOCATION Street Address P-osD Town/Village/City Tax Grid Number +WELL OWNER Name e z so Mailing Address s i'. o, ox 1gg o 10,Private O Publ is ',USE OF WELL primary 2- secondary ($RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL ❑PUBLIC SUPPLY QAIR /COND /HEAT PUMP O FARM 0 TEST /OBSERVATION O INSTITUTIONAL Q STAND -BY QABANDONED ❑ OTHER (specify. Q ;AMOUNT OF USE YIELD SOUGHT S gpm /# PEOPLE SERVED I yr^m /EST. OF DAILY USAGE go gal REASON FOR DRILLING RNEW SUPPLY ❑PROVIDE ADDITIONAL SUPPLY O REPLACE EXISTING SUPPLY 0 DEEPEN EXISTING WELL ❑TEST /OBSERVATION -DETAILED v REASON FOR DRILLING thi a[plicant shall: i. Pump the well until the water is clear. 1 Y. Disinfect the well in accordance with the requirements of the Putnam WELL TYPE MDRILLED 13DRIVEN ODUG Submit a Well Completion Report on a ®GRAVEL .t Health Department,f � ®OTHER Da-,e (,f Issue: 19 6 (/ IS WELL SITE SUBJECT TO FLOODING? YES >S NO lr WELL 15 LUC:ATra IN A KEALTY SUBDIVISION, NAME OF SUBDIVISION: 1= .��Q��r M..►�e� Lot No. Z WATER WELL CONTRACTOR: Name _T •a:lff Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: }� �,� TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER � 4,.r.aw ti I`4W LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON REAR OF THIS APPLICATION 0 A (date) PERMIT fyoF "'.2601) F`°,� 611 rrr� TO CONSTRUCT A WATER WELL This Fermit to construct one water well as set forth above is granted under the t pr)visions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and prwi�ed that within thirty (30) days of the completion of water well construction, thi a[plicant shall: i. Pump the well until the water is clear. 1 Y. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. Submit a Well Completion Report on a form provi46d by he utnam County .t Health Department,f � Da-,e (,f Issue: 19 6 (/ - -- Dare (.f Expiration: � 19 mit ssuing i a Permit is Non - Transferrable White copy: H. D. File Yellow copy: Building Inspector i 2 / % Pink Copy: Owner n,-an.rc r.,•,rvc.-. Te7e1 l n,-; l 1 T14i-- t7l 19 ec 14 43 10 N I p- -Tcz> W f-4 C>,F co wtx ' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT- CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Cammissioner of Health In the matter of application for: ... - N represent that I am an officer or employee of the corporation and am authorized to act for Homesite Associates, Inc. (Name of Corporation) - having offices at P.O. Box 185 Thornwood, New York 10594 Whose officers are: President: Daniel A. Amicucci, P.O. Box 185, Thornwood, NY 10594 C (Name and address) . Vice- President: Anthony J. Amicucci,•P.O. Box 185, Thornwood, NY 10594 (Name and address) Secretary: - (Name and address) Treasurer: (Name and address) and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subs ent acts relating thereto. ` Sworn to before we this Joy /day Signed: Of ° �o �� 19 0 Title: 5rLc Ads BETTY L. ESPOSITO Notary Public, Sla;e of New York No. QuaWled i;i r:^,r:;;r; County COm11:1c52c;: &Pira_ April 30, 19.,• Seal 20 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: Hanor Ripad Town/Village: Patterson Tax Grid # Map i:- Block / Lot(s) j Well Owner: Name: Address: Beno Construction Cor . PO Box 404, Patterson, NY 12563 Use of Well: 1- primary - secondary - x 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 xx Open hole in bedrock _ Other Casing Details Total length 41 ft. Length below grade 40 ft. Diameter 6 in. Weight per foot ____LZlb /ft. Materials: x Steel _ Plastic _ Other Joints: _ Welded x Threaded _ Other Seal: —Cement grout x— Bentonite Other Drive shoe: x 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 x Compressed Air Hours 6 Yield 15 gpm Depth Data Measure from land surface - static (specify ft) 40 . During yield test(ft) 15 Depth of completed well in feet 625 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 11 Fill and blasted rock. 11 42 Gray rani te. 42 625 i4edi un to hard granite. If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 540 1/2 GPii Pump Type 6W41) Capacity 910kj4,oAJ Depth A00 Model -21/ `q Voltage o220 HP i.O Tank Type&100cr Volume 114 Date Well Completed 8/12/02 Putnam County Certification No. Date of Report 8/2-1/02 2 :Well Drille ature) - NOTE: Exact location of well with distances to at least two permanent landmarks to be pfovided on a separate sheet/plan. Well Driller's Nam • rill i 1 ri c. Signature: Address:75 Putnam Av. , Brewster NY 10509 Date: / ► 7 /102- White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97