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Home My WebLink About0285DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -1 -15.4 - .1 ' III ' •, •�' I f rl ' � 31 �'T lirrin � kim �� I.-? SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Craig & Lynn Jacobs 77 Boulder Brook Lane Patterson, NY 12563 Dear Mr. & Mrs. Jacobs: ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 February 2, 2006 Re: Addition - Jacobs, 77 Boulder Brook Lane No Increases in Number of Bedrooms (T)Patterson, TM #13. -1 -15.4 , I have received and reviewed the plans for the proposed addition to the above - mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated February 2, 2006. The addition is approved with the following conditions: 1. The total number of bedrooms must remain at three without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low' flush toilets, restrictors for shower heads and faucets, etc. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Very truly yours, p — jm_� Gene D. Reed GR: lm Senior Enginering Aide cc:BI (T)Patterson cc: Douglas Florance Mission Arts Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 e•r• P.r, Iq•o roar ArrAeM9 ro u• r . v DSP •ate <ww Pmreue em DIL ells N (rrTJ a• Pc1Am tulle. now INIL O`tw lvD. ]Dx ImIY. Putwm tout. rnoiraa. � aALITLLDGItlg4a ]110' R. l0, Lt9e0l G0. TO PADTWe Ef1DK1111D. ATTACH _ — Dcx Jwx ro 1a]sDn rw m 4lreW' JOIDT IIAwMDM • – � y� — f= �Ol]'1J0'P,T. �� — – L Q PCIPOATILN MALL Ai ALL OH. a, rl� " — " —" DDOn wpmYDwsAnAae llAUafrlPJ v I q T I IY .. a1 r eew! •oLlxr w ra l e. IY Is. 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I�w l I oc. ve.T. eeeo • D nmAn wrD I I B;45EMENT w1LL ro wAroll ebeaw I °Lrow.s.a I>-DA. lcll.eleunc ID.oA+ eron, cow+wll:roll A10 nws• I I I I I I I I I I r1 f 7_ _F, � F -I LJ LJ -1 I-J I I® I L-------- - - - - -- I I L-------- - - - - -- I I�enyPaMerwi PUTNAM CO!;NTY DEPARTMENT OF HEALTH I I I HOUSE PLANS APPROVED H;R BEDROOM COUNT ONLY I I I I Sgt �R BEDROOMS o � s ALL SUBSEQUENT ^nE'✓ISIGN /ALTERATIONS TO THESE HOUSE L — — — -- — — — — — — — — — — — O c PLANS MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL II EXISTING II FORC, ABOVE �fq �sszo SIGNATURE 3 TITLE DATE -..� of way — — — ra+a ALL PXIPbw wowr Alm DLen 5 A 5 E M E N T / FOOTI NG and FOUNDATION PLAN m.ro,aDKA�r.I]• IeAeoa wr111y n.,+oDe:llm. .4L6 VA• . I'4 '� I. uw�i Tw.Lrosdn .iu I ®ro T � xlierll ewKL ee ,L wwru+o' eam nl w � o'�iwl� awe a I� T s. v loAOe PnC1Lr rIwLV W RaCM ro ellCf oa fTT. Dams on00aDe NDI ®1 lwvlD! Ar �� 1gwDArlpl lMll.4 CR ffL. CA4P•O s. PCOlHM. TO 9GN OM OOLID. DOtsnl® sM{M A 6MA0t: YNLL VpIrY.A1 A1O NPPL n[INroI•Lwe cM bltluL lR•f IIMSW AL4PWLe I9wMel Q •'4 a60n nWaf:D ewfx Dmten or •D nmAw TC OL. w+aaDe romoD sat �� 1 ALL WQ0gl0 MbIMM AIID TAI01 PIg1f PATH PCOlOtlD H@ aA>m LM fON tY lOL. IT ROIL OtRP YfT. CT roOL41 enoa coninALTOn lfai Aa0 mwue L01PrlLlls Arta CllDnallAml, tawlnACrow 0. ALL OPQIpbb IpfpOn Ane rAIODI PaOM PALL Y lP !Y v ro •4 pIMOtlIRI M IItLp PCR TrP, a@lMK.K � OIIML LpYMLT OMllml Ppc l'OOnb DCDIew, O NNOm DrlD0. GOMnbTOR MMT AW� OnOfNSC NOTlD. OTGP•m POOItNM WALL t%' Neil 14f1[ etae D1MalwOn IM nIDD naa rrP. ac *rocw la 10' Iw f4 TO •'4 ca.lwALion ro nl]D vaaR uasnw!'oonw onOS•DL r1Dlm. D. ua1 w La.I;nefe Pan nc rwwoAnon oo.nle. IiuwLLD. PaJnm cwY�*nDeoAmu IIALLa cAH ee - ro POOiI Dla`JroAT Iil' OP K.GI2R MO UmOI 6. aLOMO �gROW!} DlDll IHVG A MGOIk OOtlG L0.DM IGYATbIp nMT aaAn glo¢.lLr QOO M CMrA1nOn Il,LIp p.. n1Ln ALLALL eMAes Alto IglpArgw loos nw+I06 f•1 • I®M nRl I.IOnT ronCl1 RO11n0 P(wt LwA1MMG fD0 wen PQ 100! - G'P R•IA. T® IM ro roomw anLn !9plfIlk e C .aNr...l r_..m... wA.t..� Aoomcea J AL TM JACC% RFMfE)UljCE. ,,.PAMMOCKPW TOWN OF PATIU60N 1EWYCW n. PA mock" PROPOSED BASEMENT / FOOTING •mod FOUNDATION IFS A -2 9RT�0_ T Y F I G A L C O L U M N D E T A I L , I.— tl � - IT - -- _Tl� - _Tr- aI - 20'-0, 6',0* atl•.P ., a 9 I I I I Y ^DDMC" .i z I I I I nLTI- E ,I JACOBS RESIDENCE _ F I EXISTING I a 71'"�"��D 4In wswr I 1!] � TOWN Q PATIFidJ I 2 CAR o I . 2iJ2 — — — _ L — °�p6° NEW RM I 5ARA6E i e.� P=te — I- — — — — — --f I— — b. R,, o.... I d ® ;_ : I (EXISTING GAAGeLytNJ/VAD tlx 77. OPOM tlLCKY 9 E.(FNN . a i I I FAMI Y A vnT fPoO yN Y. I ""A I I ROOM _T F_ ....�.. oN I � eow m.✓u . III I I I I ® M YNN _ � a HALF ro sfA1M°w« AS vaacATm I EX15TIN6 t ---- - - - - -- - - - - - -- EXISTING LIVING DINING ROOM FIRST Se6 DOOR PUTNAhA COUdTi iicPARTP:IENT OF ,y' , � ROOM PLAN HOUSE PLANS APPROVED FOR BEDROOM COUNT ONLY EXIST( UP " F R 3 BEDROOMSL o F y ALL SUBSEQUENT REVISIOVALTERATIONS TO THESE HOUSE EXISTING PLANS MUST BE SUBMITTED TO THE PCDOH FOR APPROVAL poR_C H SIGNATURE R TITL . DATE F I R 5 FLOOR FL AN A —Q t F'Ul'nli.iul!; ^:CiiYiiV ARTMENTOFHEALTH HOUSE PLANS APPR0IIEJ i`OR BEDROOM COUNT ONLY 3 BrDHOO.AS 3 0-C y ALI. SUBSEQUENT REVISION ALTERATIONS TO THESE HOUSE PLANS MUST BE SUBMITTED 10 THE PCDOH FOR APPROVAL . AL � 4 SIGNATURE & TITLE DATE R O O F P L A N =- I IMF II II II L------ - - - - -- I II II II II II II II L� I I II A �,. -0.II II II — ---- - - - - -- II E ISTING I UNF NSHE I I W I EX15TIN 11 I MB —`3— A ATH EXI ROO BEDROOM a / _ — — . . D'4 iRM� tiBINO J� � LJ enTt+ A k €x L I / / — EXISTING MASTER m EXISTING BEDROOM BEDROOM I �2 5 E G O N D F L O O R 8 ROOF P L A N EXI5TIN6 HALL EXISTING PORCH of �Qvj T(f. . Of& II I I J �u/Sngroup �I 1 Yn. i.. w..... .vis..ne�n.oc_ ADDtncnn .4 ALTCRATICM . TFE JACOBS RESIDENCE TT. BOLDER BRC( KR D TCATM Of RATIE➢SN NEW YORK GRAC.011"JACO6 77. m A Y. SECOND FLOOR -- ROOF PLAN A- 3 ►ll� (.2¢a6 7d LwW6ts11YOtl T'rF. RAKE DETAIL ZZ i Z 6' MIN VENT IN ROOF DETAIL .o ee — L-, 7 k Vo -Mo v aa^m- LJWJJUJ UUM AJ�IJDU UL=� JJU ULWUJ rnirmn Lwu MtssbnArs L lu ILLIJI DesiqnG=p E=3 ADDRM J ALlV"TKXh THE , C JACOES =1 cc a RESIDENCE F R O N T TOWN OF PAMJN E L E V A T 1 0 N 77. BOMR UMMAD �xw yow CltAn.LYWJhCOBS OQ M FOA 77. OPMAUTE y .W DECEM�� RORANM Bb AS IMCATfD T9 92 RM OLIL 1/ -T. FROM iz ELEVATION CHIMNEY DETAIL RW SIDE ETV-AIION DETAILS j L — R 1 0 H T 5 1 D E E L E A-4 z —=. Z-- 7 tt I y•.r.Wao row v�wc.lrw�Wu as .41. �7aj- ANY7 Ia' NPOK5) HAUNCH FTC. 170M TO 50rTOM OF SPREAD FTGS. FOOTING DETAIL; f - - - - - - - - - - - - --I I -7—EXISTING '7-7 2 CAR &ARA6E SLAB GRADE 45FZA DE EX15TIN BASEMENT LAB r-ON5TR. JOINT L Lf-i L U PIMA"" vt%L — — — — — — — — — — — — — — — — - — — — — — — — — — — — — F — — EX15TIN PoRc- ABOVE _AB ON GRADE DTL5. WALL HORIZONTAL _L. CON57R. JOINT C-ON5TRUCTION JOINT E3A5EMENT / FOOTING and FOUNDATION FLAN MAGKMLL Soem" W, HALJNC,H DETAIL —zncrlz A ALMA7134. TI-E JACOBS RESDENCE 77. Kmn c %X D Tovmap,srrmct4 NnV pp( 6RAr,.LYNNl'C0% 77. KXW m=p PATM�KYP'o BASEAft,ff/ FOOTM ..j FOUNDATION. PLAN A-1 T Q, Al A A- MisstonArts Design Group, Inc. 2 Raymond Drive. Carmel New York 10512 Phone: 845- 228 -2333 Fax: 845- 228 -2594 e -mail: MissionArtsDG @aol.com TO: Gene D. Reed Putnam County Dept. of Health 1 Geneva Road Brewster, NY 10509 LETTER OF TRANSMITTAL Date: January 27, 2006 RE: Jacobs Residence 77 Boulder Brook Rd. Patterson Project #: 3131 We are sending you attached under separate cover, the following items via • U.S. Mail ❑ Overnight ❑ Pick Up ❑ Hand Delivery • Originals ❑ Reports ❑ Plans ❑ Colored Prints • Prints ❑ Photographic Exhibit ❑ Specifications ❑ Other: Copies Date Dwg. No. Description 2 1 -27 -02 A -2 Proposed Basement Plan These are transmitted: ❑ For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review /comment ❑ Resubmit copies for approval ❑ Submit _ copies for distribution Remarks: Revise as per your request SIGNED Copies to: SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Craig & Lynn Jacobs 77 Boulder Brook Lane Patterson, NY 12563 Dear Mr. & Mrs. Jacobs: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive January 23, 2006 Re: Addition — Application Incomplete Jacobs, 77 Boulder Brook Lane Patterson, TM #13. -1 -15.4 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. The following was not submitted with your application: 1. Sketch of existing floor plan for the basement (if one exists) showing all rooms with dimensions and the use of each room. 2. The proposed second floor plan needs to show the entire floor. 3. Please label the addition plans as proposed first floor and proposed second floor. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Sincerely, GDR:Im Gene D. Reed cc: Douglas Florance Envir. Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 SENDING CONFIRMATION DATE JAN -26-- 2006 THU 11:30 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845- 278 -792" PHONE PAGES START TIME ELAPSED TIME MODE RESULTS 92282594 2/2 JAN -26 11:29 00'45" ECM l.K FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... d , 1 R. FOLEY LORETI'A MOLINARt R.N., MAN, +'char flydth tll yur wuovime Nbile H. 4A 09.6 otmrro. ! Pa7lue SenKr DEPARTNMNT OF HEALTH Geneva Road Browder, Now York 105D9 .Rnrlranve.nl Me.116 !1131 I]t.61i0 ra.(M5)279-Mi Nanhy aeni9e. 115)274 -6539 WtC(497]9 -6679 1,..(113)279 -6015' rril)• 3ekrha,llor (95.51 +;1.601• t'melpl IMSI ]]A (g12 rnr1115)2n -6648 VAX CDV Rs!*F'ie•r Date: .— ....._ -- .. No. Pages (Including cawr sheet) Vrnm: (gip Putnam Comity Department of Health. .._._ 11or your Information Please respond /11101, your review ___ -- Attached as reynested - �! .49 discussed — Please. "I lnteslMev91gc 1?e'r Rm nsont of transmission /reception Aifficultks. pleasa contact this once m /e45) 278-6130 ext. 2261. BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax (845) 278 - 6648 _ ■ � � ■ Date: To: -Dear, rCLAGe- V From: Gene D. Reed Putnam County Department of Health d _ For your Information F r your review As discussed Fax #: �- -L 8 2 6 No. Pages 1. (Including cover sheet) Please respond Attached as requested Please call Notes/Messages -1--':>'er CCU(` --PVeGtS e - e- bea-S!*N4l eol' . /acyt 6V C014 VGar" 6�1 ti In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. O• roumv ccm. FICK K41.1. Oym vw I=a 20VL REW. PvL4tW c4flo. S. am POOTNOO. we BAOCMLL saweELLe AM e2mr -A- 1-1 P.T. -- !, - - - -- Loy � 1�1 I� � BASEMENT ! @ K2 ..q nA.01. oym O NIL 4•. 6• WAM ROC -KLr W/ f71 *#. 15• 1.4, AWWR OMM pmvVIce 419 64 r IW4 OTL MARINO PL OYM j" mom-OHRINIC troxr WITINO wo Irrpj. MLY VAPPR MAARIM I OYMA'X0.9. 40WAG7W OkAlom PILL "J. EXISTIN6 Wils BASEMENT VIALL.9 Vatw TVV " Win" AT W oj-� VIW. emom & 9 pomm Few NON-OHPUW epoxy Ookl4m. L J LP J LP I le — — � I i I �er�nawe� wiu LL— -- — — — — — — — — — — — — — — — — — — — - — — — — — — iii EXISTING IV W PORCH 11 AeovE NOM ALL EXTVRIOR HINDGK AW DOOR OF516 TO PeZerVe A ($J 2• x L• T I N r-, and F O U N D A T I ON PLAN W--cm "TH)v K"wm W*'Em c4x<.mm SHALL Be A mo~ or 5000 P 104 T. pwoVwa IWINF. OF 0111! " P035^'4 Honz. * TOP ^10 57"a"ni eOrri:04 CP VIA" A OW ft Rl!bAR V6Cr1 'Y 0 W-W O4 &fr. w4ifte No"Vj PRCIAM AT r0a"N001 TO OCAR, CH 50LIP, UN015TI."DW EARTH A OAAAOC FALL VORrKAL AND HORZ MCMORCANO OC MW411-W OF 4'-• OMLDPI P9W!*M GRAM P125004 OF 05 ACDAR X-C' O.O. KWnM" ARIE ASW ON 4000 POP SOIL IF SOL I r-e• MARINO, CQ"A= AM uMTIoKAOLr, CVwpv4rpm 0. ALL PHIP1911" WE'Reem AM TAKM Mom PACC SHALL W"XT CPWP=R FOR mo"" IXDI N cr Hoombrum c4NlmA4ToK KIDr ADD W To 57"FPM 1-0071h00 SHALL W IV.2H KAK tL4M onMD IN rmLv MR rrp &QTROGK %I L=O C.0"TRACmA, TO FIKD Vmpy eAsInmo po"Ho 012-114*t o"em4m No COWCAM PLOOFIM SMALL HAVE A 60100M. VIDOM OTM& TRpPeL FINISH. OUTAeLa TO PtBCarVE C'OK.00TIM PLCMM&. PIMM A" &AAA" AND POOV-4 FLOG05 FOR DRAIM44a tile w4aw PER roar mimrA". ,TL !-# t BACM4LL 6091%" pop".1. a- w I r-e• I Ir m -W .2' L• TO • He..e1Fm I TGP ZP 11 A0 TO mmo-W dotAl• MissionArts Desi .9n Group ' c: 3 17CA-&A. P6-P'.,vu. 'A-1 to= WAE ADDMa,b N,d ALTERATICM THE' JACOBS RESIDENCE 77. BOLDER BR= ROAD TOWN OF PATrOWN NEW YORK PROEcrcvAlu GRAIL & LYNN JACOBS 77. �AD CHECKMOY BASEMENT/ FOOTING and FOUNDATION PLAN A-1 SHEU + OF JAN -29 -2001 17 : "'I MISSIONARTS DESIGN GROUP 8452282594 P.01 MissionArts D sisn Croup inc. "Architecture on a Finer Scale From: } ( 'FLf, � -7q 2, Pam r to4-u0 )p14 ayr --a- -- Plwne: ��(o J � �( 1 Date: 1/?.619W 6 Re, C,vf `S CC File 0 Urgeni tkfor Review 0 Tease Comment ❑ P144w Rep[y ❑ PLAS¢ Recycte IL kA t r ■ 2 Raymond (Drive. Carmel, NY 10512 Phone: 845.228.2333, Fax: 845.228.2594. M ssigM t QG- aol mm JAN -27 -2000. Fr"! S -I-EL-'845-278-79 NAME: PUTNAM COUNTY DEPARTMENT OF P. 1 JAN-29-2001 MISSIONARTS DESIGN GROUP 84522e2594 P.02 ON^ r4ALL 94ta 110601= e4w" 4-A 0- SM1101 P094W W (2) "ft tg* L& AWAWK ft'LIS, Tw. STL, aRAWA& PL. OVM JI* No6emmm Wow sm"s 2SdOR PWWX 4". 04, (TIPW VL. ATT, W.01=0 TO 2*'x TI STAIP" vOYft RWH LASTIM wAssaff A BAfemeKT Raw 6wm. Al --mtrlaet" 'Cpl. T OCAM wr ilk ry yp @CA" 'M2AK -IIL lot . . . . . . I NAVC9 -01 -;r, r KVr NW1 1- 70TIP110A • FGWVA-"G% EXITING K-"* AT Oft"A. mm CAM on"" rom K" VIALLS 10m; aft"* ko-140"W T f6, 'Moir em f4.;ft6 TV w" tw""Wo :r BASEMENT ft PFJMM A fd. • kALL 10 NAWA4 ft"W& NC*-O" arty" dw4am. C.&f?1W?I0N AfV FINISH F, -1 L-j T-7- , -j I -j III 1EXISTINC5, PORCH wm• mj- aglomm m"w" e*w POOR PIP a4,, GF!M TO WadoW AMP 21 -121 % 0 U N ID A 7 1 0 N A N "BOOM MT4)v PLC' my"", 6(1,4 $ /I J"o IkI7 DACAPLL M 15E POSINF. OF cm - — — 4 — AND sorrom cr r • v-O' FWAVE AT V EARTH A RproFam MMON cr •com 413 PEWA CIA. IF' WL 4XTIVAC 8. ALL VIM004" 6010bOld AIM TAVM MOM FAZE 61411016 OFF ykvm pum eAmn"Ad W& M. ON LOC. -To oncNam in pgmp -%a rvp WTINS pimw 4 DACAPLL Nomkod. Pluck "Womm" WAm"m OLLAPVML& m7m- wm fla- • teo&olw papm T• 4pr W1.41 M -QZ-grk Gwp A aCA—&A. r—Nd Pit ADDrnCM &J TK iWIMIum JACM MDEW—E 11- KXw M= ptm 70" CF PAM" f4w ym FIQWcwm5t C&MG&4"lAas ,,. o RD Wrgffll)5c Y. AD IAOLM cmL AS MICATE EROWANG NAAC PROPC&D FIRST st SECOND FLOOR PLANS CRAVE'r. MAW A0 ig Am — pt FWT *1W 4 CF 10 TOTAL P.02 JAN-27-2,006 :845- 278-'7`.7c:_? r HAME:PUTNAM COUNTY DEPARTMENT OF P. 2 JAN -24 -2006 11:22 FROM:PUTNAM COUNTY DEPART 845- 278 -7921 TO:92255584 P:1 /1 SHERLITA AMLER, M3), MS, FAAP Commissioner of Heatth LORETTA MOLINARI, RN, MSN Associate CommissianerofHeakh Craig & Lynn Jacobs 77 Boulder Brook Lane Patterson, NY 12563 Dear Mr. & Mrs. Jacobs: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BOND) County Fxeewtive January 23, 2006 Re: Addition. Application lvcompletc Jacobs, 77 Boulder Brook Lane Patterson, TM #13, -1 -15.4 Review of plans and other supporting documents submitted at this time relative to the above- regarded project has been completed. The following was not submitted with your application: 1. Sketch of existing floor plan for the basement (if one exists) showing all rooms with dimensions and the use of each room. 5tt, 00-11,-6 . VA -1 * A— 1 2. The proposed second floor plan needs to show the entirelloor. St* EW 3. Paddition a label the � pla as proposed first floor and proposed second floor. Upon receipt of bmission, revised to reflect the above comments, this application will be considered further. Sincerely, GDR :Irn Gcne D. Recd cc: Douglas Florance Envir. Health Engineering Aide �I•eas� v1 o4c +H-e- -A6 v< c,Graw 1r► Oo. Ve-4 re roc � V'� u -es�-. All i 9 h �#u 9 � w,� is r- c�N�cs�d ; �ubhn f psi Wr- g0TV0 At6oT)AVF- StT �° �nme' HcultTi Bh5 27f1 -b F 4 Tr LA� e I (, ax (B _, A -P) T Nursing Services (845) 278.6558 Fax (845) 278 -6026 WJC (845) 2784678 NurRinq Home Care Fax (845) 278 -6085 ' e7eyI#N Enrly Intervention /.Preschool (845) 278 -6014 Fax (841) 278 -6648 �Reu�• K c . � 4 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH .D 1 Geneva Road, Brewster, New York 10509 '- ADDITION APPLICATION RESIDENTLAL ONLY STREET �j X `&eC &04 (4,:!;:::-TOWN 3& d d_ " NAME LT �(1 �- C.t'dl`�rPHONE MAILING ADDRESS DESCRIPT ADDITION PCHD# a - \ Z — O 6 NUMBER OF EXISTING BEDROOMS PROPOSED # OF BEDROOMS (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 -6130. 1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) 3. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #) *Non - professional sketches are acceptable 4. Copy of survey showing well and septic locations to the best of your knowledge. . Include date of installation if known. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 RW,d " SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ADDITION APPLICATION STREET NAME MAIL 91G ADDRESS DESCRIPTION OF ADDITION Q ROBERT J. BONDI County Executive RESIDENTIAL ONLY PHONE Z—jV TAX M A P # PCHD# NUMBER OF EXISTING BEDROOMS -3 PROPOSED # OF BEDROOMS 6 (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code.' Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 -6130. 1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) 3. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #) *Non - professional sketches are acceptable 4. Copy of survey showing well and septic locations to the best of your knowledge. Include date of installation if known. Label all wells and septic systems within 200 feet of the property line: Contact this office with any questions. 5. Copy of Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom count of dwelling. OFFICE USE COMMENTS Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Town Legal Bedroom Count Re: c O Tax ap #: %S, Address: Town: Year Built: ROBERT J. BONDI County Executive (Owner's 'Name) According to records maintained by the Town, the above noted dwelling, is in compliance with Town Code. is not in compliance with Town Code. The Legal Bedroom Count is: This information has been obtained from: Certificate of Occupancy: Other: Building In ect r Date Environmental Health (845)278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 •--N,Q.4:.£!' /O E 6 °46%O E. //9.47 ' `` S - 8U T O N %ME>V929S C/HL A R/ N j FT) � 1 N ° A B / 5 365 5 Z 3A/O. 0 /// O/BT3S.. 3 6. .- . 4 /00.0 107.5 5 /03.0 /09.0 nY � s • 7 /// B77\ 9 fi 6 1150 1155 C`K`; F�RXA�s/TtE STORY 20 9 0 /20 5 �o�c�.� il;4v�0 r 5 %JN.� CEOWEI N6 Roots h 7Dl fohl s s lD 60.0 55.0 m l/ 64.5 �..•, ij � sp,P_ js /C TANK lz 7/ O 6/.0 SEPT O /3 76.5 635 Pc�oro j Sio(cr / 14 82.5 66.0 GA�tc�e 3 u;; r::. ':b' h � O / /5 <5B.0 72.0 O) 16 ' 93.0 75.5 EX /S- WEL[ C /7 99.0 60.0 ' ! /'ROPOS• `� bt N. /5' 00= OO ,E• 2�, I Zp (1 — — — — — — — - — — — — — — — — — II I \ EXISTING G �!1 FINISHED TTIG EXI5TIN MASTER \ � BATH -IF- / u EXISTING - — — — — — — — — — — — — MASTER ------- - - - - -- BEDROOM EXISTING DECK BELOW EX15TING a BEDROOM #3 'rjgr °PCSaU�`e- F S OF Ntidd �= J 4 - EXISTING BEDROOM #2 EXISTING HALL EXI5TING PORCH r----------------------------- I I I I I _ � I EXISTING r -- `- EXISTING 2ND FLOOR FLAN I GARAGE i EXISTING 50ALE. 1/5" = 1'-0" I KITGH EXISTIN I G ---------- -e--- -- - -- - - -- o BREAKFAST AREA I I _ 0QN I I HALF L---------- - - - - -- EXISTING EXISTING FRONT ELEVATION , W. -O I� (-jx ROOM II" EXISTING IST FLOOR PLAN 5,-'ALE; I/8" = 1'-0" EX15TI NG PORCH Ici..ti 14..vr. EXISTING EMS17NG LIVING PLANS ROOM ,"d EXI4flNG ELEVAnCM EX-I was EX15TI NG ALIMATCM DECK THE JACORS RESIDENCE rovm cf rnneucN wwYcw Ci VGr4yNJJAR0t0wffi M' en y. EXISTING FAMILY ss ROO EXISTING EMS17NG LIVING PLANS ROOM ,"d EXI4flNG ELEVAnCM EX-I — — — — — — — — — — — — — — — fr — — — — — — — — — I I I I I I a S E C O N D F L O O R F L A N I ---------- - - - - -� I ' _I I bAKA(SE 9 TORA6e , ('-0• I I I I EXISTING I 2 GAR I GARAGE I I I I I I I I I L' — — — — — — — — — — — — — — — _ DN -- � -- IT--- - -�>_- I FAMILY 51IC N -- 1-{-- - - - - -f ( 20'-0• x 20' -9 ") — IT — — — — — IF — I I II II I 1 II II II I --1 -- I + - - -- -fit-- I ®I �A�teL I IEXISTING 11 FAMILY I I ROOM IF I Ppx ) 1 I 11 11 nose. '-EX' EXISTING EXISTING LIVING DINING ROOM ROOM ISTN. F I R S T F L O O R F L A N EXISTING PORCH .0 'ti. a."...n.,.n G.4M'.nn F�.nm.�. ADDrrKM A µ TKKYEr JACOBS RESIDENCE n.a0lpFASYn aaw 7UWN/iPATID6W NEW yOAC nuecroaFn C&M—LYNNIApC�OM 77. PROPOSED FIRST 'SECOND FLOOR PLANS A -1 ev 3/ '6 RTIFICATE OF PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmental Health Serviced, Carmel; N.Y. 10512 Engineer Must Provide P.C.H.D. Permit N - - —� -= FOR SEWAGE DISPOSAL o „ or V e Tea Map �Bloc� - �� Lot Owner/applicant / Name dd-�� EQ �Af l-��LA Formerly Subdivision Nam A/l- ��hb8v. Lot q — Mailing Address-, 4055 ft'2 Zip_ I49!i7 b Date Permit Issued COO my glee s r B� Separate Sewerage System built by 4e ��z CGN9flZVOTte/M Address SIG 6,J15 I' Consisting of �� Z i- _TIZ L'tf s allon Septic Tank and I Boa %4 LLGAI SkM i* A Water Supply: Public Supply From �,,,� p , ,Adddress or: ✓ Private Supply Drilled byD112 AgU�i AN WEPil t dress 9V5 JZIE!7i 4kgm r L. Building Type 1� �J -fin A Has Erosion Control Been Completed? Number of Bedrooms ✓ Has Garbage Grinder Been Installed? D Other Requirements I certify that the system(s) as listed serving the above premises were constructed essentially as shown on the p ans of the completed work ( copies of which are attached), and in accordance with the standards, rules and regulAtRons, in accordance with the fil I pi nd the permit issued by the Putnam County Department Of Health. Date 44 Certified by IL Q P.E: R.A. r ��1t Address ` Ol`Lense No.' E&124 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 sewerage system shall become null and void as soon as a pub(,: sanitary sower becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject �ttoof- ..modification or change when, in the judgment of the Commissioner of h it vocation, modification or change is necessary. Date 43 L �� By Title WLLL UUr1rLL11UN MZrUZU * * DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only /13 • "- / ` / S' WELL LOCATION STREET A00AESS: WN /Vll / 1 Y TAX GRID NUMBER: --go�(r,�9 -t f�ro�� 1,c Z WELL OWNER NAME: ADDRESS: lc&, P, ,-vk ID y "'i--a-313 aJ a, a� 6 (,PBIVATE ❑ PUBLIC USE OF WELL 1 - primary 2 - secondary & RESIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS ❑ FARM ❑ TEST/ OBSERVATION ❑ OTHER (specify) ❑ INDUSTRIAL O INSTITUTIONAL ❑ STAND -BY ❑ MOUNT OF USE YIELD SOUGHT _ gpm. /NO. PEOPLE SERVED s / EST. OF DAILY USAGE 500 gal. REASON FOR DRILLING [—]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY ®NEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL DEPTH DATA WELL DEPTH A 0-5 ft. STATIC WATER LEVEL ft. I DATE MEASURED _ a DRILLING EQUIPMENT ❑ ROTARY 159 COMPRESSED AIR PERCUSSION ❑ DUG ❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING 10 OPEN HOLE IN BEDROCK ❑ OTHER CASING TOTAL LENGTH fL MATERIALS: ® STEEL O PLASTIC ❑ OTHER LENGTH BELOW GRADE ? — ft. JOINTS: ❑ WELDED CWTHREADED ❑ OTHER DETAILS DIAMETER in. SEAL: [9 CEMENT GROUT ❑ BENTONITE ❑OTHER WEIGHT PER FOOT _ _ lb./ft. DRIVE SHOE ® YES ❑ NO I LINER: G YES IZNO SCREEN DETAILS DIAMETER (in) 'SLOT SIZE LENGTH (11) DEPTH To SCREEN (It) DEVELOPED? FIRST O YES ONO SECOND _ HOURS GRAVEL PACK ❑ YES ❑ NO GRAVEL SIZE: DIAMETER OF PACK in_ TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST if detailed pumping P P g METHOD: ❑ PUMPED i tests were done is in- (-COMPRESSED AIR ,formation attached? ❑ BAILED ❑ OTHER i ❑ YES ❑ NO LO If more detailed formation descriptions or sieve analyses G are available, please attach. DEPTH FROM SURFACE. waler Bear- ing well Dia' Imctcr FORMATION. DESCRIPTION WOE It. ft. WELL DEPTH ft. DURATION hr, min. DRAWOONN ft, YIELD gFm. Land Surface 6 lOjr - t� S L 3 a - ov IAA 6 2e C n f %ko eV-,;V ; -5 C rs o I io WATER ❑ CLEAR TEMP. QUALITY ❑ CLOUDY HARDNESS ❑ COLORED ANALYZED? ❑ YES ❑ NO ANALYSIS ATTACHED? O YES ❑ NO 7 A / A3 STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLLLER NAM(�an g C� DATE ' �S ADORES__ P S SIGNATURE &e t A' u S /* S /69 // / YML ENVIRONMENTAL SERVICES 221 Kear Street ^ ^ Yorktown Heivhts, N.Y. 10598 (914),245-2800 AlhertH. Padovani, Director LAB #s 93.010380 CKTENT #: 4789 NON STAT PROC PAGE 1. EDWARD SPADAN CONST. DATE/TIME TAKEN: 03/23/95 15:50 264 SEMINARY HI|L RD DATF/TIME REC'D: 03/24/95 12:40 CARMEL, NY 10512 REPORT DATE: 03/27/95 PHONE: (914)-225-8557 SAMPLING SITF: LOT 4 BO.PER BROOK ESTATES SAMPLE TYPE..: POTABLE : PATTERSON, NY KTTCHEN TAP PRESERVATIVES: NONE COL'D BY: FDWARD SPADAN TEMPERATURE..: { 4C DATE FLAG PROCEDURE RESULT NORMAL - RANGE 03/27/95 MF T. C0'JFORM ABSENT /100 ML ABSENT COMMENTS: BACT THESE R&UnTS IN61CATF THAT T AS NO OF A SATISFACTORY SANITARY QUALITY NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARD-- FOR THE PARAMETERS TESTED; AT THE TIME OF COLLECTION. SUBMITTFD BY:____ Albert H.^ F%dnvani, M.T.(ASCP) Director B'AP# 10323 LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 8 Milltown Road Brewster, New York 10509 (914)278 -6108 . (FAX) 278 -2658 CONSULTING SITE ENGINEERS Date: 5 - 1,2 '� 5 T Job No.: -to 32 Project: �lL� - 3 � Z � ,� �,°� 5S � CON 5�• CD 1�/tPL i,4t�1 G� Atten ion: Gentlemen: We enclose ( ) copies of: 6'W Prints ❑ Reproducibles or6eports O Specifications O Memorandum O Copy of Letter Description: It fog (A) fft )0TS 4r- VII ANi�16* AS VO►!J pL-A�4 S t Via: PJ Our Messenger 0 Your Messenger O Blueprinter ❑ Hand Delivery O First Class Mail O Tracings 0 Revision /Date No. 5 - AF O Special Delivery Copy to: y4 Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: _— - - -- PUTNAA COUN'T'Y DEPAFMi a 7S OF HEALIH DIVISION OF E MOLM I' PEA.LTH SERVICES owner or Purchaser of Building Section Block Lot Building Constructed by Location - Street g5 Rmicipa-lity Building Type Ov L �O42/G GAA� s Subdivision ham✓ Subdivision Lot 7 GaZLPA.NI'EE OF SUFSUPFACE SFQm.GE DLSMSAL SYSTEM .I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system, serving the above described property, and. that it has -been constructed as shoran 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 disposal 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 Director of the Division of Enviror_1;ental Health Services of the Putnam County Department of' Health as to whether or not the failure of the system to operate v�-_s caused by the willful or negligent act of the occupant of the building utilizing the system. t Dated this day of 19 , Signature -v Title _ General Contractor (Oismer) - Signatu re Corporation ' , (if Corp.) �6Cj C_ ti1 L-�.C.�'oN Corporation Name (if Corp.) Press —r- 1 J l7'`G v CL C Address rev. 9/85 mk a' WhLL UVEIrLr,11VLV mr.rumi * * DEPARTMENT OF HEALTH Division Of Environmental Health Services PUTNAM COUNTY DEPARTMENT OF HEALTH Office Use Only WELL LOCATION SiAEEi ADDRESS: 'MWN/VI=1MIrF TAX GRID NUMBER: o L) Id 0-1-BI-00 WELL OWNER NAME: ADDRESS: I -g �, v _ �3 10,661 a,PBIVATE O PUBLIC USE OF WELL 1 - primary 2 - secondary [3L RESIDENTIAL ❑ PUBLIC SUPPLY O AIR /CONO. /HEAT PUMP ❑ ABANDONED ❑ BUSINESS O FARM O TEST/OBSERVATION O OTHER (specify) O INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑ MOUNT OF USE YIELD SOUGHT_ gpm. /N0. PEOPLE SERVED �/ EST. OF DAILY USAGE 00 gal. REASON FOR DRILLING []REPLACE EXISTING SUPPLY ®TEST /OBSERVATION [ADDITIONAL SUPPLY ®NEW SUPPLY (NEW DWELLING) ❑ DEEPEN EXISTING WELL DEPTH DATA - DEPTH a!5_ _ ft. STATIC WATER LEVEL ft. DATE MEASURED 11-AD- DRILLING EQUIPMENT ❑ ROTARY IN COMPRESSED AIR PERCUSSION ❑ DUG O WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify): WELL TYPE ❑ SCREENED ❑ OPEN END CASING ® OPEN HOLE IN BEDROCK O OTHER CASING DETAILS TOTAL LENGTH fL MATERIALS: ® STEEL O PLASTIC O OTHER LENGTH BELOW GRADE ,� c7 ft. JOINTS: O WELDED C9'THREADED 0 OTHER DIAMETER in. SEAL: IN CEMENT GROUT O BENTONITE 0 OTHER WEIGHT PER FOOT —_ 1b./ft. I DRIVE SHOE M YES ❑ NO LINER:OYES SNO SCREEN DIAMETER (in) 'SLOT SIZE LENGTH (}t) DEPTH TO SCREEN (ft) DEVELOPED? DETAILS FIRST 0 YES ONO HOURS SECOND GRAVEL PACK O YES O NO GRAVEL SIZE: DIAMETER OF PACK in. TOP DEPTH ft. BOTTOM DEPTH ft. WELL YIELD TEST II detailed pumping METHOD: O PUMPED tests were done is in- COMPRESSED AIR , `. ormation attached? O BAILED ❑ OTHER ❑ YES ❑ NO WELL LOG It more detailed formation descriptions or sieve analyses are available, please attach. DEPTH FROM SURFACE Water Bear- Ing we1I Oia- Imeier FORMATION DESCRIPTION CDOE tt. }t. WELL DEPTH ft. DURATION hr. min. DRAWDOWN ft. gpm. Land [YIELD 'A0 b L3-1244 M f � WATER O CLEAR TEMP. QUALITY O CLOUDY HARDNESS" O COLORED ANALYZED? OYES ONO ANALYSIS ATTACHED? OYES ONO o 7`0 3 STORAGE TANK: TYPE CAPACITY GAL. PUMP INFORMATION TYPE MAKER MODEL CAPACITY DEPTH VOLTAGE HP WELL DRILLER NAME7P G� OATS 4% LCC q W c:u ee AOORES� �- P � /-Y^ 5 SIGNATURE C &4-vnle'f () 3/89 � � / FtlMM COIIM'Y DEPArTNM OF I WAL?S _ DhMw d I odminmewel Seddi ll u b a. Gaged. N.T.12M a� w OF 00 Fw�11 i N PWW FOR SEWAGR DISlOSAL SYSl'L►M Prts+•It SAM,N . Names Let i �. TM Map •�- Reoewsl_ ❑ Revlaieo ❑ 0� /Awiert Naar. n -�� Date of Previous Approval Melling Adtsas -;� rO Town . 7JP ' a!i � Date Sub ivisioL ADRroyed �{ Fee Enclosed 0 Amn„nr Dedift ljpe Lot Area ' 1 �iC . FiD Sftd= Ody LJ Depfb vdaos Nussbar d Hein DegSn Fbw G P D _ PCSD NedOmfisn Is Regohed Wbeis FM Is ooulpdsted Snpaeats SawWW Sy kM a snit aR-te"—GWIM Swim, Took -A �� ,�- fir, n--7216�� To be asosrudim! by Address Waar S.p*s IP SW* Fne Address an M Sawly BMW by Addr"" OtMr 1lsquie�suts 1 represent -.that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sew di sal s Rem above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a rag o ham County Department of =Kh, and that on completion thereof a "Certificate of Construction Compliance- satisfactory to the Commissioner of Heelthwill be submitted to the Department, and a written guarantee will be furnished the owner, his successor; heirs or assigns by the bulkier, that sold bulkier will plaq in good operating condition any part of said sewage disposal system during the period of two (2) years Immediately following thedate of the Nam• Once of the approwl of the Certificate of Construction Compliance of the original system or any repairp thereto. 2) that the drilled well described aboom "be located as drown on the approved plan and that said well will be in 11 in accordance with the ystwftk r r add reeu a�i%ne of the Putnam county oopwtmm* of Heath. Date i �f Si/netl P.E. RA. Address � Lfee No �% APPROVED FOR CONSTRUCTION- This approval expiry two years from the date issued un construKRIn of the building hag been undertaken and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any change or alteration of construction requires a new permit. Approved for disposal of domestic sanitary aelYaga�lnd/ , rfvate water supply only. / R_V. Title 10/88 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 00-9 -17 WELL LOCATION Street Address ,N/ 9A 1� To Village City Tax Grid Number �Dt� WELL OWNER Name Mailing a2OP Address 4ZtP_ t► _ aftivate D Public USE OF WELL 0- primary 2- secondary 12 RESIDENTIAL O BUSINESS, 0 INDUSTRIAL D P BLIC SUPPLY O AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify, Q AMOUNT OF USE YIELD SOUGHT j gpm /# O REPLACE EXISTING SUPPLY EI NEW SUPPLY NEW DWELLING) PEOPLE SERVED � "4 /EST. OF DAILY USAGE gal 0 TEST /OBSERVATION CIADDITIONAL SUPPLY O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE ®DRILLED 13DRIVEN DDUG �6RAVEI� OTHER IS WELL SITE SUBJECT TO FLOODING? YES )4 NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: No. WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ c NO NAME OF PUBLIC WATER SUPPLY: as TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: PJA LOCATION SKETCH & SOURCES OF ®ON SEPARATE 4.� d ) - l:4 (date) CONTAMINATION PROVIDED SHEET sienature 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 contaminate surface or groundwater. Date of Issue: 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 PUT.14PA CCUNrY DEPARLNOgr OF aEALTH, DIVIS 1 OF - FO M = SE-. .DESIGN' DATA -,.SH=-SUBSUFACE SEWAZZ DISPOSAL SYSM F= NO. Address owner uk)r Located at (Street) QUS40A fe Block Lot r1t �A C? . sec. (indicate nearest cross street) Municipality Watershed SOM PERCOLATION TEST DATA REQUIRED TO BE SUaMI= WITH APPLICATICNS Date of 'Pre - Soaking p Date of Percolation T dst HOLE NUMBER CLOCK TIME P�COUMCN PERCOLATION 77, 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 �*'2 � 2 _- 3 4 5 1 2 3 4 A� - - -------- --- ----- TEST PIT DAT_7.7.::'EQU1RED,,TO'BE. SUBMITTED WITH t-"TICATION DESCRIPy :'-_;N- OF SOILS -ENCOURTERED'IN TES'1_*'_.OLES 21 3 41 51 61 71 81 a 14' INDICATE LEVEL AT WHICH GROUNDWATER IS, ENCOUNTERED WA INDICATE LEVEL TO WHICH WATER 1= RISES. A= BEING RCMMMED K /A DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used /(,-_,�_ Min/1" Drop: --S.D. Usable Area Provided. No. of Bedrcans, 572. Septic Tank Capacity DD gals .-, Type Absorption Area Provided By L.F. x 24 width trench Other Signature A N1 0 �Q'�QAddre - ss /tit 0 -_Cc k Qp Tliis SPACE : FOR, USE - BY. HEALTH DZPARM�[ENT ONL`Y: ,Soil. Rate Approved:,, - sq- , f t/g , al Checked by batev 0. NA- T 1:-:: . .... ..... 14' INDICATE LEVEL AT WHICH GROUNDWATER IS, ENCOUNTERED WA INDICATE LEVEL TO WHICH WATER 1= RISES. A= BEING RCMMMED K /A DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used /(,-_,�_ Min/1" Drop: --S.D. Usable Area Provided. No. of Bedrcans, 572. Septic Tank Capacity DD gals .-, Type Absorption Area Provided By L.F. x 24 width trench Other Signature A N1 0 �Q'�QAddre - ss /tit 0 -_Cc k Qp Tliis SPACE : FOR, USE - BY. HEALTH DZPARM�[ENT ONL`Y: ,Soil. Rate Approved:,, - sq- , f t/g , al Checked by batev p•C3 TI\TA,t COICJ.W.-r 5C ?DEP,kk�`rMC��T.T ` -' _. APPLICATION FOR APPROVAL OF PLANS FORA WASTEWATER DISPOSAL SYSTEM. 1, Name and Address of Applicant: au o r_> N � . 1467 2. Name of Project 1�f�0t�DGJ�t� f 5 3.;_'._Location DV /C: o 4. _Project Engineer: w. 5. Address: `(' I DSo�: License Number: 5 l012 Phone: 2'1 _ 61 ofd 6. Type of Proect: ,/ Private /Resi.dential 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? f.1U .9: Has OEIS been',completed` and found- acceptable- by; Lead Agency? ............. n� /a 10'. Name- of Lead ,Agency ti. Is.this project in. an area under the control of--local planning, zoning, or other officials, ordinances? ........ .............................. t.)fl 12. If' 'so, have plans been. - submitted to such , author .s tie s ? ...................... . 13. Has preliminary approval been 'granted by such authorities ? -)�.LA^ 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 ?......... _ t��/A :6. Waters index number - (surface) .. ............. .I.._.............. ....... KI //tA J. Is project located near.a public water supply system? .......:.......... t,\) a '8. If yes, name of water supply WA Distance• tJwater supply , :9. Isproject site near a 'public. sewage collection or disposal system ?..... !Jo -0: Hame`of-sewagesystem` Distance to sewage system I.. 0ate `objserved:. lt' 13` -�0 23, Name of Health Inspector: /4•• 1'4 R��zc�s .-Project design flow (gallons per day) ..................... ........... (oda 2 . 25.. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.._' 26. Has SPDES Application been submitted to local DEC Office? ........ ►�1yA 27. Is any- portion of this project located within a designated Town or State _..wetland? ._.. .. .. .. .............. .. ..:............. N10 28..._ Wet.l and,_.ID_ Numbe'r......:_; .- ....... :...:...... , :... ............ :...... . 29 '2s_.Wetland. Permit required ? - ....... .... : ::......... h_w :..'. _... Has'°a pR 1_i.cati -on:, been made'. to Town or Local : DEC Office ?. _ ....... hJ /A 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 applica ion.or industrial act ivity ?........:`YES :or N0 _'. ►.l0 32,... -Is.: project. located -within ` 1; 000, feet of --. exi stence. of abandoned •landfill ` hazardous waste.site, salt.stockpile, landfill, sludge disposal site or any other potential'.: known•source:of''con'tamination? :.YES or NO ild DESCRIBE: 33: Is,there:..a local master plan or f le: with' the` Town or Vi 11Agd? `f s4. Are.coriunity water, sewer,- facilities - planned to.be.developed...within 15 years? MjNawo 35. Are any sewage disposal -areas in excess off15/% slope? 36. Tax ... Hap . ID Number ... ........... ....................... ..... . .......... 15. A 37. Approved Plans are to"be; returned, to: App-licant Engineer Zf 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 :proyided on this fom is true to the best of my know7edge and belief. False stateinents made herein are punishable. as a. Class A-Xisde✓%eanor pursuant to Section 210:45 of the Pena l Law. SIGNATURES OFFICIAL TITLES: :., Nil hi�3 2r -r "TAILING ADDRESS: {lf?'VI�sTYL , fJ :` �050G1 A5- BU /L T D /MEN5 /ON CHART 1"/N FT:) W A B / ?0.5 36.5 2 930 105.5 3 965 106.5 4 /00.0 107.5 5 103.0 109.0 6 /070 ///-0 7 ///0 //3-0 6 1150 1155 9 /Z0.0 //6.5 /0 60.0 -5-5.0 64.5 570 lZ 7/-0 61.0 / 3 76.5 635 14 8Z.5 66.0 15 660 72.0 16 93.0 75-5 /7 99.0 60.0 N O. -0 N� 0S �nis. wE WELL /197471-•. n 0 3 3 0 of z o � �' ®.1