HomeMy WebLinkAbout0276DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
13. -1 -6
BOX 4
�i
�I
• I��
J
�♦ T . '
r
111:
:ev. .
.0/88
rumor COUNTY DEPARTM M.OF lGr1LTS
Dlvblw of t wAsmeoM He" Seavle.m Camel. N.Y.1111512 tD Pwvlds Pafall /
am CER]"ItATE OF CODII7AN(*
NSTlIICTN)N PERl14t FOR SEWAGE DlISr0 L SYSTEM
LeeN.a %rl.
SulsdlylsM. N.me //�� / c.ea. Let r Tax Map
Ft/a'1G if 1 f� .f f Renewal j�' Revlaka ' p
Own /ApPYeeat Nam is t�5 vnew, o p ECG, '
'" / J Date d Prevbas App--d . 9 r
M Addeoes l� f% Lam,. C :C 04,00 U ` Town �� , i /�- K' ✓� zlp �
Date Subdivision A /nnroved Fee Enclosed 0 Amniint-
Bedlillog
Type )PE-2 It Area 4& eze- Fm seceion Odr
Number d Bedrooms Deaip Flow G P D PCHD Notldcudou Is Repaired Wbeo FM Is eompk ted
j
SePureft Seerm se System to eaneklt d der d Go Oea Septic Took .ea V6,0 L� „df� % ;-, %,,4 e - f
To be osustrudted byT' /� Address '��
Water Sapplr: PdW* Supply Fros Address
out>lelrstte Supply DdEM by d Add..o..
1 represent that 1 am wholly and completely responsible for the design and location of the proposed systenl(s); 1) that the separate sewage posa
disl system
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules regu vent 01
Putnam
County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of HMithwill
be submitted to the Department, and a written guarantee will b*'.furnished the owner, his successors, heirs or assigns by the builder, that said builder will
DISCI' In jOOd operating condition my part of said "Wege disposal system during the per lod of two (2) years immediately following the date of the Inu-
Once of the app -M of the Certificate of Construction Compliance of the original system or any repairs' Hereto; 2) that the drilled well described above
wilt be located as ~A on the approved plan and that said well will bum Instal in accords a wit the std and r s and requ o�a�i ns of the Putnam
Countyj apart nM Off Health.
Date C! /rfJR J Signed P.E.- R.A.
Addressn/ �� ~,
License NO
APPROVED FOR CONSTRUCTION: This approval expires two years from the datel, slued unless construction of the building has been undertaken and is
revocable for cause or may be amorided.or modified when considered nace - the Commissioner of Health. Any change or alteration of construction
requires a nne_w Ligon nit. Approvi d for disposal of domestic —sanini sewage /Or ate water suoDly only.
Date
Title � 4g
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 #
WELL LOCATION
Street Address
23 % o
To Village City Tax Grid Number
2. -v--S
WELL OWNER
Name Mailing
Address 0private
Py�" O Public
USE OF WELL
primary
2- secondary
RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP ❑ ABANDONED
BUSINESS O FARM O TEST /OBSERVATION O OTHER (specify
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT , gpm/ #
PEOPLE SERVED,6 --,!5 /EST. OF DAILY USAGE _8 G j Sal
REASON FOR
DRILLING
C] REPLACE EXISTING SUPPLY
; NEW SUPPLY NEW DWELLING
❑ TEST /OBSERVATION 13. ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
' /-. • i �� ` -
:�
WELL TYPE
DRILLED DRIVEN
DUG GRAVEL 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES __NO
NAME OF PUBLIC WATER SUPPLY:` r¢ TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDE
®ON SEPARATE SHEET 121
(dat.) )(signature
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
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 Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or otherwise cont inate surface or groundwater.
Date of Issue: 9 19
Date of Expiration 19 Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
lE'�UTN,A.i�C COCJ�TTY 1�EPA.L'rM�r7T OF 1~XEAL�'
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1 . Name and Address of Appl scant: AM, KIC)A
2. Name of Project: O'T2a--E B PS 3.,_._Location /C: �Sa
4. Project Engineer: �-i f�{'�i'z_�1( -}Dls, rte. 5. Address:
License Number: Phone: �L'1
6. Type of of Project:
Private /Residential Food- Service ....Commercial
Apartments Institutional Mobile Home Park
Office Building , Realty Subdivision Other (specify)
7. Is this project subject:to State Environmental•Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt ✓
Type II. Unlisted
8. Is a Draft Environmental Impact Statement (DEIS) required? U
9. Has DEIS been completed and found acceptable by Lead Agency? J/A
10. Name of Lead Agency
ti. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? .......... ............................... �l�l
t2. If so, have plans been..submitted to such. author .sties ?...................... ►� /�
13. Has preliminary approval•been granted by such authorities? WA Date Granted:
14. Type of Sewage Disposal. System Discharge....... Surface Water ✓ Ground Waters
15. If surface water discharge, what is the stream class designation ?........ O /A
:6. Waters index number (surface) .........
;7. Is project located near a public water supply system? ..................
8. If yes, name of water supply Q/A Distance td�water supply.
9. Is project site near a public sewage collection or disposal system ?..... l,10
Q. Name of sewage system Q/A Distance to sewage system _
i. Date observed: 23. Name of Health Inspector:
4 '. Project design flow (gallons per day) ...... ............................... g�
.
2.
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.._ aJo
26. Has SPDES Application been submitted to local DEC Office? ►.)>D;
27. Is any portion of this project located within_ a designated Town or State
wetland? . ............................... r.1�J
23. Wetland ID plumber ........................................................ ►J /�
29. -is Wetland Permit.• required? ................................................
Has application been. made to Town or Local DEC Office? tJ A,
30.. Does project require a DEC Stream Disturbance Permit? ................... x.10
31. is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste _ i -isposal;`
landfilling, sludge application or industrial activity? ........ YES or NO 00
32. is project located - .within 1;000-feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential.. known'source of contamination? ..............YES or. NO K) (J
DESCRIBE:
,
33. Is there a local master plan or file -with the Town or Village?
34. Are community water, sewer facilities planned to be developed within 15 years? UN VQAOO
35. Are any sewage disposal areas in excess of"15% slope? ... :.................... —go
36. Tax Hap ID dumber .......... I�G -
37. Approved Plans are•to••ba returned to: ................ • App-licant _Y/_ Engineer
If the application is signed by a person other than the applicant shown in Item•1, the.
application must be-accompanied by•a Letter of Authorization: Failure to comply with this
Provision maybe grounds for the rejection of any submission.
I hereby affirm, under pena7ty of perjury,-:-that information provided on this
forr,7 is true to the best of my know7edge and be ief. Fa lse staterr,ents made
herein are punishable as a Class A Hisderreanor pursuant to Section 210.45 of
the Penal Law.
f
SIGNATURES & OFFICIAL TITLES:
',AILING ADDRESS:
FORMAT Date August 10, 1993 -
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
RE: Department of Health Review of
Kessler, Robin Proposed Sewage Disposal System
349 Mooney Hill Road for property:
Patterson, NY 12563
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill Road
Town: - Patterson, N.Y.
Tax Map: 12.-4-5
Dear Ms. Kessler:
Please be advised that -an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed:•for—the captioned .property has been made to the Putnam
County Department of - :Attached. please find a .copy of the
latest.. site plan. .. t.
If'you. have any questions, concerns or information which may bear <`
on the Health Department's review of this application, you may
call: Mr. Hedges or Mr. Morris of the Health Department at 273 76130.
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Carlson, Richard A. & Agnes W.
5 Manor Road
Patterson, NY 12563
Dear Mr. & Mrs. Carlson:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage. Disposal System
P
or property:
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill Road
Town: Patterson, N.Y.
Tax Map- 12. -4 -5
Please be advised that an application for a Construction Permit
relative to the construction of a. sewage system and /or well
proposed, for. the captioned property has been made to the Putnam
a
County De.p'r.tment of 'Health. Attached ,please find. -a .copy .of. the
latest. site plan:
If*you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call': Mr. Hedges or Mr. Morris of the Health Department at 273 -6130.
Very truly yours,
By
Ag V-
Title
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Harris, Andrew & Hettwer, Mary
Mooney Hill Road
Patterson, NY 12563
Dear Mr. Harris & Ms. Hettwer:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill Road
Town: Patterson, N.Y.
Tax Map : 12.-4-5
Please be advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed,, for. .the captioned property has' been made to the Putnam
County Department. of: Health.. Attached please fihd..a .copy of the
latest. site plan...:.
If you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call:Mr. Hedges or Mr. Morris 'of the Health Department at 273 -6130.
Very truly yours,
By
Title Agent
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Taub, Murray G. & Judy M.
6 Manor Road
Patterson, NY 12563
Dear Mr. & Mrs. Taub:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill Road
Town: Patterson, N.Y.
Tax Map : 12.-4-5
Please . be advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed., for. the captioned property has been made to the Putnam
County. Department, of'. Health... -Attached .please find a, .copy of the
latest. site plan.
if-you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call': Mr. Hedges or Mr. Morris of the Health Department at 273 76130.
Very truly yours,
By
T i t le Agent
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Ladau, Robt. & Anne H.
Mooney Hill Road
Patterson, NY 12563
Dear Mr. & Mrs. Ladau:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill` Road
Town: Patterson, N.Y.
Tax Map: 12. -4 -5
Please. be advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed,-. for•.the captioned property has been made to the Putnam
County Dep ar f_ tment . o Health.. Attached please f ind a copy. of . thee
latest. site plan. ..
If,you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call': Mr. Hedges or Mr. Morris of the Health Department at 273 7-6130.
Very truly yours,
'By
Title Agent
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Chamberlain, James & Lois
Mooney Hill Road
Patterson, NY 12563
Dear Mr. & Mrs. Chamberlain:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill Road
Town: Patterson, N.Y.
Tax Map: .12.-4-5
Please. be advised that an application for a Construction Permit
re-l-Ative to the construction of a sewage system and/o ' r we * 11
proposedj for. the captioned property has been made to the Putnam
County Department of. H.eal.th....-.::-Attached please find.,'a copy . of I the.:
lates.t site Plan.
.If *you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call:Mr. Hedges or Mr. Morris of the Health Department at 27876130.
Very truly yours,
B Aaed
Title Apen
RECEIVED BY:
Address:
Tax Map:
JK;cj
4A
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Hamilton, Susan
P.O. Box 25369
Los Angeles, CA 90025
Dear Ms. Hamilton:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address: Mooney Hill Road
Town: Patterson, N.Y.
Tax Map: 12. -4 -5
P leas e.be advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed: for. . the captioned property has been .made to. the Putnam
County Department of Health attached please find. a..cop.y of, the,..
latest. site plan.
If *you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call: Mr. Hedges or Mr. Morris of the Health Department at .273 -6130.
Very truly yours,
By
Title Agent '
RECEIVED BY:
Address:
Tax Map:
JK;cj
PUINAM COUNTY DEPARn TENT OF HFAL_ TH
DIV - ION OF ERV1PLNRMML HEALTH S: ICES
DESIGN DATA SHEET- SUBSUFACE SEMP E DISPOSAL SYSTEM FILE NO.
owne_Y AM4b,\, CA t2le-- NM,W P.ddress �v. �rX 2%�G GtI 1MAA -b P �iJ
Located at (street) Sec. 12 . Block Jot
(indicate nearest cross street)
M=icipality Watershed G�oTad�
SOIZ PEF2COLA cN TFST DATA R.DQUT.RED TO BE SUB4I= Pr= APPLI=CLNS
Date of Pre - Soaking :7- 16' -- 1,72 Date of Percolation Test -1—(6-
HOLE
NL': B ER C= T'I2 PEE CO=CN PERCOIATICN
Run Elapse Depth to Water From hater Levu
No. Tines Ground Surface In Inches Soil Rate
Start -Stop Min. Start Stop Drop In -. "'Min /In Drop
Inches Inches inches
111:)�!�,12.eZ :0
N
32:1.
('4
2 1/I - A , I / /.:
. . � 3 l/I,: ti
5
1
5.
G
NOTES: It Tests to be repeated at same depth until apprucirnatel.y equal: soil rates
are* obtained at each percolation test hole. All data to* be suhmittbd
for review.
2. Depth me zurements to be mane fran top of hole.
rev. 9/85-
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCI TION OF SOILS ENCOUNMERED IN ;T SOLES
DEPTH HOLE NO- j HOLE NO. HOLE No.
G.L.
-
2 I'T C) Gi
31
4
5'
61
7`
81
91
.101
12'
13'
14'
7ND!C-kTE LEVEL AT WaICF1 GROUNDMITER IS ENCOUNTERED
INDICATE LEVEL TO W-KCH WATER LEVEL RISES AFTER BEING AUNT=
.DEEP HOLE OBSERVATIONS MADE BY: DATE:.
DESI&N
Soil Rate Used Min/1" Drop: S.D. Usable Area Provided
No. of Bedroans 2k Septic Tank Capacity gals.- Type
.Absorption Area Provided By L.F. x 24" width trench
7
Other 9. P2
Name Signature
Address '1 1? �Aj SEAL
THIS SPACE FOR USE BY'SEALTH DEPARZENT ONLY:
Soil Rate Approved sq.ft/gal- Checked by
Ir
&j
CIO,
L
No. 56124
-00n--MiO�
Date
V-1
PUTT. I COUNTY DEPARTMENT OF HEM, H
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of Aj. A DA &U -'HWA \
Located at
(T)'� \�S���Section Block Lot
Subdivision of
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to authorize -E-E (-g
a duly licensed professional engineer or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules.
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education., Law, the. Public Health Lana, and the Putnam County Sani-
tary Code.
Countersigned
P.E. , _y-� - , h
Address
Very truly yours,
Signed �-
Osaner of Property
ODX f-'�27<-'
Address '
Town
Telephone
Telephone
Lo
C
POOP
FIRST FLOOR 1590 SO. FT.
BEDROOM
134 X 142
fjEATH i:Eo7N CLOUT
DRESS
In
CL. I Cl
BEDROOM BEDROOM
13' x 142 138 x 100
_eCC•:D $0. FT
L R M R /
PUTNAM CpUNXY DEPT
MOUSE PLANS !. PROVED F
:Tl .. Y
T
.a N- l
ROOMS
9Ignatur0 &TIt��.�w- "
or 171-AY "IM
__-�1 Date
a _
i.'
s
v � � t 2 c �,• �I\ � /� IF
/ / � s /'l -�- .. •a l 4a`. �r� /ice �.. t,�. •� _ /
1
\ R�
1 `1
j;
LAURENT ENGINEERING
ASSOCIATES, P.C.
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
RANDOLPH W. LAURENT, PE. (914) 278.6108 - (FAX) 278.2658
HARRY W.NICHOLS, JR., PE. ffA CONSULTING SITE ENGINEERS
August 9, 1993
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
ATT: Mr. William Hedges
RE: Proposed SSDS
Mooney Hill Road
T.M. 12. -4 -5
Town of Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. One (1) print of Drawing SS -1 "Proposed SSDS", dated 8 -6 -93.
2. Four (4) prints of Drawing SF -1 "Preliminary Design for Fill
Placement Only ", dated 8 -6 -93.
3. "Application For Approval of Plans For a Wastewater Disposal
.System ".
4. "Construction Permit for Sewage Disposal System ", dated
8 -6 -93.
5. "Application to Construct a Water Well ", dated 8 -6 -93.
6. "Design Data Sheet ".
7. "Letter of Authorization ", dated 8 -6 -93.
8. Two (2) copies of Residence Floor Pl.an(s), for "Bedroom Count
Only ".
9. A check in the amount of $300.00 for Review Fee.
10. Letter from Patterson Building Inspector, dated 8 -5 -93.
11. Neighborhood Notification list and certified mailing
receipts.
August 9,.1993
Page 2
93042 -A
Kindly review the enclosed items and contact us with your
comments and /or approval at your earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
. C
Harry W. Ni ols, Jr., P.E.
HWN:bd
93042 -A '
enc.
cc: Mr. R. Montgomery Jr. w /enc.
s-
0
��CTTNAM CO�CJNT'X- nEP.A.RTMENT OF' HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: AWOpa &yS- MAN. +V2P--rMh�
2. Name of Project: 132 -- �P�� 3.,_, Location /C: r
4. Project Engineer: _(� 4- u) j�6L4 Ift='. 5. Address:
License Number: Phone: 2-7 - 6lof3 1
6. Type of Project: t: .. ,
V Private /Residential• Food - Service ....Commercial
Apartments Institutional Mobile Home Park
Office Building:, Realty Subdivision Other (specify)
7. Is this project subject to State Environmental - Quality Review (SEQR)?
Type Status (Check One) Type I... Exempt ✓
Type II. Unlisted.
8. Xs a Draft Environmental Impact Statement (DEIS) required? fJ U
9. Has DEIS been completed and found acceptable by Lead Agency? ..
10. N,ame of Lead Agency
ti. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ........ ..............................
12. If so, have plans been..submitted to such, author .s ties? ..................... rJ /A
13. Has preliminary approval been granted by such authorities ? Date Granted:
14. Type of Sewage Disposal. System Discharge...... -'Surface Water ✓ Ground Waters
15. If surface water discharge, what is the stream class designation ?........ O/ /A
:6. Waters index number (surface) ........... ...............................
7. Is project located near a public water supply system? .................. N�1
If yes, name of water supply Distance to6water supply
si,Is project site near a public sewage collection or disposal system ?..... Q0
Nine of sewage system Q/A Distance to sewage system
'ate otserved: _ 2� _�!, 23. Name of Health Inspector: K/17— • .l-A.524EL,
bject design flow (gallons per day) ..................................... Fe
,g�-
r•
:• s. r 2..
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. e�p
26. Has SPDES Application been submitted to local DEC Office? ...............
27. Is any portion of this project located within a designated Town or State
wetland ? .................... .............. ............................... n)0
28. Wetland ID Number ......................... ............................... 1J 14
'29. -Is Wetland Permit• required?. .............. ...............................
Has application been made to Town or Local DEC Office? hJ /1�
30. Does' project require a DEC Stream Disturbance Permit? Q0
31. Is or was 'project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste disposal;```
landfilling, sludge application or industrial activity? ........ YES or NO 00
32. Is project located within 1;000-feet of existence of abandoned landfill, '
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? .....'.........YES or No k)d
DESCRIBE: =;
33. Is there a local master plan or file-with the Town or Village?
34. Are community water, sewer facilities planned to be developed within 15 years? dN KQ, WQ
35. Are any sewage disposal areas in excess of 15% slope? .....................,...
0o ff _
3,6. Tax Map ID Number ......................... ............. ................... I2
37. Approved Plans are'to "be: returned to: ................ . Applicant Engineer
If the application is signed by a person other than the applicant shown in Item.1, the.
application must be-accompanied by-a Letter of Authorization: Failure to comply with this
Provision maybe 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 Pena 1 Law.
SIGNATURES & OFFICIAL TITLES:
',AILING ADDRESS:
v
DESIGN DATA S'r =- --- URSUFACE SB4,hLE DISPOSAL SYSTEM FILE NO.
Owner A ti/ Akr 1/i'LAO Address EP EyX '2*6 , I _'t=1MXK) EV—, o - (,
Located at (Street) �D N ti` 4-fl LV ��� Sec. 1� " Block Lot
(.indicate nearest cross street)
Msunicipality ,b� —j`� me_ j Watershed
SOIL PERCOLATICN TEST DATA RDQU= TO BE SU&4I= WITH APPIJCATICNS
Date of Pre - Soaking '7 I Date of Percolation Test
SOLE
N[zmm CLOCK TIME PERCOLATION PE RC OLATIC N
Run Elapse Depth to Water From Water Level
No. Time Ground Surface In inches Soil Rate
Start -Stop Min. Start Stop Drop In Min /in Drop,
Inches Inches Inches
111. -12'• a 2 p� 2� 2'i 'h .
2 2: P9 , I2 i 1 2- r/� �a'
\ 4 2 2 '�7 a
2 W. - I h - 1' /.
4�2.
5
1
2
3
4
5
NOTES: 1.- Tests to be repeated•at same depth until approximately equal soil rates
are* obtained at each percolation test hole... All data to* be suhmitt�d
for review.
2. Depth irnasurenents to be made fran top of hole.
rev. 9/85
TEST PIT DATA REQUIRED TO BE SUBMITTED WrM APPLICATION
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DEPTS HOLE NO. j HOLE NO. '?
G
1
2
3
4
HOLE NO. �
INDICATE LEVEL AT WHICH GROUNI ,Q= IS ENCOUNTERED
INDICATE LEVEL TO WHICfi WATER LEVEL RISES AFTER BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MR.DE BY:�, DATE:.;
DESIGN
Soil Rate Used .Min/1" Drop: S.D. Usable Area Provided
No. of Bed.rocros 24 Septic Tank Capacity gals.' Type
Absorption Area Provided By _lj L.F. x 24 width trench
Other /-7 1 1 I , I _ 2 � 4�Z, 19 P2
1& 0 ,p
Nam 1
Na �( ?_ _ �ti�_, (�� �� ,`j�f , Signature V
Address :22 � .. -: C) �- • SEAL
OFD No. 56124
THIS SPACE FOR USE BY 'B ALTH DEPAR MENr ONLY:
Soil Rate Approved sq.ft /gal. Checked by Date
I
IOM
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date 2.) - <;: - 7/-j
Re: Property ofM Q� �/� ��1�\ {- fQ'Fi•/(���
Located at N jLL -yLc�>
Section Block 4 Lot
Subdivision of
Subdv. Lot # Filed Map # Date
Gentlemen:
This letter is to authorize`( ,�-
a duly licensed professional engineer 1�z or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules .
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Countersig:
P.E. , P
'�)- 1 i 1~� Djz I UE
Address
Telephone
Very truly yours,
Signed �Owner of
V d _ �,�X
Address
alT
Town
(41A) 09 _ fail
Te pho e
JOHN N. CALBO
Building Inspector
TOWN OF PATTERSON
PUTNAM COUNTY Telephone
878 -6319
PATTERSON, NEW YORK 12563
August 5, 1993
Mr. William Hedges
Putnam County Health Department
Rt. 312 Geneva Road
Brewster, New York 10509
RE: TM - 12. -4 -5 (12.5 acres)
Mooney Hill Road
Patterson, New York
Dear Mr. Hedges,
This is.to inform you that the above noted.tax parcel
constitutes a single building lot in the Town of Patterson.
If you have any questions,_ please do not hesitate to contact
this office.
Very truly yours,,
t
Frank Blasi
Temporary Building Inspector
cs
cc: Mr. H. Nichols
Neighborhood Notification List
T.M. 12. -4 -4
Patterson
12. -4 -1
Kessler, Robin
349 Mooney Hill Road
Patterson, NY 12563
12. -4 -2
Carlson, Richard A. & Agnes W.
5 Manor Road
Patterson, NY 12563
13. -1 -18
Harris, Andrew &
Hettwer, Mary
Mooney Hill Road
Patterson, NY 12563
13. -1 -20
Taub, Murray G. & Judy M.
6 Manor Road
Patterson, NY 12563
13. -1 -21
Ladau,,Robt. &.Anne. H.
Mooney Hill Road
Patterson, NY 12563
13. -1 -22.2
Chamberlain, James & Lois
Mooney Hill Road
Patterson, NY 12563
Kent
12. -3 -1 Hamilton, Susan
P.O. Box 25369
Los Angeles, CA 90025
i
\ f Itv I'1 Oy 41V
To
Neighborhood Notification List
T.M. 12. -4 -4
Patterson
13. -1 -15.1 Rinaldi, Salvatore & Diana
13.- 1 -15 -.2 132 Fairway Drive
13. -1 -15.4 Carmel, NY 10512
13. -1 -17
13. -1 -18 Harris, Andrew &
Hettwer, Mary
Mooney Hill Road
Patterson, NY 12563
Kent
12. -3 -1
Hamilton, Susan
P.O. Box 25369
Los Angeles, CA 90025
1
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Rinaldi, Salvatore & Diana
132 Fairway Drive
Carmel, NY 10512
Dear Mr. & Mrs. Rinaldi:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address :Mooney Hill Road
Town: Patterson, N.Y.
Tax Map :12. -4 -4
Please be advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well_
proposed,, for. .the captioned property has been made to the Putnam
County Department of. Health. :.Attached please, find a.copy of the:
latest site plan.
If you have .any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call': Mr. Hedges or Mr. Morris of the Health Department at 278 -6130.
Very truly yours,
By t
Title Agent
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Harris, Andrew &
Hettwer, Mary
Mooney Hill Road
Patterson, NY 12563
Dear Mr. Harris & Ms. Hettwer:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address:Mooney Hill -Road
Town: Patterson, N.Y.
Tax Map :12 . -4 -4
Please be advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed:• for. the captioned property has been made to the Putnam
County Department of Health...-.Attached please find.a. copy .of the,..
latest site -plan.
If,you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call': Mr. Hedges or Mr. Morris of the Health Department at 273 -6130.
Very truly yours,
By
Title AQ t
RECEIVED BY:
Address:
Tax Map:
JK;cj
FORMAT
NEIGHBOR NOTIFICATION
CONSTRUCTION PERMIT
Hamilton, Susan
P.O. Box 25369
Los Angeles, CA 90025
Dear Ms. Hamilton:
Date August 10, 1993
RE: Department of Health Review of
Proposed Sewage Disposal System
for property:
Name: Ms. Amanda Cushman Hoffman
Address :Mooney Hill Road
Town: Patterson, N.Y.
Tax Map :12 . -4 -4
Please be .advised that an application for a Construction Permit
relative to the construction of a sewage system and /or well
proposed.: for. the captioned property has been made to the Putnam
County Department . of Health..- , Attached .please .find a..copy of the.
latest site .plan.
If,you have any questions, concerns or information which may bear
on the Health Department's review of this application, you may
call: Mr. Hedges or Mr. Morris of the Health Department at 273 - 6130.
Very truly yours,
By
Title Age '
RECEIVED BY:
Address:
Tax Map:
JK;cj
3 Q
7
MTKAM MUM DEPARTMEM OF EIZALTH' J-
DMWIm offZevk=iMMW Redill SMA16& CaniiwL N.Y " 11612 I
112 SEWAGE DISPOSAL S1
Subwldsn Name Sam. W #
MWMg in
beeee to PWVWPN 01_.�.
np
Date Subdivision Approved Fee Enclosed U Amniint,
Ae)- 51 te;P legZ19 EZA4 Z Lot Arm FM Swdm 0* V.M. "VC0
111111111112 TY" S�F ... . I LJ D-P*
NwWbw of Bodnionts Design Flow G P D PCM NotMakdon Is Required Wbm FM Is completed _1
sopwaft &MUINP System to am" at GoUsss Sop& Tank and 44-7H7
To be ounbeeted by
Wallso, SEP*. Psh.ft Sqp* Frooa Address
an Je- JMv#Ao Sup* Darted by -FRIP ---Add.
Otbasr.Requkemeoft—
represent that I am wholly and completely responsible for the design and location of the proposed system(s); .1) that the separate
gp=L_diVI system
above described will be constructed as shown an the approved amendment there to and in accordance with the standards. rules on4Tr 07 Vu1nam
County Department of ►@qftN and that on completion thereof a "Certificate of Construction Compliance" to the Commissioner of Healthwill
0
be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the bulk ier. that said builder will
place in good operating condition any part of said sewage disposal system during the period of two'(2) years Immediately following the "to of the Ism-
once of the app ►- &I of the Certificate of Construction Compliance of he original system or any r S thereto; 2, that the drilled well described above
A
o Ins ad
will be located as shown an the approved plan and that said well will b dance rith the ndarA uies and reguMTons of the Putnam
County 04"Tta" of. Health.
Dow, 9 silo,! P.E. _�A.
Addre-
IjUe-, IL4&- Aj conse No
APPROVED FOR CONSTRUCTION- This approval 6xPIr@Z two Years from the date issued unless construction of the bl(ilding.has been undertaken and Is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change onto or alteration of construction
requires a now permit. ad for disposal of Uki sanitary sewage, and/or private My!!ff supply only.
Rev e
88 Date
10/
i
ii
RANDOLPH W. LAURENT, P.E.
HARRY W. NICHOLS JR., P.E.
August 28, 1995
Mr. William Hedges
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: SSDS Renewal - Permit #P -38 -93
Robert Montgomery
Mooney Hill Road
Patterson, N.Y.
Dear Bill:
Enclosed are the following:
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
(914)278 -6108 - (FA)O 278 -2658
CONSULTING SITE ENGINEERS
1. Four (4) prints of Drawing SS -1 "Proposed SSDS ", dated 8 -6 -93.
2. Four (4) prints of Drawing SF -1 "Preliminary Design for Fill Placement Only ", d�d
8 -6 -95.
3. "Application For Approval of Plans For a Wastewater Disposal System ".
4. "Construction Permit for Sewage Disposal System ", dated 8- 28 -95.
5. "Application to Construct a Water Well", dated 8- 28 -95.
6. "Design Data Sheet ".
7. "Letter of Authorization ", dated 8- 28 -95.
We would appreciate your review, approval and issuance of the Construction Permit at your
earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Ha ' W. Nich Is, Jr., P.E.
�
HWN:bd
93042 -1
enc.
cc: Mr. R. Montgomery w /enc.
- r
o I-
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1 . Name and Address of Applicant: ALA 'An, NM �,o j-�D tii�KI
D . j jpx GU S !uS Ar i e2 I
72
2. Name of Project: (����� 3.._._LocationOV/C:_ �o
4. Project Engineer: W 5. Address: ��!J�,�.11z�1�t�.Iti►
License Number:_ _• Phone:—,?,
6. Type of Pro.i.ect:
✓ Private /Residential Food.Service ....Commercial ,
Apartments Institutional Hobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject'to State Environmental - Quality Review (SEQR)?
Type Status (Check One) Type I.. Exempt ✓
Type II. Unlisted.
Y
8. Is a Draft Environmental Impact Statement (DEIS) requ.ire,d?
9. Has'DEIS been completed and found acceptable by Lead Agency? ......:.... NJ/ /A
10. Name of Lead Agency rJ /A
11. Is this project in an area under the control of-local planning, zoning,
or other officials, ordinances? 0
12. If so, have plans been _submitted to such : author .sties ?'....`................ rJ /b
13. Has preliminary approval* been 'granted by such authorities? NSA Date Granted:
14. Type of Sewage Disposal, System Discharge....... Surface Water V Ground Waters
IS. If surface water discharge, what is the stream class designation ?........ /A
:6. Waters index number ( surface) ........... ............................... ►. ,
i7. Is project located near a public water supply system? .................. N ()•
8. If yes, name or water supply Q/A Distance td water supply
9. Is project site near a public sewage collection or disposal system ?.....
0. Name of sewage system Q/A Distance to sewage system
1 . Date observed:. 23. Name of Health Inspector: t� e.
Y
Project design flow (gallons per day) ..................................... OD
25. Is State Pollutant Discharge Elimination System (SPDES) 'Permit required ?.. �p
26. Has SPDES Application been submitted to local DEC Office? .......... A
27. Is any portion of this project located within a designated Town or State
wetland? .................................. ...............................
28. Wetland ID Number .......................... ............................... ►4
29. -Is Wetland Perm, it• required?*..............................................
Has application been made to Town or Local DEC Office? IN) /..k
30. Does project require a DEC Stream Disturbance Permit? ...................
31. Is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste—ii.sposal;}'`.
landfilling, sludge application or industrial activity? YES or N0 )v
32. Is project located within 1,000•feet of existence of abandoned landfill, `
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known source of contamination? ............... or NO K)(J
DESCRIBE:
33. .Is there a local master plan or 'file•with the Town or.Yillage?
34. Are community water, sewer facilities planned to be developed within 15 years? V :NK)
35. Are any sewage disposal areas in excess of' 15% slope? ........................ S10
36. Tax Hap ID Number ........................................................
37. Approved Plans are'toba returned to: Applicant Engineer
If the application is signed by a person other than the applicant shown in Item.I 'the.
application must be-accompanied by y-a Letter of Authorization: Failure to comply with this
provision may 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 know7edge and belief. False staterents made
herein are punishab7e as a Class A Hisder,-eanor pursuant to Section 210.45 of
the Pena 7 Lair.
>IGNATURES & OFFICIAL TITLES:
TAILING ADDRESS:
PUR M.CCUN'TX DEPARM,97r OF aEALTH
DIV' - .ION OF HEALTH S 7ICES
DFSiGN DATA S'dFEEET- SUBSUFACE SEWAZE DISPOSAL SYSTE•i FILE NO.
cwner ��eess D. D �G (c� bl� v
Kited at (Street) Sec. Blodk 4 Lot
(indicate nearest cross street)
Municipality Watershed o
COIL PE:'2MLb=C -N TEST DATA REQC IRM TO BE SUEMS= WITH A.PPLICATiCLNS
Date of Pre-Soaking. 'j , (� Date of Percolation Test
HOLE
=
-
NUwB'-PR CL=
=-r,
P 2CO=CN
4
PERCOi.� MCN
Run
Elapse
Depth to Water From
Water Level-
No-
Tug
Ground Surface
In Inches.
So-i-1 Rate
Start -Stop
Min.
S tart Stop
Drop In
Min /In Drop
..
1
Inches Inches
Inches
2
=
3
2
4
3
�..
4
; �j�AA - :7iI
5
..
1
2 2
A
2
2
3
4
=�"I _ I !�� 2�i 2A
5
1
.
2
3
4
5
1.' Tests to be repeated at sane depth until apprcximately equal soil rates
are' obtained at each percolation test hole. All data to' be suh nitUd
for review.
2. Depth ma.siirements to be made fran top of hole_
rev. 9 /g5
TEST PIT DATA RDQU.Li2ED TO BE SUBMiT' M WITH APPLICATION
DESCF TION OF SOILS ElCak=M IN iT BOLES
DEPTH HOLE NO_ HOLE NO_ `?! HOLE NO.
6'
71
9'
10'
11'
12'
14'
INDICATE LEVEL AT WMICH GROUNI ?WTR IS EIJOOUNI'ERED N/A
IN- DICkTE LEVEL TO hHICH WATER LEVEL RISES AFTER BEING ENCOUNT —ERED N�A
DEEP ROLE OBSERVATIONS MADE BY: },1( (� , W , W�5 pz:51� DATE:. _ 2 P -
DESICMi
Soil Rate Used �IO Yin/1" Drop: S.D. Usable Area Provided Gi la �•
No. or Bedrooms Septic Tank Capacity �D 9�s • ��YPe0 1 C
Absorption Area Provided By r p L.F. x 24" width trench
Other
Na1re `�i- �� �i I liH-D �� Signature
1�-:,�
Address ��j�(I € L� Tai �1 SEAL w
n
THIS SPACE FOR USE BY 'HEALTH DEPAMIEW ONLY:
Soil Rate Approved sq.£t /gal. Checked by Date
PUTI .1 COUNTY DEPARTMENT OF HEi. .'H
DIVISION OF ENVIRONMENTAL HEALTH.SERVICES
Date
Re: Property of .ALLW 2A I�lSL(1✓AQ H OfElAA\ J
Located at
(T) fLj Section Block
Tom•
Subdivision of
Subdv. Lot #
Filed Map #
Lot
Date
Gentlemen:
This letter is to authorize
a duly licensed professional engineer V or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam.County
Department of Health, and to sign all.-necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Laser, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly yours,
1 .
Signed
o�. 0i,•ner of Property
Countersigned: s, No.5S124 w _
P. E. , ��. , Address
i�1214 6�CVKA —01A
Address TOIVA
elephone
�11:4 ) -j
Tel phone
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 # sn9 --9.
WELL LOCATION
Street Address
/)
V llage City Tax G� '- 4rfidNumber
1
- 2 Z_ '7 -
/ 0.
WELL OWNER
Name �
Mail * g Address JPrivate
Public
�E OF WELL
6'' primary
2- secondary
J] RESIDENTIAL
0 BUSINESS
0 INDUSTRIAL.
❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify
b INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm /#
PFOPLE SERVED,5-tZ, /EST. OF DAILY USAGE &Ck� gal
REASON FOR
DRILLING
0 REPLACE EXISTING SUPPLY
WNEW SUPPLY NEW DWELLING
❑ TEST /OBSERVATION CIADDITIONAL SUPPLY
13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
13DRIVEN
DDUG
GRAVEL. 0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �_NO
NAME OF PUBLIC WATER SUPPLY: A4 TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
)ON SEPARATE SHEET
(ate) (s�.$nature)
r�
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;, (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as of to degrade or otherwise contaminate surface or groundwater.
Date of Issue:
Date of Expiration 19� Permit Issuing Official
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 _ Yellow copy: Bldg. Insp. Orange copy: Well Driller
M l
l
FV'iT) M COUMY DEPAlliilEW OF HEALTH
D1.ww aramba4maw BOOM Sae.loe.. Cnsd N.Y. twit > to Fla ld.:I `taki
M CdMUftATE OF: COMKAANCB
COIN PMW Fast SEWAM D18 MU:STUZM
at W O^Arll� I f LL— i2Ur�fJ
Imi Nabs " : -. Let r
ZIP
42 `71 i.�fil�1� - Lot Area � $. � (:.�
4!0 Fm Seetiea Onb Wm., Vd M �D
Numb PCHD Notldwllon M Regdmd Wbea Fig b implobd
Sopseab ""MOM a Srtm to am" 414,P51) a Soptla Tact ••a d 0
Tta M:aadeou/od by e �/� Address
WSW Suffb: F Sw* Fi Address
ee Z_._Pehats Snub DeMed M ��••"
I represent'ahat I am wholly and: ompletely responsible f6r the design and location of the proposed system($). 1) that the separate saw Ai "I stem
w
.bo described will be constructed as shown on the approved amendment there to and in accordance with ten standards, rules a regulations o ruin
County Department of HmaA,. and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Coinmissbner.of Haelthwill.
be submitted to the Department, and a written guarantee will be furnished ten owner, his sucamon. Heirs or assigns by the bulklar, that mid builder will
Place in flood .operating condition any part of said wwage disposal system during the period of two (2) yens Immediately following thedat. of ,the lieu -
ance of -tM,appmal of ten Certificate of Construction Compliance of lhf original system or any raWirs.t, 0: 2) tent ten drilte0 well described Woes
WIN be located as shown on the approved plan and that said well will be insta in accordance wtth ten standa % ru f rpuu O of the Putnam
County Deportment of Hatttyyh,,.
Date 1 Signed P.E. b /R.A. _
L Address ' d License NO -�
APPROVED FOR CONSTRUCTION: This app val expires two years from the date i ad unless lonstruction of the building .has been undertaken and if
revocable for cause or may be amended or modified when considered necessary by ten Commissioner of Health. Any change or alteration of construction
R2V . require& a "N permit.. ApWojMd for disposal of domestic �sanitary
sewage. and private water supply only.
Is-
10/88
Oab
—�
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
APPLICATION TO CONSTRUCT A WATER WELL p
PCHD PERMIT # /��
WELL LOCATION
Street Address
op 1
r?
To Village City Tax Grid Number
2.
WELL OWNER
Name
1
Mailing
-0 NX 12- -l(
Address OPrivate
P _ _,Ofj 0 O Public
USE OF WELL
0- primary
2- secondary
® RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED
O FARM O TEST /OBSERVATION O OTHER (specify,
O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT gpm/ #
E3 REPLACE EXISTING SUPPLY
Et NEW SUPPLY NEW DWELLING)
PEOPLE SERVED_ to /EST. OF DAILY USAGE �i� Sal
O TEST /OBSERVATION Q ADDITIONAL SUPPLY
O DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN
DDUG
OGRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. _
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES Z NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
MON SEPARATE SHEET 4
i
. 9- (date) I (signature
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
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
Department attached to this permit.
3. Submit a Well Completion Report on a form
requirements of the Putnam County Health
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 su a mannerCa.5__not--to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19� ��...
�'
Date of Expiration 19 � Permit Issuing 0 ficial
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
BEDROOM
134 X 142
EATH
1 s. rX 'Loscl
DRESS. RIA.
C-.CSET
.ODF
WASTER
BEDROOM BEDROOM BEDROOM
134 x 142 138 x loo 134 x 194
Ercc•::) F,;,, CRpjTU*10UNT- Y DEPAR","KENT OP Atm oo,
HOUSE P A P- "S A P P 0 F, 0,R
FIRST FLOOR 1590 SO. FT.
P
JOHN N. CALBO
Building Inspector
TOWN OF PATTERSON
PUTNAM COUNTY
PATTERSON, NEW YORK 12563
August 5, 1993
Mr. William Hedges
Putnam County Health Department
Rt. 312 Geneva Road
Brewster, New York 10509
1l i�
C
RE: TM - 12. -4 -4 (40.66 acres)
Mooney Hill Road
Patterson, New York
Dear Mr. Hedges,
This is to inform you that the above noted tax parcel
constitutes a single.building lot in the Town of Patterson.
If you have any questions, please do not hesitate to contact
this office.
Very truly yours,
Frank Blasi
Temporary Building Inspector
cs
cc: Mr. H. Nichols
Telephone
878 -6319
LAURENT ENGINEERING
ASSOCIATES, PC.
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
RANDOLPH W. LAURENT, PE. (914) 278.6108 -(FAX) 278.2658
HARRY W.NICHOLS, JR., PE. ffA CONSULTING SITE ENGINEERS
August 10, 1993
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
ATT: Mr. William Hedges
RE: Proposed SSDS
Mooney Hill-Road
T.M. 12. -4 -4
Town of Patterson, N.Y.
Dear Bill:
Enclosed are the following:
1. Four (4) prints of Drawing SS -2 "Proposed SSDS ", dated 8- 10 -93.
2. "Application For Approval of Plans For a Wastewater Disposal
System ".
3. "Construction Permit for Sewage Disposal System ", dated
8- 10 �
.93.
4. "Application to Construct a Water Well ", dated 8- 10 -93.
5. "Design Data Sheet ".
6. "Letter of Authorization ", dated 8- 10 -93.
7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count
Only ".
8. A check in the amount of $300.00 for Review Fee.
9. Letter from Patterson Building Inspector, dated 8 -5 -93.
10. Neighborhood Notification list and certified mailing
receipts.
:August 10, 1993
Page 2
93042 -C
Kindly review the enclosed items and contact us with your
comments and /or approval at your earliest convenience.
Very truly yours,
LAURENT ENGINEERING ASSOCIATES, P.C.
Harry W. chols, Jr., P.E.
HWN:bd
93042 -C
enc.
cc: Mr. R. Montgomery Jr. w /enc.
PYJ'TNAL� COU].V"TX �Ep,p,,RTMENT OF' HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1. Name and Address of Applicant: ALA �SQ.l -l-t
2. Name of Project: �Ot� ��� 3.._. Location /C:�o
4. Project Engineer:1`� W t�l�ND1�dz 5. Address: �T%l FILE Iii)
l
License Number: Phone: 21 _ 61,19 b
6. _Type_ of Project:
✓
Private Residential Food-Service ....Commercial
Apartments Institutional Mobile Home Park
Office Building. -Realty Subdivision Other (specify)
7. Is this project subject: to* State Environmental-Quality Review.(SEQR)?
Type Status (Check One) Type I.. Exempt ✓
Type II. Unlisted.
8. Is a Draft Envirbnmental Impact Statement (DEIS) required? ............, I.IU
9. Has DEIS been completed and found acceptable by Lead Agency? nJ1A
10,. Name .of Lead Agency
11. Is this project in an area under the control of -local planning, zoning,
or other officials, ordinances? ...... ..............................
12. If so, Have plans been.-submitted to such. author .sties......................
13. Has preliminary approval been granted by such authorities ? M/,A,_ Date Granted:
14. Type of Sewage Disposal: System Discharge .....•. Surface Water v Ground Waters
15. If surface water discharge, what is the stream class designation ?........ 0/ /A
:6. Waters index number (surface) ........... r.V,6,
J. Is project located near a public water supply system? .................. n)r�
8. If yes, name of water supply WA Distance td water supply
9: Is project site near a public sewage collection or disposal system ?.....
.0. Name of sewage system Distance to sewage system
:1. Date observed: 23. Name of Health Inspector:
•f. Project design flow (gallons per day) ...... ............................... `�iDD
's?, -
2 .
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 00
26. Has SPDES Application been submitted to local DEC Office? ............... KVA
27. Is any portion of this project located within a designated Town or State
wetland ? ............... .................. ............................... r)�)
28. Wetland ID Number ........................................................ u&
29. -Is Wetland Permit., requ i red? .......... ....... 6 )0
hJ
Has application been made to Town or Local DEC Office? :.:.......
........ /'.
30. Does project require a DEC Stream Disturbance Permit? ................... f.�D
31. Is or was project site used for agricultural activity involving application
of pesticide$ to orchards or other crops, solid or hazardous waste disposal;` "`.''�`
landfilling,•sludge application or industrial activity? .......: YES or NO 0
32. Is project located-within 1,000-feet of existence of abandoned landfill, '
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other potential known .source of contamination? .....•.
.........YES or NO k1Q
DESCRIBE:
33. Js there a local master plan or file•with, the Town or Village? ...........
34. Are, community water, sewer facilities planned to be developed within 15 years? Q W:fQ 00
35. -.Are any,sewage disposal areas in excess of* 15% slope? V0
36-.-. Tax-' Ha •- ID Number ..... ............................... . ... ..........
37 - App,rove`d. Plans are* to"be; returned to: ................ Apps icant _Y/ Engineer
I-f the application is signed by a person other than the applicant shown in Item.1, the.
sppli`cat_i;on =gust be-accompanied by -a Letter of Authorization: Failure to comply with this
provision may be grounds for the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this
form is true to the best of my know7edge and be l ief. Fa lse statements made
herein are punishable as a Class A Xisdameanor pursuant to Section 210.45 of
the Pena 1 Lair.
SIGNATURES & OFFICIAL TITLES:
',AILING ADDRESS:�°r��dt� 1, •`i �t--�� h
DESIGN DATA S•HJ=- SUBSUFACE SEWP� DIS:PPOSSAL� SYSTEM FILE NO.
Owne s p . o
r
Located at (Street) QODNr- Sec. 112- Block - Lot
(indicate n'PA e—s tI cross street)
Municipality EV- - - watershed o 0
SOIL PERCOLA.TIC N TEST DATA RDQU= TO BE SLT&41= WITH APPLICATIONS
Date of Pre-Soaking, Date of Percolation Test
HOLE
Nth CLOCK TIME PERC OT=CN P£RC D=C N
Run Elapse Depth to Water Fran Water Level-
No. Time Ground Surface In Inches Soil Rate
Start-Stop Min. Start Stop Drop In Min/In Drop
Inches Inches Inches
3
4
5
NOTES: 1.• Tests to be repeated at same depth until approximately equal •soil rates
are* obtained at each percolation test hole. All data to'be suimitted
for review.
2. Depth mea.svreTents to be made fran top of hole.
rev. 9/85
a
1 �
•.tai
�? Z-
2-
3 "
fl
�4
.5
3
4 I j
66
2tj 2
2�
�1
5
1
2
3
4
5
NOTES: 1.• Tests to be repeated at same depth until approximately equal •soil rates
are* obtained at each percolation test hole. All data to'be suimitted
for review.
2. Depth mea.svreTents to be made fran top of hole.
rev. 9/85
a
TEST PIT DATA REIQUIRM TO BE SUBMITTED WITH APPLICATION
DESCPLUITION OF SOILS MMIIERED IN TEST HOLF-S
DEPTH HOLE NO. HOLE NO. HOLE NO.
63
71
8'
91
10,
13'
14'
INDICATE LEVEL AT waica GROUNDRATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH. WATER LEVEL RISES AF= BEING ENCOUNTERED
DEEP HOLE OBSERVATIONS MADE BY: M r—, DATE:.
DESIGN
Soil Rate Used D Min/I" Drop: S.D. Usable Area Provided r
No. of Bedrooms Septic Tank Capacity p gals.* Type
Absorption Area Provided By z9 - L.F. x 24" width trench
Other LA C2
Name
Address
T_
THIS SPACE FOR USE BY-HEALTH DF-PARDENr ONLY:
Signature.
SEAL
No. 56124
Soil Rate Approved sq.ft/gal. Checked by Date
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Date
Re: Property of z:LU'L9WAQ HGr FM,, (J
Located at
(T);�(� Dpi Section ��, Block �- Lot
Subdivision of
Subdv. Lot #
Gentlemen:
Filed Map #
Date
This letter is to authorize y' k) . jJI -r,z .
a duly licensed professional engineer V or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules.
or regulations as promulagated by the Commissioner of the Putnam County
Department of- Health, and to sign all necessary papers on my behalf in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code. �q
'gyp Very truly yours,
Signed
'tom:
Owner of Property
Countersigned: s�^ No. 55124
P. E. , P-- . Address
Addi-esg TOWA
Telephone
�4(4)�2��_
Tel phoneT
/ \ r
All
E;XtST:IIN6 — --- -�
RADE
1. 'r.OH fill must be stabilized by alloving the koH fin to settle naturally for a period
of at least 6 months and include, at least one freeze -thav cycle or Sill stabilation may
be .achieved by mechanical compaction in approximately si:r inch lifts to the approximate
density of the undisturbed underlying granular soil. The results of density tests
must extend three (3') feet performed, in the undisturbed underlying soil and in the till pad-are to be submitted to
tfT1i1 pad d three thieve the Putnaa County Health Department if mechanical compaction is to be utilized.
onal soil with the final 2• site modification activities involving placement of Sill are to a conducted during
soil with a,wi 1 to three relatively dry periods to minimize soil smearing and excessive soil compaction.
o-" the with a one (1)eto three 3,. Run of bank Sill shall be suitable for sewage absorption, be free of Sines or other
ch =s deep end ha lext inches wide. unsuitable material and shall have an in -place percolation rate at least equal to that
p an ,- ..., in the natural soil after the required stabilization period. The engineer /architect ,O
+agt.v in the till after stabilization. (\