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P ITNAM COUNTY,DEPARTMENT OF HEALTH . a `
ev 3186 Dtvtston of Environmental Health Servtaes, Carmel, N Y.10512
i En eer 1VFast Provide
y t<' P C:H D Permit p
CERTIFICATE OF CONSTRUCTION;,COMPLIANCE FOR SEWAGE DISPOSALSYSTEM S
Town or Yf
at r �/• Ta: Map f 3
,. Block Lot �.
Own r% pltcant Name S a edy Satidiviston Name '� ' u = // Sabdv.' Lot p
. ... -.4 -., -
dareae N P Date Permtt Issues L7
Separate Sewerage System -ballt by Address
Conalethg of ' I: LJ 0 GaDon:Septtc Tank end
FO Y• PP Y �m
Water Sp •
1 bu Private' Sapply I)rWed
on
Q
Badlding Type -�d i� Has Eroeton Contiol -Been mpletedY S
Ntimber of Bedrooms Has Garbsge.Grindei' Been inetelledY
Other Regalrements �. •Ti2r f�''J �/ ��'
,i certify that;thesystem(s) as listed serving the ,above- premise 's were wnetructed`easentidlly ae'shown the: plans of the completed wozk`(cbpies
of which; are,attaghed),'and in accordance ` with the itandW4r ,' rules and r` lit16no; in accorc�aoc` " "wi ' filed plan' and: the 'permit ,issued''by the
Putnam County De rt %
w nt f Health
P:Er�Y-```__ t t2.A: ,
Address i S leans No." / `f
{
Any parson occupying promises served by' fns above system(sf shall promptly take such actbn`aa,may be'rropadry to toc, ' ho correction of any unun)tary
conditions resulting from such usage Approval of tho separate sswsvage system shall bewms null and void'as: own as a pubt": ionitary "sewor becomes
availablevnd the-'app'roval-Lof the.:private; water suppiy.,shall become null and voi0 when a er`wpply bo�omei:avalgbN. Such - approvals are
'subject cation' or change when, `,in the` judgment of the Commissioner of, H th, :fur svocM modiflcation or Change is necessary,
:;Date�i�C.t� G/ TItN�d
,
RANDOLPH W. LAURENT; P.E
HARRY W. NICHOLS JR., P.E.
December 5, 1996
Mr. William Hedges
Putnam County Health Department
4 Geneva Road
Brewster, NY 10509
RE: Individual SSDS Compliance
O'Dell Subdivision - Lot #7
Town of Patterson, New York
Dear Bill:
Enclosed are the following:
xa
ON
LAURENT ENGINEERING
ASSOCIATES, P.C.
MILLBROOKE OFFICE CENTRE
Route 22 & Milltown Road
Brewster, New York 10509
(914)278 -6108 - (FAX) 278 -2658
CONSULTING SITE ENGINEERS
1. Four (4) prints of Drawing S -7 "As -Built Plan ", dated 11- 11 -96.
2. "Certificate of Construction Compliance for Sewage Disposal System ", dated 11- 11 -96.
3. Three (3) copies of "Guarantee of Subsurface Sewage Disposal System", dated 1 -1 -96.
4, Well Completion and Well Log Report, dated 11- 30 -95.
5. Water Analysis Report, dated 11- 14 -96.
r,n CD
6:'-- Money order in the amount of $200.00 payable to Putnam County Health Department.
these are any questions concerning the enclosed, please call.
" Yery-truly yours,
`";! -:LAMENT ENGINEERING ASSOCIATES, P.C.
w
Harry W. Nichols, Jr., P.E.
HWN:TR:bd
95061
cc: E. Pescatore w /enc.
utp wrbli kvr1rLG11V1V ME.rVRl
DEPARTMENT OF HEAt.TH bivisioh Of Environmental H6aith Services
PUTNAM COUNTY bEPARTMENT or HtALTH
^�
Office Use Only
v Fs-
WELL LOCATION
11110 AOURESS: [Owfily1tcluticily TAX GRID NUAttlp:
rat � — 2
WELL OWNER
NAME: ADDRESS:
Fes
Q p
PRIVATE
O PUBLIC
USE OF WELL
1 - primary
2- secondary
(71 RESIDENTIAL O PUBLIC SUPPLY IJ AIRICOND. /HEAT PUMP O A ANDONED
C] BUSINESS d FARM d TEST /OBSERVATION 0 OTHER (specify)
C1 INDUSTRIAL O INSTITUTIONAL d STAND -BY d
I111OUNT OF USE
YIELD SOUGHT ��Z� gpm. /ND. PEOPLE SERVED / EST. OF DAILY USAGE i5? gal.
REASON POR
DRILLING
CJREPLACE EXISTING SUPPLY []TEST /011SERVATION [JADDITIONAL SUPPLY
W)EW SUPPLY (NEW DWELLING) [)DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH It. I
STATIC WATER LEVEL it.
I DATE MEASURED
DRILLING
EQUIPMENT
Cl ROTARY YCOMPRESSED AIR PERCUSSION O DUG
O WELL POINT d CABLE PERCUSSION d OTHER (specify):
WELL TYPE
d SCREENED d OPEN ENO CASING e-OPEN HOLE IN BEDROCK .O OTHER
CASING
DETAILS
TOTAL LENGTH,_ _ ft
MATERIALS: MTEEL O P4ASTIC O OTHER
LENGTH BELOW GRADE _ _ ft.
JOINTS: d WELDED O THREADED . ❑ OTHER
DIAMETER :_ In.
SEAL: CEMENT GROUT d BENTONITE I]OTHER
WEIGHT
PER FOOT Ib./I1.
DRIVE SHOE YES d NO
I LINER: DYES wft
SCREEN
DIAMETER (in)
'SLOT SIZE
LENGTH (it)
DEPTH To SCREEN (ft)
DEVELOPED?
DETAILS
FIRST
O YES (i NO
SECOND
_
HOURS
GRAVEL PACK
" YES
C] NO
GRAVEL
SIZE:
DIAMETER TOP
OF PACX fd.
DEPTH K.
BOTTOM
DEPTH h.
WELL YIELD TEST I If detailed um in
M HOD: O PUMPED I tests were done is in-
1
COMPRESSED AIR , formation attached?
Cl BAILED O OTHER 1 O YES ONO
,WELL
If more detailed lormitian descriptions or slave analyses
OG ate available, please attach.
DEPTH FROM
SURFACE.
Whir
gEAr.
In9
Well
Dis -.
Ineler
PoAMAnok OESCAIPTION
coot
It
It
WELL DEPTH
It.
DURATION
hr. min.
DRAVIDO'NN
It.
YIELD
9rm.
Sunrtu!
°
CS Q
Y d clouDr NAItDNESS
ti COLoPEO ANALYZED? d YES ONO
ANALYSIS ATTACHED? B YES d00
rMAXFn CLEAR TEMP.
5TORAGL TA1 X t tt#g r
CAPACITY v. CAk•
11PORMATION
�u 9 CAPACITY
4 DEPTH
-- __Q :Z VOLTAGE�GHP
WELL DRILLER NAME OAJE /�
ALBERT M. HYATT & SONS, INC.
ADDRESS Well Dri lling SIGIIATURE
Rte. 311 R.R. 2 Box 171A
1 "RSON, NEW YORK 12563
3189 -- - - - U
3'iiT y
CERTIFICATE OF LABORATORY ANALYSIS
LAB ID NUMBER: 96 -7712
CLIENT: Albert Hyatt & Sons
RR 2, Box 171A
Patterson NY 12563
SAMPLING LOCATION: Outside spigot: Ed Pescatore, 7 Caroline Dr, Patterson NY
COLLECTED BY: M. Hyatt
DATE COLLECTED: 11/12/96 TIME COLLECTED: 1:05 PM
DATE RECEIVED: 11/12/96
DATE OF REPORT: 11/14/96
ANALYTE RESULT* UNITS MAX CNTMT LEVEL ** METHOD ANALYZED
Total Coliform Absent Must be "Absent" SM18(9223) 11/12/96
E. Coli Absent Must be "Absent" SM18(9223) 11/12/96
This sample; as submitted - to the laboratory, and as compared to the New York State limits for drinking
water quality for the tests performed, was:
ACCEPTABLE. _ NOT ACCEPTABLE.
4 all
n
` -Maryann Fasano, Assistant Laboratory Director
NYS ELAP #11218
CT Lab Approval #PH -0171
* Underlined results are unacceptable according to health department and /or US EPA codes.
** Maximum Contaminant Level (maximum permissible concentration allowed by health department and /or US EPA codes).
618 Clock Tower Commons, Brewster, NY 10509 -9241 / 914- 278 -7600 / Fax 914- 278 -7754 / E -mail: NoAmLabs @aol.com
PUTNAM COUNTY DEPARIMENr OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PC5 COZ6 r
.Owner or Purchaser of Building
Building Constructed by
Location - Street r
�tJL. e e-s y-4
Municipality
Building Type
!3 a 3
Section Block -Lot
Ga�,5�L,
Subdivision Name
Subdivision Lot #
GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL 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 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 follcaing 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 Environiiental Health Services of the Putnam County
Department of Health as to whether or not the failure of the system to operate was
caused by the willful or negligent act of the occupant of the building utilizing
the system.
Dated this day of 4friV 19 �Ie
General Contractor (Owner) - Signature
Corporation Name (if Corp.)
Address
rev. 9/85
mk
Signature1�.yy, ++
Title �92N
Corporation Name (if Corp.)
Address
Tn1 R S 649412 i a Z IM Ate, Fm Seeffm Ody' Depth Z V Volans ZfYS
Nao•bw d Bedroom 4� Design Flow G P D TOO PCHD Notmcmdm Is Regdmd When M V am*W d
Sepgnls Sewomp Symen to callow d-1290 GVlon SepfJc Took eniL_f �� L' �• •��iic = %r Cr�C �, GEf
To be.celashuded by 7�t3•r� Address
Water Sappb: Pdit Sappy Fnn ' Addraa
an ph iaw, Sq,,* Dried by - _ Add m
War Reaa6emeua AS' If Z
1 repro nt'.that 1 am wholly and completely responsible for the design and location of the proposed system(s). 1) that the separate seway di al s stem
above described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a regu ns o • 114"1
County Department of Health, and that on compWion thereof a. "Cafificate of Construction Compliance" satisfactory to the Commissioner of Mealthwill
be submitted to the ppartnisnt, and a written guarantee will be furnished .the.owner, his succeerors, heirs or assigns by the butow. that said builder will
Dim in good operating condition any part of Said away disposal system during the period of two (2) years immediately following the date of the eau-
once of the approval of the Certificate of Construction Compliance of the iginal system or any repairs then i 2j t t the illed well described above
wM M located as shown on the approwd plan and that aid well will be instal in_.aecordenp with stan:4 wits cad r u ns of the Putnam
County Departnam of N•Nth. G
r q c O.E R.A.
Date Sign
Address ,^'t+ r{jg rar✓rzc - License No
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construdro� of the ikling .MS been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of stealth. Any change or alteration of construction
requires a w permit. Approved f r disposal of domestic sanitary �seyrage- epd/o water supply only.
REV.
10/88 Oate
-a
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 #_L__I�!_`�
WELL LOCATION
Street Address
Ca O '
o Village City Tax
v
Grid Number
WELL OWNER
Name
Mail ' ng Address
Y Zr"
JRPrivate
0 Public
USE OF WELL
® - primary
2- secondary
J19 RESIDENTIAL
O BUSINESS
0 INDUSTRIAL
❑PUBLIC SUPPLY
O FARM
U INSTITUTIONAL
QAIR /COND /HEAT PUMP
O TEST /OBSERVATION
O STAND -BY
0ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
gpm /# PEOPLE
SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
13 REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION L1 ADDITIONAL SUPPLY
JONEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
c
WELL TYPE
DRILLED
DRIVEN
DDUG
GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES __X_NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No. `7
WATER WELL CONTRACTOR: Name ZM> Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: N& TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: N�
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
f� 7S
P ON SEPARATE SHEET J_
c
(date) ignature) - -_ 7
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 - -L-f— Permit Issuing 0 icia __
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
:G>XC7'13CJ,,TAt-�C CO CJ�] TY 1�EP A. 'z MENT O F HE.A.L.T
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAG.SYSTEM
1. Name and Address of Applicant:
• �-�e� �y Coy /z
2. Name of Project: P/_0/00s ed Locationo/V /C:
4.. Project Engineer: /Tao""- 1 �,% ��r -�G,� 5. Address: Millbrooke Office Centre
Brewster, NY. 1x509
License Number: 4657 $2 Phone: (914) 278 -6103
6. Type of Pro.iect:
:., Private %Residential Food.Ser.vice Commercial ,
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7:. Is this project subject'to State Environmental - Quality Review (SEAR)?
0
Type Status (Check One) Type I.. Exempt
Type II. Unlisted. X_
8. Is a Draft Environmental -Impact, Statement, (DEIS) required? NO
9. Has DEIS been completed and found acceptable by Lead Agency?
10. Name of Lead Agency W
11.. Is this project in an area under. the control Of -local planning, zoning,
or other officials, ordinances? ......... ............................... /old
12.-If so, have plans been .submitted to such : author .sties....................... /II
5
13. %Has preliminary approval; been granted by such authorities? IV14 Date Granted:,
I4.:Type of Sewage Disposal:'System Discharge...... -Surface Water X Ground Waters
15. If surface water discharge, what is the stream class designation? ........
i
'6. Water_$ index number (surface) ...................r........... ......... N�
'�. Is project located near a public water supply system? .................. No
°. If yes', nave or water supply �� //� Distance to water supply --"
9. Is project site near a public sewage collection or disposal system ?..... A/b
'0. Name of sewage system /�A Distance to sewage system
1. Date observed: 23. Name of Health Inspector:
{ �00
~• Project design flow (gallons per day) ............:........ ..............
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. No
26. Has SPDES Application been submitted to local DEC Office? ............... N
27. Is any portion of this project located within a designated Town or State
wetland ? .................... Alp
28. Wetland ID Number. ............... ............................... IY1114
29.. 'Is Wetland Permit, required?.............................................. No
Has application been made to Town or Local DEC Office? ..................;
30. Does project require a DEC Stream. Disturbance Permit? ...................tea Wi. -n
31. Is or was. .project site used for agricultural activity involving application
of pesticide$ to orchards4or other crops, solid or hazardous waste dispose ,
r
landfilling, sludge application or industrial activity? ........ YES or Nn -- r�
32. Is project located within 1;000�feet of existence of abandoned landfill, co Zn
hazardous waste site, salt stockpile, landfill, sludge disposal site or
any other °potential known•source of contamination? ..............YES or NO* A/v
DESCRIBE:.
33. Is there a local master plan or file -with the Town or Village? ..... Ale,
34. Are community water, sewer facilities planned to be developed within 15 years? Ukk -aw,7
35. Are any' sewage disposal areas in excess of 15ro slope? A70
36. Tax�Map ID N. umber ......................... ............................... /3 — 3
37. Approved Plans are to'"be= returned to: Applicant - Engineer
If the application is signed by a person other than the applicant shown in Ite .p•1, the.
.application must be - accompanied by -a Letter of Authorization. Failure to comply.with this
:provision may be grounds for the rejection of any submission.
I hereby .affirm, under penalty of perjury.- that information provided on this
form is true to the best of my knowledge and be lief. Fa Ise stateM,ents -made
herein are punishab7e as a Class A Hisder,reanor pursuant to Section 210.45 of
the Penal Law. 11 % J .4 A
SIGNATURES & OFFICIAL TITLES:
Millbrookh Office Centre
'AILING ADDRESS: Brewster, NY 10509
.d 17r ° T
PUMM CCUNTY DEPARTMENT OF HEALTH =
DIVISION OF HEALTH SERVICES
DESIGN DATA S=- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
owner �d i✓GY�. Address y ,L�x Y/?" CG��,� NY �osrZ
Located at (Street) Ca e- Z)r l ✓ � Sec. 13 Block �; 2 Lot
(indicate nearest cross street)
Municipality /-G Yll6kgdA7
Watershed
�rd�pvj
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - .soaking
Date of Percolation Test
� 3
HOLE
NUKBER CLOCK TIME
PERCOtMCN
PE ROOLATICN
Run Elapses
Depth
to Water Fran
Water Level
No. Tire
Ground Surface
In Indies
Soil Rate '
_ Start-Stop Min. '_
Start
Stop
Drop In
Min /In Drop
Inches
Inches
Inches
21 S0
e
3�'. ► �o - _Q Lo 3.0
30
4
5
33; 3' -7
4
5
1
2
3
4
5
:iN=: 1. Tests to be repeated: at same depth until apprcmimately equal soil rates
are obtained at each percolation test hole. All data to' be,suhmitUd.
for review.... :• .
2. Depth measurenients:to be made fran top of hole.
TEST PIT DATA *REQUIRED TO BE SUBMITTED WITH APPLICATION
DESCRIPTION OF SOILS ENCOUN MED IN TEST .HOLES `
DEPTH HOLE NO. 1 HOLE NO. 2 HOLE NO.
G.L.
sc� i� •' " Oo 450 L '
s .
2' ILT Y ::SA VD
3' 61cT 64WO
4'
5'
-77 oc YY yu
71 ��
8' '
10' .
11'
12'
13'
14' rr
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED Nt�-
DEEP HOLE OBSERVATIONS MADE BY: RWVy 0��W S J✓ ..� _ DATE: le-7
DESIGN -
Soil Rate Used 21-3a Min /1" Drop: S.D. Usable Area Provided-
No. of Bedroms Septic Tank Capacity JZSa gals. Type ✓ �
Absorption Area Provided By ( L.F. x 24" width trench
Other
Name Signature OF N
0�
// SEAL 5
Address �%i ���r �CP. �)� cam , v�r� 47 ..
* Q x
LU
` THIS SPACE FOR USE BY HEALTH DEPAPMVM ONLY: F 0.
.. OAP�.
Soil Rate Approved sq.ft /gal. Cbecked AOFE�`O�
by Date
a
Tee
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONIMENTAL HEALTH SERVICES
Date
Re: Property of ��wgro� /�G.S6a �vk-e_
Located at ca✓O�!1r�
(T) Section r Block Z Lot 3
Subdivision of a
Subdv. Lo ;1 Filed slap Date
Gentlemen:
This let ter is to .authorize /iL_14O /S
..a duly licensed professional engineer X or registered architect
(Ind4cate)
to- apply for a Construction Permit for a separate -sewage system, to
serve the above noted property in accordance with the standards., rules
or regulati.ons..as promulagated by the Commissioner of the Putnam County
Department of Heal tin', and to' sign. all .ndcessary papers on my :behalf. in
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the -Public Health Lai-.r, and the Putnam County Sani-
tary Code.
�i
ounce i3ned:
P.E. , R.A. ,
Millbrooke Office Centre
Address
Very truly yours, ,
Signed �.
Oi.°ner of Property
or A,�<��
Address
O Sv"n
Brewster, ,NY 10509
Telephone
914 - 278 -6108
Telephone:
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