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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
EW;
Internal Use On
PERMIT#
%os��6y
lAil
LJ Ly Repair Permit issued in last 5 years U Not in Waters
❑ . lJ / Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
N
TM # I ,5
PHONE #
Name & Relationship (i.e., owner, tenant, contractor)
DATE q- FACIL TY TYP �' G,y,'; PCHD COMPLAINT #
PROPOSED INSTALLER �` t PHONE # 1 i% Vo -gg
ADDRESS 610 R 2 Q N. e�j ,IJF�GISTRATION /LICENSE # �� — _
/ ;6,3/
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
I, as owner,agree to the conditions stated on this form
SIGNATURE KEA ' o6 I N 5 TITLE PfJeAt a DATE
(owner)
I, the septic installer agree to compl with the conditions of this permit for the septic system repair
SIGNATURE TITLE a�� DATE
(installer)
Proposal approved with the following conditions: ;
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. No completed work is to be backfilled until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
Pro osal Approved �� Proposal Denied El
q
-'e:24 b r
7
1 pector's Si nature & Title Date Expirdtion Date
,Repair proposal is in compliance with applicable codes Yes No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
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
February 12, 2001
William & Judith McHugh
5 Caroline Drive
Patterson, NY 12563
Re:. Addition- McHugh, Caroline Drive
No Increases in Number of Bedrooms
(T)Patterson TM #13. -2 -4
Dear Mr. & Mrs. McHugh:
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 form this Department dated February 12, 2001. The addition is approved with the
following conditions:
1. The total number of bedrooms must remain at four 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,
Michael Luke
ML: lm Public Health Technician
cc: BI (T) PA
1
•1
DEPAR T M N .t OF I-MALT� i
Dlviiion of Enviranmental Health Ser oes
4 Genova Road
BTewstsr, New York 10509
Tel. (914) 278-6130 Fax (914) 278-7921
BRUCE R. FOLEY
Public Health Directcr
ST TOWN IAP # a "2
PCF�
MAMINO ADDRE
DESCRIPTION OF ADDITION a�5 Le- _ /ate _X-69— _
NUNIBER OF EXISTLNG BEI3I OONT IS PROPOSED # OF BEDROOM5,�,I_
(FROM CERT. OF OCCUPANCY OR
CERTIFICATION FROM BUILOLNG M. PECTOR)
*Arty addition -,Ntdch is considered a bedroom requires formal approval of plans (Construction
Permit; j prepared by a - rof_ssional Engineer or Registered Architect in accordance with
applicable sections of the Pumam Co=ty Sanitary Code.
Please submit this feat a,,d *-h: fo'lowing to Putnam County Health Dept., 4 Geneva Rd.,
Brewster, NY 10509, Phone 278-61' ?0.
1. Certified check or money ordzr for $100.00
Sketches of existing floor plan (drawn to scale, all living area Including basement)
* Non - professional sketches are acceptable
3. Two sets of proposed floor plan (drawn to scare, with name, street, and to,,, map ,14r)
* Non- p:ofcssiorW sketches are acceptable
4. Copy of sun ey showing well and septic location, 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 Cent. of Occupancy from Town or Certification front Building Dept. with legal
bedroom count of dwelling.
Q ac,E
Cornrnen:s
r:b 99
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DEPARTMENT OF HEALTH
Division . Of Environmental Health Services
4 Geneva' Road, Brewster, New York 10509
(914) 278 -6130 -
Putr. »rr. County Dept. of Heats
4 Geneva Road
3:awster. NY 105C9
Re:
Residence
Tax Map � 02
To`vr1
rentIemen:
BRUCE R._FOLEY. R g
Atting Puhlla ,Moalth Dire!-t.-jt
Accotding to records maintair %d by the Town, the above noted dwelling
IS
1.9 ;NOT
in complian— vith ToNti — : code and the total number of bedrooms on record
is
This information has been obtained from:
;rERTIFICATE Or OCCUPA14CY:
ASSESS__ -- _...�....n
OTHER
ilding Inl/v for
F M-V Floor
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FINAL PLAT PREPARED FOR ARTFiUI:Z J. e REGINA T. ODELL F.M. 2271
-roWN of PA- rTER.SON
PUTNAM CO. N, Y'
�5CALE: 1 " = 50'
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_ )nR i 1n PA i -) _ � ...s
Owner/Afflimult Neale,
Date at Previous Approval
Ad&.s.I'L�410o la 1 LLD><l t= Tows 1-T 50
Date_ Subdivision 'Approved Fee Enclosed Amnnnt �Ofl• dv
was Tips Lat Area � . 3� to Fm Seed oo oba LJ Do,& vahme
Naasbar d . _ Deeigo Flow G P D . PCSD NOdEadim b Regdred Wpb= F101e cmmisbd
Sepande Sewe"W Sy.a. to eo=M of W G O. S.put: Tank .bILG!� � L � � _ �I%M `, g
Ts be ,by Address
Walter Ssipply: Palle Supply Front Addreas
on ✓ wavab Supply Deed by Address
OIMe R�ggfteneaos
1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(s). l) that the separate !aware disposal $tam
above.descNbed will be constructed as shown on the approved amendment there to and in accordance with the standards, rules a r"u ens o Dam
County Department of Health. a" that on completion thereof a °Certifkate of Construction CampIlianee^ satisfactory to the Commissioner of Mealthwill
be submitted to the Department, and .-a written - guarantee will by furnished the owner, his success"$, hews or assigns by the bulkier, that said builder will
piece in good operating condition _ any part of said sewage disposal system during the period of two (2) yeas Immediately following thedate of the isw•
area .of the approval at the Certificate of Construction Compile oft • riginal system or any repairs t . o. 2) hat th drilled well'de$ts'ibad above
w)N be located as dmwm'on the approved plan and that said well will M in 1 in accordance with the $tender ru and u ores of the Putnam
County Oapartment of MNlth.
Daie %Z-- �'/ signaq P.E. tl R.A.
Addre a 1 LicenseNo 'fA
APPROVED FOR CONSTRUCTION: ThL pproval expires two years from the date issued unlej, c.,t,.ction of the building has been undertaken and is
revocable for cause or may be amended or modified when considered necessary by the Commissioner of Neagh. Any change or alteration of construction
require$ •raw per t Approved for disposal of domestic sanitary .sewage, anSlo,00 water w y only.
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Lot 6
CWP.LL %jVr1rLP.11V1V �,rVn�
* * DEPARTMENT OF HEALTH
Division Of Environmental Health Services
Y PUTNAM COUNTY DEPARTMENT OF HEALTH
Office Use Only
WELL LOCATION
STREET ADDRESS: ,/ 1 TAX GRID NUMBER:
Route 311, Lo ; Patterson, New York ��-
WELL OWNER
NAME: ADDRESS:
10 PEIIVATE
Anthony Petrillo, Sherwood Hill Rd., Brewster, NY PUBLIC
USE OF WELL
1 - primary
2 - secondary
2QxRESIDENTIAL O PUBLIC SUPPLY O AIR /COND. /HEAT PUMP O ABANDONED
❑ BUSINESS ❑ FARM 0 TEST /OBSERVATION ❑ OTHER (specify)
❑ INDUSTRIAL ❑ INSTITUTIONAL O STAND -BY ❑
MOUNT OF USE
YIELD SOUGHT 5 gpm. /NO. PEOPLE SERVED 2 - 4 / EST. OF DAILY USAGE gal.
REASON FOR
DRILLING
.[]REPLACE EXISTING SUPPLY ❑TEST /OBSERVATION ❑ADDITIONAL SUPPLY
uONEW SUPPLY (NEW DWELLING) []DEEPEN EXISTING WELL
DEPTH DATA
WELL DEPTH 585 ft. I
STATIC WATER LEVEL 59 ft.
DATE MEASURED 12/22/93
DRILLING
EQUIPMENT
❑ ROTARY X19 COMPRESSED AIR PERCUSSION ❑ DUG
❑ WELL POINT ❑ CABLE PERCUSSION ❑ OTHER (specify):
WELL TYPE
❑ SCREENED ❑ OPEN END CASING XU OPEN HOLE IN BEDROCK O OTHER
-
CASING
DETAILS
TOTAL LENGTH 40 ^ ft.
MATERIALS: xJaSTEEL ❑ PLASTIC ❑ OTHER
LENGTH BELOW GRADE 39 ft.
JOINTS: ❑ WELDED xiaTHREADED ❑ OTHER
DIAMETER 6 in.
SEAL:EMENT GROUT O BENTONITE OOTHER
WEIGHT PER FOOT 19 1b./It.
I DRIVE SHOE ❑ YES ❑ NO LINER:OYES ONO
SCREEN
DETAILS
DIAMETER (in)
SLOT SIZE
LENGTH (It)
DEPTH TO SCREEN (ft)
DEVELOPED?
FIRST
O YES ONO
HOURS
SECOND
GRAVEL PACK
❑ YES
O NO
GRAVEL
SIZE:
DIAMETER
OF PACK in.
TOP
DEPTH tt.
BOTTOM
OEFM K.
WELL YIELD TEST If detailed pumping
METHOD: ❑PUMPED t tests were done is in-
t
cOxCOMPRESSED AIR , formation attached?
O BAILED O OTHER 0 YES 0 NO
WELL LOG it more detailed formation descriptions or sieve analyses
are available, please attach.
DEPTH FROM
SURFACE.
Water
Bear.
inq
Well
Dia-
meter
FORMATION DESCRIPTION
pot
tt.
ft.
WELL DEPTH
ft.
DURATION
hr. min.
DRANIOOWN
It.
YIELD
gpm.
Surtice
$
Brown soil. w /cobbles
8
585
White limestone
585
6
—
320.
10
WATER ?ELI CLEAR TEMP.
QUALITY ❑ CLOUDY HARDNESS
O COLORED ANALYZED? x13 YES ONO
ANALYSIS ATTACHEDYES O NO
STORAGE TANK: TYPE diaphragm
CAPACITY 48 GAS.. 12
WELLORILLERNAME MILL DRILLING, A
ADDRESS Putnam .Avenue 17 4
S
Brewster, NY •
o rt i resi ent
PUMP IHFORMATION
TYPE submersible CAPACITY 7
MAKER Gfli)T.nG DEPTH —T&UT-
MODEL 7FHO7412 VOLTAGIA30 HP 3/4
3/ ay
PUMIAM COUNTY DEPART OF HEALTH
DIVISION OF ENVIRONiZffWLAL $FALTH SERVICES
Owner o'�Purchaser of Building
Building Constructed by
c�,.al <
Location
- — Street
Municipality
Building Type
13.
Section
Subdivision Nam
Subdivision Lot
GUARANTEE OF SUBSURFACE SE�MGE DISPOSAL SYSTEM
Block Lot
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. shcwn on
.the approved �plari.gr approged amendment..thereto;.. and`'.in . accordance. with.•'the:'
standards rules and regulations of the Putnam County I7ep3rtment 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 follcwi.ng 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 cccupant.of the building utilizing
the system.
The undersigned further agrees to accept as conclusive the determination of
the Director of the Division of Environirnntal 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.
D_ ted.
eral C6fitractor_eb'—,,m&r) -
�' Arpor�atioa harp_ _Wf �Corpo. �)
J
Address q�,�
rev. 9/85
mk
Signatur d.
Pe-
Title
Co"rporation Name (if Corp.)
Address
�E
;r
TARLTON ENVIRONMENTAL LABORATORIES9 INC. CT Cert: PH -0404
A Division of Northeast Laboratories, Inc.
DANBURY: P.O. BOX 2328 ° 22 KENOSIA AVENUE C DANBURY, CT 06813 -2328
BERLIN: 129 MILL STREET " BERLIN, CT 06037
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
MILL DRILLING
PUTNAM AVENUE
BREWSTER, N. Y. 10509
DATE SAMPLE COLLECTED:
12/30/93
-` "TIME COLLECTED::
UNK
COLLECTED BY:
MI)
DATE RECEIVED @ LAB:
12/30/93
DATE(S) TESTED:
12/30/93
TESTED BY:
TEL
PURCHASE ORDER NO.:
REPORT DATE:
1/3/94
SAMPLE SITE:
TONY PETRILLO
LOT #6
ROUTE 311
PATTERSON, N. Y.
SOURCE:
WELL
TREATMENT:
NONE
TEST PERFORMED RESULT: RECOMMENDED LIMIT
BACTERIAL' Mg /L = MilUgrnmv per liter.
Total Coliform (Bacteria) 0 per 100 rill '' .. 0 er 100 m1
CHEMISTRY:
Chlorine Residual .00 In -- - --
RESULTS BASED ON SAMPLES SUBMITTED /COLLECTED: 12/30/93
SAMPLE, AS TESTED ABOVE: UOTABLE or OkOTPOTABLE
(PER EPA STANDARDS FOR POTABLE WATER)
COMMENTS OR NOTES (IF ANY):
CT: DANBURY AREA (203) 748 -7903 — FAx (203) 748 -0652 o CT: NEw ftwNIHARTFORD AREA (203) 828 -9787 — FAX (203) 829 -1050
TOLL FREE WITHIN CT: 800- 826 -0105 o OUTSIDE CT: 800- 654 -1230
''1}t T77
j.
(j PUTNAM COUNTY DEPASTbffiVT OF HEALTH
11 DMdon of &ANA Rental Hedt6 Sere c* Caemel, N.Y 10512
�' Enahleer Mdot PnovMe� `�r.
Pezmit ll
3 .
CERMCATE'OF CONSTRUCTION COMPLIANCE FOR SEWAGE DISPOSAL SYSTEM-
Town or Vmage
er!► O
A-t L,
/ pUcant Name
AVSJOLAIC Fonrwm L / Subdivision
Ma01og %ddmas I� G1 l� p : Lo rah Subdue Lot Ge
Fee Enc]os,ed, Amount `7.a Date Permit Issued 14
6
Separate Sewerage System balit by l- fSb Address
Consisting of �'.Z. Gelled Selirlc Talk and � a � o
Water Supply: Public Supply. From Address p
Prlvate Supply Drilled by It SA Address S'`G
Building Type ltzs L c., t 4 Lot Size j j_ 3 � Has Eros iorl rnntrnl Rpm„ rim= l pr PA ?
Number of Beilrooma Has "Garbage- Grinder Been InstalledT NO
Otber Requirements
I certify that the system(:) as. listed serving the above premise's'were_ constructed essentially as shorn
on t e, plans of the completed work (.copies
of which are attached). - and -in accordance with the standards, rules and 4sKl'tin9, in accordance with the` filed 1 and the permit issued by the
Putnam county1)eparimenpt of health.
Date ` °3� —.L:..' ertofied.bY P.E. R.A.
Addest o� Llansa No. �t1al
Any
person oecupyiny,premis�s: s�►ved.by:Me above system(:) shall,Promptly taki wch action as may be,naosus►y It rd the correction of any unsanitary
conditions resultiPp from ,such `usage: 'App'
Pprovel of the: yparats sewwa9a systNr► pNll wcoene null and void as soon ii a.pubtio sanitary .sewer beoon►sa
available and the approval of .the - private mratei supply shalt become null end.-voW. vihen a public viatw supply becomes 'available. Such approvals we
subject to podificat'lon or change when; In the Judgmant' of tM::Contnlissionw. of Hw @h. wfh rsvocetbn, modification o►.chanOe Is necessary.
3/89 oats *P� "�/`�� / �y' �''-nN'" "
il
-7.
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 (Town)Village/City Tax Grid Number
WELL OWNER
N e Mailing Address
pPrivate
,�O Public
USE OF WELL
(D- primary
2- secondary
® RESIDENTIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP 0 ABANDONED
0 BUSINESS O FARM O TEST /OBSERVATION 0 OTHER (specify,
0 INDUSTRIAL O INSTITUTIONAL O STAND -BY O
AMOUNT OF USE
YIELD SOUGHT A?' gpm /# PEOPLE SERVED /EST. OF DAILY USAGE6�j gal
REASON FOR
DRILLING
O REPLACE EXISTING SUPPLY 0 TEST /OBSERVATION 12. ADDITIONAL SUPPLY
® NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTING WELL
DETAILED
REASON FOR
DRILLING
,
WELL TYPE
®DRILLED
DRIVEN
DUG
C]GRAVEL
0OTHER
IS WELL SITE SUBJECT TO FLOODING? YES ✓ NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
DISTANCE TO PROPERTY FROM NEAREST WATER MAIN:���
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 9
®ON SEPARATE SHEET 4
Z_
(date) (s nature)
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 39Anner as not to degrade or otherwise contaminate surface or groundwater.
Date of Issue: 19��
Date of Expiration 19 - Permit Issuing Official �r
Permit is Non - Transferrable White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
Garage & laundry room by builder.
1st Floor
2nd Floor
EM-Ly Mom
IO CSC W- 0,
' IMwC •00�f
PUTNAN COUNTY DEPAP !';~ ?ENT OF HEAT". .
T A?(C
FOR
'go-USE P � . t. ..
BEDRCJ)('" : C'j- i
nr �
Signature &Titer°
'Two Story 32x66
2505 Square Feet
1
r
8. Is a Draft Environmental Impact Statement (DEIS) required? ............... tJ U
9. Has DEIS been completed and found acceptable by Lead Agency? :.......... ti /4
10. name of Lead Agency rJ /h
11. Is this project in an area under the control of-local planning, zoning,
or other officials, ordinances? ........ ...........•................... ►.Jil
12. If so, have plans been submitted to such . author .stiesi..................... rJ A
13. Has preliminary approval been granted by such authorities? WA 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 ?........ O/A
:6. Waters index number (surface) ........................................... K)p,
7. Is project located near a public water supply system? .................. ti
S. If yes, name of water supply _ 4.1�A Distance to='water supply ,
9. Is project site near a public sewage collection or disposal system ?..... 1.10
0. Name of sewage system WA Distance to sewage system
1. Date observed: `�— �� . 23. Name of Health Inspector:
;. Project design flow (gallons per day) ..................... '46a
a pUTN.A.� COiCJ�TT"SZ" DJE7P,A.R.TMIENT O>E' �EAL.TH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1.
Name and Address of Applicant:
_� f� u 11-1'
2-0 L0o02 1411 1.-
2.
Name of Project: 6- 12 PDGJ1;t�
3.._._Location /C: jJ
4.
Project Engineer: �� Vll.
�i liNO�����_. 5. Address: r—,) t21V_e,
License Number: 6;
Phone: 21 _ (o 1ofd
6.
Type of Pro ect: ^• ,. :: r:
: - ..
Private /Residential'
Food Service : ....Commercial .
Apartments
Institutional Mobile Home Park .
Office Building:
Realty Subdivision Other (specify)
:
7.
Is this project subject to State
Environmental-Quality Review (SEQR).
Type Status (Check One) Type I.-.
Exempt ✓
Type II. Unlisted.
r
8. Is a Draft Environmental Impact Statement (DEIS) required? ............... tJ U
9. Has DEIS been completed and found acceptable by Lead Agency? :.......... ti /4
10. name of Lead Agency rJ /h
11. Is this project in an area under the control of-local planning, zoning,
or other officials, ordinances? ........ ...........•................... ►.Jil
12. If so, have plans been submitted to such . author .stiesi..................... rJ A
13. Has preliminary approval been granted by such authorities? WA 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 ?........ O/A
:6. Waters index number (surface) ........................................... K)p,
7. Is project located near a public water supply system? .................. ti
S. If yes, name of water supply _ 4.1�A Distance to='water supply ,
9. Is project site near a public sewage collection or disposal system ?..... 1.10
0. Name of sewage system WA Distance to sewage system
1. Date observed: `�— �� . 23. Name of Health Inspector:
;. Project design flow (gallons per day) ..................... '46a
r• . 2
25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.. �Jo
26. Has SPDES Application been submitted to local DEC Office? ......... ......
ip,
27. Is any portion of this project located within.,a designated Town or State
wetland? ................................... ............................... r.l0
28. wetland ID Number .......................... ...... ........................ ►J /d
29. •Is Wetland Perm. it. .............. ...............................
Has application been made to .Town or Local DEC Office? .................. hJ /.
30. Does project require a DEC Stream Disturbance Permit? ................... 1.1D
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 K)v
32. Is project Iocated•within 1;000• feet .of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge.disposal site or
any other potential known - source of contamination? .....'.........YES or NO f�lil
DESCRIBE:
33. Is there a local master plan or file.with the Town or Village .
34. Are community water, sewer facilities planned to be developed within -15 years? UN I�N3AOQ
35. Are any sewage disposal areas in excess of' 151%, slope? ...... - go
..................
36. Tax Hap ID Number ............................................................ _
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•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 proyided on this
form is true to the best of my knou7edge and belief. False state:rrents made
herein are punishable as a Class A Hisde,-,eanor pursuant to Section 210.45 of
the Penal Law.
SIGNATURES & OFFICIAL TITLES: Lit., n/�l tr � A�Ec
MAILING ADDRESS:
t- PU'IMM- OOUNW DEPART OF HEALTH
DIVISION OF HEALTH SEF a3S
DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO.
owner G t'� +�1 11=1 Address _w.00r-> 441U- ff��A t�
;Located at (street) (5 -Seca 1Z Block :2 Lot .(C-0�r-
UndicAte nearest cross street)
Municipality PcA I + -e_ rc n n_) Watershed
SOIL PERCOLATION TEST nATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Date of Pre - Soaking y Date of Percolation Test "7
HOLE -
NLFIDER C= TDM PERCOLATION PERCOLATION
Run Elapse, Depth to Water F rcca Water Level '
No. Time - Ground Surface In Inches Soil Rate
Start Stop Mih. Start Stop Drop In Min /In Drop
Inches Inches Inches
3:0 ai 3 g
2:0�
4 -
5
1 '
2
3
4
5 -
NOTES: 1 Tests to be `repeated' at same depth until approximately. equal soil xates
are.., obtained .at each percolation test hole. All data to' be- sukmittt�3
'for review,:..
2.: :. Depth.. measurements ` to be made fro-n top of hole.
DEPTH
G. L.::.:
1'
2r
3'
4'
5'
7'
8'
9r
•-10'
TEST PIT DATA REQUIRED Tp.BE SUBMITTED WLM APPLICATION
DESCR_TPTTON= OF SOTT S F1QM7h7T'PPF n TM unr Fc.
-HOLE NG.
HOLE NO.
�; '-71
G T
INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED V)I k
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED ON-
DEEP HOLE OBSERVATIONS MADE BY: '' II �vv II , f
�t i �J t'e�al S R r .. DATE: `1 ITO
DESIGN r
Soil Rate Used Min /1" Drop: S.D. Usable Area Provided SOcCD ��Z
No. of Bedrooms 4 Septic Tank Capacity l2 be gals. Type�O�t✓
Absorption Area Provided By .445 L.F. x 24" width trench
Other
Name {,.cla � ^G✓�-} vm,*v,.-6e ,,, r!r w.Ssoc. Signature
V
Address �3— �y� }�. �V�+�c SEAL
G� 1
z
el/so v� , PJ�1. 12.5 bl
No. 66124
THIS SPACE FOR USE BY HEALTH DEPA1MVM ONLY:. g�FESSIO�P
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
I
(T)�`��j6jJ Section Block �%i Lot
Subdivision of . Q�
Subdv. Lot # 62 Filed Map
Date
Gentlemen: /
This letter is to authorizear�
a duly licensed professional engineer !/ or registered architect
(Indicate)
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules .
or regulations as promulagated by the Commissioner.of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in c<
connection with this matter and to supervise the construction of said
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
�r. �fi��✓ Very t y yours
Signed
Countersign
P.E. , A-I ,
Add 6s S
E . r'
er of ~Pro'p`erty
Addr1ess
�rllit ,. � � .►
Telephone
putriam County Department of Health
Division of Environmental Sanitation
AFFIDAVIT - CORPORATE a4NER APPLICATION
FOR PERMIT. APPLICATION SUBMITTED- TO -
.PUTNAM COUNTY HEALT}j DEPARTMENT
TO: Commissioner of Health - In the matter of application for
---- ---- -- - ---- represent.
that.I am an officer or employee of the corporation and am:authoriied'
to act for.
�e�,�-
— . (name of corp or
having offices at1�1�f`tA�QO Q ( —� — _ — _. _ _ _
_ _ _ _. _ C._'• _ _ Whose officers -are
President v V9 — — � �� j�� 0
Addres
---- - - - -__ Name ancT ! -- __— ___ - --
' s) j�
Vice "President �t� 1�
(Name and Address) — z.
Secretary Ci_
• (Nam_ a and Address)— ^ ^ —
Treasjurer' -
.' ',(Name and Address)—
and that I= am-and will be individually responsible fon any' or all aptp�
of. the- corporation With respect to the approval requested and-all Sub-'
a6ts relating -thereto. _
j.
Sworn: to before ine this day Signed
of 19 Title`�Q `
Notary Public"
• ...... r....% . _ ---- .
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