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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -11 BOX 4 00123 „ y WIN I how Al �ljk #6 00123 PUTNAM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVICES PLICATION TO CONSTRUCT A WATER WELL l y P nc or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # — —/' Map %loci Lot(s) Well Owner: Name': J A dress: Use of Well: Reside tial Public Suppl Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought = gpm # People Served Est. of Daily Usa a gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes No Name of subdivision Lot No. Water Well Contractor: �� ��� .Address & /6 Is Public Water Supply avai able 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 Xj� 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 water well driller certified by Putnam County. „ --I Date of Issue d�a Permit Issuing Ofci r 111-4 Date of Expiration q c Title: /�hL Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 7 Boyd Artesian Well Co., Inc. 1054 Rte. 52 Carmel, N.Y. 10512 (845) 225-3196 Fax (845) 225-8420 dt wl� 0 -\� p . VJ lwl- jo all a� Ar q�r�'�5 vflo LiA, 251131.33 4 3 7 1 00 co co It 0 �o 0 7 ral 2.24 AC. V03 1� Qi --.j 0 209.73 .9 z 0 3b 2 • • 180 oo,_ 0 1 it 2 N� 'PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE F TMENT SYSTEM PCHD CONSTRUCTION PERMIT # P" 41— i 1 h Zy 0J Located at 646 1-4 + 6 �-D UT-f,� /�J l Town or Village fAT-I—PL/50H Owner /Applicant Name. J� . CAN /50 -WrioH Formerly 0' 14 A'`?—A Mailing Address F 19 I e) DX H �9 Date Construction Permit Issued by PCHD Separate Sewerage System built by Tax Map I ") ° Block 2 Lot I I Subdivision Name Subd. Lot # pArTI�"aM , 0 %] vol 0 J ,Vi C-6 i4'5 Luc n()H Consisting of M50 Gallon Septic Tank and Other Requirements: 1-46W Y04 Zip 1%611 Address P,0,60y ' 41 661 L-F AlbS , f P-Cw—k Water Supply: Public Supply From Address or: 'X Private Supply Drilled by Building Type P-. 151Dr H(6F Number of Bedrooms 4 IQ V of i Rid 1 T Address i D'% K ?,11 PftDF -5o d t Has erosion control been completed? Has garbage grinder been installed? 1-40 I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- , uilt 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 County I?epartmeent of Health. I bate: 11 10 yi � Certified by h�444,-"Az, Y P.E. X R.A. 7�� Address lz'- ZL- WWAMPro�A jssyonal) 1 a ,5 a T License # �)�l 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 are subject to modification or change when, in the judgment of the Public Health Director, such revocation ificatio r change is necessary. By: Title: Date: IlLirz White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 OUTAW. COUNTY- HEALTH DEPT. U-96 3 6.6 I d6n46 Road (W) 27"130 arewster,.Ny 10509 Date '�7.'Receiybcl 1 L--,z �, Dollars $ The Su*m Of �For - &-Y-� Is THANK YOU► • 0 Zt ❑ Credit Card Ej Cash Check ❑ M.O. M-0. AL], BY PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION. REPORT Well Location Street Address: A 6 4 t e si, Town/Village: 'p, )%"" Tax Grid # Map It, Block �- Lot(s) Well Owner: Name: Address: T1. Cantci c7 o;n Use of Well: 1- primary 2- secondary j Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion -,k Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade _ 20 ft. Diameter 45 Weight per foot /% lb /ft. Materials: _ Steel _ Plastic _ Other Joints: _ Welded Threaded Other Seal: Y Cement grout _ Bentonite _ Other Drive shoe: -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 Compressed Air Hours 2 Yield � gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface j '5' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information 360 aL' Pump Type Capacity . Depth Model Voltage HP _ Tank Type 1 Volume _1 6061 Date Well C mplet d Putnam County Certification No. 057 Date of Report Well Driller (signature) r NOT : EfAct location of well with distances to at least two permane t landifarks to be provided on a separrheet/l5lan. Well Driller's Name rtl)f. 4<. ," Signature: Address: y /e M Y. �3 Date: tZ White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 r4o6-43!40" W 90 ays! ArW "s AIIVHI as ,9 N. y. _5 Tzzrs-4-0 W. F- (Zou-f S o" 4 44 4etf,7, !"ej, f,7, 4c" pRO Tqx ART) 41 'ropos At k STC DIMENSI ®N CHART (in feet) Number A B I 20 35 2 56 60 3 95 96 4 130 126 5 135 132 6 138 135 7 141 1,40 8 145 149 9 I49 146 10 153 153. 1 1 156 157 12 160 162 1'3 165 1 67 14 169 171 (5 173 176 16 178 181 17 214 211 I S 211 207 19 207 204 20 205 199 21 202 196 22 98 193 23 96 190 24 93 I8"1 as 91 183 26 89 181 27 87 I79 28 85 187 � AO a� �0 b° 27 1 G0'LF, 26 '4B5 as 2q Z3 SoGiD p, 2z 21 zo !g NOV -20 -2003 12:37 PM HARRY W NICHOLS 914 279 4567 P.02 a •� BRUCE R. FOLSY * LORB'iTA MOLINARI RN., M.S.N. Public H4611h Vhw1w• � • .41oekN Pwblk„ l�tolsti ,,1>irr9ro►.,, _„ . . . � • "" Dfrrera • qj Parinu Scrykw .. DEPARTMENT OF • MALTH 1 Oeflew • Road - -• $rewiter, New YoIX '10509 __,:._.......,_ �b an,sW ROM 014)211.430 Fur(914) 371.1911 t(wasslordw 014)211.4ss . -mc (914)4194471 AX(9t4) 271,008s tarly'ToleMeNo' pin 21t • 4014 Frncbool (911) 371.40n FAX(914)17r-6641 E911 ADDRESS,VRIFIC,411JIN FORM OWNERS NAME: �V G00SrpLl'laN, �. .... .. , T/I,�'MAp l+Ti<1MBER::... i� • _' 2 _' � � . •.. • • ._.., ,_'.. , .. , .. , .. _. .. E911 AEORZSS: • . TOWN: f�2O _ ...��.... .............. AUT1101t=D T4WN.QMCYA1w:. _._._.• _ , DATt; The Putnam County Department of health will not issue a Certificate -of Construction Compliance-unless the above form is completed; i.e., a legal E911 address ! as4jgned by an authorized town oMclal. This form is to be submitted-'*------- • • ... with the application for a Certificate of Construcdon Compuance: -- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH. j'SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREA J , y, CQKcoyw uo 4� Owner or Purchaser of"BUilding . J, Building Constructed by Location - Street SYSTEM zZ Tax Map t-, - lock Lot TownNillage Subdivision Name Building Type Subdivision Lot -I represent that I am wholly and completely responsible for the location, construction and drainage of the sewage'treatment system serving the above that is has been constructed as shown on the approved plan or approved, an accordance with the standards, rules and regulations of the Putnam County D hereby guarantee to the owner, his successors, heirs -or assigns; to place .in g any part of said system constructed by me which fails to operate for immediately following the date of approval of the- "Certificate of Construct sewage treatment system, or any repairs made by me to- such system, ex( operate properly is caused by the willful or negligent act of the occupant of 1 system. The undersigned further agrees to accept as conclusive the determinatic Director of the Putnam County Department of Health as tovIiether or not to operate was caused by the willful or negligent act of the occupant of t system. Dated: Month Q Day Year Eoo� Corporation Name (if corporation) Address:. State t" t Zip�'� >rkmanship, material, .scribed property, and dment thereto, and in u tment of Health, and d operating condition period: =of two years Compliance" for the t where the failure to building utilizing the of the Public Health failure of the system building utilizing*the Title: Corporation N (if corporation) Address:- State' . Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street. Yorktown Heights, N.Y. 10598 ( 914) 245-2800 Albert H. Padovani, Director LAB #: 32.308662 CLIENT #: 3653 NON STAT PROC PAGE: JV CONSTRUCTION INC DATE/TIME TAKEN: 10 /2 4 /03 02 t 30 BOX 449 DATE /TIME REC' 1i„ 10/24/03 03:25 PATTERSON, NY 12567 RE PORT DATE n - 1 1 /03 /03 Y'HONEv (914)-225-7912 SAMPLING SITE; TM 130-2-11 SAMPLE TYPE—i TYPE- PO TABLL: o #646 RT 311, PATTERSON , NY l='RE SE RVA`i' I VES : NONE: COL ` D H Y z JERRY . . TEMPERATURE.,: NOTES...: HOSE COL I FORM METH, n MF DACE. FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUT NAM CNTY PROFILE: 10/24/03 MF T. COL I FORM ABSENT /100 i N._ ABSENT 1 008 10/24/03 LEAD (IMS ) 1.1 pPb 0._.15 ppb 9101 10/24/03 NITRATE N 1 TROG 3.59 MG /L 0 -- 1: o 9i39 39 10/24/03 NITRITE NITROG <0.01 !' G /L. NIA 9146) 10/24/03 IRON (Fe) 0.140 MG /L 0-0.3 mg / I 2037 10/24/03 MANGANESE (Mn., r '= 0.010 MG /L.. 0---0.3 mg ,` 1 2037 10/24/4=3 SODIUM (Na) 45.3 MG /L.. NIA 10/24/03 pH 7.3 UNITS 6.5 -8.5 ` 043 10/24/03 HARDNESS , TOTAL_ 328 f" G / L N /Ei 1.0/24/03 ALKALINITY (AS 356 MG /L iii r`A 10/24/03 TURBIDITY (TUR 1.7 NTU 0-5 NTU COMMENTS BACT THESE RESULTS INDICATE= THAT THE m' WATE R (WAS AO , NUT) OF A SAT ISF ACTORY SANITARY QUALITY ACCORD HE NEW YORK STATE: AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. Pb /Cu LEAD limits for p EPA Lead & Copper r than 10 of their than 15 pph and a treatment must be potential. ab I is schools are set at 15 ppb . Rule for Public Systems requires that no more distribution points have a LEAD value of more COFFER value f Wit_. e o c1_. i' 1.3 mg/L, =Isia water- undertaken to reduce the wc!'•=€='.rs corrosive Fe/Mn if both iron and manganese are present, >ent, their total value combined shall not exceed 0.5 mg/L. Na No limits for Sodium are prescribed. Suggested guicir_ri.::nes state that for people on a sodium restricted diet, the water should contain no more:. than 20 mg /L of Sodium. For t.-hose on a moderately restricted diet, a maximum of 270 i1gi'L. of Sodium YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB Q 32.308662 CLIENT *: 3653 NON STAT PROC PAGE 2 JV CONSTRUCTION INC DATE/TIME TAKEN: 10/24/03 02:30 BOX 449 DATE/TIME REC'D: 1004/03 03:25 PATTERSON, NY 12567 REPORT DATE: 11/03/03 PHONE: (914)-225-7912 SAMPLING SITE: TM 130-2-11 : #646 RT 311, PATTERSON, COL'D BY: JERRY NOTES...: HOSE DATE FLAG PROCEDURE SAMPLE TYPE..: POTA8LE NY PRESERVATIVES: NONE TEMPERATURE..: COLIF8RM METHi NF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD is suggested. PH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS -CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: /]bert H. fadovani, M.T.(ASCP) Director ELAPR 10323 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 1z Telephone (845) 2794003 Fax (845) 2794567 November 21, 2003 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, NY 10509 RE: Individual SSTS Compliance - JV Construction 646 NYS Route 311 Patterson, NY Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -1, "As -Built SSTS ", dated 11/21/03. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 11/21/03. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 11/21/03. 4. Laboratory Report, dated �� �'1�� p►yl 5. "Well Completion Report", dated loj 22j o3 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. "E -911 Address Verification Form ", dated 11/21/03. If there are any questions concerning the enclosed, please call. Very truly yours, \J Harry W. Nich is Jr., P.E. HWN:gav 02- 028.00 PUTNAM COUNTY DEPARTMENT OF HEALTH t DIVISION OF ENVIRONMENTAL HEALTH SERVICES © K FINAL SITE INSPECTION - Date: 101014-73 — F'/! P. Inspected by: Street Location �(_j! 5 76 31 f Owner J`� 1%, Caysr�2uc�io.v. Town P4YTf eye: J Permit # rp. St7 _ 9!2 TM # 2 Subdivision Lot # ----- 1. Sewage System Area a. STS area located as per approved plans .......... :............. b.. Fill section - date of placement 3:1 barrier 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. Septic tank size - 1,000 ........ 25 ........other............ b. 'S eptic' 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 & trenche e. Junction Box - properly set ....... ............................... 6. renc es 1. Length required 61 7 Length installed i�' 7e 2. Distance to watercourse measured -f- (&a 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 % ...................... 8. Size of gravel 3/4 - 11/2" diameter clean .................. 9. Depth of gravel in trench 12" minimum .......:......... 10. Pipe ends capped .................... ............................... g. Puma or Dosed Systems 1. Size of pump chamber ............ ............................... 2. Overflow tank ........................ ............................... 3. Alarm, visual/ audio ........:....... .:............................. 4. Pump easily accessible, manhole to grade .............. 5. First box baffled ..................................................... 6. C�yycle witnessed by H.D.estimated flow /cycle........ 10[1. House/Buildirig a. douse located per approved plans .......................:...... b. Number of bedrooms .......................... . .,� IV. Well /y`i Well located as per approved plans. ...... : ........................ b. Distance from STS area measured -�- jpp - 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 plain f. Curtain drain outfall protected & dir.to exist waterco g. Footing drains discharge away from STS area........... h.. Surface water protection adequate :` ......:.................... i. Erosion control provided ............ ............................... Rev. 12/02 P •t SITE INSPECTION FOR FILL PAD Date: /,0 9 f� Inspected by: Fill pad located per the approved plan Fill Pad Length 3 Required Length_ Fill Pad Width % Required Width / 5 Fill Pad Depth Required Depth Run -of -Bank Fill Qualityoa� Slope from Top to Toe a o wt Impervious Layer Installed NIPi Erosion Control Installed Sieve Test Results (if applicable) Additional Comments: -9 Reserved for Field Sketch if Applicable MIN OCT -08 -2003 10:12 AM HARRY W NICHOLS J 914 279 4567 P.01 00-137- PUTNAM COUNTY DEPARTMENT OF HEALTH _ DIVISION OF ENVIRONMENTAL HEALTH SERVICES $,EQt MqT FOR FINAL INSPECTION For:. Fill Date: 1 6 " B Trenches PCHD Construction Permit Located: (T) 96 41..r- Owner /Applicant Name: TM U, Lot Li Formerly: Subdivision Name; Subdivision Lot # Is system fill completed? mss Date: Is system complete? Date: Is system constructed as per plans? Is well drilled? ,, „ . _ a Date: Is well located as per plans? Are erosion control measures in place? _ _ C I certify that the system(s), as listed, of the above premisenas been constructed and I have inspected and verified their completion in accordance with the issued PC HD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health, Dale: ! D - 8 —O 1 Certified by: PE &-,!. RA D,esii Professional Address:. a oS� /� 1 _ tau sue,. / i Lic, # Comments: FOR: C3 ADAM GENE O (N ) Form FIR -99 i LORETTA MOLINARI R.N., M.S.N. Public Health Director 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 /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 October 15, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: J.V. Construction NYS Route 311, (T) Patterson TM# 11-2 -11, Permit # P -47 -89 An inspection of the fill pad at the above referenced project has been completed. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the separate sewage treatment system. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. GDR: cj Sincerely, Gene D. Reed Environmental Health Engineering Aide d 1� SENDING CONFIRMATION DATE OCT -15 -2003 WED 17:08 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 -278 -7921 PHONE : 92794567 PAGES : 1/1 START TIME : OCT -15 17:06 ELAPSED TIME : 00'40" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... P s. (ARBTfA MOLWARI R.N.. M.S.N. ROBERT J. BONDI P.Bae /Mal* D&n C-" 6Ye I. DEPARTMENT OF HEALTH I Geneva Rood, Brewster. New York 10509 Ewln.mmiz) Beaha (945)378.6170 Fu(845)278.7121 N9rM" 5wvb= (845)178 -6559 WIC (8.5)=78.6678 F- (845)779.6895 EaMy letemenmMadW (965) 278.6014 Fax (545) 278.6618 October 15, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: J.V. Consi=ion NYS Route 311, (f) Patterson TMN 11-2-11, Permit 9 P -47 -89 Dear Mr. Nichols: An inspection of the fill pad at the above referenced project has been completed. Trench plans must be submitted to this Department for final approval of construction prior to the installation of the separate sewage treatment system Please note that field measurements by this Department in no way suggests the and size, depth and location of the fill pad. If you have any furthor questions, plcaeo contact me at 845 -278 -6130, ext. 2261. Sincerely, �'"�"" D Gene D. Reed Environmental Health Engineering Aide GDR:cj NOV -10 -2003 11:09 AM HARRY W NICHOLS 914 279 4567 P.01 rMAN COUNTY DEPARTMENT OF HEALTH DIYYSxON.OF LNmONMNTAL HEALTH SERVICES:. BEQ1 TE FOR F AL INSEE=ON For: Fill Date: ' ll- a �= o Trenches - ,/ ; . _•.......... . . PCHD Constructioa Permit # . EA-1- 99 Located: s9hT_ z Qa,1!i -I L (T) M — Em e soo Owner /Applicant Name: 4, �14_a"X&Qe_Zi,p". TM 18, 'Block � •__ Lot Formerly: Subdivision Name: ? ?° Subdivision Lot # Is'system fill completed? Date; I Is system complete? ves Date: 11- od- 0 3 ,y Is system constructed as per plans? vs Is well drilled? „ „, s Date: _,= 0_6.03 .Is well located as per:plP.ns? �tss Are erosion control measures in plane? Yt5 -.. ..•,... I certify that .the systetn(s), as listed, at the above premises, has been constructed and I have inspected. and verified• their odmpletion in accordance with the issued PtHD Construction *Permit arid • ' ' :;;`' <. >:: ':'.: ' approved plans and the Standards, Rules and Regulations of the Putnam County Department • of HealtlL ; ; Certified by: Desigorofessional Address:•Q, es' :•;►�a t��Isr iicl 5 6_1 z q Comments:.'"'' ` `•, FOR: o ADAM AGEm la s s'.,. (NAM.E).:::,:: _. ( ♦ IAMr . P1 M, I^" r` l it 1Tk/ M1 M^M MM rr flf P9 LORETTA MOLINARI Public Health Director 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/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 November 13, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Field Inspection — J.V. Construction NYS Route 311, (T) Patterson TM# 11-2 -11, Permit # P -47 -89 The above referenced separate sewage treatment system can be backfilled. There are no open comments to be addressed. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR: cj , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM,; PERMIT # P Located at -311 Town or )�i l ge Subdivision name A Subd. Lot # Tax Map 13, Block :z Lot ! (_ Date Subdivision Approved Renewal Revision Owner /Applicant Name Co ",Arvc:fl Date of Previous Approval - ! 3 --0,3 Mailing Address A0, 130y, -442 A-? ATfvr e4 V Zip 3 Amount of Fee Enclosed Building Type l 6 Lot Area 2 No. of Bedrooms Design Flow GPD_gdC Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of gallon septic tank and G ei7 �� T Other Requirements: To be constructed by TB D Address Water Supply: Public Supply From Address or: — ,o' Private Supply Drilled by J', f3, D; 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 s, sY tem 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: 'Address R.A. Date /0- License # 'a le- 12—:1 APPROVED FOR CONSTRUCTION: 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 w nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new p e arge of domestic sanitary sewage only. By: Title: Date: la /2 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM:CO T WTY. )X0. !OF-HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGETREATMENT SYSTEM Address' il4q /47�� -Vsall Owner, Located at (street) Y. -:5 Tax Map jj Bloch 2 Ldt (indicate nearest cross street) Municipality. Watershed d 13 F I�t, SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test .1-6- 9 - 0-3 ..... ........ 2 .3 X o Is, 4 5 P 2,2- - V3 -7 I S� JI 14 -3 2.1 :.j:'3"j-- 3 7 4 5 2 3' NOTES: 1. 9; repeated' at same depth until approximitely equal percolation rates are obtained at each percolation test hole. (ix-; & I min for 1-30 mWinch, :s 2 min for 31-60 min/inch) All.data to be- submitted for review.., 2. Depth measurements to be made from -topof hole. Form DD-97 Indicate level at which? groundwater -is encountered Indicate level at which. mottling is observed Indicate level to which water. level rises after being.encountered Deep hole observations made by: Date . Design Professional Name: Address:S' <) f; Signature:„ Design Professional's Seal TEST PIT DATA - 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES. DEPTH HOLE NO. HOLE N0. HOLE NO. G.L. - -- 0.5' 1.0' 1.5' 2.0' . 2.5' 3.0' 3.5' 4.0' _. 4.5' 5.0' 5.5' 6.0' . ....... 6.5' 7.0' 8.0' 8.5' 9.0' 9.5' _. 10.0' Indicate level at which? groundwater -is encountered Indicate level at which. mottling is observed Indicate level to which water. level rises after being.encountered Deep hole observations made by: Date . Design Professional Name: Address:S' <) f; Signature:„ Design Professional's Seal Harry W. Nichols Jr., P.E. Patterson Park, suite 106 2050 Route 22 Brewster, NY 10509 = . Telephone (845) 2794003 Fax(845)279-4567 To: P C 1 lTti h-. G ✓mil ✓ O CLd Attention: Ra/olr J0i E , Date: Job No.: 0a /'32 Project 1''vaaas-e—d� 5S r s 311 Gentlemen: We enclose (S- -copies of: B/W Prints Reproducibles Reports Tracings Specifications Memorandum Copy of letter Description: Revision/Date No. o Sent Via: /"Our Messenger Blueprinter First Class Mail Special Delivery Your Messenger Hand Delivery Copy to, Very trul yours, J Harry W. -Nich Jr., RE. e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PERMIT # CONSTRUCTION PERMIT FOR SE E TREATMENT SYSTEM Located at N T ID �vlM I 1 Subdivision name N X Subd. Lot # W h Date Subdivision Approved N f Owner /Applicant Name ArLF P 0' 1-t ,',1~=A Mailing Address HL 4 1L% o Amount of Fee Enclosed Q Building Type 1"cikiGi-�r Town or Village Tax Map Iii r Block 2— Lot Renewal X Revision Date of Previous Approval OF;-- )4- t,L-A PLt po PoUbu + LVNI:� o 1-4 7 zip )�A %O Lot Area 2 -1 ,-t,. No. of Bedrooms 4 Design Flow GPD 9 uu Fill Section Only >< Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of �-6,0 gallon septic tank and Other Requirements: To be constructed by 7 ° Ps 1 p Address 66I L F- N65 Water Sup"I : Public Supply From Address or: X Private Supply Drilled by J -60 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: Address r P.E. L %�'`'� �ifJ`al R.A. Date -� j1-2! ayl l E c l License # 5 6 I Z APPROVED FOR CONSTRUCTION: 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 wh sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit proved discharge of domestic sanitary sewage nly. / l By: Title:ak Date: i( b Z—" White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 - -I. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CnNRYUJI T A WATER WFUr please print or type PCHD Permit # 4-7 - Orl Well Location: Street Address: Town/Village Tax Grid # Ny 6 � ��l � PNTTEjfL-'50H Map 1?,, Block '3-,Lot(s) Well Owner: Name: Address: Atf�D 0 M61-41 -4ELLA P.GNP 0U�1�tiilAaa,�J � g. Use of Well: 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 S-4•- 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 Drilled Driven Gravel Other Is well site sub'ect to flooding? J .............................:................... ............................... Yes No x. Is well located in a realty subdivision? ...................................... ............................... Yes No 'A Name of subdivision Lot No. Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No _ l 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: Applicant Signature: G u 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. yyy ev ision or alteration of t o approved plan requires a new permit. Well to be constructed by a waterlwell ller certified by Putnam County. Date of Issue Date of Expiration v Permit is Non-Transferrable Permit Issuing Title: White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 BRUCE R. FOLEY Public Health Director TO: PROJECT: 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 (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM - • DELEGA TED 0 TOWN: C SE P PV DATE SUB'D APPROVAL: 1,11A NOTICE OF COMPLETE APPLICATION DATE: ` J L- Indicate level -at which - groundwater is encountered MOc Indicate level at which mottling is observed ry 3?P_' Indicate level to which water level rises after being encountered- Deep Nfl -s" hole observations made by: GE1'5 WEP I AAW w • n1iWOL,; TV-- M Dad o Design Professional Name: Ws kLtroL6, 1-QE cat co�'` Address: WS of wEwra� Signature: Z No. 5 024 Design Professional's Seal �i°ApFESSIO P�' TEST PIT DATA _......._. _..... 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH MOLE NO. HOLE NO. 2- HOLE NO. 3 G.L. 0.5' : Ap �a►L 1-8P 6011- Tol' 50it, 7DP 561L 1.0' 1.5' . M1' mm ER 2.0' LOAM Uk� 5 2.5' W wk a 4AM Cb 3.0' W dttT� �- iNl smAU. 3.5' 4.0' __.._..... SW ft\1I� 4.5' 5.0' 5.5' VN 771 IN 72� 6.0' __.. 6.5' 7.5' 8.0' 8.5' 9.0' 9.5' 10-.0' ..... - Indicate level -at which - groundwater is encountered MOc Indicate level at which mottling is observed ry 3?P_' Indicate level to which water level rises after being encountered- Deep Nfl -s" hole observations made by: GE1'5 WEP I AAW w • n1iWOL,; TV-- M Dad o Design Professional Name: Ws kLtroL6, 1-QE cat co�'` Address: WS of wEwra� Signature: Z No. 5 024 Design Professional's Seal �i°ApFESSIO P�' PUTNAM COUNTY DEPARTMENT OF. HEALTH: __ DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner A LFkD, 01 mg IN Address 1-$0 fMs"tJOEu,A K pOOL4�lj dM10 Located at (Street) � �J11 Lid. ���� Tax Map Block 2 Lot (indicate nearest cross street) _ unici ali p tY �P{t` "G ON Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of'Percolation Test Depth to Water Wafer From ou d ev tt Time eta se•.Tithe Surfa a (In.cbes) iarp Ia Percol an ]FIoie No.. :. Run Ngt�t Sto m. Start Sta c. es mlInch . 1 i 95° 1006 i5 V 3 j�2s �� }� 2) Z`i 3 (0/1 4 .5 2 1 � Na — 1011 3 c�4 22 1 30�..�. 4 I - I� �0 21 �2- �o 5 3 af;; .. q� ,� �t: r� .. , NOTES. tt�dle. at same depth until approximately equal percolation rates are obtained at Each pocM�S ^� �l�n (i.e. s 1 min for 1 -30 mm/inch, s 2 min for 3-1 -60 miii/inch) All data to be- bmttt d . ew. . ;�it#� ' rrurments to be made from top of hole. Form DD -97 DEPTH . G.L. .. . . 0.5' .. 2.51 3.0' 3:5' 4.0' 4.5' 5:0'. 5:5'........ 6.0' 6.5' 7.0. 7.5' 8.0' 9.0' . 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN.TEST HOLES HOLE NO. f HOLE NO. HOLE NO. 3 Indicate level at which groundwater is. encountered t/oot.16 Indicate level at which. mottling is observed. /1.ro A. � Indicate level to which water level rises after being encountered Deep hole observations made by: r:�`V i`-. , G , l7k �-f -, Date a-Ailaz Design Professional. Nat fie: Address: Signature: Design Professional's'Seal C r,': .4e-e, r/ Sa�+� I Le�x 6 PROJECT I.D. NUM S 81:20 ' SEAR •�. >. � , _,.,. i ...... . ._ $t t En W t WiW rr t APpend* C ' , _. ..._..__ _ • • i � v �n{n�n til�OuilJty Re � SHORT ENVIRONMENTAL ASSESSMENT FQRME • • 4 For UNUSTtp 60PONS Ordy PART I— PROJECT INFORMATION (To be COMPIeted by APPlloant or M-00t aponwtj t. APPLICANT JSPON80A !. PAW9CT NmLj — ' PROJECT LOCATW& , -- 4. PRECISE LOCATION (&"I Wdnaa and road Interne Owl e, VwJi mt landmarks, *to, or pmwe owl S. 13 PROPOSED Aar$M,..: : ❑ IAodiflaallonlaJtsratlon -- . a. t)ESCRIBE PRWEG'T t3WEFLYt. , 7. AUOUNT OF LAND A"ECT M initlaty . "I-1-1 -I agrea UI Z �� _ __ - .....•.. 6. PPOPOM ACTION OOUKY WITH E7WMG ZONING 01I4THEA EXIMQ LANG NSej REBTRtOT{ON81:_:::; :: >_;i _::: •r::. a;i: t 9. WKAT Ls PRF.W LAND VJ:VICI W OF, PROJE0IT 9-p, O.ntw `13w, uatrw ❑ Conuneralal ❑ Agriculture O Patworewopen .p.o. ❑ 0(tw 10. DOES.ACTION IAVOLVE A PEiWR APPROYAL, OR FUNDWO, NOW OR ULTOAATELY FROM ANY OTHER 00MMMF.NTAL AGENCY (FEDERAL, STATE OR LOCAL? ❑ Yaa p yea, Ili{ aper►oy(aI ar►d perlalt/apprwala _ 11 • DOES ANY ASP�E�CT OF:TN9 AQW #W4 ,A 0JA WMV VAUD PUJW OR APPROYAIt . z s ❑ Ya. 7 HO U y�+. Wt ape�Y fkilrM ww P"llawovilJ 12. AS A RESULT. OF .PRO?,08$R.I10T.10N WILL "WIS PFAWTIA MWAL NO= M001fIGAiIONf I, ❑Yw I CERnFY THAT M INF.OA6MTION PAOVIDEO A60VE Ia TRUE Appuunuaponaor nun« �' - • �, • ��VS i�� L . � �' �' Date: Slpntlum If the 00tl06 1s In ths.Coastal Area, and you aro a at agenay,.complete._the Coastal•Assessment Fonn'belore proceedlnp with'thls assessment n nT 1, .. 'r 11% /In ^ ►1 ■ AWL 17♦/ "�•A'A r!•SU �TI� /►� l�'����I�, -A b— Awe w.. A DOES ACTION EXCEED ANY TYPE I THRESNOtA IN i NYCRfi PART 011.17' If yea, 000rdinale'tlie renew Prot## and•uae{t►rFUll'EA ❑ Yfs O No ;•. _ S. WILL ACTION RECEIVE COORDINATED REVIEW A$ PROVI9EA POR VNUaTED ACTIONS IN 0 NYCitf4 HART 011.0? 11 Not a niyativs declarittlon may a supfrtaded by a notttef.Involved ipenoy 0 Yes C. couLO ACTION RESULT IN ANY ADVERSE 9FF.EOTS,ASSOOIAT90 WITH Ti1E fOLLOWINO: tMsvrfre may W handw(ltNn, 11 legible) C1. Ulatin9. air Quality; aurfaoi or groundwat0r Quality or quantity, noise levels, exla N 1r611.Ie.P49arQ , ao114 waste p�oduotlon a Disposal, pot•ntlal lot fiction, draln+pe of hooding pioWaal& ?. lxplaln brieliyi C2. A•sth•tic, 9911cultural, uchaeological, historic, or other natural *(Cultural re &ouroes; or community or nslghborfaod chaiiCtea Explain Wlellr: I jCJ. v•9•lat1on or fauna, fl&h, ahellflah cr Wlldllle apeclss, &Ipnlllaanl habitats, or threatened or indanpufd ipfrclfat-Explaln briefly; - — i C�4. A community's exititng plans or goof& a& offtclally adopted, of a Change In was Or Intensity of u&a of iand.Or.other naturat.re&oluoas?,ExP).iin Wetly cs. Growth, suoa.vV•nI development, or related aoUfIll" I"Iy 19 be Induced by the proposed aotlon? ExpI+M briefly. C6. t-ong term, short term, oumwative, or other effect& not bulled In 01•Cb? Explain btWily. C7. Other Impacts (Including changes In use of either quantity W type of energy)? Explain briefly. 0. WILL THE PROJECT HAVE AN ILIPACT ON THE ENVIRON&{ENTAlA CH/WACTERISTICS THAT CAUSED THE EBTABUSHMENT OF A CEA? ❑Ya ❑No E 15 THERE, OR 1:1 THERE UKELY TO a; C K8OVSY_RELAT EIE TO POTENTIAL AOVEROE ENVIRONNTAL IMPACT"? ❑Yea ONO- -If Y .ar' _ ER -- - . _ .. .Yp}air► briefly ART III — DETERMINATION OF SIGNIFICANCE (To be completed by'Agency) INSTRUCTIONS: For each adverse effect Identified avow, determine whethir It Is substantial, large, Important or otherwise significant. Eacn effect should be aaseasad In 0; nn tlon with Its 0) NtUng. Q.e, urW of rvialk.(b� probablllty .ol•.00�yafrtg;;(oj,4urstlon; (d) irrovfrslblllty; (e) peopraphlo scope; and (1) magnitude. It. necessary, add attachrnentti or refereno# supporting materislfl: 4vii, that •zplanations contain sufficient detail to show that all relevant adverse Impws.hove (teen Identified and adequately addressed. It question 0 of Pail II was checked yes, the determination and signlfldance must evaluate the potentlal Impact of the proposed. action on the enYlronmental characteristics of the CEA, ❑ Check this box If you have Identified one or more potentially large or significant adverse Impacts which MA' Y ' occur. Then proceed directly to the FULL EAF and/or prepare a positive declaratlon-0"o-4-a"' : O Check this box. It you. ve, determined, aced on the Informatlon and analysis nd .any - supporting documentation,. that the proposed action WILL NOT resull' In any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons .supporting this determination: anw of Wd Agwy rat 0( Type Namd .. . a Apacy :yu►ur, o ss Y Vw4two of rmww ill 01114(ant 1190 lespona KH fT 3 0. P.UTNAM 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: 0) 4+/s4 -A 2. Name ofproject: 3 Location TLW�i:.r. 4. Design Professional: 6'�('� �0� U FG5. Address: © IVY 6. Drainage Basin: 7. Type of Project _ ........... _ .... k 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 w Exempt :Type II = Unlisted ' 9. Is a Draft Environmental Impact Statement (DEIS) required? .......................... I3 10. Has DEIS been completed and found acceptable by Lead Agency? ..........::::._ A 11. Name of Lead Agency A, 12. Is this project- in an'area under the control. of local planning, zonin ,or other..:. P J .. P r : g� .g, officials, ordinances? .. ... _y; r 13. -If so, have plans been-submitted to such authorities ..... :. Flo IV 'Ili 14. 'Has preliminary approval been granted by such authorities? �90 Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water 'A groundwater 16.. If surface.water discharge,-what is the stream class 'designation? t ' 17: Waters index number•( surface) :. :....................... ............................... r ,. 18. Is project located near a public water supply system? ....... .........................:..... 19. If yes, name of water supply tJ Distance to.water supply o'i� A 20. Is project site near,a public sewage collection or treatment system? :...::...... :.. 21. Name of sewage system : Distance 6 iewage.`syCstem ,�, ,j1�-- 22. Date test holes observed �y j �1 �� 23. Name of Health Inspector 6� -: 24. Project design flow (gallons per day) 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... !`S 26. Has SPDES Application been submitted to local DEC office? .......................... Form PC -91 2 27. Is any portion of this project located. within a designated Town or State wetland?:" 28. Wetlands ID Number ........................................................................................... HA 29. Is Wetlands Permit required? ..................................................... I ............................. 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 ap-p'lic'a"tion 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? ............................................................... 35. Are any sewage treatment areas in excess of 15% slope? ................................ 36. Tax Map ID Number .................. I ......................................... Map Rtodk, --Lot. 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE:.All applications for review and approval of a new SSTS to be loc*ated 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, tinder penalty ofterjury, that information provided on this form is true to the best of my knowledge and belief. False statements 'made heiein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal, tio �aw. SIGNATURES &-OFFICIAL TITLES: : r ., .- -1 .::.2 Mailing Address: .............................. ..... 1 c � 0 = IAI,� In" & 13 , ;'8 1 Located at fb i I T/V [ J T5� W Tax Map # Subdivision of . It 9 Block_ Lot 1 Subdivision Lot # Filed Map # `-= Date Filed Gentlemen: ' This letter is to authorize V� ',� n1L�1,' J a duly licensed Professional Engineer < 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 CQ=tv Sanitary Code. of NEW. P.E., R.A., # 48 No. Mailing Address ` State N Zip S- (Y'\ Telephone: Very truly yours, Signed: - (Owner Property) Mailing Address: �� (%00aj'-4\ State Zip Telephone: kAg Form LA -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 1z Telephone (845) 2794003 Fax (845) 2794567 March 22, 2002 Putnam County Health Department One Geneva Road Brewster, New York 10509 Att: Mr. Robert Morris; P.E. Senior Public Health Engineer Re: Individual SSTS (Renewal) Alfred ,O'Hara Route 311 Town of Patterson T.M. # 11-2 -11 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing SS -1, "Proposed SSTS," dated 3/22/02. 2. Five (5) prints of SF -1, "Preliminary Design for Fill Placement Only," dated - 3/22/02. 3. Short EAF, dated 3/22/02. 4. Application for Approval of Plans for a Wastewater .Disposal System," dated 3/22/02. 5. -Construction Permit for Sewage Disposal System," dated 3/22/02. 6. "Application to Construct. a Water Well," dated 3/22/02. 7. `Design Data sheet." 8. Two (2)copies of residence floor Plan(s), fo 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, Harry W. Ni ols Jr., P.E. HWN: JM: jmm 02- 024.00 DEPTH . G.L. 0.5' 1.5' 2.51, 3.0' 3:5' 4.0' 4.5' 5:0' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' . 9.5' 10.0' TEST PIT'DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN.TEST HOLES HOLE NO. I HOLE NO.-' a HOLE NO. 3 Indicate.level.at which groundwater is. encountered t/ ©� Indicate level at which. mottling is observed Itlo wAe Indicate level to which water level rises after being encountered ---- Deep hole observations made by: �', Z� ice, c, Lit }-� Date 2 )zt,/oz . Design Professional. Name: Address: Signature: Design Professional's -Seal t'7-: ,4t1e, a ri Sati.f { G6az T' EUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner ALf �� � Address 04 fi)G? K)1,LLA Q� P0jt4l�� !J 1i;57a Located at (Street) Tax Map Block L- Lot (indicate nearest cross street) Municipality Watershed r CSI gl� 1L1 SOIL PER_ COLATION TEST DATA Date of Pre- soakingl i `� I� Date of Percolation Test Depth to Water F o r n rmGoud Wai`er e L vel h Percdla on Dole No Run No Time Start Stop EIa se.Time �1VIip.) Surface (Inches) 'Start Stop Dro In Indies Rate Mm/Inch .. 3� 1 s° i006 ►� Z1 L� '� 5 / 2 1 5 3 1 r es t,r per. °cotii, t subm ttAd 9p th. rrte€ uiem at same depth until approximately equal percolation rates are obtained at each (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data:to be to be made from top of hole. Form DD -97 4 5 1,0/ i . 2- i 3� 1 5 1 2 3 r es t,r per. °cotii, t subm ttAd 9p th. rrte€ uiem at same depth until approximately equal percolation rates are obtained at each (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data:to be to be made from top of hole. Form DD -97 TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. e HOLE NO. '� HOLE NO. G.L. 0.5' pP SLjL +af SoiL it? �ij� i�F 601L. 1.0' 1.5' 2.0' LOAM L►G � � ^t • � o� 2.5' 3.0' W �t tT�'r W i srnl+A, 3.5' �Lb% \J 4.5' 5.0' v� 5.5' 6.0' _.._... 6.5' 7.0' . 7.5' 8.0' .8.5' 9.0' . . ........ 9.5' 10.0' .... a Indicate level at which groundwater is encountered t"- Indicate level at which mottling is observed Indicate level to which water level rises after being encountered N Px= Deep hole observations made by: GENE F-M I AAW W, !4wU ML4 PE D N � � Design Professional Name: Hh ' HkLk�oLA ; Jf- 'f F Address: x-460 F-T- of New y A Q Y Signature: _ Design Professional's Seal 60t PUTNAIII COUNTY DEPARTME \T OF HEALTH .. DMSION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEiiIS REVIEW SHEET FOR CONSTRUCTION PERMIT NAME OF OWNER: STREET LOCATION: REVIEWED BY: RIM, GR, AS, SRDATE: ----TAX FLAP =: (CONFII MED) Y DOCUITENTS Y (REQUIRED DETAILS ON PLANS CO\ ?'D) . 1 PER,lI1T APPLICATION U� HOUSE SEWER -`' /" FT. 4 "0'; TYPE PIPE CAST IRON f) - )WELL PERMIT OR PWS LETTER �NO BENDS; MAX BENDS 451 W /CLEANOUT PC -97 RENEWALS (LETTER OF AUTHORIZATION _)SITE NOTE (NO CHANGE) DESIGN DATA SHEET (DDS) % FILL SYSTENTS . CZJ� CORPORATE RESOLUTION (__)< 10' HORIZONTAL; PAST TRENCH SLOPES 3:1 TO GRADE SHORT EAF (FILL SPECS! FILL NOTES 1 -5 PLANS -THREE SETS FILL PROFILE & DIMENSIONS . UHOUSE PLANS - TWO SETS fSUBD ANCE REQUEST WL__)FILL Lti EXPANSION AREA FILL GREATER TH4N2 FEET SUBDIVTSTON ` 12C ) CLAY BARRIER L SUBDMSION FILL CERTIFICATION NOTE. IVISION APPROVAL CHECKED RATE DEPTH GAUGES (VOL. ON PLAN FO R R.O.B., UNCLASSIFIED & IMPERVIO JS REQUIRED DEPTH !(__ )SEPARATION DISTANCE FROiI TOE OF SLOPE AIN DRAIN REQUIRED THE \GENERAL (LF TRENCH PROVIDED GOFT MAX. ATED IN NYC WATERSHED TO CONTOURS L. PLANS SUBMITTED TO DEP - I00 %EXPANSION PROVIDED - (� DELEGATED TO PCHD U� FREE CRUSHED STONE OR WASHED.. GRAVEL (DEP APPROVAL, IF REQ'D („DEEP TEST HOLES OBSERVED SEPARATION' DISTANCES ON PLAN_ - FROM SSTS PERCS TO BE WITNESSED - 10 TO P.L. DRIVEW AY, LARGE TREES, TOP OF.FIL_L EX- APPROVAL SSDS ADJ, LOTS 0 TO FOUNDATION WALLS WETLANDS,(TOWN/DEC PERMIT REQD ?) 00' TO WELL, 200' IlN DLOD,150' TO PITS DATA ON DDS PLANS & PERIviPI SAME 00' TO STREA -M, WATERCOURSE, LAKE )PRE 1969 NEIGHBOR NOTIFICATION 0' TO CATCH BASL�i, 35' STOR`IDItAI�\, PIPED WATER • LETTER BUZBA U(__)10' TO WATER LINE (pits - 20') - ( -7y 100 YR. FLOOD ELEVATION W/I200' (_ JL L\TERlMIITENT DRAINAGE COURSE (___)USOIL TESTING AIL S> N YEARS OLD (___)(__)200'/500' RESERVOIR, ETC. _ 150' GALLEY SYSTE&IS REQUIRED DETAILS ON PLANS , UUIO MI\ TO LEDGE OUTCROP . �-- SEWAGE SYSTEM PLAN - (NORTH ARROW) SEPTIC TANK ( iTC )SSDS HYDRAULIC PROFILE Yle:�J_DRNIENSIONS 10' FROM FOUNDATION; 50' TO WELL (� 'GRAVITY FLOW WELL ..-. �CONSTRUCTIONNOTES- 1- 15.___.__._. - -__ -- .-- .- __. - -- �- TO PROPERTY LINES - �� �- - - - -.. DESIGN DATA: PERC & DEEP RESULTS ( LOCATION OF SERVICE CONNECTIO\ ( __) 2' CONTOURS EXISTING & PROPOSED (__ Nn. ' 15' TO PROPERTY LINE LIJDRIVEWAY & SLOPES, CUT ' SLOPE (FOOTINGIGUTTER/CURTAIN DRAINS U SLOPE IN SSTS AREA (520 %) c ( ) _)USDA SOIL TYPE BOUNDARIES Li REGRADED TO 15 %, IF REQUIRED . UUTITLE BLOCK; OWNERS NAME ADDRESS TMn, PEIRA; NAME, ADDRESS, PHONE# DOSE/PUIvTP SYSTEMS X", )DATE OF DRAWING/REVLSION PU11P NOTES DATUM REFERENCE U DOSE 75% OF PIPE VOLUME/DOSE VOLUME NOTED ULOCATIOi I OF WATERCOURSES, PONDS C� DETAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) (��LAKES,WETLANDS WITHIN 200' OF P.L. U PIT AND D -BOX SHOWN & DETAILED PROPOSED FINISH FLOOR AND 1 DAY STORAGE ABOVE ALARM CURTATN.DRATN BASEMENT ELEVATIONS TANDPI PES 5' BOTH SIDES, DETAIL WELLS & SSDS'S WAN 200' OF SSTS ' PROPERTY METES &BOUNDS *L�2 5' NIL`I to CDS = >5 %, 20'-4 %, 25' -3 %, 35' -1%°, 100 % -<1% UEROSIOi i CONTROL FOR HOUSE WELL & 0' blIs I to CD DISCHARGE /100' with 182 cons day discharge SSTS, EROSION CONTROL NOTE U(�lU' bIIN to NON PERFORATED PIPE CONRYIENTS: (ItEVS ITEET) 09/01100 JAN -25 -2002 03 :52 PM HARRY W NICHOLS 914 279 4567 P.03 M ...................... �.�. ._..— ..._.,..._ ..... __.._.. ,.._.. _.. BRUCE R FOLEY public Ntolfk -Dirfctor LORETTA MOLINARI R.N., M.S.N. Azaociatr Public Realth Dfreclor Dlrtctor oj.Patttnt Sfrvicrr DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 RFQjjEST FOR FIELD TESTING ATTEN710,N; 0 ADAM STIEBELING GENE REED :U1 information below must be A& completed prior to any scheduling. DATE: ENGINEER OR FIMi:r ;�% L s PHONE N' REASON: - DEEPS: PERCS:.j� PUMP TEST: A ROAD ;STREET: &S J i� 3/,1 SUBDIVISION:' LOTN: OWNER: %s a,1�...�•�1.�.. 0, A . -N �S ITS NO 0 qty Proposed SSTS-within the drainage basin of West Branch or Boyds Corner Reservoirs. 0 A Proposed SSTS within 300 feet of a reservoir, reservoir stem or control lake. Q tL Proposed SSTS within 200 feet of a watercourse or a DEC wetland:. 0. ,0 Proposed SSTS design flow greater than 1000 gallons /dny -or SPDES Permit'required. 0 IL 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 answ*red jw to any of the questions, NYCDEP must witness the soil tWing....This Departmenr 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. ?f e /— :5 FOR COUNTY USE 0 \LY ;�:�I.G DATE: .� a�_� TIME: i9 \I %I ENT!., _ (MOTEST) uy �6 8 y V W 5 2 AC 5.59 AC. em.A+ 622• / / i i • . L i MY. YML. - 96 AC. 1.71 '+�• �- -� �' V 5 A�1 2.45 AC. CALL. Y 290.65 F ,211.90 50 AC. vi c. AG �• I i ve.t/'c. Af°'pp2 57 ' ¢ ' - \kV g � 23 , ' a' 1.4� I � 4.69 AC. ¢ \� 58 26 t� r�4.95 AC. 1P59 J, 27.5A . 15250 25 , 1,44 At g r • \ BSA N n a 670.06 CA' ; 61y15. Z �" 2 �tp I 600.00 `s 60 a m 58.34 c , tw 5.35 AC. CAL. a 57 `•� 510.2.611 58 6.49 AC. 1 t 8 393. 1 5l8.3e 21 At 1. 15 At 121.7 AG / \ �d r `/ 4 a 2 9 3. /Ba / 1 -39 At I CIA 1t t t � � �.� °� 69, /0 tA45 ,�, t • 7a �4„si 4. � 4 � . � ��:. g 435.63 •, � 2.39 C. (` P/0 23-1 9 ` P/0 23 I - I 0 >�° 7• A di 3.34 a - - - - - �- - - -- `� - -- -- - - - -- 881.35 At -- -- REVISIONS SPECIAL DISTRICT INFORMATION '• N 633.16 y 16].20 // / WA-Q r •rIT•Ko sans •NI SCHOOL •SCN• CAIM CENTRAL SCHOOL DISTRICT •-- 31ZDUZ /• ~ 60.1 g T►+ 2 �� 163.0 4 \6.61 / O 3/1/61 sso•w % 0.6.iL' •f•TWU••AIS6.0• -1 sons oA 7.47 AC. 19+.i •.0 59 a / 5 6LZ-n JOIN •OADA6C60 sn4a•w Wol oso•w sT ,DM• , / 103.86 AC. CAL. 2MAM A• N$ n 193.45 , 21.97 AC. 561.32�e 2 7 AC r••A �n/n Aw• A/UM'YF L•T1.obwo•7 stye 61 '\ I f�1•. 1 1 22.2 A 6L6- 48.43.46 i /1 /MM 20.89 AC. 20 60 a 4.73 .61 426.T9 , A,o 18.99 .'. 845.7E ' 62 \ V., 19.86 AC. 18 5a6.62 Of -•� 19 - P-06•AC. ` i . raw 217.02 16.64 AC. ` 10• �4 $159 � 1 \ 4 AC.�I' 18, 92 , n 1.00 ACAI. S 16 s I a 5 I 11 5.71 Al 8392 .. \ AC CAL . �• ` 454.22 1.3 A ° g.63 At- • 1 ' 1.77 A 690.96 � 1 1.10 AC. CAI. 3114 I 3.2 / • 6�j6 L,1 AC. 1\ 6.. 85 AC 64 1 • 1 3A1 10.58 AC. CAL $ 1.59 AC.1 °ca i s 1i16.a0i 65 2D6,2 W • 3.1 a 9.78 AC. I2a3.um 12! s `' \ Ie.6Y3AC. 66 2351 +5 461. 509.,2 AC. 8.82 AC. CAL. \ I •) r - - - - - 1061.23 1]6.25 31.3 •� Y 374.16 r 67 7 2 li 41.2 AG ` 14.57 AC. CAL.L33T.se 5 ,Q1 A p 4.aC'r 7. 1 t 8 393. 1 5l8.3e 21 At 1. 15 At 121.7 AG / \ �d r `/ 4 a 2 9 3. /Ba / 1 -39 At I CIA 1t t t � � �.� °� 69, /0 tA45 ,�, t • 7a �4„si 4. � 4 � . � ��:. g 435.63 •, � 2.39 C. (` P/0 23-1 9 ` P/0 23 I - I 0 >�° 7• A di 3.34 a - - - - - �- - - -- `� - -- -- - - - -- 881.35 At -- -- REVISIONS SPECIAL DISTRICT INFORMATION 444M A•• • WA-Q r •rIT•Ko sans •NI SCHOOL •SCN• CAIM CENTRAL SCHOOL DISTRICT •-- 31ZDUZ STALE LINE COINIT LINE -- TOWN LINE - -- VILLAGE LINE - - -- LOCK LIMIT - - - PROPERTY LIM ORIGINAL LOT LINE - - - OIV=D AREAS CONTINUOUS OWNER% ROAD R.O.M. STREAM/WATERLINE SPECIAL DISTRICT L SOIDOL DISTRICT LC PART OF PARCEL BOU s/sM A106 / sLrsal/a I610ruNW•M6T uVS4aw 3/1/61 sso•w 10 0.6.iL' •f•TWU••AIS6.0• -1 sons oA FIRE , •F• FIRE PROTECTION 013TRICT No. I s/1 1 •6W4r W 6LZ-n JOIN •OADA6C60 sn4a•w Wol oso•w 16 2.vm ,.y 611160 N 2MAM A• N$ n •Ftt •6r sA /r vs r••A �n/n Aw• A/UM'YF L•T1.obwo•7 stye 61 6 •• /640, N+1 N f�1•. 1 1 A 6L6- 48.43.46 i /1 /MM 338 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Q /IS - O Y Well Location: Street Address: Town/Village Tax Grid # Q J /Of1f&A-9.Q01%) (%) Map /3, Block :)- . Lot(s) %I Well Owner: Name: w -�- Address: &4& If Use of Well: 2c, 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 gpm #People Served I Est. of Daily Usage 7., gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason 3 0 W4,(,L for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? .................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes W No Name of subdivision Lot No. Water Well Contractor: ILL Address: 11 2,�W 57&-7z- & .................................. ............................... Yes No Is Public Water Supply available to site? o Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contaminatUtb vid on separate sheet/plan. Date: 2 (.� 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. evision or alteration of the approved plan requires a new permit. Well to be constructed by a water ler certified by Putnam County. Date of Issue l/ l Permit Issuin icial: Date of Expiration / o Title: Permit is Non- Transf rr ble White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97