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HomeMy WebLinkAbout0284DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -1 -15.3 1L # M% BOX 4 00093 �r 00093 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Goy DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Address aece-P,57? apoek z.A, Located at (Street) ZZ Tax Map 13 Block _I Lot (indicate nearest cross street) Municipality. so, Z - Watershed EA:5 7- -j3gj Alcli SOIL PERCOLATION TEST DATA Date of Pre-soaking 0/,)-- 7 e9e5;1 Date of Percolation Test &Z /3 fzoog" _0 ........... .......... . NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. :g I min for 1-30 min/inch, :5 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 : W., W. ........ ........ ......... .. F Gro.uh rom*. F, ve ... ti ..Mole Time Ea a Time Surface e No p p Start t C 2 Yx- s%z 3 - 4 5 8, 58 9,.2 � 2-7 zz yy —3 2 %1%24 — 9115C 3 19- a 31Y 2- /f /33 3 /0;00— /0,1 30 73/1,/ 9:5- 1 4 5 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. :g I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEN fAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION Name of Project T3ou�n �7z t�tzoo�� for? (T)(u) p.�- rr-�T75a�/ County Site Location Building construction begun ° Extent Is property within NYC Watershed ? ................. E�'Yes 0 No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) L [7 Hilly F7 . Rolling F--J Steep slope �entle slope F--] Flat 2. F--] Evidence of wetlands F--J Low area subject to flooding F--] Bodies of water 0 Drainage ditches Rock outcrops 3. Property lines or corners evident ................... .... ............................... F--J Yes F No 4. Do water courses exist on or adjoin the property? ............. * ................ Yes -- No 5. Will these affect the design of the sewage system facilities ?............ Yes No 6. Do watershed regulations apply in this development ? ....................... Yes Q No 7 Will extensive grading be necessary? ........................................... 10. No 8. Will extensive fill be necessary . for SSTS? ......................... .....7 � Yes EiK 9. Do filled areas exist within the SSTS area? ........ ..................... ........... Yes If yes, what is the condition of the fill? SECTION C. SOIL OBSE VATIONS 10. Appearance of soil: Sand a Gravel Loam F--J Clay 0 Hardpan O Mixture . 11. Observed from: Borings F--J Bank cut 0 Backhoe excavations 12. Soil borings/excavations observed by on 13. Depth to groundwater on - - 14. Depth to mottling 2 on 15. Are test holes representative of primary & reserve areas... .......? ....................... a Yes F-] No 16. Soil percolation tests made by I-IA=y lytel -/o[. 5 7, 6�, on F 3 0 oa 17. Soil percolation tests witnessed by ej'eN,--- p on SECTION D (on back) Form ST -1 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? 0 Yes F--]No. 19. Will groundwater or surface drainage require special consideration? ..................... [:]Yes a No 20. Will gullies, ditches; etc.; be filled and watercourses be relocated ? ......................... 0 Yes ElNo 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__] Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist? ..................... ............................... ffYes. a No 23. Additional comments 24. Site observer /inspector and title 25. Date(s)'of observation(s)inspection(s) S J3 -- . - - - - -- - oo e�rGS ©� 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 a• AUU- 16 —ZOOO 11:52 AM HARRY W NICHOLS BRUCE R FOLEY Public Health Director 914 279 4567 P.01 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 ATTENTION: a ADAM STIEBELING GENE REED LORMA MOLINARI R.N., M.S.N. Aseoalate Public Health Director Director 4/ Pollen( Services Ali information below must be fuU completed prior to any scheduling. DATE: 6" /&-06 ENGINEER OR FIRM: r� p- PHONE N. REASON: DEEPS: 01 PE4RCS: i PUMP TEST: o RD /STREET: 8l OA X d1 d *' (7 roo Lti C TONVN. d TAX MAPN• SUBDIVISION: 136. Wsw $ k f LOT #: OWNER: i Em h _ei g, YES NO o Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. 0 4d. Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. o 'L. Proposed SSTS within 200 feet of a watercourse or a DEC wetland. 0 )d. Proposed SSTS design How greater than 1000 gallons/day or SPDES Permit required. o Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This._pepartment will determine the NYCDEP project status (Joint or Delegated) based on the response, if you answered j= 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 sole responsibility of the design professional to schedule rewitnessing of the soil testing with NYCDEP. 9 FOR COMM USE ONLY DATE: � / a 3,113 cz;> TIMZ; 'S /'3 C% t� ,�CDC? t7 C�11�iV_�T3; (FtELDTEST) :R 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: F & R Development Co. 66 Argyll Ave. New Rochelle, NY 108.04 2. Name of project: 3. Location TN: Patterson 4. Design Professional: Keane Coppelman Enarfi. Address: 6. Drainage Basin: 7. Type of Project: 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 (SEAR)? Type Status check one Type I Exempt x Type II . Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? No 10. Has DEIS been completed and found acceptable by Lead Agency? ............... - 11. Name of Lead Agency,- 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... Ye s 13. If so, have plans been submitted to such authorities? No 14. Has preliminary approval been granted by such authorities? Date granted: No 15. Type of Sewage Treatment System Discharge ................. surface water x groundwater 16. If surface water discharge, what is the stream class designation? .................... - 17. Waters index number (surface) ........................................... ............................... - 18. Is project located near a public water supply system? No 19. If yes, name of water supply - Distance to water supply - 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system - Distance to sewage system - 22. Date test holes observed - 23. Name of Health Inspector - 24. Project design flow (gallons per day) 800 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... No 26. Has SPDES Application been submitted to local DEC office? .. No Y 2 I� 27. Is any portion of this project located within a designated Town or State wetland? No 28. Wetlands ID Number ............................................... Is Wetlands Permit required? .............................................. ............................... No Has application been made to Town or Local DEC office? No 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 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, landflling, 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 No other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town 'or Village? No 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? No 35. Are any sewage treatment areas in excess of 15% slope? . ............................... No 36. Tax Map ID Number .......................... ............................... Map 3.1Block 1 Lot 13 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 I .,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. Fa "e tatements made herein are punishable as a Class A misdemeanor pursuant toWect *0110.45 pf the Penal Law. SIGNATURES & OFFICL4L TITLES. T"-4-11? Mailing Address. yr 1Z DEVe O PMEJ�3T Go • G(G ARGYLL AV. E. NEvJ_ VOCk-16i.LE I tQy I Oqo64 ocJGDc��r2� ©� G��N€ 27r 1lr G j TEST PIT PROFILES r Hole,', Z Lot # 3 Hole # Lot # Depth to water Alb) jy, 5 Hole #_ Lot #_ Hole # Lot # 3 Hole # Lot # Depth to water Wo Aj Depth to water /yr Depth to water Depth to mottling ; �l o ni - Depth to mottling. Al,�, v j7- Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. x�� ,� s, cti G.L. u � ;}� ��Si c':� G.L. PO 1"e-' r y 4.0-,. 0.5 T5. 0.5 G ! 0.5 7;, 6.0 �fN/' 6.0 1.0 1.0 1.0 8.0 9.0 2.0 2.0 -' 2.0 3.0 5 . yk m,. 3.0 3.0 5.0 5.0 5.0 6.0 �. 6.0 �/`�1�/� 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 /�yc• r'� (tip 10.0 10.0 Hole,', Z Lot # 3 Hole # Lot # Depth to water Alb) jy, 5 Depth to water Depth to mottling jVy/, Depth to mottling Depth to rock/imp. J1%> /V,,r Depth to rock/imp. G.L. f' ' ►�, �_ / G.L. 0.5 �'� 0.5 1.0 1.0 2.0 2.0 3.0 3.0 4.0-,. 4.0 5.0 5.0 6.0 �fN/' 6.0 7.0 7.0 8.0 8.0 9.0 9.0 10.0 A-00-f-5 10.0 Hole # Lot # Depth to water Depth to mottling Depth to rock/imp. G.L. 0.5 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 la - u%.r— tJ —GVVV 11 .JJ MI'1 rlMKKT W 1`111.1.1UL-:D BRUCE R. FOLEY Public Health Otramr 719 er7 9561 P.04 LORETTA MOLtNARI R.N., M.S.N. Assodlate Pablk Health Dkoctor Dtrsctor of Portent Services DEPART OF HEALTH 1 Oeneva Road Brewster, New York 10309 REQUEST Fad FIEL.n TESTING. ATTENTION: o ADAM STIEBELING ±.GENE REED AM information below must be,iWIX completed prior to any scheduling. DATE: ENGMI ER OR FIRM: �'� � � G4�OL -5 �� PE PHONE #: REASON: - DEEPS: )k PERCS: o PUMP TEST: o ROADISTREET: �OJuvg— N'VOu- LA H l• TOWN: p Tr M TAX bW#: SUBDIVISION: F60046F--• SP-00E CD T(V 005 LOT#: 3 0WNER: 01 r—P-A1-A 7A A,, YES NO 0 Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. 0 Proposed SSTS within 500 feet of a reservoir, reservoir stem or control lake. 0 )!t Proposed SSTS within 200 feet of a watercourse or a DEC wetland. o Proposed SSTS design flow greater than 1000 gaRonstday 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 yA 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 sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COMY USE ONLY DATE: TME: (FMLDTEST) i 97 6fT.s7 19 M 170. x 157.N 193 170.43 29200 P/0 3- ' , i P/0 3-1-22 r P/0 ° X28 I 4 �/ 38 p 3.71 3 I , 66 24` a P/0 3-1 sy� 20 soo4e er 3 AC. 24„ 25 '26. 23 27 ` ACCAt. / / _ 1.e.r 3.01 AC. e17a 4p R00 Rd+ g' : 3.65 AC. 36 po ?� 291.97 }19.09 239.34 s 1019 25 1.7 I X48, CdL. /ROp tia , 440.99 1. z2.z 23 Hrr� C.0 2.27 1.88 `y, /goo 41 s 40 , AC'.s� R�2 a �.84AC C.CAL 16oto `6330 / 4 42 v . '5 ..... 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J '• 393. 1 ^ E39.3B `� I . \ _ �\ �1 �� \ \ . � �\ �� \ ♦ \ \,� i . �\ ' �• � 4\\ \\ �� \� \ �` � �� � � � - \\ \ \\ � � \ - \\ \\ �� ((� ,\ \ \\ 1 �. � � \� � � � 1 1 / \� �` \ \ `: ` 1 1 \ � � � .' PUTNAA'COUNTY H TH DEPT. 0 2 2 9 3 6 . ; ;. 1 Geneva Road (845) 278 -6130 � Y 0 PUTNAM COUNTY DEPARTMENT OF HEALTH A� DIVISION OF ENVIRONMENTAL HEALTH SERVICES Q CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SE NT SYSTEM PCHD CONSTRUCTION PERMIT # P _ C — 01 Located at S1 Epp 6��-- 1-P� V'_ Town or Village �6�M Owner /Applicant Name )1A (_1 Formerly D i FP__AH*'2_A A Mailing Address �A= Date Construction Permit Issued by PCHD _ Separate Sewerage System built by ZaL Consisting of C 2 Q Gallon Septic T Other Requirements: Water Sunoly: Tax Map `r�' Block Lot 15 Subdivision Name Subd. Lot # p� � 5� e' ' zip i C <0� -`v50 G (fly j Address y -g- TULt4 Mo 0& Ste" _/ \0' 01 ank and moo Vf- Prb'� Public Supply From. Address k or: Private Supply Drilled by Address 105`1 �l X12 CtB- >3i to�fv Building Type �5 t e` l�L Number of Bedrooms Has erosion control been completed? Has garbage grinder been installed? f e_� N t 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 Co ty Department of Health. Date: 2 Certified by P.E. )4 R.A. sign Professioni1) Address 4 K r3� iw'�oA License 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 ar ubject to modification or change when, in the judgment of the Public Health Director, such revocation m/J ificati7;Zge is necessary. B ,� Title: eJ t"' ' — Date:', Zi 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: F1 �u W 44-4 I-v-o k R9.1 To��jj'nNillage: Fd -jkFSB tj Tax Grid # Map 14 j, Block I Lot(s)16, � Well Owner: Name: 1 Address: eS�9 3 -A Use of Well: 1- primary 2- secondary .20 _�( Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion __K_ Compressed air percussion Other (specify) Well Type Screened Open end casing 1C Open hole in bedrock Other Casing Details Total length AJ_ft. Length below grade �0 ft. Diameter A in. Weight per foot _�lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded7y Threaded _ Other Seal: X Cement grout _ Bentonite Other Drive shoe: JC Yes No Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours Yield J& gpm Depth Data Measure from land surface- static (specify ft) 5? 1 During yield test(ft) ,w Depth of completed well in feet 9,0s Well Log If more detailed Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. information descriptions or sieve analyses Land Surface /C 7-L(/ W 0-0 . " � c4 Dal O'YVQ,w .- are available, please attach. Aff t -T"' ISTL -SE at- mil 92!a If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 5 v Capacity Depth :L40 Model Voltage HP Tank Type idy- %2- Volume Date Well Completed Putnam County Certification No. 00 Date of Report Well Driller (signature) NOTE: Exact location of well with distances to at least o permanent landmarks to be provided on a separate sheet/plan. �yd Arfesia,� We v Cho •d/I t, � 6(1 f� � Well Driller's Na e ru Address: 05 Signature: Date: L l0 White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 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 J'6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 February 7, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed Compliance: JGC / formerly Di Franzia 81 Boulder Brook Lane, Lot #3 (T) Patterson, TM# 13 -1 -15.3 Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: 1. All water analysis must be performed by a New York State certified lab. If CW Environmental Services is aNew York State certified lab, please provide certification number for verification. The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. . Very y yours, Robert Morris, P.E. Senior Public Health Engineer F7T"�'1 Harry W. Nichols Jr., P.E. IV Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 February 1, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance - JGL Boulder Brook Commons, Lot # 81 Boulder Brook Lane Patterson, New York Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -3, "As Built SSTS," dated 12/10/01. 2. "Certificate of Construction Compliance for Sewage Treatment System," dated 2/1/02. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System," dated 2/1/02. 4. Laboratory Reports, dated 1/9/02 and 1/28/02. 5. "Well Completion Report," dated 1/10/02. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. `T -911 Address Verification Form," dated 12/11/01. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. INichs Jr., P.E. HWN:jmm 00- 135.00 N NORTHEAST LABORATORY of DANBURY ,N ACCOg0�� { 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 �o 203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 a )GABS www.NORTHEAST LABORATORIES.com LABORATORY REPORT REPORT TO: J.J.C. ASSOCIATES - DATE SAMPLE COLLECTED: 1/2/2002 22 TULIP ROAD TIME COLLECTED: 5:36 P.M. BREWSTER, N.Y. 10509 COLLECTED BY: GARY DATE RECEIVED @ LAB: 1/2/2002 TESTED BY: LAB #11471 LAB I.D. # NY -0003 REPORT DATE: 1/9/2002 SAMPLE SITE: DONNA BARRETT, 81 BOULDER BROOK LANE, PATTj�RSON, N.1. SAMPLE POINT: KITCHEN SINK SOURCE: WELL TREATMENT: NONE MAXIMUM CONTAMINANT TEST PERFORMED RESULTS METHOD # LEVEL (MCL) OR STANDARD BACTERIAL: • Total Coliform (Bacteria) 0 per 100 ml SM 9222B 0 per 100 ml PHYSICALS: • Color (Apparent) 25 - EPA 110.2 15 • Odor ND' - - 3 Units • pH 6.44 - EPA 150.1 No designated limits • Turbidity 35.0 NTUs EPA 180.1 5 NTUs CHEMISTRY: • Nitrite Nitrogen <0.005 mg/L as N EPA 354.1 • Nitrate Nitrogen <0.20 mg/L as N SM 450ONO3D • Alkalinity 42.0 mg/L SM 2320B • Hardness 62.0 mg/L EPA 130.2 • Iron 2.86 mg/L EPA 236.1 • Manganese 0.09 mg/L EPA 243.1 • Sodium • Lead 3.15 mg/L EPA 273.1 0.002 mg/L EPA 239.2 1.0 mg/L 10 mg/L No designated limits No designated limits 0.30 mg/L 0.50 mg/L Combined limit for Iron plus Manganese = 0.50 mg/L 20.0 mg/L ** 0.015 mg/L * ** ml= milliliter mg /L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count . "Notification Level ** *Action Level COMMENTS: -All holding times (were) met. SAMPLE, AS TESTED ABOVE: MOTABLE or ONOT POTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) RESULTS BASED ON SAMPLES SUBMITTED: 1/2/2002 Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800- 826 -0105 •OUTSIDE CT: 800 -654 -1230 CW ENVIRONMEN'T'AL. SERVICES 380 OLD WATERBURY ROAD — UNIT #12 SOUTHBURY, CT 06488 203- 267 -6539 (FAX:SAME) WATER ANALYSIS REPORT TO: JGC Associates DATE SAMPLE COLLECTED: 1/28/2002 22 Tulip Road TIME COLLECTED: 1:10 P.M. Brewster, N.Y. 10509 COLLECTED BY: Gary DATE .RECEIVED: 1/28/2002 TESTED BY: ELAP#11715 FILE I.D. # CW -050 REPORT DATE: 1/30/2002 SAMPLE SITE: 81 Boulder Brook Lane, Patterson, N.Y. SAMPLE POINT: Outside Spigot SOURCE: Well TREATMENT: None DATE MAXIMUM CONTAMINANT TEST PERFORMED RESULTS METHOD # TESTED LEVEL (MCD OR STANDARD PHYSICALS: • Color (Apparent) ND Units SMWW 2120 B 1/29/02 15 Units • Turbidity 1.62 NTUs SMWW 2130 B 1/29/02 5 NTU CHEMISTRY: • Iron <0.03 mg/L SMWW 3111B 1/30/02 0.30 mg/L ml--milliliter mg/L –milligrams per Liter ND --none detected MCL= Maximum Contaminant Level TNTC =Too Numerous To Count S.U. Standard Unit NTU= Nephelometric Turbidity Unit TON = Threshold Odor Number *"Notification Level — Manganese Action Level= 0.50mg%L – Lead ActionLeve1= 0.015mg/L COMMENTS: -All holding times (were) met. - RESULTS BASED ON SAMPLES SUBMITTED: 1/28/2002 sident Results Certified by JMS Laboratory PH -0218 — ELAP# 11715 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner. or Purchaser of Building Tax Map . Block . Lot Jet, Building Constructed by TownNillage �1 t)0U0 R- i�VOQV LAKE, �QJL PEA 6P-mt, co Location - Street - Subdivision,Name . Building Type Subdivision Lot # 1 represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed• as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in.good- operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment'system, or any repairs made by me to such system,,except where the failure to operate properly is caused by the willful or negligent act of the occupant.of the .building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the'failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the s},stem. Dated- Month Day Year 4-WAL, Signature - Title: Aeneral (4ntr for (Owner) - Signature .�� � f�S�t;C,�p�1✓S T� V P�S�,o�,t�� Corporation Name (if corporation) Corporation Name (if corporation) Address: yL y LI.Q 1-C7 PD bpy b_i State Zip Address: 1-1 WW UZJr) � State �4 .. Zip Form GS -97 tw BRUCE R.: FOLEY .. LORETTA `MOLINARI- RN., M.S.N. Ppblic Health Director 0 Associate Public Health Director Dlre2tor of Patient &rvkei DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Eovlroamental Health (914) 278.6130 F"(914) 278.7921 Nutsla8 Services (914)278.6538 WIC (914) 278.6678 .Fut (914) 278.6083 " Early lnitervi 6x'(914)111'• 6014 Preubool (914)278-6092, Fu(914)27F-6649 E911 ADDRESS VERIFICATION FORM OWNERS NAME:% TAX MAP NUMBER:� ` r l 1911 ADDRESS: loge AUTHORIZED TOWN OMCIAL. (Signature) . DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed; i ei, a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance, l Exi ST WELL -� IN 0 0 �v Putnam County Department of Health Division of Environmental Health Services Appr�e as noted for conformance with -- --,; of thw DIMENSI ®N CHART (in feet) Number tRGX C LLG.69.90' f0 P97P. A B 1 25 38 z 22 62 3 29 5S 4 28 54 5 32 50 6 36.5 47 - 7 41.5 44 8 47 42.5 9 53 42 0 58 4z 11 77 110 I 77 107 3 7r 104.5 14 79 102.5 15 81 100 16 83 99 17 85 98 19 800 97 19 91.5 96 CU5HM NB3M 215.42' 1 ', 'Vrryryry /�ptl �.� N v v9 b c i ` v o ` UI� tRGX C LLG.69.90' f0 P97P. #+� 92.42' j 706 pcW, LOT No. 3 ASMA �- 2.067 PG. t 1 s ', 'Vrryryry /�ptl �.� N v v9 b c i ` v o ` UI� PUTN ADI CO1JN7Y DEPARTMENT OF HEALTH l DIVISION OF ENVIRONMENTAL HEALTH SERVICES °f FINAL SITE 1;SPECTION Date: Inspecte y: g::�, TZ�Fr) Street Location e%/<,&dg j�Az g:,r_, Owner ise;¢Nelg Town Permit # P 6 -©/ TM r ! 3 - / -- ! , 3 Subdivision Lot # 3 1. SewaQae System Area YES 0 COMMENTS a. STS area located as per approved plans ........................... �a ✓� . b. Fill section - date of placement ' 3:1 b.arrier Lgth. Width Avg.Dpth c. 'Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.....:.::. e. 100' from water course / wetlands ...... ............................... , II. Sewage System a. epttc'rL tank size - 1,000 ....... . , .....other ................ 125 ... b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft- Original soil between box & trenches e. Junction Bo - properly set ............................ f. 1 renc es T.ength required SOc-> Length installed i5-c2a 2. Distance to watercourse measured+t o 0 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% ......................... s Ok- 8. Size of gravel 3/4 -1%" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped .................................. :.................... g. Pump or Dosed Systems 1. Size ot pump chamber ................ ............................... 2. Overflow tank ............................. ............................... IF 3. Alarm, visual/audio .................... .......:.:..................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ..............::............... 6. Cycle witnessed by H.D.estimated flow /cycle.......:... III. House/Building /love Cs C,_ p /q" a. house located per approved plans ... ............................... b. Number of bedrooms :....................i&.. gp ................... . IV. Well a. Well located as per approved plans . ............................... f e-& - b. Distance from STS area measured •t- /e,> 6_--1 ft ........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. 'Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & du.to exist watercourse g. Footing drains discharge away from STS area _ h—Surface viater protection_= adequate 3 -- 1 •"�: �I+TATIAn PAII }TA� T\T!1 \I1�P�V - -- BRUCE R. FOLEY Public Health Director November 16, 200 LORETTA MOLINARI R.N., M.S.N. 6j! Y F Associate Public Health Director Director of Patient Services 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 (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - D'Francia Cushman Road, (T) Patterson Lot # 3, TM# 13 -1 -15.3 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: 1. Properly install silt fence as per the approved plan. 2. Laterals need to have a two foot section of solid pipe from junction box to the trench. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Very truly yours, Gene D. Reed GDR:cj Environmental Health Engineering Aide NOV -07 -2001 11:50 AM HARRY W NICHOLS 914 279 4567 14 0ASM V Dig FotS .1 Ag WMmrit =ll bf "OR&W p& a Aq xc - . imtp � sue:. t caavadorF� 2'$ q� Owned Nem Gn �N t is ryam dlloom�p�todt H A u synaoa oosop�tMl' ... Daaa Is syit� aoautetioad w � It `�"�o! Is rYd WAW M PWOW t cxst'dj►tthstd� rbr�ea� w t�mv � trsbeen vams+nss�ed urdl �ri hipeeted tad yet" tb4r oompledoa W +idoo t .�_ .,Con own pamb Ud spprovid ptsm *ad ter dmaduk UW &d ,Cottatlr Dqutmeot of I Ll Due. Addreas: c Ko. A"lc0 A I('ll I_7.. �1al11 I.fCI.1 17 • laa Tom! • �tdr.- a7f�_7ga1 • ti��M P• 01 _.Q O SENDING CONFIRMATION DATE NOV -8 -2001 THU 16:18 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE PAGES START TIME ELAPSED TIME MODE RESULTS 92794567 : 1/1 NOV-08 16:16 00'43" G3 OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... NUV- D7 -SYOi 11989 A" HARRY H'Hlo"O s _- et♦ 910 •991 P.O. A?iOR�OM1I CANN ��M��yyprraa/ TnMw... 9 iaoil4il HW -T -Mi UK) 12:02 TFLIM -M -7921 NW:PUR WI CARRY 0EPFRTPFNT IF P. 1 oaa u Al ua�it� '�AJ� Ark NI KIA Lw/IOOr1011R� � �i dir �IM�� � •�w,•nw�arNdrd11..4ia1M . PA Agra - iaoil4il HW -T -Mi UK) 12:02 TFLIM -M -7921 NW:PUR WI CARRY 0EPFRTPFNT IF P. 1 NOV -13 -2001 04 :13 PM HARRY W NICHOLS 914 279 4567 P.01 NOUdB-2001 16:17 FRQ'I:PUTNAM COUNTY DEWAT 645- 276 -7981 TO:92794567 MOVE -07-3601 l! low AM MAPAT N NICHOLS 014 279 ASST P.91 .. ,..■ .. �'rio�iroa a AFL 1 Iwo"= �,�Ir�arAlrrww�� Ql. / -s mdudtbm-i NA ���, �``i .04f bra ■ NOU -7�t I+�p 12:02 1FLe64s -� ^75X'1 Nnu- 1l -aAA1 TUF 16:25 TEL:845- 278 -7921 NAM2: MMM CMXrY 0FPPRTM6dT OF' P. i NAME:PUTNAM COUNTY DFPARTMFNT nF P. 1 I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .,CONSTRUCTION PE A GE TREATMENT SYSTEM, PERMIT # 0 -�L-dJ Located at cu,5f+Hrk) # 12-0 Np Subdivision name gN P- B Gib° S+ub: d �l I Date Subdivision Approved 71 e1g 1 Lot # ;> Town or Village Tax Map 1 4) Pj+-r-- ,S0 W4 Block 6 Lot 0- Renewal Revision Owner /Applicant Name J C 1 Date of Previous Approval Mailing Address- { i� �'� ' P51-0i 0J4 Zip 1()(714 1 Amount of Fee Enclosedj� Building Type W5B Lot Area 1°C'INo. of Bedrooms 4 Design Flow GPD__8 00 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: To be constructed by T 6 P 1 -5z gallon septic tank and 1�,) Cy+ Lni j Address Water Supply: Public Supply From Address or: 4 Private Supply Drilled by -M� Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: A61 ,,, Z 'P.E. .. � R.A. Date �5! Qi Address 'N i 1 ' � �' ix .oho Fl- (V3- License # `� (10 9 APPROVED FOR CONSTRU TION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Approved pr discharge of domestic sanitary sewage only. xtB y: i6` e Title: Date: White copy - HD F' e; Ye ow opy - Building Inspector; Pink copy- er; OratW copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL Q please print or type PCHD Permit # 01 Well Location: Street Address: ��, Town/Village Tax Grid # c�i�� illj' F-4 �1,� m� p/o 14? f Map q Block Lot(s) Well Owner: Name: Address: OJ Use of Well: A Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 4�i gpm # People Served .4-6 Est. of Daily Usage %00 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling _ New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type >C Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No 7C Is well located in a realty subdivision? ...................................... ............................... Yes A No Name of subdivision Lot No. Water Well Contractor: j 1,1 ? Address: Is Public Water Supply available to site? Yes No Name of Public Water Supply: °-' Town/Village �. Distance to property from nearest water main: — Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: 11 �-SI IID 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 warr well driller certified by Putnam County. Date of Issue Permit ssuing Official: Date of Expiration 2-17, -0 25 Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 \'i BATH _ 11 1 1 j %- 1 L•s.ar.J 1. • .J < �. 1) .� BEDROOM .c 0[ ; y'•8' x 12'Q' DRESSING BEDROOM 3. W/�l K 13' -0' x 10'•0" CLOSET a L j MA -STER SEOF100 m BEDROOM 2 OPEN N 17%0 a 16'•8•• 13 O' H Is ..a 1 PUTNAM COUNTY D PARTMENT OF HEALTH � f U$E PLANS APPROVED \F,0R BEDROOM COUNT ONLY, SECOND FLOOR ALL SUBSEQUENT N't' I�LV 60MALTERATTO S �04,q� ilob E4 4 S F PLA YS MUST B '7;LiAYI•.: TED TO THE PCDOH FOR APPROVAL t— SJc, —t •TVlWl Fc IT r DINING MOOI.•1 13, 0- r 12'.0.. LIVING MOO 17'•0" r 1 i'•0" KITCHEN p L. MORNING AGOM OPEN ' ABOVE FOYEM l MW r FAu1LY R00" 13' 0- a 1?* 0" FIRST FLOOR 4828 DIVIS- ~ 1-OF Ewntomaim HEAm SERVT DESIGN DATA SHEET SUBSUFACE SEKAGG DISPOSAL SYSTEM FILE NO. Owner Y/✓01•.W i57 0 s, 1 Kl/ Address 7 eOX i',stz*r� Ixxated at (Street) CQ-I2> I/\AAW (ZDA0 Sec. Block Lot In, (incRca to _� nearest cross street) mudcicality _ PA ?ri;2�Ot�l Watershed C_(ZOTUN SOIL PERCOLA=CN TEST DATA RDQ(TMM TO BE SUEMITM WITH APPLICATIONS Date of Pre - Soaking 11- 13 -1D Date of Percolation Test if - 13 -CIO BOLE NtPSBm CT= TIME b PERCOLATION . PERCOLATION Run Elapse Depth to Water Frcm Water Level No. Time Ground Surface In Inches Soil Rate Start. -Stop Min. Start Stop: Drop In Min /In Droo Inches Inches Inches l 1 12:23 -12:5 3 : 30 24-''" 27 2 I' : 54 - :I : ZA• : 30 3 i. G5 1 • �� •.� k q' 2 a l� I4 2Co 5 2 1: �' - 2: 0-7 �o 2 j 3 : Q. 3 , 30 20 4 14 225 i2 5 1 2. 3 - 4 - - 5 r:o'M: 1. Tests to be rip ated' at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be submitted for review. 2. Depth measuretents to be made fran top of hole. rev. 9/85 TEST PIT DATI UIEtED TO BE SUBMITTED Wriu I ;,IC x 1UN DESCftIP'a +.1 OF. SOILS ENGOUNTERM iN TESZ _.OLES ' DEPTH. HOLE N0. I HOLE N0. 2. HOLE NO. _4- �' S G.L. i g w i 1' 2' 3' 4' SAN �Y � :• i�L. i.OA N� 6' �(2, AVM 7' r" KAvoL`( 8' i-DAM 9' Mo . NO WA1159.. . lit 1.2 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOPUNTERED DEEP HOLE OBSERVATIONS MADE BY: ��_! �I bZ I IJ.1 DATE: DESIGN Soil Rate Used Min/1 °_.Dr0p: S.D. Usable Area Provided No. of Bedrooms 4 Septic Tank. Capacity, /250 gam. •T7rpe Absorption Area Provided-By r9 L.F. x-24" width trench Other z'- o .. a F �. a. l= L C �D�t ��la 'f t LAUREMT E/VGINRE 'Al G Na;e AS_soc lAT ES P• c. Signature V/JV SEAL Address ��Z ; �� •�� �� �••-' Address N 124 . . t�l to�'1EtZ A/—O c - yoRr oFE3Q , ZiIS SPACE FOR USE BY HEALTH DEPARLMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by -Date i�L. Stt.TY �(2, AVM r" KAvoL`( i-DAM 1-UAM' P, D� NO yVATr:IZ. 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENOPUNTERED DEEP HOLE OBSERVATIONS MADE BY: ��_! �I bZ I IJ.1 DATE: DESIGN Soil Rate Used Min/1 °_.Dr0p: S.D. Usable Area Provided No. of Bedrooms 4 Septic Tank. Capacity, /250 gam. •T7rpe Absorption Area Provided-By r9 L.F. x-24" width trench Other z'- o .. a F �. a. l= L C �D�t ��la 'f t LAUREMT E/VGINRE 'Al G Na;e AS_soc lAT ES P• c. Signature V/JV SEAL Address ��Z ; �� •�� �� �••-' Address N 124 . . t�l to�'1EtZ A/—O c - yoRr oFE3Q , ZiIS SPACE FOR USE BY HEALTH DEPARLMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by -Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES .DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner J 1 to jA6 A Address ,`M-A I N ; E (rTiwu-) rsJ IoTi� Locatedat (Street) C06 FAN' 00D i F'MtOd Tax Map' M Block Lot `c (indicate nearest cross street) - Municipality 11' H Watershed eA,5 bPAK%O SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test 17 11 _1 2 3 4 5 1 2 - 3 -.. 4 5 1 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 mnn/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. 60 HOLE NO. HOLE NO. G.L. 0.5' G _ �n 709 ,b6V E- (a ifl�h .. 4 -G, V,7 p-6 T6 1.0' 1.5' 2.0' _ 4'�� `��� ��- 4`- c" Div, �'- j. KA 2.5' 3.5' �QCC GiT 5 5 i>� 4.0' _ 4.5':Q�. 6.0' 6.5' IL 7.5' 8.0' o, 10.0' Indicate level at which groundwater is encountered N005 Indicate level at which mottling is observed N OMc Indicate level to which water level rises after being encountered i ANAE Deep hole observations made by: 6 6Hc HO 50 CPLAP6) 0q10:X) , J ' "LVP ,5 »'f6 Date 11 5) ° 1 Design Professional Name: rw-m y' Address: �� o MW 105- VL Signature: I A ' Design Professional's Seal 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner ' N �t �-� Address %� + �,r; i ,�� �R ,� �. � # i l� Located at (Street) Tax Map Block 1 Lot d`} (indicate nearest cross street) Municipality Watersheds SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test Hale Na Run No T�nte Mart. Stog : Ufa a Time �n:) Surface (Xaches) Start l; #ap ilrQp In Inc es Rate M�e>FInth 2 33 9, s— A 2, 3' .� rlldd'' lad 6,3 4 5 C' 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 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. 3 0.5' 1.0' 1.5' 2.0' 2.5' - 8`-t" X711 3.0' .3.5' 4.0' Lb Arm 4.5': 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered W i-la Indicate level at which mottling is observed A0wt Indicate level to which water level rises after being encountered Deep hole observations made by: A. ( CLAV), Date l I � e'� Design Professional Name: hikes-' yoL Address: tNf114 -to f,,1 10 ,�Oj Signature: Design Professional's Seal W w NO. ���� ��OFESS101, %% 2 PUTNAM COUNTY DEPARTMENT OF HEALTH .DIVISION OF ENVIRONMENTAL HEALTH. SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner J i H P j PP-AH C- I A Address ?0 �11'447 N Located at (Street) cu'�k"d. k (ftoe� Oun Tax Map iii> Block Lot 1'5`° (indicate nearest cross street) Municipality H Watershed SOIL.PERCOLATION TEST DATA Date of Pre-soaking al 'Lj) 00 Date of Percolation Test NOTES: -1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, :5 2 min for 31-60 tniifilinch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 5 Via, 011, 2 9;3 1 1 3 101"A �2i% x'011_ (1�) 4 5 2 I'LL 1/4 3 4 5 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. :5 1 min for 1-30 min/inch, :5 2 min for 31-60 tniifilinch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. I HOLE NO. T -,HOLE NO. I 0.5' 1.0' 1.5' 2.0' P��n S RNQ 2.5' 3.0' i0l�c� 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' C- Ina leVel at which groundwater is encountered hoNE Wade l&l at which mottling is observed N bH1 I -3 a�,e l�l to which water level rises after being encountered NA I dle gservations made by: M. bQ M H6V-1 (PCA40) Date Desgpffro€eisional Name: V--XP Address: / o5O ` L Signature: Design Professional's Seal M �. .r_u�.:� Yl' •� •may. r' E .� ,�",�''y J,�"Y Kam' •`• '��, r 2 14.16-4 (9195) —Text 12 PROJECT I.D. NUMBER 817.20 SEQR Appendix C _._.. State Environmental Quality Revlew SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT. INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME , P 3. PROJECT LOCATION: Municipality P)krjj��P�A_ County P11—iHAt-1 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) CU5AHp�H fZ-OAV 5. IS PROPOSED ACTION: ® New ❑ Expansion ❑ Modlflcatlon/aiteratIon 6. DESCRIBE PROJECT BRIEFLY: __... . 7. AMOUNT OF LA AFFECTED: acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? ELYes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? &osldenttal ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest/Open apace ❑ Other Describe: �,Jt46i.r_ 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR.LOCAL)? . ... - ❑ Yes O No If yea, list agency(s) and permlt/approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ® No If yes, list agency name and permll/approvai 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes ErNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE i'r �� 140 L AppllcanUsponsor name: Date: LL Sl9nature: !' If e action Is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 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 Harry Nichols, P.E. Patterson Park Suite 1, 06 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: DiFrancia Cushman Road, Lot #3 (T) Patterson, TM# 13 -1 -15.3 Dear Mr. Nichols: January 22, 2001 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject local wetlands regulations. You should contact local wetlands officials in this regards. 1) Subdivision data indicates that two feet of fill is required in the SSTS area. The fill has not been shown' Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. 11 9TRF1 Ve ruly yours, Robert Morris, P.E. Senior Public Health Engineer Ii ._ — To: P(-,, H D Harry W. Nichols Jr., P.E. Panerson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 Date: w -Job No.: OD _ 3 Project Attention: T—v Gentlemen: We enclose (5 ) copies of: • B/W Prints O Reproducibles O Reports O Tracings • Specifications - O- MemoFand= _ O Copy of letter - .O _ Description: _ Revision/Date::No. Sent Via: O. Our Messenger O �Blueprinter O Your Messenger O Hand Delivery Copy to -O First Class Mail 0 Special Delivery O _ Very truly yours, Ha tNichols Jr., P.E. BRUCE R. FOLEY Public Health Director -LLLORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Service: (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845)278-6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: DiFranca Cushman Road, Lot #3 _...(T) Patterson, TM# 13 -1 -15.3. Reservoir Basin Dear Mr. Nichols: November 27, 2000 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on November 8, 2000 is complete. The Department Will notify you by December 12, 2000 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 project, such as stormwater plans e_r iY Letter to: Harry Nichol, P.E. - November 27, 2000 -2- or the creation of impervious surfaces, and the project applicant should contact the Department of 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. RM:tn Very truly yours, Robert Morris, PE Senior Public Health Engineer BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services 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 (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 Harry Nichols, P.E. Patterson Park Suite 106 .2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: DiFranca Cushman Road, Lot #3 -- -(T)- Patterson, TM# 13 -1 -15.3 November 27, 2000 N Dear Mr. Nichols: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot,' percolation tests must be witnessed by a representative of this Department. 1) Subdivision file indicates that two feet of fill is required in the approved SSTS area. 2) It appears that the SSTS expansion area is outside of the area approved on the subdivision plat. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Robert Morris, P.E. RM:tn Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: ]DI STREET LOCATION: j t ^I�� — ©J VIEWED BY RM, R, AS, S.A.: J TAX MAP #: (CONFIRMED) 1 � Y DOC. TS Y N (REQUIRED DETAILS ON PLANS CONT'D) RMIT APPLICATION �U)HOUSE SEWER - `/" FT. 4 "0'; TYPE PIPE CAST IRON ()WELL PERMIT OR PWS LETTER (_)NO BENDS; MAX BENDS 45° W /CLEANOUT C -97 ETTER OF AUTHORIZATION ESIGN DATA SHEET (DDS) ORPORATE RESOLUTION [TORT EAF LANS -THREE SETS :OUSE PLANS - TWO SETS ARIANCE REQUEST SUBDIVISION EGAL SUBDMSION SUBDIVISION APPROVAL CHECKED _ 7 ()L )PERC RATE (( .� (_)(_)FILL REQUIRED "DEPTH �) CURTAIN DRAIN REQUIRED GENERAL YLOCATED IN NYC WATERSHED . PLANS SUBMITTED TO DEP LEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED C )EX- APPROVAL SSDS ADJ, LOTS /WETLANDS DS (TOWN/DEC PERMIT REQ'D ?) (_) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION )LETTER BUZBA 100 YR. FLOOD ELEVATION W/I200' ( )/ ( )SOIL TESTING LOTS >10 YEARS OLD SEWAGE SYSTEM PLAN - (NORTH ARROW) �) SSDS HYDRAULIC PROFILE GRAVITY FLOW CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS T CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT �)�FOOTING /GUTTER/CURTAIN DRAINS (_� USDA SOIL TYPE BOUNDARIES LiETITLE BLOCK; OWNERS NAME ADDRESS , / TM #, PE/RA; NAME, ADDRESS, PHONE# (l / -. DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES,WETLANDS WITHIN 200' OF P.L. ((_)PROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS (/ 4 ( )WELLS & SSDS'S W/IN 200' OF SSTS ( (� )PROPERTY METES & BOUNDS (_)/ (__)EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01 /00 7 RENEWALS (__)L)STTE NOTE (NO CHANGE) FILL SYSTEMS 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE FILL SPECS/ FILL NOTES 1 -5. FILL PROFILE & DIMENSIONS FILL IN EXPANSION AREA FILL GREATER THAN2 FEET CLAY BARRIER FILL CERTIFICATION NOTE {� DEPTH GAUGES �) VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIIOUS (_) SEPARATION DISTANCE FROM TOE OF SLOPE TRENCH �LF TRENCH PROVIDED 60FT MAX. PARALLEL TO CONTOURS 0100% EXPANSION PROVIDED (��DETAIL/DUST FREE CRUSHED STONE OR WASHED GRAVEL 7- )L _)GEOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS . 10' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL ( 20' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD, 150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. expan) L)50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER (__JL)10' TO WATER LINE (pits - 20') (x(__)50' INTERMITTENT DRAINAGE COURSE (__)(_)200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS (_)�10' MIN TO LEDGE OUTCROP SEPTIC TANK (_)10' FROM FOUNDATION; 50' TO WELL W ELL DIMENSIONS TO PROPERTY LINES (_) LOCATION OF SERVICE CONNECTION (_)MIN 15' TO PROPERTY LINE SLOPE SLOPE IN SSTS AREA (520 %) (= )(_)REGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS ,6PUMP NOTES DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED (_)DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) PIT AND D -BOX SHOWN & DETAILED 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL 15' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % -<1% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge L 10' MIN to NON - PERFORATED PIPE Harry W. Nichols Jr., RE Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax(845)279 -4567 November 8, 2000 Department of Health One Geneva Road Brewster, New York 10509 Att: Mr. Robert Morris Senior Public Health Engineer Re: Application to Construct a Subsurface S-ouge Treatment System DiFranca Cushman Road, Lot #3 (-T) Patterson, TM# 13. -1 -15.3 Dear Mr. Morris: �NFTy f In response to your letter dated October 25, 2000, we offer the following: 1. Design Data Sheet is now provided. We believe we have adequately addressed your concerns and we request the issuance of the construction permit at your earliest convenience. Very truly yours, d Harry W. ichols, Jr., P.E. HWN.jm BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., 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 October 25, 2000 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: Application to Construct a Subsurface Sewage Treatment System DiFrancia Cushman Road, Lot #3 (T) Patterson, TM# 13.4-15.3 Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on October 4, 2000 is incomplete. Please be advised that the following information is required before the Department may commence its review. ® Design Data Sheet with current percolation test witnessed by a Representative of this Department has not been submitted. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166: RM:tn Ve tJruly yo Robert Morris, P. E. Senior Public Health Engineer Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 September 26, 2000 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE:, Individual SSDS - Lot #3 Boulder Brook Commons Subdivision Cushman Road Patterson, N.Y. TM #13.4 -15.3 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -3, "Proposed SSTS," dated 9- 25 -00. 2. "Short EAF," dated 9- 25 -00. 3. "Application for Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 9- 25 -00. S. "Application to Construct a Water Well," dated 9- 25 -00. 6. "Design Data Sheet." 7. "Letter of Authorization." 8. Two (2) copies of Residence Floor Plan(s), for Bedroom Count Only." 9. Review Fee in the amount of $300.00. If there are any questions concerning the enclosed, please call. Very truly yours, H ' Jr., . N P.E. � HWN:JMhis 00- 135.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'J APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicants LC-X N 6' off Mi~ , 2. Name of project: �-01" 00'ji t ON, 6°',Ts�3, Location TN: 4. Design Professional: f}a V"' 5. Address: 5vTff I`a PM IT-9V-1'60a VO4- 6. Drainage Basin: rt 7. Type of Project: T. ?� Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty. Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9., Is a Draft Environmental Impact Statement (DEIS) required? ....................:.... �fl 10. Has DEIS been com leted and found acceptable b Lead Agency? P P Y ............... 11. Name of Lead Agency A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... T6711 13. If so have plans been submitted to such authorities? Ns� 14. Has preliminary approval been granted by such authorities? 43 Date granted: N ?� 15. Type of Sewage Treatment System Discharge ................. surface water .A groundwater 16. If surface water discharge, what is the stream class designation? .................... HA 17. Waters index number (surface) .......................................... .................... ............ '! A 18. Is project located near a public water supply system? ....... ............................... N0 19. If yes, name of water supply 1\1 1k Distance to water supply NN, 20. Is project site near a public sewage collection or treatment system? ................ of 21. Name of sewage system rrN Distance to sewage system 22. Date test holes observed �y 23. Name of Health Inspector M),VZ. 24. Project design flow (gallons per day) ................................. ............................... 10 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... NO 26. Has SPDES Application been submitted to local DEC offices 36: Tax Map ID Number .......................... ............................... Map Block d Lot lrj -.S 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, un der penalty of perjury, that information provided on this form is trite 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 LA;v. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... 115063 joO 2 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ............................................. ......................................................... ............................... 1 29. Is Wetlands Permit required? ............................. ..... ........................ ............. Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... � 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? .........................�� 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... ND 35. Are any sewage treatment areas in excess of 15% slope? . ............................... NZ 36: Tax Map ID Number .......................... ............................... Map Block d Lot lrj -.S 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, un der penalty of perjury, that information provided on this form is trite 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 LA;v. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... 115063 joO PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at Gu fa A HNW "'�D TN P, T FW-50 N Tax Map # �, Block 1 Lot Subdivision of boy L17E P-- B �- Subdivision Lot # Filed Map #-.- Date Filed I �� Gentlemen: This letter is to authorize`" iql c'R O L#�' A, Ft: a duly licensed Professional Engineer X or Registered Architect to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this matter and to supervise the construction of said wastewater 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. Very truly yo rs, ,rod NEW., y� Countersigned: ��`� �,; c`�0<s i Signed: v.= P.E., R. A., # 9• net of Property) Mailing Address `'' 1 ,,1°�- Ma ding Address:- -�?�� ► ��V� O. State ,.�J Zip 0 s State �� Zip D 5 Telephone: C Telephone: (9 i�)j Form LA -97 1 ev. 0/88 A Type W Am FM Sftd= Only L_j D"A Vab=e Deelglia Flow G P D PLED Nedleadan Is Required When FE is Sopulaft So a use Sydm ft Gomm of Soptlh Tonle -ad To he 'by Address WININ! PdWlv Supply Yon Addrees an ha a% Supply Wood by -M L L_-Addien I rep►esencthat I am woolly land completely ►esponsiblelfor the design and "t Won described will bstructed as shown an the approved amendment there County Department of Hmltk . and that an completion thereof a "C"ficsto' be submitted to ;tha Department, and a written guarantee will be furnished so" in good Operating.condflion any part of. said as I disboul system &"Go Of the approval of the Certificate of Construction Compile . of WIN be located as Omm on the approved pion and that aid-well will =nte County Department of "ankh. Data 0 wlj ned Ionlof the Proposed SYSIAM(S). 1) that the .separate dI!WI system to and in accordance with the standards. rules am —requalVions or of Construction CornpliancW* satisfactory to the Commisslo her of Health will the he owner, his successors. he Irs or anions by the 6411doi►, that said bul" will d I uring the period I of t (2 almmediately following the iitevf. the Isom- o►iginal system or anyT".'.Yt 0.2) that " drilled well disioribed 16 in accordance with the sts d ruft0anoWso—GUM—sof ' the Putnam NO-224! 194 APPROVED FOR CONSTRUCTION: This approval expires two years from the date inVed unless construction of the building has been untlertaken end is revocable for Cause of may be amha Wad of modified when considered necessary by the Commissioner Of Health. Any change or alteration of construction MQuIres a new Parmit., Approved for disposal of domestic unitary /or a water supply only. Date —Title f - i 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 o Village City Tax Grid Number WELL OWNER Name Mailing Addr ss Viivate O Public E OF WELL 1 primary - secondary 9BUSINESS RESIDENTIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION 0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT _.A5gpm //1 O REPLACE EXISTING SUPPLY NEW SUPPLY NEW DWELLING PEOPLE SERVED /EST. OF DAILY USAGE _gal O TEST/ OBSERVATION G ADDITIONAL SUPPLY CI DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING t WELL TYPE DRILLED DRIVEN DDUG GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES jj NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: D L t No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO NAME OF PUBLIC WATER SUPPLY: }J TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: /A LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ON SEPARATE SHEET W_'i� L" '? 141 - 1411 9 date) U rina'tu'ri) 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 other<ta{nia to surface or groundwater. Date of Issue: a`�.�� 19 t- "------ _._....... 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 •:��. :v: ;:.: : i : i'• .....::!� .............: 'i :....:•:'• .. :!vii:..:•iJ.ti :•:v : :: <•:. .......: i •.y-.... .; ...... +i 48, 9ATH • LAC JC.l .I. •.••• ' . b BEOROOM c ;J PRESSING WALK' SEOROOM J. Ix 1J• -0' x 10' -0' '`'� CLOSET I - MA- STER.SEOROOM OPEN BEDROOM 2 1J' O" n 15..8..., J --�. . •,{. ;.,;'J! f S T v O Y° SEC0ND.FL'0:0R _ 48' - ► - 5. . KITCHEN I M tom-+ r Othl1tYG ROOM I_{ORKIF14- Fi00,M 1l ••�� Ott, I q -t — OrEN + fAhOVE I LIVING ROOM w � FAMILY MOO" tOYEM _I RST FLOOR 4828 pt7'T'NA.I� COUN'1�X XJ�:P.P,.R.'TI�ENT' OF' >tiEAL'TH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM I. Name and Address of Applicant: k2 �31 2. Name of Project: 1�I�'1�P4°J�r2 3.._._Location T/V /C: 4. Project Engineer: W Q GN01.l 7t2 5. Address: License Number:­ 1o12q Phone: 6. T pe of Pro ect:. i _ 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 tSEQR)? _ Type Status (Check One) Type I.. Exempt- ✓ Type II. Unlisted. 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. t�1U s. Has DEIS been completed, and found acceptable by Lead Agency? ......:..... _ A 10 Name of Lead Agency tt. Is this project in an area under the control of -local planning,' zoning, N or other officials, ordinances? +J o 2._ If so, Have plans been_su'b;aitted to such. author .sties ?....__ ....:.......... n1/i5, 3. Has preliminary approval•been 'granted:.by such authorities? WA Date Granted: 4. Type of Sewage Disposal: System• Discharge,...... Surface Water v Ground Waters 5. If surface water discharge, what i.s the•stream class designation ?........ O/A 3- Waters index number ( surface) :......... ............................... KI/4— . Is project located near a public ,water supply system? = n1G 3. If yes, name of water supply W/A Distance to' water supply ?- Is project site near a public sewage collection or .disposal system ?..... uo Name of sewage system Q/A Distance to sewage system Date observed: �• �% . a 2j. Name of Health Inspector: h_kgUo2 k) Project design flow (gallons per day) ..................... .............. �� .... r 2 . 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.._ eJp 26. Has SPDES Application been submitted to local DEC Office? p, 27. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... 28. Wetland ID' Number ................ ............................... /d 29. -Is Wetland Perm, it;, requi red? ................................................. Has application been made io Town or Local DEC Office? .................. nJIQ 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 disposal'," landfilling, sludge application or industrial activity? ........ YES or NO �Jv 32. Is project located-Kithin 11 ObO - feet of existence of abandoned landfill, hazardous waste sits, salt stockpile, landfill, sludge disposal site or any other potential'known•source of = contamination? .............. or N0 K)d DESCRIBE: 33. Is there a local master plan or file -with the Towrf or Village? 34. Are community water, sewer -fa -cilities planngd to be developed within i5 years? VW N)0100 35. Are any sewage disposal areas in excess of' 15% slope? ........................ '��0 t 36. Tax Map ID Number ......,.. ....... ........:. �•� �I 37. Approved Plans are .to'*be. returned to: Applicant _Y Engineer If the application is signed by a person-other than the applicant shown in Item.1, the. application must be•accompanied by y-a Letter of Authorization: Failure to comply with this ,provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury,• that information'prd'vided on this form is true to the best of my. know7edse' and be 1 ief. False statements. made herein are punishable as a C7ais A Hisdameanor pursuant to Section 210.45 of the Penal Law. , ; 3IGNATURES & OFFICIAL TITLES: NAILING ADDRESS: ' of?tyJs' 4 r�- K) ,Y. 10506 V ' LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 RANDOLPH W. LAURENT, P.E. (914)278 -6108 - (FA)) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS October 19, 1994 Mr. William Hedges Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Boulder Brook Commons Subdivision - Lot #3 Cushman Road Patterson, N.Y. Dear Bill: Enclosed are the following: 1. Four (4) prints of Drawing SS -3 "Proposed SSDS - Lot #3 ", dated 10- 19 -94. 2. "Application For Approval of,Plans For a Wastewater.Disposal System ". 3. "Construction Permit for Sewage Disposal System ", dated 10- 19 -94. 4. "Application to Construct a Water Well ", dated 10- 19 -94. 5. "Design Data Sheet ". 6. "Letter of Authorization ", dated 10- 19 -94. 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 8. "Corporate Affidavit ", dated 10- 18 -94. 9. Check in the amount of $300.00, review fee. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenienc. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. chols, Jr., P.E. HWN:bd 94097 enc. cc: Mr. R. Marino w /enc. ru1LvtY•1 vn��. 1 y�rtntticluv1 yr nrte,;121 . - J DIVIS- ', OF ENVnZCtMENTAL REALTH SERVI... DESIGN DATA SHEET- SUBSUFACE S5 AGE DISPOSAL SYSTIM FILE N0. �Q CAmer f,l W,157 f "I K) 15? Address '�7 Zy4' Irxated at (Street) �Q-SH I\AAt,] ( DAD Sec. � � i Block Lot (indicate nearest cross street) ". M n i cipality 5 Watershed C,2O7U N SOTS, PE RCMATION TEST DATA RDQUIFtED TO BE SL7PMITI'ED WITH APPLICAT'ICNS _ Date of Pre- Soaking I I - 13 - O Date of Percolation Test I I - 13 -°/O a, HOLE NUMBER CLOCK TIME P"atCX1LATIC N _ PERCOLATIC 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 5 10 2 (Y2 :;A - -1 ; Zq : 30 24 " 2�0% 2% . 13 3 f:25 - I'•55 �Q 2�#'' 2� %� Zy4' !� 5 a, t2 .3 5 1 3 .. 5 NorEs: 1. Tests to be rgpeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be submitted for review.. 2. Depth measureients to be made fran top of hole. rev. 9/85' DEPTH G.L. if 2'. 3' 4' 5' 6' _ 7' 8r 9r TEST PIT DATT" 9QUIRED TO BE SUBMITIM WITH 7` ' ,SCATION DESCRI171_�)N OF SOILS ENCOUNIERED IN TESZ• _oLES HOLE NO. l HOLE NO. 2 3 HOLE NO. 5 fn �K 101. NO v</4,T 1Z_ 11' 12' _ 13' `. 14' *4IL p50i L f.lD�(, SAN 0`(, i �I t-TY h t t,TY ! G�24VElX � �L4V�L'( l-4A M L_,-;A m ii T7 0 .VJATf52- �l0 INDICATE LEVEL TO WMICH PATER LEVEL RISES AFB BEING E:JOOUNTERED DEEP BOLE OBSERVATIONS MADE BY: ;,7 kA DATE: DESIGN Soil Rate Used Min/1" Drop: S.D. Usable Area Provided No. of Bedroans a Septic Tank Capacity, (250 gals. Type Absorption Area Provided By L.F. x 24" width trench Other Z �' o' ' G G. '2 /:7,/ Name ASSOC IA Signature Address p2 �f ray I l�,'7oj Jb� YiitinM i'a SEAL ti °L �~ No. b�12a ` �'1irr� ,yEtrryoPr fn�D�l A�0FEmz.��,t��`�. l T^:IS SPACE FOR USE BY HEALTH DEPAR2,FM ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date Re:. Property of !� Located at (T) Section 1'/.1 Block Lot Subdivision of_ pt�VY� "AAkA0o )`5 Subdv. Lot Filed 2Iap Date Gentlemen: - T This let ter i s to authorize �"Yv!j �-(J &C-I,�,v a• duly licensed professional engineer or,registered architect a (Indicate) to- apply for a Con- struction Perrin- for a separate -sewage system, to serve the above noted property in accordance with the standards, rules. or regulations as promu.l.agated by the Commissioner of {lye Putnam County :, aepartnient of Health, and to sign. al-1 .necessary papers on my :behalf. in connection with this matter and to supervise the cons_truc.ti.on of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health La1, *, and the Putnam County Sani- tary Cade. Countersigned. Very truly yours, Signed e�t-y CUSiDht %1��1 ((L1 �3Z l�l�t(lwoBf,`q-_-'N (e"ep, P - E., R.A., 11 5�%:�' Address Q1.� Address :Telephone L"k�f i � Town Telephone Putnam County Department of )Health Division of Environmental Sanitation AFFIDAVIT - CORPORATE 94NER. APPLICATION FOR PERMIT. APPLICATION SUBMITTED- TO PUTNAM COUNTY HEALTH DEPARTMENT TO: Commissioner of Health - In the matter of application for represent. that .I am an officer or employee of the corporation and am; authorized' to act for, � `Qx'�. l.)I� LSL.YV_` -,.'L .._ -� I .LS O fz.,D (name of corporation) b� having offices atc'� Whose officers are President N 7 _ ;A3C _______��._ Name ana Address)— • ; Vice - President —y_ - -- -(Name and Address) Secretary _ — — (Name and Address)— Treasjurer' _ _ (Name and Address_ )— and tiat I= am-and will be individually responsible fo,n any"or all aptf; . of. the- corporation With respect to the approval requested and -all .sub- sequent acts relating thereto. Sworn: to iiefore me. this / day Signed ` ._ of 19 Title t j — Notary Public' BONME I DAMS Km= 07grg. or RIM, 0'2245 Corpor4te Seal