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HomeMy WebLinkAbout0274DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 13. -1 -3.2 BOX 4 d' JUN -24 -2003 08:37 FROM:INSITE ENGINEERING 845225971: BRUCE R. FOLEY 'ublic Health Director ATTENTION: DEPARTMENT 1 Geneva Brewster, New OF HEALTH Road York 10509 TO:2787921 P: 1/1 LORETI'A MOLINARI RN., M.S.N. Assn late Public Health Director Director of Potlent Servicec ❑ ADAM STIEBELINC XGENE REED All information below must be hu y completed prior to any scheduling. ENGINEER OR FIRM: DATE: d v��' -013 PHONE 9: 7- - 145-14, `( V REASON: DEEPS: ` PERCS: �K PUMP TEST: ❑ ROAD /STREET:. e* Lk T OWN. FA1I Soni TAX MAIM ty -v-%, era 00i - a te..J pc.4T- i 14AWA*fvzw Fw f70E SUBDIVISION: &-,Txr7r of 6w'e�agw ,Iu.ew i1foM--4vffgft OWNER:- Vl,-Jr.ew'f "I vru. ? 3 —, 1-- 3. Z. LOTM 2- YES NO ❑ X Proposed SSTS within the drainage basin of West Brflnch or Boyds Corner Reservoirs. 0 X Proposed SSTS within 500 feet of it reservoir, reservoir stem or control take. t� Proposed SSTS within 200 feet of a watercourse or it DEC wetland. ❑ p>; Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. 0 Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yq to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the aole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. VOR COUNTY USE ONLY j DATE: Z$ 3,f eo TIME; 7/ 9 9 to / A i 00 FELD'I' ST) 1 Yale Corner Kent Hills Es• g�E fake Carmel 3 uAfcp 11 1 -.g s �.s A i 1 1 1 �lm �WirTi• a � 4. � 6�v.ilY' ��Y•'tv. i 1 1 1 FIM ki .r 4 �R ., /611 �lm �WirTi• FIM ki .r 4 �R ., /611 0 1� loixza NAIL L.CAL 2.27 1.88 $i f \� "a \eA 41 5 40 ° � I 18e b' \� I6o sRS. I�. CzioAL Ie0.20 \63'+b / q 42 Y, 1R • 1Z�3 d 35`> r ' 2.67 AC. 24 1.60AC. �♦ • y ✓� ', uu 9 `,� ss I>r Ve • 8 ♦ 2.16 CAL ses. ` 51a.9e n 4, 44 543 3es.o9 �p r 4 � AC.CAL 2yz21, C. 1.25 AG 1�-' ' �.2 n 8 'V 36 •� °; 3 r�' g 45 7 • 1.65 41 40 e39 p 138\ .8 46 1.46 AC. 20° « a g 8 9 86 AC. •6 . v 176 . ° � 334 s'• . �,. a °,o,+ q . ».s ; LSO 1.7 AG c ° : • • E I ... co + c9 47, 4 ✓$ r 14 � 9a. , 5.121AC.CAL. 3.99 AC• CA 7, - 44 + AI N ' ♦.IY A f1 �4� 3.4pG CAL C ic. « l ;1' ., e9 ♦ 32 •1 1 eot'12 Nb a a x41 @ • 37 ei9te 8 Be �r +e 'Y 120 �1,9i AC CAL a _ 1.60 X20 3.64 AC. CAL S58AC Lse „t. 8 °31 ., 4 nyy K 51 � 1.9 AC.CAL e4& , � �� 35 $ N3.3 AC. CAL. �� 8 t03 1.12 164 AG �� ''r, 4.09 AC. it j 13.83 AC. CAL. 8 0 2IBAC.. m `8 B1 \.se ., �wr 3 16 AC. 4P 295 #_ -� 34 ,A A t ��, 3.59 AC CA r ♦N BT qR. �� •ky 5'ni€ -211 ACCAL!m \go 5.01 AC, 86 IJ9AC. �,\ •. i " ; . 21 nl r eta, 4os.00 s w • /i' 8 65.0.4 1.93 AG lino =222 AGCAL a4o 61D99 �♦ 28 U4AC. 1.25 AC. q w CA rl, ;Nl : z: s 32 � . 4�C. CA � •�i o ' e€ ez e4 1.27 AC cP a ,P �� . • 8 7-16 AC.CAL r• 5 52 ,f „ 103 A , 5 29 \ D• : r .' 1 3.8 AC CAL. 6s 3.50 AC. x 45 X91 •tip '�T,1,�. e _ 300. tJ /T,fgAGG " p9 6 4.67 AC. CAL. AC. AC. 1.01 l23 CA �o� o z 7 �•' '� ., rr t t� ' N LBT AC Y W. .n• 3D \li i0p °� 54 % 1.4 • • \."�/ r?' 661.76 AC.+ w •^, • I ,emu ♦`ra 1.26!• 13 3.36 AC 5.0 ?IC. /4l 53 '♦ 92 �� „ 7e AC. 2.06 AC. e J 7s Ise 75 300.00 `Z.'i 'x•54 26.75 AC. i.41 AC. q \s sxlx6 y'�a r 3aze �� /• • ' 6.21 AC. CAL. $ 96 Ac. 1.71 AC c •ss e 50 r. AC. I 409 }6 e14.3G 6' 6 ° /¢d 5 pOf 2.45 AC 55 A�. 29o.6s F 1lt yD . �P' •. BB ID ' f`'Ib +S4 N 'T • 5.24 AC • 1 $' • 1.44 A 5.59 Ac. eo1.g+ -d 57 \ \0� $ 23 1 ♦ e. al 6rca9 4.69 AC. %I &A t IszSO 26 1`s .c 27.52 AC/ 3J �4+` °\ 25. 1.44 ACA' °'.Iw•c: 4.95 AC. 59 X A • p ' 670.08 r;CA 86 A R. elZ�S a ' 2 / 57 `4 5.35 AC. CAL. 515.24612 o ' 58Dti 6.49 AC. x.2.0 At O 8 • syl to 2pe °ggg� 61.1 f o Y..�• 163A 4 \8:63 +IPf 1.5554ci 59 / ( w 7.47 AC. 194.1 6i • �, / 7T. •OMN 1 u 5 / 1 1 21 x I� 21.97 AC. 103.86 AC. CAL 565.12 6hJ a 2.7 AC. 22.2 - / 20.89A C.� .. 20 P N 60 p �4�9Pff j 4.73 AC. `N 14 61 426.79 �ocaa Ie.99 •I y •.� %ice ^ \ ` +'f, ` "''1fW -�..� . , 62 055.00 4DZ35 I 506.62 19.86 AC. e + 19 1 206 AC. � I 1 � ettep�i PT . , w zlT.ox : � i'yp`rm1EE 10 • ♦f ✓� 16.64 AC. °1I ° 9 AC: 18.92 ro♦ xi 1.00 AC e % \ M,yy ✓�a, ACA s 16 I a •06 ♦ Id II 5.71 Al 4 L s k sk ° 1.73 A g 43 C8 " ik�kStxl `cP r po ta4a l !.�F Iggfi \83.92 AC. CAL. \ 454.0 r,♦ ✓, 15 63 f 07 A ItirL IN ,e+„ :_, l 690.96 ° 3N•p1 � \ :?`cif.„ 3a,1 W 1 1.10 AC. CAL. 14 ' 3.2 4 I.B AC. 64 ,at3i1 , . C85 Ac. 13 �A 1sT \ 10.58 AC. CAL g 1.59 AC. 65 a 1 W tf �` "•�5�' 9.78 AC. Izel.u01' f eL{gi I9.66 AC. ` AC. 2.35,x: .\ 509.42 . 8.82 AC. CAL. J. ?6 67 $° 7 1.77,. g I 412 140 ` i 4.57 AC. CAL t.se 5 ,Q.4 .& p�4 8 • 2T A A : a i } 4f s o ° • �' 393. 1 638.35 \Vi 8 2-1 At \ l 1� t►�iv4 C 121.7AC. 44 n ( i' >< \ 6t39 AC. _Q ♦¢,3�lA .4;•2.53' AL SOI Y 435.63 °y . 23• C +�°J 7D • 1� 7 ; •^€ ? °fi - r- - - - - -- -- - - - - -- R P/0 23 1 9 P/0 23-1 -10 _ $Qi as Ac�"`b j "' -- 3.3a A_ a 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 (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Date: a2 /®'2-; To: GQ 055,A Fax #: 7 7 3 — ®3 5 From: Gene D. Reed Putnam County Department of Health /Foryour information For your review As discussed No. Pages 7 (Including cover sheet) _ Please respond Notes/Messages pE ' 'D EC�� Attached as requested Please call W. WrA W, A ' a "AAIks / In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. d SENDING CONFIRMATION DATE . JUN -27 -2003 FRI 08:55 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 919147730355 PAGES : 4/4 START TIME : JUN -27 08:52 ELAPSED TIME : 03'07" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... d BRUCE R FOLEY i.ORETTA MOLINARI RN., M.S.N. NUk %.),h D4 .,O, 0 M..bk Pr611. M.Ph D6+..9.r Dh-,l 4, Pomm 8b0en DEPARTWNT OF HEALTH 1 G-eva Road .Bnemw. New York 10509 &nln.eeaul K.12, (6/5)278.6130 r.rt(945)279.7921 nor.bq ae7•kr. (949)279.6554 WIC (945)274 -6679 Ihs(94S)174.6015 pry Ulnvmlbn (945)278.6014 rrorb9d (9451270 -daM 8.5(945)279 -6N9 Date: ll A-7 //,,,, 'GAX /"()VT!R QFth`ET 1 To: �ssx (L z f _ F. a: 7 7 3 —,0'3 5 No. Pages )f (Including cover sheet) From: t:enrD -1tnd Putnam County Department of Health For your information am For rospond For your review r Attached as requested As discussed Please Call Notea/Messaxes In the event of transmisalen/reception difficulties, please contact this office at (945) 278.6130 ext. 2261. AM COUNTY DEPARTMENT OF HEALTH N OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM a PCHD CONSTRUCTION PERMIT # Q- ( ?' o a Located at '1 3D Cashman Rood. own r Village 'PtL+ -e rsnrn Owner /Applicant Name �i1n1 Pi1-i- Lf_ i l7Q i `. Tax Map 13 Block Lot Formerly N14 Subdivision Name F.,�Jr ke o{ e 6 1.64A-� A Im Mvii{��,1, er�- Subd. Lot # ).- Mailing Address R, t). -RQX -71,o Ctirme) Al Y Zip Date Construction Permit Issued by PCHD 4mkV Separate Sewerage System built by Mon 9r Address Consisting of 15vo Gallon Septic Tank and 5C)c (., F (, �- 7' i., ; ,,d e a65 n r0-M r n Other Requirements: _ 'c,'10` a eL Water Supply: Public Supply From Address or: Private Supply Drilled by P C p3 c Xs ��;� S, 'Tn Address %� na,,, q �e . fv ; s t e n N `� Build— ingType 'J�F_5; dpiiiid Has erosion control been completed? NU Number of Bedrooms S Has garbage grinder been installed? Al Q 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: % '3 Certified by P.E. _ CY R.A. .: 5i'�e Orttfnt-e -nn $Surve- -qin 4, net ( sign Prof ss' nal)LCndse'.�/�c A�clu +ei�urt, ��• Address 3 r� ;,r� +-� P - r �2 rme_i . r� License # 61-7 1 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 ct to m dification or change when, in the judgment of the Public Health Director, such revocation, m - ifi ation o ange is necessary. B Title: Date: 6 Y• White copy - HD File•, Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 130 Cushman Road Town/Village: Patterson Tax Grid # Map j Block Lot(s) 3 Well Owner: Name: Address: Helen & Vincent Leibell, P.O. Box 760, Carmel, NY 10512 Use of Well: 1- primary 2- secondary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment X Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing X Open hole in bedrock Other Casing Details Total length 32 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb /ft. Materials: _X_ Steel Plastic Other Joints: Welded X Threaded Other Seal: X Cement grout _ Bentonite Other Drive shoe: X Yes No. Liner: Yes _X_ No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yief&KVest _ Bailed X Pumped Compressed Air Hours 6 Yield _ja gpm Depth Data Measure from land surface- static (specify ft) 28' During yield test(ft) 120' Depth of completed well in feet 705' 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 Drillincr in If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Sub Capacity 10apm Depth 660' Model lOG5 15 Voltage 230 HP 1.5 Tank Type WX302 Volume 86 allon Date Well Completed 10 /11 /0 Putnam County Certification No. 006 Date of Report 12/03/04 W r (sigrAure) Adam 1. Bea NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's Na Signature: am L. Beal Address: 4 Pufrinm Ave., Brewster, NY Date: 12/03/()4 10509 White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 Jun 01 05 08:43a TOWN OF PRTTERSO MAY -31 -2005 17:42 FROM:INSITE ENGINEERING 8452259717 BRUCE R VOLEY Public Health Dirperor �P C F � y0 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 845 - 878 -2019 p.2 TO:8782019 P:2/2 LORETTA MOLINAM. RN., M.S.N. At$Nlatc Public Madih Director Director of Patient Sorvitet , Envlrontoeetal Health (914)279-6130 FxKQ14) 271-Ml Mures Serriw C9 14) 278 - 6551 WIC (914) 278 - 6671 Fox (914) 271.6085 Early Intervention (914)278 -6014 Freaalkoal (914)271.6012 Fax(914)278 -6641 OWnRSNAME: j.j1(1S jejn+ Le.b e l j TAX MAP NUMBER: E911 ADDRESS: O el 1 ain Din Drt M TOWN:r,_r�n.. AUTHORIZED TOWN OFFZC1Ai,: '(Signature) r DA'Z'E: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above forum is completed, i.e., a legal E911 address is assip.e4 by an authorized town official: This form is to be subm3itted with the application for a Certificate of Construction Compliance. (E 911YF,.RiRN!) e LORETTA . MOLINARI- R.N., M.S.N. Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 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 (84 5*) 278 - 6648 August 14, 2003 Insite Engineering & Survey 3 Garrett Place Carmel, NY 10512 R: ° bell Crushman Road. Lot #2 (T) Patterson, TM# 13 -1 -3.2 Reservoir Basin Dear Sir: ROBERT J. BONDI County Executive The. Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on August 11, 2003 is complete. The Department will notify you by September 2, 2003 of its determination. The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ® Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 -(d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a prof ect, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of U r Letter to: Insite Engineering & Survey - August 14, 2003 -2- Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. VZ truly yours, Robert Morris, PE RM:tn Senior Public Health Engineer b a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address OL SFlal," 72e)4V Located at (Street) ���- i / Tax Map � Block �_ Lot 3 d (indicate nearest cross street) Municipality. P,¢ -rrgA75,aAJ Watershed "57- J M yC_H SOIL PERCOLATION TEST DATA Date of Pre - soaking ZA 0 :3 Date of Percolation Test 7- 2- 9 o 3 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 3 �'�Z- ��3 /� — 3. 7. 4 5 2 g; 3 y �- 9i � � 16 / •' 2 75 3 3 �1 •' GiG / s '' 4 5 1. 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. I HOLE NO. r6%o Indicate level at which groundwater is encountered A j r u Indicate level at which mottling is observed A o /jg- Indicate level to which water level rises after being encountered Deep hole observations made by: Date _7 L;t 0 Design Professional Name: Address: Signature: Design Professional's Seal 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCLAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project PXTTI TZS ©N County Site Location G 4/5WAIAW I—CA 12 Building construction begun Aj 0 Extent �- Is property within NYC Watershed ? ................. 21 Yes 0 No SECTION B. TOPOGRAPHY (Please check all appropri to boxes) 1. � Hilly F7 Rolling � Steep slope Gentle slope F--J Flat 2. 0 Evidence of wetlands 17 Low area subject to flooding F7 Drainage ditches a Rock outcrops 3. Property lines or corners evident ....... :.............................................. 4. Do water courses exist on or adjoin the property? .....6 .....:.............. 5. Will these affect the design of the sewage system facilities ?............ 6. Do watershed regulations apply in this development ? ....................... 7 Will extensive grading be necessary? ................. ............................... 8. Will extensive fill be necessary for SSTS? ......... ............................... 9. Do filled areas exist within the SSTS area ?..... If yes, what is the condition of the fill? SECTION C. SOIL OBSE VATIONS 10. Appearance of soil: Sand F-1 Gravel Bodies of water a Yes [?J"No r7 No Yes No Yes a No Q Yes U o Yes aYes 4 No Loam Clay Hardpan Mixture 11. Observed from: Q Borings F--J Bank cut Backhoe excavations 12. Soil borings /excavations observed by ��r �� 917 G' , D H, on Z2 13. Depth to groundwater eVo ji 6� on 14. Depth to mottling _ yo kj U on 15. Are test holes representative of primary & reserve areas ...... ............................... 16. Soil percolation tests made by .fit r &�A/C. on 17. Soil percolation tests witnessed by �, 7Z G n on SECTION D (on back) J Form ST -1 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes 19. Will groundwater or surface drainage require.special consideration? ..................... Yes dN 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... Yes o SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... F--J Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist ?..A .&.'f-. ! f. .1.....' .- R4:..f........... Yes a No 23. Additional comments 24. Site observer /inspector and title �' 2 E E r,�� 25. Date(s) of observation(s)inspection(s) TEST PIT PROFILES 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. 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 7 A PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .APPLICATION TO CONSTRUCT A WATER WELL ^ please print or type PCHD Permit # 3� Well Location: Street Address: Town/Village Tax Grid # Gu hm N Ropc) PAi ER500 Map l3 Block 1, Lot(s) Well Owner: Name: Address: Vine-e(4 LEibell P.0 G Use of Well: -g Public Supply Air /Cond/Heat Pump Irrigation 1 rimary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought �_ gpm #People Served �_ Est. of Daily Usage Soo 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 . .......................... Is well located in a realty subdivision? ............ ............................... Yes_ )C No MsAOK 5abdIVISION PLAT PrEPAiREa FoK E3tAtE AR Name of subdivision flab bE+h At lem M enit�o m E 0.y Lot No. Water Well Contractor: To 6E OETERruNGp Address: N/A Is Public Water Supply available to site? .................................. ............................... Yes No �( Name of Public Water Supply: N/A Town/Village N/A Distance to property from nearest water main: N /A Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: 1 -3o m0 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 a driller certified by Putnam County. ZA41 Date of Issue 'J Permit Issuin cial: Date of Expiration GJ a Title: Permit is Non -Trans rrab e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 M PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION Property of MR. VINCENT LEIBELL Located at CUSHMAN ROAD PATTERSON . Tax Map # 13 Block 1 Lot 3.2 Subdivision of ESTATE OF ELIZABETH ALLEN MONTGOMERY Subdivision Lot # 2 Gentlemen: Filed Map # 2573 Date Filed 1 -19 -03 This letter is to authorize INSITE ENGINEERING SURVEYING & LANDSCAPE ARCHITECTURE. P.0 a duly licensed Professional Engineer _ 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 tretment and /or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. Countersigned: P.E., R.A., # 61931 INSITE ENGINEERING, Mailing Address SURVEYING & LANDSCAPE ARCHITECTURE, P.0 3 GARRETT PLACE,CARMEL State NEW YORK Zip 10512 Telephone: (845) 225 - 9690 Very truly yours, Signed: (Owner of Property) Mailing Address: P.O. BOX 760 CARMEL State NEW YORK Telephone: (845) 279 - 3773 Zip 10512 Form LA -97 /NS/ TE ENG/NEEWNG, SURVEYING & LANDSCAPEARCH/TECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 0: Putnam County Health Department 1 Geneva Road Brewster, NY 10509 LETTER OF TRANSMITTAL Date: 8 -1 -03 Job No. 03148.300 Attn: Robert Morris, P.E. Re: SSTS for Leibell Cushman Road, Town of Patterson TM# 13 -1 -3.2 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via the following items: ❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Specifications _......_....._._. ❑ Copy of Letter Change Order ❑ ❑ COPIES DATE NO. DESCRIPTION 5 8 -1 -03 CD -1 Construction Drawing 1 - 7 -30 -03 CP -97 Construction Permit 1 1 7 -30 -03 WP -97 Well Permit —1� - 7 -30 -03 --- - - - - -- Short EAF 7 -29 -03 DD -97 Design Data Sheet _ 2 --------- --------- 5 Bedroom Modular Floor Plan 1 --- - - - - -- f PC -97 ' Application for Approval of Plans THESE ARE TRANSMITTED as checked below: ®For approval ❑Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ REMARKS: $300.00 Fee and Letter of Authorization was dropped off by Mrs. Leibell on 7- 29 -03. COPY TO: Iot2002.dot SIGNED: a �Jhn M. Watson, P.E. . J IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE 14484 W87)--Text 12 PROJECT I.D. NUMBER 817'.21 SEOR ;a Appendix C State Environmental Quality Review SHORT, ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I-- PROJECT INFORMATION (ro be completed by Applicant-or Prolect sponsor) 1. APPLICANT !SPONSOR 2. PROJECT NAME SSTS FOR THE LEIBELL MR. VINCENT LEIBELL ALLEN MONTGOMERY 3. PROJECT LOCATION: Municipality pAjjEgSON County PUTNAM 4. PRECISE LOCATION (Street address and road Intersactlons, prominent landmarks, ate., or provide map) SEE LOCATION MAP ON CONSTRUCTION DRAWING 5. IS PROPOSED ACTION: 5a New ❑ Expansion ❑ Modffication/sIteratlon S. DESCRIBE PROJECT BRIEFLY: CONSTRUCTION OF A SINGLE FAMILY RESIDENCE, DRIVEWAY, SSTS, WELL AND APPURTENANCES 7. AMOUNT OF LAND AFFECTED: Initially 6.85 +/- acres Ultimately 6.85 +/- acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Eyes ❑ No it No, describe briefly S. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Q Residential ❑ Industrial ❑ Commercial ❑ Agriculture ParklFor"VOpen 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 ❑ No If yes, list agency(@) and permlVop"provals WELL PERMIT - PUTNAM DRIVEWAY PERMIT - TOWN OF PATTERSON COUNTY HEALTH DEPARTMENT SSTS - PUTNAM COUNTY HEALTH DEPARTMENT AND NYC DEP BUILDING PERMIT - TOWN OF PATTERSON 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Cl Yes RNo If yes, list agency name and permlUapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes (R No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE INSITE ENGINEERING, SURVEYING & LANDSCAPE ARCHITECTURE, P.C. AppllcanUsponsor name: JOHN M. WATSON. P.E. 7 -30 -03 Date: Signature: 1 / It the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment 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: MR. VINCENT LEIBELL PO. BOX 760 CARMEL, NY 10512 2. Name of Project: SSTS FOR LEIBELL 4. Design Professional: JEFFREY J. CONTELMO P.E. 6. Drainage Basin: EAST BRANCH 7. Type of Project: 3. Location :( V: PATTERSON INSITE ENGINEERING, SURVEYING & 5. Address: LANDSCAPE APE AR H ITECTU R P.C. 3 GARRETT PLACE CARMEL, NY 10512 X 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) ? .............. Yes/No YES Type Status (check one) ...................................... ............................... Type I Exempt Type II Unlisted x_ 9. Is a Draft Environmental Impact Statement (DEIS) required ? .................... Yes/No NO 10. Has DEIS been completed and found acceptable by Lead Agency ? ............. Yes/No N/A 11. Name of Lead Agency N/A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............................................................. ............................... Yes/No YES 13. If so, have plans been submitted to such authorities? Yes/No NO 14. Has preliminary approval been granted by such authorities? NO Date granted: N/A 15. Type of sewage treatment system discharge ........................ surface water X groundwater 16. If surface water discharge, what is the stream class designation? .......................... N/A 17. Waters index number (surface) ............................................. ............................... N/A 18. Is project located near a public water supply system? Yes/No NO 19. If yes, name of water supply N/A Distance to water supply N/A 20. Is project site near a public sewage collection or treatment system? .......... Yes/No NO 21. Name of sewage system N/A Distance to sewage system N/A 22. Date test holes observed 7 -29 -03 23. Name of Health Inspector GENE REED 24. Project design flow (gallons per day) ............................. ............................... 1,000 25. Is State Pollutant Discharge Elimination system ( SPDES) Permit required? ... Yes/No NO 26. Has SPDES Application been submitted to.local DEC office? ......................... Yes/No N/A Rev. 11/02 Form PC -97 Pg. 1 of 2 27. Is any portion of this project located within a designated Town or State wetland ?... Yes/No NO 28. Wetlands ID number .................................................................. ............................... N/A 29. Is Wetlands Permit required? ...................................... ............................... Yes/No NO Has application been made to Town or Local DEC ........................... Yes/No N/A 30. Does project require a DEC Stream Disturbance Permit? .... .........................Yes/No NO 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 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 NO DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .........................Yes/No UNKNOWN 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................Yes/No UNKNOWN ............ ............................... 35. Are any sewage treatment areas in excess of 15% slope? .............................. Yes/No NO 36. Tax Map ID Number .............. ............................... Map 13 Block 1 Lot 3.2 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 1, 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 & OFFICIAL TITLES: I ITE ENG EERIN RVEYING &LANDSCAPING Mailing Address: AR RE, P.C. 3 GARRETT PLACE, CARMEL, NEW YORK 10512 Form PC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner V i r-f "t LE i 6 E LL .Address P,o Bak 76o EARmF L NY iossz Located at (Street) CushmaN RoArl Tax Map 13 Block 1 Lot 3.2. (indicate nearest cross street) Municipality pA.jERso�, Drainage Basin F ost BrANCh LjoggshEd SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test , 7`- ;,a -o3 Hole No. Run No. Time Start -Stop ` Ela %Tirime �1VIin.) ' Depth to Water From Ground Surface (Inches) Start Stop Water Level Drop, In Indies Percolation Rate Min/Inch P� 1 :�q - 9:,q io. _ ss 2-3- 3 3.3 P1 2 '30 -q:4 1 11; 18 21 3 3.7 Pa 3 q.4� -�: 53 3.7 4 5 P1 1 q,2,1 -q: 33 1z 3 X1.0 P), 2 q:34 - q,'50 16 18 21 3 5.3 P1 3 a:51 -10:07 16 1 3 53 4 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are ontainea at eacn 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. s 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5'. 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. [A HOLE NO.. D2 HOLE _NO. 11 TOr wL T..o<,.., oRRni6E Ec.AW -n 21 1 Indicate level at which groundwater is encountered N/A Indicate level at which mottling is observed NIA Indicate level to which water level rises after being encountered N JA Deep hole observations. made by: 3704,N M. GJAi'ao f&: _ . PA, .l th Gc�,,n 3roSsd Date 7- a9- 63 Design Professional Name: Jef f rey J. Contelmo , P. E. Insite Engineering, Surveying & 4` +•< \ Address:Landscape Architecture. P.C. y 3 Garrett Place, Carmel, New York 10512 Rd SR. Signature: Design Professional's Seal s ,r JUN -1 -2005 09:53 FROM:INSITE ENGINEERING 845225977 r 70:2787921 P:2-/2 PLYMAM COM"TY DEFAiHT1Yl M OF HE"TH 1)>IVTS10N OF ENMRONM>Et'.N"TAL MALTH SERVICES ATTENTION P JOSEPH � GENE MQU-15 FOR PiTIAL INSPECTIgN Four rill All information must be £illy completed pniar. to any Trenche& inspections being made: PCHD Construction. Petnvt # 12xr V — �f Located: r-i1.61n Owner /A,ppllcant Name: �,� cLc►.! b.' It 'I' ,!, -:- ;Block � Twat Fa rmerly: mA Subdivision, Name n& tr Q lw (kq bfln „@ l lr,�, n mu� orr e r+� Subdivision %:Ot # _ , Is system fill completed? Nttt nom: Me! - Is..sy&bC u:M npiete? bate: is system n. l as per plans? 7. Is'weli drxae Hate: i - Is -1 located`.as peer plans? y t- s Are erosion control nxasms in. place ?. jr-N I certify that the system((); as] ist.ed, at ft above preini.SCs has b"a CAI15 acd and X lave ivVwtea and veirified'tlieir completion in awm' 4anca with the issued 'PCHD Cons[i Oon Pcrrait and approved plans and the Stmdards,:Rules and,Ke-gulations of the Putnam County Department of Health: Fortn'FIR -99 r� u a �nnr irn Ara, fain TM • OACZ- '770 -7Q:1 tAgMF • Pi'iTNQM rrn ,n,TV nG•OpOTMCkIT nC '� a { '_`' V.a -. .� s ., "ter^---- v'�.,'."__["„2"'"„".�,.�» a _ s x'. 7a ? a a - yE g~ � � 3 -, Sheet of �� 4 T L # s y. Pi1TNAlVI CUUNTYreDEPARTIV�ENT OF HEALTH DIVISION;OF EI_VIRONMENTAL HEATLH SERVICES _s I; c�'W, �p4_ FIELD €ACTIVITY REPORTx 1: ° F G _ ff , i . l f� T t F M B f _ � _ y 9 r -i z' i� ar° 2 .v- . t i - Street , Town State' _Zip C - 3 a` 7 4 PERSON IN CHARGE _ i. _. Yw ? t ;.nom 3 ,? _° I'll �: Fry 1 - - i x' y f J a i S 7 rtarhe and Title fi 3 Alk ,TYPE OF FACILITY , x re, .t a 5 FINDINGS: x`. ... s; ", - g ; _ ,. -�- `~ °� a > , d _ � ?" W ' r 3 y� /j /�/y /�J} ✓ fi h 5 F .4 � itt T4 F - I 1 - �l tom- -� 3 �± -. ! 3 — - � '. v ',� � .4 u e :�3 '.T a -rF= {',ri., x�' Y, i:: -a4 }.z� of _%:1. 1N S5 - -�'� l�a .,r%' rte° ��- c�L- -i N r 11 � � ,r.i E . � 5 � E9 �T -'fx' X � .-.. a,« E � : _, p jYj, 'e " 3 ,t i `� s` /� 4 - E Y rx t. Y:F' a � f :. , ,, ; f PUTNAM COUNTY REAL 1 Geneva Road d, (8,40) 278 Brewster, N �0509,i f Receive I � d of T4he m pf, i 5 f- `` � C7 Cash:' ❑.Check � ' �� O Credit Card gy� 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at Town or Village a+tEacn., M-ap- So6chu-smo Pipf P(epookca f-6& ti* Subdivision n P'FFirmhg+L, Al1Ew► MaNFawu Subd. Lot # �_ Tax Map 13_ Block J. Lot 3.), Date Subdivision Approved 1-101—c13 Renewal ---- Revision .--� Owner /Applicant Name li a c EN t LE b E LL Date of Previous Approval N /A Mailing Address Pt). Boy 76z C ARmfiL Ny Zip Amount of Fee Enclosed 300.o0 (PrEyiousl)l 5uhmo*ed) Building Type -R side-th al Lot Area 4,15 +j_ No. of Bedrooms Design Flow GPD 1,000 9c Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 1, 5 oo gallon septic tank and 5 0 W Lf- OF :2.0 w, e E A -veoApt'i oN lruiches Other Requirements: To be constructed by To Be p arh,NEd Address ►•( /q Water Suunly: Public Supply From Address or: X— Private Supply Drilled by 7o BE. DE +FRm,ry 1 Address N/A I re_A esent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the enarate sewage treatmentsystem 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 7-30-03 N CMP5) S Av pfki* LA&WsC PE Arc6.+ECt�R6, P.c. Address .� , Qae+t LA" rnr1.NV loc,12, ___ License # 4 19 3U 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 pe: it. Approveffor discharge of domestic- sanitary sewage only. i By: "� IMAtn Title: J A�/ /0` Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 JU 11N.JH.LdQd_-JU A_L141 1U.) H0111f Ici I-J1. •L • T- I I IM-L rUUf-t7-(jUjj pUTNA.jM XP",PA_k'1MENT OF REAIA DIVISION OF ENVIROKNIENTAL REAM( SERVICES ATTENTION 0 ADAM v G�NE REQUFST F T,INSP,' ION Fin All information must be fully conipleic'e, pn';1­r to any Trenches inspections being made. C� PCHD Construction Permit A Located, C106AMAIJ 90AD orj Owner/Applicant Name: \/i,4LC1J'(jf -1 11'(0- TM l Block Lot Formerly: , S o'ti Is system fill completed? ubdivisl Lot 0 Ys system complete? S Date-. ---- ----- (­ Date: Is system constructed as per plam? Is well drilled? Is well located as per plans? 5 Date: Are erosion control measures in certify that the �y3t'*s), as fisted, ,acted and I h4ve inspected ied their completion In with the issued PCIJD Construction and verif Oil tilt; at.;; ,.,,w premises has been coast,,., approved plans and the StanOLrd.s, PUICS , el Ve&,Ujati0nS of the oUtUaril County Department of Date- PE _X RA Address: ofessvin M _t_—nd—sr- �a.cit h urve jn�q Comments: __3 Garre Place ftec ure pc, Lic. 0 Carmel wy — ------------------- Form RFR-99 TAT :3 eHIa33NION3 31ISNI *1013 0 2:t.-T t7002-t—f10N Y `I�e . CI "� August 21 2003 �er��rlC, � Department of - ��Environmental Protection Robert Morris, RE ass Columbus Avenue Putnam Co. Health Dept. ;'Valhalla, New Yom 1059 4 Geneva Road s.laas Brewster, NY 10509 "Christopher O. Marc! Commissioner Re: Cushman Road Lot 2/Leibell Residence. SSDS Cushman Road Patterson, Putnam East Branch Reservoir DEP Log # 14028 (Joint Review) Dear Mr. Morris: Bureau of water Supply This letter is to inform you that the New York City Department of Michael A. Principe, Ph.D. Environmental Protection (Department) has determined that the above- be" commissioner referenced application is complete. In addition, the Department has no objection Tel (914) 74? -2001 - to the approval of the above - referenced regulated activity. This determination is Fax (914) 773 -0343 based on the review of submitted documents including the plan titled "SSDS prepared for Leibell ", dated 08/01/03. The applicant must contact Sissy De La Ossa of my staff at (914) 773 -4416 at least 2 days prior to the start of construction of the SSTS so that a Department representative may inspect and monitor the installation. Sincerely, anny Shedlo, P. . Project Manager Engineering Design & Review ,1 ti O CITY DEPART,y 0, ` ma xc: John M. Dunn, P.E., NYSDOH Q ~`'RONMENTAL PRO"(C�`O www.nyc.gov /dep ,(718) DEP -HELP t a mu _U1 =Wl.avd .JU h1NI IUJ WUN11 Id ; dWUN August 21, 2003 w" Robert ]Morris, P.E ' Putnam Co. Health Dept. : 4 Geneva Road Brewster, NY 10509 Re: Cushman Road Lot 2/Leibell Residence. SSDS Cushman Road Jt Patterson, Putnam East Branch Reservoir DEP Log # 14028 (Joint Review) Dear Mr. Morris: This letter is to inform you that the New York City Department of Environmental Protection (Department) has determined that the above- ,.., referenced application is complete. In addition, the Department has no objection to the approval of the above - referenced regulated activity. This determination is ' - based on the review of submitted documents including the plena titled "SSDS prepared for Leibefl ", dated 08/01/03. The applicant must contact Sissy De La Ossa of my staff at (914) 773 -4416 at ' least 2 days prior to the start of construction of the SSTS so that a Department representative may inspect and monitor the installation. Sincerely, IkE %' U4 army Shedlo, P. . s' Project Manager Engineering Design & Review .;: xc: John M. Duvet, P.E., NY,SDOH �0 'd S0: 9T j0, T End iVM- 212 -bT6: X?J 9NId33NI9N3 d3Q DAN PU'I`NAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE DE SUBSURFACE SEWAGE TREATMENT SYSTEM \1 i alsdi L�, ._bP .(I 1'l I I a �= Owner or Purchaser of Building Tax Ma^p� Block Lot Building Constructed by . /YU;�Sc�bd'viso�. 1�lQ.f Fr,G�4ru� �� f 3 c-.Awen Location - Street Building Type &Mzae of E U ?�a L:,44-ln /4 U /l rA v 0ql a rnZ-j _ Subdivision Name Subdivision Lot # I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above- described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations ofthe Putnam County Department ofHealth, and herebyguarantee 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 _21(!� Year ��Signature: rzf . r_,� 2 Title: Aener'al Contras or (Owner) - Signature Corporation Name (if corporation) Address: Corporation Name (if corporation) Address: State zip State zip Form GS -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION 1118 0� Date: Inspected by: -7111 /° S Street Location C u-s6l t r dAj :gw,4 rp Owner Zozaeil- Town ,RkgZ:Z-1-20 -SOA/ Permit # ?- 13-03 TM # / / - 3 Subdivision Lot # Z 1. Sewage System Area . a. STS are4, located per approved plans ........................... -� b. F ll4 ction date of placement 1 barrier Lgth. Width . Avg.Dpth C:, Natural soil not stripped...,,, ............. ............................... d. Stone, brush, etc., greater an 15 from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a. Septic tank size - 1j'000 .... ..... 1,250 ......... other ... t!Fe9.. ,..; b. ' Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All' outlets at same elevation -water tested ................. 2. T otected below frost .................. ............................... 3..: Minimum 2 ft.Original soil between box & trenches e.: Junction Box properly set .. ............................... 6 renT' c- hes -- . .; 1. Length required 6,90 Length installed 6o a 2. Distance to watercourse measured 4- i Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2 diameter clean ........ ....... . .... : 9. Depth of gravel in trench 12" minimum ....... :........... eends ca pped ........................ ............................... . Pum or DosedPSvstems '--+--Size of pump chamber ................. ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... M. House/Buildiiig a. house located per approved plans . ............................. - :: b. Number of bedrooms....... .. IV. Well Wei Well located as per approved plans . ......:........................ --�_ b. Distance from STS area measured -t too 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. Backfll material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dir.to exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate .... ....:.......................... i. Erosion control provided ................. ............................... Rev. 12/02 v v� d� d� Ira CC �o Page 1 of 1 JMSEnvironmental Services, l 'C. WATER. SOIL AND AIR AHALYS :S �Llk 41 Kenosia Avenue I Danbury. Connecticut 06810 1 Telephone 203 -798 -2229 P F Beal and Sons Inc Mailing Information: Collector's Information: JMS ID: 000794 Name: P F Beal and Sons Inc Name: Adam Beal Address: 4 Putnam Avenue Address of site: Leibell Chusman Road City: Brewster City: Patterson State: NY Zip: :10509 State: NY Zip: Phone: (845) 279 -2460 Fax: (845) 279 -6613 Phone: Sample's Information: Site: Tank Date Collected: 5/3/2005 Date Received: 5/4/2005 Preservative: HNO3 Time Collected: 11:00:00 AM Time Received: 2:30:00 PM Temperature: <4 Lab No.: J0504444 Matrix: Water Date Analyzed Test Name Result MCL Method 05/05/05 Alkalinity 244.0 mg /L N/A SMWW 2320 B 05/05/05 Hardness 310.0 mg /L N/A SMWW 2340 C 05/05/05 Lead (flush) <1.0 ug /L 15 ug /L SMWW 3113 B 05/05/05 Chloride 70.0 mg /L 250 mg /L SMWW 4500 Cl C 05/04/05 Color ND 15 Units SMWW 2120 B 05/04/05 Turbidity 0.2 ntu 5 ntu SMWW 2130 B 05/04/05 Odor ND N/A SMWW 2340 C 05/05/05 Iron <0.1 mg /L 0.3 mg /L SMWW 3111 B 05/05/05 Manganese <0.1 mg /L 0.05 mg /L SMWW 3111 B 05/05/05 Sodium 14.1 mg /L 28 mg /L SMWW 3111 B 05/04/05 pH ' 7.6 S. U. 6.5 -8.5 S.U. SMWW 4500 H B -NY 05/05/05 Nitrate 0.2 mg /L 10 mg /L SMWW 4500 NO3E 05/05/05 Nitrite 0.1 mg /L 1 mg /L SMWW 4500 NO3E 05/05/05 Sulfate 5.6 mg /L 250 mg /L SMWW 4500 SO4F 05/04/05 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 05/04/05 4:00 PM Total Coliform Absent Absent SMWW 9222B Comments: At the time of the analysis the sample was Acceptable for Total Coliform Signature: ir�l���tQG _ Reviewed By: Michael Lapman Sharon Houlahan, Director President State #: PH-0218 ELAP #: 11715 CONNECTICUT. NEW YORK AND NELAC CERTIFIED Toll Free 866- JMS -5097 1 Corporate Fax 203 -798 -2408 1 Lab Fax 203 - 798 -2107 1 wwwirnsenvironrnental.com /NS/TE tL--A11'1VDSCA GINEERING, SURVEYING & PE ARCHITECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 TO: Putnam County Health Department 1 Geneva Road Brewster, NY 10509 LETTER OF TRANSMITTAL Date: 6 -3 -05 Job No. 03148.300 Attn: Gene Reed Re: SSTS for Vincent Leibell 130 Cushman Road, Town of Patterson TM# 13 -1 -3.2 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via ❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Copy of Letter [I Change Order ❑ the following items: ❑ Specifications COPIES I DATE �� NO. DESCRIPTION 5 6 -3 -05 t AB -1 _ As- Built Drawing 1 — 6 -3 -05 — j CC -97 y -GS-97 Construction Compliance 1 5 -26 -05 '� Guarantee 1 - - 5--- 3-- -0-5 —+ Water Test Results _ 1 Y 6I 1 -05 276 $300.00 Fee —u_Y 1 1 6 -1 -05 12 -3 -04 WC -97 E -911 Address Certification _._,.._______.._._ _._...._._._ .__._..._.___._.._.r________ —.. -- Well Completion Report A1.1 Basement Floor Plan i T 8 -6 -05 �� A-1.2 j First Floor Plan — f 8 -6 -05 -- -- Ai 1.4 Second Floor Plan f 10 -29-04 CD -1 Construction Drawing THESE ARE TRANSMITTED as checked below: @For approval ❑Approved as submitted 7 For your use ❑ Approved as noted ] As requested ❑Returned for corrections ] For review and comment ❑ 1EMARKS: COPY TO: 12002.dot ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints SIGNED: ey J. ontel E. Principal Engineer IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE PUTNAM COUNTY D"ARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT IWILocation Street Address :. 130 Cushman Road TownNiilage:. Patterson Tax Grid # Map f Block Lot(s) 3 Owner: Name: Addma: Helen &' .Vincent Leibell, P.O. Boa 760, Carmel, KY 10512 Use f 1 -pri nary 2 -se Weil: ndary X Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Instiltdional Standby Drilli g Equipment X Rotary Cable percussion Compressed air percussion Other (specify) Well Pe Screened �, Open end X Open hole in bedrock _ Other Casiz Details Total length 3 2 ft. Length below grade 31 ft. Diameter 6 in. Weight per foot 19 lb/ft. Materials: Steel _ Plastic Other Joints: _Welded X Threaded Other Seal: X Cement grout — Bentonite y Other Drive shoe: Yes No Liner:. Yes .K. No Scree Details Diameter (in) Slat Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours second Well ieumst Bailed • X Pumped'` Compressed Air Hours 6 Yield _.1.5_ gpm Dep Data Menure timm land su a (� y ) 110 Depth of completed well in feet 705' Well If metailed info descns sievyses are please ford on or ble, ttach. ' . From Surface Water Bearing WeN IMikmkr(la) Formation Description ff. ft. ' Land Surface g D -12 7AR If yield at dill during list: was tested nt depths Irilling, f r e t Gallons Per Minute Pum Stora a Tank Information '+; p Type Sub Capacity 10CFVM pth 660' Model 10-015 oit 2 3 0 HP 1..5 ank Type WX302 Volume 8 allon Date Well pleted 10 /11 /0 Pubuft Comay CertiflMon No. .. a 006. 12/03/04 Adam 1 - ---.,_, -- NOTE: L"XaCt 10=101101 Well Witt) 019tanCe910 -at Iea9t TW0 pE[ ==R SS>+ WKS [u oe pr "Jvu V91 a �c nay au�4vY�a•a. Well iller's Address: Dznam Aue ta.- , oup oar, NY Signa e: N 4 t- Date: 124014n4 10509 am L.. Heal White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 ,111 �o 77� RCOURSE . , _ �i ,n Co. 1^ I F I I , 1 I 4 PPnPnr�cn rY unn� nn.ru....- N0. oo OF DMMLING CORNER of DNEWNG a ER of DNEU NG REMARKS 1 44 57' _ SErnc TAW MANHOLE I 2 49' 61' — SEP77C TANK MANFIOLE 2' 3 51' 63' — PUMP PIT MANHOLE r 4. 57' 67' — PuwP Prr MANNaE.2 5 73' 117' - CLEUVOUT 6 105' 16Y. - PROP eox 7 109' 165' - DROP BAx 8 114' 166' — DROP WK. 9 119'. 167'. — asap BOX 10 124' 169' -- DROP aW* 11 146' 216' — ovo .aFi+rc 12 149' 218' END OF TRENCH ' 13 " '152' .. . '2'18'.., _ . EW _Ql� jai 14 155' 219' — 00 OF nwICH. 15 159' 220' " _ p 16 83' 112' " : — o+ro a nom► 17 88' 114' — 00 CF. n.WVCH .. . 18 95' 117' — END OF m�Nar+ 19 102' ' 119' — EW ar n 20 111' — 97' ware spa. A BRYAN • � 3JySE 4703 SB1�j2S�, A � +� 149. g3• SBJ h \\ \\ \ IELL 43 >.10• 0y \ \\ 1\ A8508nCk1 \ \ \ \\ ) r � LOT 2 4N•i DRCP mr (rip. oa jPLW prr O 's-W GALL 4 I AGE j 451. .� 0 S76g3'50'•W .� roes 75 7o'w KpRaL �1ody NOW or h HELL h � �� q�r'� �ti h�O OVERALL PLAN `s h SCALE.• 1` = 100 1g \C \ \\ EXPANSION ASSORP77ON 1ROVCN (1YP.) . (10OW EXPANSION PROWDE0) 14. PRIMARY. ABSORPAON 7R£NCN (TYP.) 0 DROP BOX (TYFt) A C 5 B 8 17 9 „n O PUMP PIT —�" n (FOR FUTURE 1 2 DFANS10N) Z O 1500 GALLON SEP17C TANK NA1101 OF nos DOCUMENT, unu.ESS L#4XR nfE DfRECncW 1 LIC04sm'PROFmoNAL .ENS IS A NOLAnON,OF 11!X4 7209 OF ARnCLE 145 OF IFE ONA AROV..LAW. - - .•WALE• 1 X30 B _