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HomeMy WebLinkAbout0323DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -23 BOX 4 ri �. 6 A I r ' �1r 00132 SITE LOCATION -M OWNER'S NAME_ MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY TM# PHONE —7 LMAn )-4 MA Aa ' AY2.k ?A-,^Z-A&0 PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITYf -3 . PROPOSED INSTALLER :Zt�ff f; �71Zz✓ PHONE S ' 27' ° 606' ADDRESS '( '�QIin M4, 60 �<;�Lt-i-U i:Eft ,—Z,._ REGISTRATION# 2( - (1 -4 Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. �1'TZ�7.^�l 0 a...... _ �_.y�/yl �f�7t'7S l��(/ i-.-vy — ;'1a.. �i �.i�T /. R.:7. lJ.1s• As..�- . I, as owner, or reported agent of owner agree to the conditions stated on this form. SIGNATUREy�� TITLE i/ DATE_ -Pwposal approved with the following condition 1: Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved" Inspector's. Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML j. DATE ( 13 -2- 23 -3 I 0 � tNq�� t X - I i - Zvov c-i C JCPnZ PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY � 6 )--. SITE LOCATION �/'- a•�y 1"I-la d, °/L TM# /�' ?- OWNER'S NAME A -X,— 0 `i/�Al-- PHONE MAILING ADDRESS 14&lma., -�cl PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e., owner, tenant, etc. DATE TYPE FACILITY X-(!X PROPOSED INSTALLER Z ?, PHONE Gqk ADDRESS may' S',, t G,� ..���� REGISTRATION# ProDosal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. GIB I�U7�C C %D 6/ft(-Cn1J ;(Am= Si' -ry:Tt I, as owner, or reported agent of owner agree to the conditions stated on this form. <C SIGNATURE `'`- TITLE DATE I ' Z0002 Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title ;/DATE/ COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE N, 14 tAt ,ve k o- � ��-�- M PUTNAM COUNTY HEALTH DEPARTMENT. C DIVISION OF ENVIRONMENTAL HEALTH SERVICES 001- Ply FIX," I.X&I-11104ZA 1 • MCML USE ONLY SITE LOCATION OWNER'S NAME PHONE_ MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e., owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE ADDRESS REGISTRATION# ZY Cl Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage dispo'sal system Different location may require submittal of proposal from licensed professional engineer'or registered architect. 1, as owner, or,repqrted agent of own_ er agree to the conditions stated on this form. SIGNATURE L k-, - A, C - TITLE I t Proposal approved with the following conditions: I Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete, septic tank, three precast 6'diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved —, Inspector's Signature & Title. //DATR/ COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC-RP 99NIlL - ._ 17 14�, .� 37 sit vim; `71 S7' -� i' PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION OWNER'S NAME _ MAILING ADDRESS PERSON INTERVIEWED -- PCHD Complaint # ---Name Relationship i.e., owner, tenant, etc. DATE S'_ 17" PROPOSED INSTALLER TYPE FACILITY PHONE 60Y-4,-, z--7q-&a6,5 ADDRESS ��'� (J�h► (.N �V�a REGISTRATION# Oyq Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. d P&A-)561/ 70 A-570L /tic,' 61t-60, CZ A56 , 2z— I-fJM i 1. ova 6 du rn X Ae4 —a-S 9CYOTY I, as owner, or reported age t of owner agree to the conditions stated on this form. SIGNATURE �' TITLE DATE -i7-�. Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6 deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved_ J Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) DATE &I cs 4&b7- el M -P P-A kl/P,07*t-� 6PUL, b?4.rl- ?tg lw- 23 fltwooe Inn),ae, dAu-a�� tie -b N SITE LOCATIONr 7 / LZ f L TM# , Z `Z OWNER'S NAME PHONE i S 7 - '15 MAII,INQ' fij)D WSS PERSON INT IEWED .... PCHD.Complaint # ZA Name & Relationship i.e., owner, tenant, etc DAVE TYPE FACII,ITY� r;} ✓;t r t PHONE` Z. ?C PROPOSED O STALLER )rfrl"i t;.. �� ADDRESSi`�b.. �.ry %?a REGISTRATION#.... o � � Pr (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional'engineer or registered architect. 5� "� rt �c_YV •`rte,,' -?' f.. � ;,�;�.., �i��.�.r �;;�...?� R��"� t���;`.. �f�'r*1 .j.�{ } .. �, 12 lT I ! . _..:.:I 1 i .. ... . I, as owner, o ,reported age to owner agree to the conditions stated on this form. . y f... ,?C; o , c ... TITLE SIGNATURE ATE Proposal approved with the following conditions: 1. Procurement of any Town,pern it,, if applicable.-.. 2. Submission of as built repair sketcli ii duplicate showing: a. Owner's name b. Site Street Name, Town and Tax. Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number.. 3. System repair to be performed in accordance with the above proposal and conditions. � v 1 �as�3 d,n It 0-0-a 4) Rzc Ld e.. O PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0-rH DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM ;kw� Owner - ?A Address HAX 746- E 6499�--I- � Located at (Street) Tax Map Block 'a Lot (indicate nearest cross street) Municipality Watershed 5A5 r SOIL PERCOLATION TEST DATA Date of Pre-soakine /I /J 7�94� Date of Percolation Test ... ........... . ........... .... ....... ................. ............. ........ .... .............. . ....Depth.to: .:ater.-'::':';::: ...... Va, er, ... .. ........... .. .. .. ..... F.rom+:.G'r'-.o-'.und':"':-' Level Percolattot► ... . ....... ......... ..... . ......... ........ . .. .... '-st PS4:�ii Time 0. 0 04�: . 4: t ...... .. ... -e ..... ..... MtWIttch 9: 4 R" ........... ............... ..................... ........... ..... ..... ... 10 ....... ... ........... .......... . ..... . . ..... - ......... - ....... By 2 30 4 5 I /oil 3 3 i 1"13 - i J; 41 -3o i 9 /2 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min for 1-30 min/inch, :5 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES A re-- DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner (9 Address &%6'4a Located at (Street) Tax Map 13 Block !Z, Lot. (indicate nearest cross street) Municipality � AZT 72�pN Drainage Basin :. SOIL PERCOLATION TEST DATA Date of Pre - soaking /O /y/ �10 Date of Percolation Test / O/B /l o Hole No. Run No. Time Start - Stop Ela se Time I in.) Nth to Water rom Ground Surface (Inches) Start Stop Water Level Dropp In Indies Percolation Rate Min/Inch 1 io n _� 3 ® — t o 2 3 4 5 2 4 5 r 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation ra aic .,�.a�..�., u= . N� =• percolation test hole. (i.e. <_ 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to'be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLII SERVICES FIELD ACTIVITY REPORT N AiyfF • (y'll -ed Z A Tel: &ZA Street Town State Zip PERSON IN CHARGE OR TNTF.R VTFWFT): Dnu- -, Name and Title TYPE OF FACILITY: 5,` »y FINDINGS: 2- i_ 'q_ 1 --- n -7 en _ Signature and Title RFP()RT RFrFTVFT) RY' I acknowledge receipt of this report: SIGNATURE: 02/96 Title: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES /�mg-ff DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM #12 x14 Owner � I unit �� fi/A7z, 4 Address , f gf� �`T : F g:: IG � Located at (Street) 2 f 3 / Tax Map 13 Block — Lot (indicate nearest cross street) Municipality Watershed ".5T 2A/11�H SOIL PERCOLATION TEST DATA Date of Pre - soaking t ®77/99 Date of Percolation Test 10/8/2a NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 1 l `o t r 3 4 1.�a 4 .9� 5 ell 2 _ 0 �.a 4 �— a 3© 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. 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' 30 / G 7.0' I D 7.5' 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: Signature: Design Professional's Seal 801 t „ L C7LL,. f F. CA� r7. l G 1H ° 37 'b 0.77 H016A9 .. .�32 D 3 \J, •' 6¢Y,, ' AL N At 4G AG n ` S $ AC. TS, 69 v `•' 34AC �;i -n.,. Jv 88 !. 1x4 'IxD I.S AGCAL x.64 AC. CAL. " 0 5.58A6. 1,66 �• 1,60 AC • / • g1B. AC. 90 91 l�1.9 AGCAL yg 3.3 AC. CAL a o . A s ) +)�) 35 1.12 1.61 AG'�" �i Lei : &3 I Ia A mn \ 8 gZ;,S6 O $ .e � Dt rqb ,�C. + i . •30`� \ 1 11 13.83 AC. CAL v 34 �� 67 aye dti 359 AC CA 5,014G 66 1J9'0C• 3 1. �'+' At Rn/ 'rsr 419.00 s r 33 yf4 t26 •• 1.29 PQ /!' ` 6.463 e` 52 P/ DT X222 AGCAL n1.n Sy Ac '°C• ea t 8 P-16 AGCAL , ° •6 52 61 Jt 6Z •, • E03 4 _° 127 AG pA' 3.50 AC. 53 A A36.1 C 72 19 4 6 8 2.34 1. \'' A9619 97 s, r4i�d 2 ° t - tC. ,1) 3O F, 4 4.67 AC. CAL AC. AC. 1.01 123 A n ! 0395. 4i 1.87 AC a u.$ •+ t bti 661.16 8 12 L� I; Orr �• ��DA' S4 ii aAtCAL t . ab • r 7e 1.2 ,f " '.'° _ 3 3.36 AC. 2.06, AC. 4r, •r• 5.OI9'AC. 9� 654 �� 53 Y� 26.75 AG 3 J 79 t66' is 3oD., 99 / I AC. 6 - 16.21 AC. CAL. $ - 96 AT 1.71 AC � , '• /% :D9y6 p,6% ! 58 26 9 3828 /� J 5 5'4 2.45 AC. CAS. 290.69 R 21790 �/� /- . AC. - I '•+% •, �'J •'• 191 ACC 366 91 ' T • . r r ipt 10 5.244 AC64 A�2 m 57 1°� 23 -ice, a tLM 1.. i�o�58 4.69 AC 0� 7.5 26�c.a 22 Af/ 4.95 AC �s0g259 fi %}� f 2• e LM At` % / ��q0 �•Or .86 AC 6$'16 ti R " \ �' •. 60 ? (� t ice} %5 35 AC. CAL. \u 970.24612 O I?•l- [p z 2.0 AC A61.1 go 7.47 AC. 1961 D1. JOYM 21 A / 5 / 96832 193.15 , /647 103.86 AC. CAL. 2.7 AC K / / 1 22.2 4.73 AC. / s 428. T8 ' 62 \ 00 I 6fi9. 102:1 19.66 AC. p 18 r' 192.08tA 1 'i ID t �16.64 AC. 8 171 1.59 1 18. A2r s 1t6 q \or LAL. 1.73 A \83.92 AC. CAL. 63 1.10 AC, CAL, 1 4 �� 1 I 3.2 I, 6.65 AC, \ 64 13 .I • 1 s 10.58 AC. CALp1p1 L" M G 1216.65 41 9.78 AC. 12814"' M � t \ a 16.66 AC. 66 • I 9• ° 8.62 AC. CAL. it e: r _ _ .: - \ 1041.23 IA• • A - \ t Tr 67 1 � • * I` 41,2 AG \ 14.57 AC. CAL 770 5 2 `• \SS 1 >y I'm s �•• 14 121.7AC. / * * 6 7 3 �.� �: \ • j .138.y 0 d% 1 • t. 2 pipes /1 t1 469. 11 K 1 Y' 0�c / � • � . $ 439.6! •, 4�a 7 L :. #'' �P /0 23 -1-9 ` P/0 23.1-10 _ S''I.AG • ___ry --------------- G - - - -- .�1 - -- - - - -r REVISIONS SPECIAL DISTRICT INFORMATION �!'S +3 rY1uD 1n•.v Awe s e-t •e,r ewl¢It:o �. , c► tent aw SCHOOL -soil• CAM ,.L '6 D151HIGI •••372002 MATE LINE zt.t CODIITT LINE s m Aws s el1•sa.yt 1s LOr uYC Sx,rr to /nuLINE /e t/vr acaH 10 tlt•au.nrlxlu tt a))oao antra a• FINE •F- FINE FRMECTION OISTOICT NO. I TOWN LINE + VILLA4E LINE ,ftt,rt3 3/1 n, 4w II tL2-tt. JDNN.0.0 ADDED 0 /1tn)0N1 ' OCA LIMA 3A /01 otoeY a u-TIA • se 8 /1/s9 rJ P NOPEAIY 111E .i! i 21nmAl A11DX n •ra3 •n 3A/" rJ - "a xuu i6• rwno•A )Mt AYS ONIOIA 1. LOT LINE NVft YN a Loll.nb t. -127 t U ra -.- 1e 0.)V). •e •t) _Z2 338 �• I RECORD OF PRONE CONVERSATION Time: t 3 Date: Person calling: A 7)-n L, Phone #: (, a A — C 5 d 7 Reason () Inspection: ee and/ Peres' Schedu' ' ` L. Tentative /to be confirmed () ( ) Pct -if -er5cn 1 Town: Road /Street: Tax Map #: 13 — oti —02 Comments: RECORD OF PHONE CONVERSATION Time: 1 13 � Date: 10 Person calling: Gain (y� ��� Phone #: Reason () Inspection: WDeeps and /or eres: Scheduled Tir Da Tentative /to be confirmed () ( ) Road /Street: #ARMA6 C GII.0 L� Tax Map #: t ?7 oZ.. ' _)-_ 3 Comments: S GOU'+a l CO �� L gtonvill r(- � 8 �'•.� 8 �`, � s 43 4 Corner e err r S.C. e / ES ES • + u \ 'JM N � Q Town It ake Czar �` Deans' J k 1 1 12531` Z 1 ; D 1 O t 1 a �!s•'� Ice � �i tPont ` 1 rners 84 `( r el so °� *CA RMEL HS County Courthouse County office Building 1 57 ' +\ C bA Ludington 1 onument 1 312 L +'S 52 OZD _— -- '`Raymond Hill 512' Cem o 04 § k 1 1 12531` Z 1 ; D 1 O t 1 a �!s•'� Ice � �i tPont ` 1 rners 84 `( r el so °� *CA RMEL HS County Courthouse County office Building 1 57 ' +\ C bA Ludington 1 onument 1 312 L PUTNAM COUNTY DEPARTMENT OF HEALTH Area DIVISION OF ENVIRONMENTAL HEALTH SERVICES Views DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM A t Owner `�`z�/� K� Address Located at (Street) �- f- '�, / / Tax Map Block Lot (indicate nearest cross street) Municipality. PAr:-rFR:5ew, Watershed —C-4 ,r- Mi'Ame—w SOIL PERCOLATION TEST DATA Date of Pre-soaking 71;� ,/ Date of Percolation Test 7 /[ 3 /y 9 1 NOTES: 1. Tests to be reheated at same death until annroximately eaual nercolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 1:43 - a, -t cv o ` 2 2 — 2-:17 g 3 3 .21,Vb- 3.119 30 L Z!Y-0- 1 911' % 20 4 3 :20 - 3' 5o . 3 0 ! `1 — 2-0 0 5 l ,'F y - 9,./ o 0,10, � 1 � 2 3 l% 4 f 342 - 5 1 2 3 4 5 NOTES: 1. Tests to be reheated at same death until annroximately eaual nercolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH 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' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. a HOLE NO. Indicate level at which groundwater is encountered A&;4P Indicate level at which mottling is observed n/a t4.Q Indicate level to which water level rises after being encountered Alo de Deep hole observations made by: S, 2e t Date 7 3 y P.41 D.14- 00402, Design Professional Name: Address: Signature: Design Professional's Seal 2 Al ►�►d '` wry all q• RECORD OF PHONE CONVERSATION DATE: Z-2: / TIME: PERSON CALLING: _ PHONE #: REASON () Inspection• () Deeps and /or Peres: SCHEDULED FIELD MEETING DATE: I O ROAD /STREET: TOWN: TAX MAP #: SUBDIVISION: LOT #: OWNER: � �� V'a COMMENTS: ©WA 1`ZA 0 11,4- R1T.9GF- elRc e TEST PIT PROFILES P r i mA ray Hole # �_ Lot # _ Hole # Lot # _ Hole # Lot # Depth to water !j,lo 4 e Depth to water J Af o d P Depth to water Depth to mottling A/,; P Depth to mottling A/0 4 Depth to mottling �- Depth to rock/imp. ILI o N p R' Depth to rock/imp. A1,9ja Depth to rock/imp. . N G.L. G.L. G.L. ,/ 0.5 r° ° j ... `7`� �o.�/ 0:5 �' ` 0.5 i 1.0 2.0 Ailoe C1.0 K,• 1.0 ta 2.0 ,'K 2.0 % � 3.0 3.0 3.0 T, 4.0 4.0 4.0 5.0 . D• ; s ti W 0_ V� 5.0 Srztvo 5.0 6.0 ® 6.0 6.0 7.0 0, 6 vel 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 Hole # �_ Lot # Hole # �_ Lot # Hole # Lot # Depth to water y( go e Depth to water �q%�,e Depth to water, Depth to mottling Alaw v Depth to mottling Ajvn e Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. �.L. G.L. k G.L. 0.5 14"' To��� ;l 0.5 10 .0 e 1.0 edi ow o 1.0 .0 /e'owe sA"RR 2.0 e u, SO Ay 2.0 o zP.0 5,`Ity /oc,f,•i 3.0 / 3.0 .0 - 3- 4.0 4.0 5.0 (9 0 5.0 C-falj;4h 5.0 a 6.0 o e 6.0 a loo6e 6.0 7.0 7.0 Naha ve 7.0 8.0 8.0 8.0 Z, 9.0 9.0 9.0 C4 10.0 10.0 10.0 PUTNAM COUNTY DEPARTMENT OF HEALTH. DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner Q t -fA x � Address jZ�- 3 (% �. 6 7�7�xtC� 7 Located at (Street) 72A/ WALI_ ,���� Tax Map Block Lot (indicate nearest cross street) Municipality Pg�7��5�� Watershed J�—:AS T 'g?,4AjC8 SOIL PERCOLATION TEST DATA Date of Pre-soaking /��� Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Depth to Water From Ground mater Level . Percolattaa Hale No Run No TimeIa Mart Stop se Time: �IVIEn) Surface (Inches) ` Start Stag Dro in Inc�es Rate M�ts/Inch 3 /o. f 1 17 3 �-'- 4 C7 G 7 �1 5 �C. �o; ,�:� 23 .21 _ g 2 to : ;2 - 2 S 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 o PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ; 1 6 (� DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner __ 0 / ZIA KA Address i4 a S'c Located at (Street) e--072.A( 1,,/,¢LI- y�� Tax Map Block Lot (indicate nearest cross street) Municipality P�TT �y?soN Watershed J�—:/{,S j B?1AAje H SOIL PERCOLATION TEST DATA / Date of Pre - soaking �// / 7 Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 Depth to Vi!ater W. -A er :. Hole No Time Elapse Time From Ground Surface (Inches) Level prop In Percolation:: Rate "an: No Run Mart . N 0 p ca) Start Sto Inches :.... 1)� �a 2 Log 3 D 3 �2.n� .4 5 1 10 "o r� 2 J�.�3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 b RECORD OF PHONE CONVERSATION Time: Date` �{ /,oZ /9 Person calling: -SLAG►' Phone #: �j 07 Reason ( ) Inspection: XDeeps and /o eres: Scheduled 2;®0 Time: / Date: -�5_,41R Y N Tentative /to be confirmed () ( ) Town: 1'G 4f Road /Street: Tax �Iap #: Comments: �� M �� - ~_ Akins Solomon 311 SE TOWN 46 ESA of own �J May t J (Mendel Pond 311 Haines orners PonA Corners to que Area rz HS OES Ile Brewsfe�r, Pond ernian MS pq i9.z6 HILL C.CAL C CAL 1468 t3 : \;p °'/ 4,p g 41 0 40 •o :, / r th -- - 63 / 42 G . -3 V r� 350 ,U r1 Aa 9 Iu 1 a5 • „ ' 2.61 AC. 2, ; 1� '74A i° ' /4 2.16 CAL p 9 AC. ,•z. 1.25 AG 3.2 ti g " .3t1$ ., Y •. 43 Z 3es,o9 u+•n • AC.CAL 2]L21 ' ' 1 138 46s r zoop !!g •� 9.86 AC. g34'I�p "�` •g2.2ACS b140AC.� g�KB! 761.6 41 40 139 38 \ 1.46 AC. :AL '1F 8 >p a J6 G j $ ,48 u� 89 �f.IxA Z w 3,4AM ,,. AG 1Agt�O 5- 12 `,, 3.99 AC. �CAL 8 AG j3� �� 120 r1.9 AC CAL • 1.60 A S58AC. 1.68 a sfia b �+► 36 `N3.64 AC. CAL. 41 Ac. I \ 4 � S AC, 90 91 • 2 , ,p IJ • , 51 �y y AC CAL �� 3.3 AC. CAL.• a B fi 1.03 LIZ 154 AGE 30 ��4.09 AC. 2.18 AC. 4n^ \ 8 %ts 0 8 u a 3 a I. fi AC. 195 a IC. 83 AC. CAL. o ^'q +. 5 >d 34 3.59 AC CA "� eT 1.19AC. X 211 aC CAL a•" �' 5.01 AC, 86 93 A �1�s 4os,00 a r � \ ae 164 90 51 �•' 8 85 ,o . �q � � 1 93 AC. S%• 1 40� 5221 m =2.22 AC,CAI �CA 19 ?� ri 114AC.' S 1.25 AC /.nA `g �blr L 'IcALAG 9AC. '� . BI 82» L03A " 8 216 ACCAL � $ 52 „ a ,r _ 3.50 AC. 53 x�s77 ., p\4� , 8 2.34 1.72 i� ° _ yp° 00 01 A 6 AC. AC. 1.01. l23 A u ,39'y gl .� h;4 1J se 4.67 AC. CAL 66I66j.'6 ` T. I.B7 AG to �' 30 8 a, N -V ' pP' t�se 1.26M AC. ' I.IfA 53 10 92 ` r r> 78 AC. j >y K 3,36 AC. 2.06 AC. ,� 5.0�'AC. tidy 6' �,, 2675 Ac. a 7s 1s6 q28 & i a is 3oa �i e� / 54 ' 6.21 AC. CAL. 8 - 96 Ac. 1.71 4C. c` I z`' s25zfi gam% 3aee 55 so Ac. I 45 AC. CAL 290. 88�1C. I f 2.. 65 8 2j1 g° •' - /1 .. i at. - I ' ~ iT 10 ' 1.54 AG 5.2 AC _ 23 • 4 59 AC. 4.69 AC. 4 `,�0� 58 0 27.52 A . M.50 !' g 14.95 AC. �x�459 X s5, 1.4p4rAC8g -�_ 610.08 3i 600.00 CA 66 A 6j2�9. a \•,/ A 24 Y' 60 m 3ea4 j 57 / '4 5 35 AC. CAL. a 1 , ' 6.49 AC. 31 N 6. / 131i 61.1 � O 4v9r ,Ifi.fi] 59 O % ; 7.47 AC. 194-1 N A ,�• �owx l 21 g , 21.97 AC. 2 103.86 SAC. CAL. s 2.7 AC. I I 1 22.2 ]04.66 + \ 20.e9AC. ..� ' 20 Q { N 60 j z a6l 4.73 AC. 61 426.19 ,� • 5c .62 206 19.86 AC. 18 " 1 19 2.06 SAC. N / w 211.02 � 211.02 10 `i9� 16,64 AC. °I 59. AC. - - rti I 1 63 A r� 18.92 + " m,0 AC / _ 0 A 16 S I a 65 II 5.71 Al 1.73 A .03 At " 5 Ln c.- \83.92 AC. CAL. ` 4s4.0 1pi J , ' 15 $ `? facl 63 IM A fl� • 31 I4 N , � - -` 690.96 \ 11,10 AC. CAL. 13 6.85 ac. 64 �f C ? 9 10.58 AC. CAL g 1.59 AC., ea 12,6.ao1 • c 206.2 ," 1 65 - N e 3.1 9.78 AC. 1263.4101 12 ¢ 8 a 18.88 AC. 66 2.35 ` 661.45 551 AC. C. 8.82 AC. CAL. •,� * 1 31,.16 , - I �6 7 67 A I 1 1.77 1 ' I C. C. T AG �_ i 41.2 AG \ -14.57 AC. CAL ��ui.le 5 2 s 1 1 1 39]• 1 fi36.36 OS 21 AC ++ ff8 1.1 S VI'r el4 D 209.13 /� / It 1` J.t x.68 70 4s LAC 1l °3 1.43 , AL AL A , I % .• 439.63 i 7 23, r. , T 70, P/0 23 -I -10 _ �9I,�s Ac�ro '� -- 3.34 OWNER'S NAME SITE LOCATION 6 �'_ PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR •- 4:?o kC9 rrtcC:~ PHONE (576' ° ,T-Z � TM# /3-Z..- 179 PCHD Canplaint i Name C. Relationship (i.e, owner, tenant, etc.) TYPE FACILITY 4—C PHA A%% PROPOSED IDBTAL� REGISTRATION # Q Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original Different location may require submittal of proposal from licensed registered architect. sewage disposal system. professional engineer or 's Sianature & Proposal amroved with the followinq conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g. ,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNAZVRE ��,�. f--•- TITLE DATE [PM: Mite MV; Yellow (jai ffi); Pink (AppUamt) PC -RP 97 —PtT� a -4,4-/? A 710 citttDo srz ire 06 ace &Tc fl R) 154 ----7 P D. Iii `SPECTION Date Dom/ Inspector nNo evidence of failure CjEvidence'of failure DEvidence of seasonal failure ------------------------------------------------------- (Indicate North) aocs= J -------------------------------------------------------- (1) Indicate location of SSTS A. Size and type of septic tank gallons MiMetal ® Concrete OPlastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING NVATER SUPPLY OPWS Shared Krell [Individual well Drilled ® ®Casing above ground COivBENTS : r�ft= a e PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFO% %NIATION r Name of Project TM?'-r' Year of Construction Size of Parcel SECTION B. TOPOGRAPHY (Please check all appropriate boxes) l. ®Hilly- ®Rolling ®Steep Slope ;34& ope ®Flat 2. ®Evidence of wetland ®Lori- area subject to flooding ®Bodies of water ®Drainage ditches Rock outcrop ' YE.S LLQ 3. Property lines evident? 4. Water courses exist on, or adjacent to parcel: 5. Existing individual wells within 200: ft of the existing SSTS? SECTION C. EXISTING SUBSURFACE SEWAGE TREATIMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. [level CI'Gentle Slope ®Steep slope B. ® Well drained ®Moderately well drained ®Somewhat poorley drained ®Poorly drained C. Area available for SSTS. (Primary & Reserve) ®Extremely limited OSomewhat limited fflAdequate ft x ft i 4 r BRUCE R FOLEY Public Hedth Director a # �E'W io DEPARTMENT OF 1 Geneva Road Brewster, Now York HEALTH 10509 LORSiTA M01MM . RX, M.S.N. Anodaft Public MMM Dbwcmr lAb eior of Patient SrnWCW Envin"enhl Raft (914)278-6130 Fa (914) 279-MI Nnnlq SNAM (914) 278 -6558 WIC (914) 278 -6678 . Fax (914) 278 - 6085 Early 6terveatlon ( 914) 278 - 6014 Frachooi (914) 2786082 Fax (914) 278 - 6648 OWNERS NAME: �eff ohy Vt ((%� w. TAX MAP NUMBER E911 ADDRESS: Z - lie 1— ` -e C i t- c -� TONM lT� ers CD V" AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 62 -z, The i'utnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, Le., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance.. . (E911 VM*W CO y a -e BRUCE R. FOLEY y LORETTA MOLINARI RN M. , S.N. Public Health Director �t+w YO Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Eorlioumcctal Health (914) 278.6130 ' Fax (914) 278-7921 Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 . Pax (914) 278-6M Early Intervention (914) 278 - 6014 Preschool (914) 2796082 Fax (914) 278 - 6648 OWNERS NAME: �Q"T a �a —t4 t- IM o h y TAX MAJ�AMSER: _- - /3-2.-2,3 E911 ADDRESS: 2 0 ���/ L -tie f 'e c t rc I -e. TOWN: AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 7 �Z,) The iu'tnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, ie., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application fora Certificate of Construction Compliance.. (E91IVEBfRtvi) YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani, Director AB #: 93.000795 CLIENT #: 12225 NON STAT PROC PAGE 1 'HARA, P. DATE/TIME TAKEN: 06/14/00 10:QOA .0. BOX 282 DATE/TIME RECD: 06/14/00 11:00A ATTERSON, NY 12563 REPORT DATE: 06/16/00 PHONE: (914)- 878 -7529 AMPLING SITE: HARMONY MHP SAMPLE TYPE..: POTABLE ... . - _..... RT 311 PATTERSON ._ ___ _ _ . _ _.. _ _ _. .. PRESERVATIVES :- MME - -- - OL'D BY: P. O'HARA TEMPERATURE..: < 4C OTES...: KIT TAP COLIFORM METH: MF DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 06/14/00 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 COMMENTS: aCT THESE RESULTS INDICATE THAT THE NAT (W ,(WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDING TO THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. WMITTED BY: Albert H. Padovani, M.T.(ASCP) Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT C. ell Location Street Address: Town/Village: Tax Grid # Map Block Lots) �n Owner. 1 z2 *m a Use of Wed: 1- primary ndary _ Residential _ PubGc Sumly ! Air d/heat Pump Irrigation _ Business J Farm _ TeWhionitoring _ Other(specify) Industrial Institutional Standby Equipment _ Rotary ,_, Cable percussion Compressed air pier+ tamer (sue) ell Type _ Screened _ Open end casing Open hole in bedrock _ Other - Casing Details Total length _„I j_fL Length below grade _& Diameter Weight per foot lb/ft. Materials: Steel , Plastic ^ Other Joints: WeWd '[breaded _ Other Seal: Cemerht gtotiY _ Otintt' Drive shoe: Yes No Linea:_ Yes _ No Detrits Diameter (in) ISlot Size Length(ft) Depth to Screen (ft) Developed? First I I Yes *O Hmus Second I I I alt Yield Test Baited —pumped Compressed Air Hours j, Yield Win ]Mph Duft yield tcskft) Who M of compleoed wen in fed Q If ell Log If more detailed information descriptions or lave analyses are available, atta� Depth From Surface Water Bearing Wdt Masao an) Formatba Doerlptio>. IL 8 Land Surfix • Q ° drtm e • Ao t/ R If yield was tested at different depths during drilling, Hit Feet Gallons Per Nfinute Pump/Storage Tank Information M 0 PUMP Type Capacity Depth Model Voltage . HP ank Type volume Ras r�W& 0/9 -' a NO'1'!r: to location of well wilh distin at least taro to pro -VUW on a sepal plan. .. WellDrilleesName I e •� /..� Sigmative: Date: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Town/Village Location - Street Subdivision Name Building Type Subdivision Lot # I represent that I am wholly: and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: q M S Day Year 0 o General Contractor (Ow er) - Signature Corporation Name (if corporation) Address: '?' 0, d - Z �... c State _�� rS ° �1 Zi C �S� p Signature: V DA Title: qt��� 0. ti P Corporation Name (if corporation) Address: ' - ?c 2 Z Stated -T+e `Sa � Zip t Z. F ( 3 Form GS -97 BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (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 May 26, 2000 Sean J. Daly P.O. Box 418 Shenorock NY 10587 Re: O'Hara Route 311 (T) Patterson, TM# 13 -2 -23 Dear Mr. Daly: The above regarded application is and cannot be processed. This means the project cannot be forwarded to a Putnam County Department of Health reviewer for comments or approval until the following has been received: 1) ®Standard E911 Address Form. 2) El Construction Permit Application. 3) El Certificate of Construction Compliance Application. 4) ❑A certified check or money order in the amount of- El $300 for a Construction Permit. ❑ $300 for a renewal of a Construction Permit. ❑ $150 for a revision of an approved Construction Permit. ❑ $200 for a Certificate of Compliance. ❑ $100 for a Well Permit. ❑ Other If you have any question regarding this matter, please call me at (914) 278 -6130 ext. 2152. Very truly yours, I. Theresa Nemeth Senior Typist Pt -- t,- A� ax s L—, - vq P.- 41 a z IV 7, 7 5.1 NY- .�N 1 —4, t Kan -17 10 �.,7 -01 r. vf, :iv:: t • > Y st, a ? '".: a M ?'..kt..a? l.kt' .r'MN �. y s x , q :^:'" F €+. ; `�,d qfi .yr'tc ' E _,.�,;.0 s• f " .x.. lt� xk"' �' T r..� .. 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" „x; p....,, •,.r: g, •a•: �qga: '"';:.. r < •s w PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES C NSTRUCTION PE IT �Q , ! AGE TREATMENT SYSTEM PERMIT # V Located at To r Village Subdivision name Subd. Lot # Tax Map Z3 Block 2. Lot Date Subdivision Approved Owner /Applicant Name "ZMgA Mailing Address Renewal Revision Date of Previous Approval Zip Amount of Fee Enclosed Building Type L Lot Area No. of Bedrooms Design Flow GPD Fill Section Only Depth Volume Separate Sewerage System to consist of gallon septic tank and L , T -- Other Requirements: To be constructed by '77, A, �Z:2. Address Water Supply: Public Supply From Address or: Private Supply Drilled by 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 P.E. R.A. License # Date 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 pe prove o charge of domestic sanitary sewage only. / By: Title: Date: 6 ` White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 -s PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of Located at,P_til,,2GG ov ��?��50�,� Tax Map # 3 Block y Lot 10-3 Subdivision of 7,erviz_ 4;c b� 0 Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize SPA T� S —P,4 a duly licensed Professional Engineer L-- to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County Sanitary Code. ,Countersigned. P.E., R.A., # �. Mailing Address 114& State 11 Zip Telephone: / j 5�7 Very truly yours, Signed: �-- (Owner of Property) Mailing Address: O , S o'X g- &.I, State 0-e uo �OH�l Zip P-563 Telephone: 9-- -7 9- - -7S 2 Form LA -97 14164 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR Appendix C . State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME 3. PROJECT LOCATION: Municipality �iT � / vK S0.1— / County fn /. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) IV /� r�,QS>?N, N y 2-:5-6; -3 5. IS PRO PO � A/SCTION: M ew ❑ Expansion C Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PR " §ED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? L1LY'es 0 No If No, describe briefly 9. WHAT IS SENT LAND USE IN VICINITY OF PROJECT? esidential 0 Industrial 0 Commercial 0 Agriculture 0 Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR I,0CAQ. es C No It yes, list agency(s) and permit/approvals /� C:. AS ©/� 1._3u 1L[,>jA M;7 10,6�OT. 11. DOES ANY AYE F THE ACT. ?1`1 HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes uj N/,: It yes, list arency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes QX1 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant /sponsor name: � j Date: J ` Signature: 4tk I If the action is in the Coast Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 14.16 -4 (2/87) —Text 12 PROJECT I.D. NUMBER 617.21 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR ( 2. PROJECT NAME 3. PROJECT LOCATION: Z© 7i2 1i,2�il 7�i C"'4czi �} Municipality Soi) County R) 7w' fj"'7 a, l'ht_UlSt LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) SEAR /z 5 3 5. IS PROPO D ACTION: n 0 Expansion C Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: , / �'%%G s'y5 7Z-7-^12 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8. WILL PR SED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? es 0 No If No, descrlbe briefly 9. WHAT I P /S LESENT LAND USE IN VICINITY OF PROJECT? C!7 sidential ❑ Industrial L i Commercial ❑ Agriculture. ❑ Park/Forest/Open space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FELQM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL) 7 �. t 'X j r27 fJ/�.� L7Yes L�JNo If yes, list agency(s) and permit/approvals Bal L PIA -157 11. DOES ANY ASPECT THE ACT, 71`1 HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes If yes, list a.ency name and permit/approval 12. AS A RESULT OF PRO ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? 0 Yes EU4 o I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicantlsponsor name: Y 4, �— Date: Signature: If the action is in the Coa' I Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION 14EEl r4LF C 19 �& NAME OF OWNER -/) d /� A,C REVIEWED BY RM, GR, AS, MB, BH (o DATE i.? TAX MAP # 13 DOCUMENTS APPLICATION / RMI- PWS-LE-T-TE�R �jr�51 �ry OF AUTHORIZATION / DATA SHEET (DDS) .ATE RESOLUTION - THREE SETS PLANS - TWO SETS VCE REQUEST SlIBDIVISION LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PRE 1969 NEIGHBOR NOTIFICATION LETTER BI/ZBA 100 YR. FLOOD ELEVATION OTHER REQ'D PERMIT(S) REQUIRED DETAILS ON PLANS ;WAGE SYSTEM PLAN - (NORTH ARROW) ;DS HYDRAULIC PROFILE RAVITY FLOW INSTRUCTION NOTES ESIGN DATA: PERC & DEEP RESULTS CONTOURS EXISTING & PROPOSED Y N . EROSION CONTROL:HOUSE;WELL, SSDS . PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS WELLS & SSDS'S W/IN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAMBENDS 45° W /CLEANOUT FILL SYSTEMS CLAY BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH LF TRENCH PROVIDED 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS _15'WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200' /500' RESERVOIR, ETC. _150' GALLEY SYSTEMS 15'MIN to CDS= >5 0/o,10'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' - <1% 20'MIN to CD discharge /100'with 182 cons day discharge SEPTIC TANK DRIVEWAY & SLOPES, CUT F—F-1 10' FROM FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES ® DIMENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET r—MPROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1., Name and address of applicant: 2. 4. 6. 7. 0 o.�/ , �t%Z Z7, 513 Name of project: iLkC SAM 5W 3. LocatiotcDV: Design Professional: n - 5. Address: , $p,C Drainage Basin: 5 ' y zo�n ? Type of o'ect: Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ..... ............................... ............ Type I Exempt Type II Unlisted �- 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... AZA 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... �L. �• 13. If so, have plans been submitted to such authorities? 14. Has preliminary approval been granted by such authorities?,,... Date granted: 15. Type of Sewage Treatment System Discharges:...:......? surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... -- 17.:Waters index number (surface) ............................................ ............................... 18. -Js project located near a publi water supply system? ...................................... 5 19. If yes, name of water supply 1�rhC. Distance to water supply$Q 20. Is project site near a public sewage collection or treatment system? ..-.*:.... ........ N O 21. Name of sewage system Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) .................. ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application'been submitted to local DEC office? ......................... 0—' Form PC -97 Z, 3 .27. Is any portion of this project located within a designated Town or State wetland? ,G 28. Wetlands ID Number .. ............................... .................... .. • . • w 29. Is Wetlands Permit required ?` Has application been',made to Town of Local DEC office? ` 30. Does project require A- DEC Stream %Disturbance Permit? ............... M > 31: Is or,waspproject site used for °agricultural .,activity. involving application of a s� pesticides,tor orchards -or other.cro s solid or'hazardous waste dis osal t r. p , landfilling; sludge application or industrial activity? .. ... Yes/No ^ r R 1VD f - 32 Is protect located within 1,000 feet of existing or abandoned landfill, hazardous: waste it salt stock ile landfill sludge disposal site or :an P g P Y ` ' other potentially.known source of contamination? ;Yes/No I V D Y DESCRIBE. i 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 4 15 years in or adjacent to project srte� ,y ti f •. .. .... } ..• 35: Are any sewage treatment areas in excess of 15% slo 'e? .. .................. �.., 36. ` Tax Map ID Number .......................................................... Map_ Block Lot Z3 37. Approved plans are to be returned to ..... Applicant Design Professional NOTE Allwapplications for review approval of a new SSTS to be located within.the NYC.Watershed shall, be�sent't61he 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 project, such as'stormwater, tans or the creation •of'. . _.,P , . :impervious surfaces, and the project applicant should obtain the appropriate forms for such activities fr om �. DEP and,submit those forms to DERfor•review"and approval, ,. = 4. r { If the application is signed by a person other than the applicant shown iii'Item` 1.,the application must be accompanied by a Letter of Authorization :(Form LA -97). Failurq.to comply with this, provision maybe grounds for the rejection of any submission. :r ` -I hereby affirm, under penalty ofperjury ,that infor "mation rovided on this orm is true to the best of my knowledge and bekef. "False statements made herein are punishable as a Class misdemeanor pursuant to Section 210.45 of the Penal Law # SIGNATURES'& OFFICIAL TITLES: j IA 46C I Mailing` Address OL PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION REVIEWED BY RM, GR, AS, MB, BH Y N DOCUMENTS TjPERMIT APPLICATION PC -1 WELL PERMIT_ PWS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS - THREE SETS HOUSE PLANS - TWO SETS VARIANCE REQUEST SUBDIVISION &AL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED STANDPIPES GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME PE P 1969 NEIGHBOR NOTIFICATION TTER BI /ZBA 0 YR. FLOOD ELEVATION ,QTHER REQ'D PERMIT(S) REQUIRED DETAILS ON PLANS WAGE SYSTEM PLAN - (NORTH ARROW) �SDS HYDRAULIC PROFILE GRAVITY FLOW Y NAME OF OWNER DATE TAX MAP # ;ROSION CONTROL:HOUSE,WELL, SSDS �ERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION L CATION MAP EP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE PUMPED, PIT & D BOX SHOWN & DETAILED 'Fl H - USE - NO.OF BEDROOMS WELLS & SSDS'S WAN 200' OF PROPOSED SYS. PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE Nq BENDS; MAX.BENDS 450 W /CLEANOUT . FILL SYSTEMS /LAY BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS FILL NOTES FILL CERTIFICATION NOTE . DEPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME r,ILL IN EXPANSION AREA THE H LF TRENCH PROVIDED 60 FT MAX. (PARALLEL TO CONTOURS 100% EXPANSION PROVIDED O` PLAN - FROM SSTS 10' TO P.L., DRIVEWAY, LARGE TREES, TOP OF FILL 20' TO FOUNDATION WALLS _15'WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER ,10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGE COURSE 200'/500' RESERVOIR, ETC. _150' GALLEY SYSTEMS rONSTRUCTION NOTES to CDS = >5 °/q 10'- 4 %,25'- 3 %,30'- 2 %,35' -1 %,100' - <1 % SIGN DATA: PERC & DEEP RESULTS ®15'MIN 20'MIN to CD discharge /100'with 182 cons day discharge 2�90NTOURS EXISTING & PROPOSED SEPTIC TANK 6 VEWAY & SLOPES, CUT ]0' FROM FOUNDATION; 50' TO WELL VO TING /GUTTER/CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES DIMENSIONS TO PROPERTY LINE TITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION - TM #,PE/RA; NAME,ADDRESS,PHONE# I)AfE OF DRAWING/REVISION bbATUM REFERENCE POCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: 6, , I/ t-I (7 7 Y Y `i�) e-j:1- t- t, �r' , i-� k"t ' s yV\ e o V\s -e y o v �- 1 A. y J• cLt od (D 'vpr�Tt-v(y Y'o tjrs� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Street Location H *41-f I 19:�, r Towne r TM # 2- `�. 2, 1. Sewae-e Svstem 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 tankTize - 1,000 ... l X250. ..other ................ b. Septic tank installed level ... ...... ............................... C. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All out --lets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box -properly set .............. f. Trenches T. -Length required Length installed 2. Distance to watercourse measured 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 - 1' /z" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped., ..................... ............................... g. Pump or Dosed Systems Size of pump chamber ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle......'..... III. House/Building . A. ouse located per approved plans ... ....................:.......... b. Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured ft........... c. Casing 18" above grade .................. ............................... d. Surface drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ....................:.......... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ... ............................... i. Erosion control provided ................. ............................... Rev. 6/97 Date: Inspected by; Owner. Permit # Subdivision Lot # Form ST -3 D O INN m InIm IlifM IRm� B L'o'ri IMAM Form ST -3 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 1-2"h w Address Located at (Street) ZY .: L3 /1 Tax Map Block Lot _ (indicate nearest c oss street) Municipality Drainage Basin 667— A&*X,14 Hole No. Run No. Time Start - Stop. Ela se Time (pMin.) Didto Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 21 '/e /z '� 3 7,3 2 ill' a- 30 A7 - zi Xz Z ' L /Z 3 //' .30 _ ZZ , . Z '/z Z 4 - 5 1 /Oslo . a 3o i - 3 3/ l 2 `/ 3o 4 Y 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH 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' 7.5' 8.0' 8.5'. 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. Z, HOLE NO. 2 Indicate level at which groundwater is encountered 4 /,' Aler Indicate level at which mottling is observed &A—Aiy Indicate level to which water level rises after being encountered Deep hole observations made by: Date t� 8 Design Professional Name: E - --Z', Address: Signature: al 0V NEW �nSEPHS 3-- PLom8)1,j(-1 i BEDROOM 12) }_ s'-WX W-• KITCl4EN JING U-21 x W-01 MODEL 6T 3 BEDROOM, 2 BATH NOMINAL SIZE 25' X 48' ACTUAL SIZE 2(o'-8" X 44'-Or' TOTAL AREA = 1113 SQ. FT. LIVM ROOM W-10, x 121-6l W- u4 V19TEe IAJLeT MASTER BEDROOM 141-5, x 121-6* PUTNAM COUtITY Dp ,p p, ;,a v ,Tr, ENT 0 V HOUSE 1OLVE, RPPRCJV"T-Y-) p i 'C f' ,EDV.oc�,�l cOUNT 0NIL 7�c —. f4z.�Vw q,,,,ire&Title --JR Z -'LIS I e P/ W- -k I L J. SK 315BEE IfilictL — ( CLMED 19 oQ2 LITERATURE PLAN vAT.F. 1,13al �„� 3.,PLUM81AJ6 22' (o' OWN=. } .10 CA - KDROM 02/ -7B"7x - DNIW3 - i LIVM RDOM n, - io, x 4' - 6' s7t 4f, qld sKumwM6 MOIDEL 692 3 BEDROOM, 2 BATH NOMINAL SIZE 28' X 48' ACTUAL SIZE 26'-8" X 44'-0'; TOTAL AREA = 1113 SQ. FT. MASTER BEDROOM 1, X-91 x IZI-61 I 6V*-.Fj • 619 -;T I - a>Tt. RF45M SUL 9,LU-Mr. W,-.; 15 1940 V EZ a Ll I'm c 7UL&K NOINJOL :. 7— Tlr.E- 1-11TEFZATURE PLAN i -ri, ur. 12 a 2o, 134% QiYEnS 2' o" W9TW IN LET T tit "1 wm 0 MASTER BEDROOM 1, X-91 x IZI-61 I 6V*-.Fj • 619 -;T I - a>Tt. RF45M SUL 9,LU-Mr. W,-.; 15 1940 V EZ a Ll I'm c 7UL&K NOINJOL :. 7— Tlr.E- 1-11TEFZATURE PLAN i -ri, ur. 12 a 2o, 134% QiYEnS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ►L M PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY - 02� 0(0 SITE LOCATION . a NI0 ay T, 3 1 TM# 3- 2,--2-3 L o?-* t 6 OWNER'S NAME '��-4-� r �� A 'G,r�- PHONE & V S 576---7-!�-2e2 MAILING ADDRESS .? ©. (� o ?C 2R z �j �-t -Fe �'so AJ . u, [ 2 r,�, -3 PERSON INTERVIEWED PCHD Complaint # Name Relationship (i.e., owner, tenant, etc. DATE - y -d 6 TYPE FACILITY fie S PROPOSED INSTALLER PHONE 079-,g ADDRESS REGISTRATION# Proposal (include sketch locating all adjacent wells): Ty wffT'e4 NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. Lo 0 ��L`l�°'� I���o I, as owner, or reported agent of owner _ agree to the conditions stated on this form. SIGNATURE �\ �' � v TITLE e9 - DATE 4 Z 3 (e Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gala Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposalapproved 3 �2 Ela a Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML I rie I if p[14999 P 9TTtR soN Aly �s63 �7�- 75;9 J SITE �JC'P�s i i> IBS PUTNAM COUNTY HEALTH DEPARTMENT. DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY LOCATION A" i � ,m C 1 /Y'.�e XT3 TM# -2 — �13 �y OWNER'S NAME n'14 cl rri PHONE 3 MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # ame Relationship i.e., owner, tenant, etc. — •� DATE TYPE FACILITY,- &J�,, I - ' PROPOSED INSTALLER S re-T e,4 �el, PHONE �l S��'S7a ��5� % T! Y ADDRESS �i' / q ITO= r 1 _V( '� REGISTRATION# PL° 1 f S o 0 o a (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may re uire submittal of proposal from licensed professional engineer or registered architect. QC-_ I, as owner, or re . o agent of owner agree to the conditions .stated on this form. SIGNATURE TITLE ^ DATE Proposal approved with the following conditions• 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title COPIES: White (PCID); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE - A t I I-lee 11°jc C i ro le _�Z? 513_ >� i '�1 I 0' 40ro\ Ac,, eC;rcl� q0 X11 P\-311 _ °S PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCMimi EWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT Located at ge Owner /Applicant Name lgro. 42111A&0' Tax Map /-3 Block Z- Lot 2,3 Formerly Subdivision Name Subd. Lot # Mailing Address / loo /3�2)C 2 F3 2- Zip 12-5&3 Date Construction Permit Issued by PCHD ,p 2-02- & Separate Sewerage System built by � 0'"4oO Address &6n9es —f %f y 145-63, Consisting of 12-50% Gallon Septic Tank and Other Requirements A-14 Z 1A/ Water Supply: Public Supply From. Address or: Private Supply Drilled by 46;e� TlAA/ W,15VZ Address Building Type 4---rvP--A47*Z-. Has erosion control been completed? S Number of Bedrooms Has garbage grinder been installed? I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and a standards, rules and regulations of the Putnam County Department of Health. Date: � 22 Certified by P.E. R.A. (Desi r fessional Address i Sa License # z 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 revocat n, tnodifica n or change is necessary. By: Title: d�� Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 BRUCE R. FOLEY Public Health Director LORETTA MOLINARI- RN., M.S.N. �' Assoclme Public Health Director Fw �0 s Director of Patient Services DEPARTMENT OF H1 :lei 1 Geneva Road Brewster, New York 105C.- Environmental Halts (914)279-6130 Fax(914)278-Ml Nursing services (914) 278 - 6558 WIC (914) 278 - 6678 . Fax (914) 278 -608S Early Intcrva8on (914) 278.6014 Preschool (914) 278082 Fax (914) 278 - 6648 € i OWNERS NAME: TAX MAP�AMBER- E911 ADDRESS: TOWN: /3,Z_ z3 Z 1 -44e t- l -R, tf-ers ') N AUTHORIZED TOWN OFFICIAL: (Signature) DATE: 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 is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction. Compliance.. (E911VERFRM) DR= R. FOLEY * LCMUffA MOLD ARI• R31, M S ILL Ar6% Hcd* Db aor Axvds* Pof¢ Mwft DkWw Douro r ef Pdow 8nok o DEPARThESW OF HEALTH 1 Gomm Road Bnwdw, New York 10509 E..4.■.e.eo aura p1t�rle -6130 ta►A rn -701 Nw Be (914)rn -bur w�c (914)rn -6678 .1��14) rn -wts Zotf l�e1 (914) 278 -6014 Tosefod X14)27 AM lWg(914) 278 -660 OWNERS NAME: �i �- �� t-C, 0. c- V►�-o �y �iP TAX M"'AMBER: E911 ADDRESS: 2- 3 "{ i-e �- -t- -Q C V- c TOWN: l �� r s a ✓1 AUTHOPj2ZD TOWN OMCL4 L: . . (signitum) V DATE: The intnam Co>omty DVarfineut of HenM wM not iasae a Cwd teate of Conte Camptiance ®less the above farm is comptet* i.e., a bgat F911 address is assigned by an antb+oriud town oMdaL II& fur® is to be snbmittted with the application for a Ce df"te of Construction, Compiiam* . PUTNAM COUNTY VZrA rMZlrr OF SBALM DIeMw Pit dl Htiallh Ses�loea. Cssaal. N.Y.1S612 �� to PwvWa Paassalt L RQ MN PESM POE SEWAGE DEPOSAL STI M tat wa. Date Subdivision ADDrovei___ ZIP e.■+rls 'type .I Lit An& oar Dep& vahans, Naaber of H -VAL& Dealgl Flow G P D PCHD Nod&mtka Is Yegalrod. When FM Is, eampieted So-oft SowanPe Syetaai to aadat d Gall. Sapd. Tech saad To be oasishaeted by (�• Addmse Water Saippb: P - H, Saptdy Few Adlitess on P.t..ee Saipgb DdBed -br = R Z;1 4,16 .. Otbar Ra�aboeaata I represent that I am wholly and completely responsible for the design and location of the proposed system(s). 1) that the separate sew di sal s Item above described will be Constructed as shown on thaapproved amendment there to and in accordance with the standards, rules a regu qM O nam County _ Department of MMltl% and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Commissioner of MMlthwlll be submitted to the Department, and a written guarantee will be furnished the owner, his successors. hairs or assigns by the builder, that mid builder will Place to good operating Condition any part of said sewage disposal system during the period of two (2) Immediatey, following theate of the heu- ance of, the approval of the Certificate of Construction Compliance of the original system or any repo t eto, 2) that the drilled well describe above WO M kicated as shown on tits approved plan and that Bald wall will be I al, ran with t and► s, rules and rpu aB{%nt � Putnam County Departm d of MMlthr Onto Signed P.E._ R.A. Address License No � ` — e APPROVED FOR CONSTRUCTION: This approval expires two year f m the date issued unless Construction f the building .has been undertaken and is revocable for cause or may W amended or medified when Consider esmry by the Commissioner of Mira Any Change or alteration of construction Rev. a no pVm" for disposal of domestic ri age, a / private water iuppy only. Rev . 10188 ate BY Title BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New -York 10509 Environmental Health (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 May 26, 2000 Sean J. Daly P.O. Box 418 Shenorock NY 10587 Re: O'Hara Route 311 (T) Patterson, TM# 13 -2 -23 Dear Mr. Daly: The above regarded application is and cannot be processed. This means the project cannot be forwarded to a Putnam County Department of Health reviewer for comments or approval until the following has been received: 1) ®Standard E911 Address Form. 2) ❑ Construction Permit Application. 3) ❑Certificate of Construction Compliance Application. 4) ❑A certified check or money order in the amount of: ❑ $300 for a Construction Permit. ❑ $300 for a renewal of a Construction Permit. ❑ $150 for a revision of an approved Construction Permit. ❑ $200 for a Certificate of Compliance. ❑ $100 for a Well Permit. ❑ Other If you have any question regarding this matter, please call me at (914) 278 -6130 ext. 2152. Very truly yours, Theresa Nemeth .qpninr Tvnict PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH.SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM (�?- c� tf, Owner or Purchaser of Building C�- C , t3 z Z 3 Tax Map Block Lot . S" o ni Building Constructed by _ Town/Village A 0 k 2 Z C:"- cr v vL.v �% T' Location - Street Subdivision Name Building Type Subdivision Lot # M E-f p I represent that) am wholly: and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above - described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a ' period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated: Month S Day. I Year a o c-)e General Contractor (Owner) - Signature Corporation Name (if corporation) Address: '?` CO, d Z Z_.. c-s o z State ��� � Zip ( S� � `Signature:'`' Title: �A_ ti 1" Corporation Name (if corporation) Address: ` d ° ?� 2— Z State FS-6 A Zip tjf n Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani, Director AB #•: 93.800901 CLIENT #: 9401 NON STAT'PROC PAGE' i N NN NN N N N NN NNN NN N N N NNN NA(NNN NN N NNNN N•NN NN N N NNNN N N NNNNNN N N NN N N N N N N N N N NN N N N N N N N NNN ARMONY MOBILE HOME PA DATE /TIME TAKEN: 07/23/98 08:00A .O. BOX 282 DATE /TIME REC D: 07/23/98 11 :00A ATTERSON, NY 12563 REPORT DATE: 07/30/98 RHONE: (914) -878 -7529 AMPLING SITE: RT. 311 SAMPLE TYPE..: POTABLE. PATTERSON PRESERVATIVES: NONE IL'D BY: P. OHARA _ TEMPERATURE..: RTES...: WELL #2 COLIFORM HETH`: MF •N NNNN NNN NN NNN N N NN N NN N N N NN NNNN N N N NN N N N N NN N N N NN N N NNNNN N NN N N NN NNN N N NNNN NN NNNN NN DATE FLAG PROCEDURE RESULT NORMAL- RANGE METHOD PUTNAM CNTY PROFILE 07/23/98 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 07/23/98 LEAD (INS) <1 ppb 0 -15 ppb 12345 07/23/98 NITRATE NITROG- 0.31 MG /L 0 - 10 9139 07/23/98, NITRITE NITROG <0.01 MG /L. N/A . 9146 07/23/98 IRON (Fe) <0.060 MG /L 0 -0.3 mg /l 2037. 07/23/98 MANGANESE '(Mn) <0.010 MG /L .0-0.3. Mg/1 2037 07/23/98 SODIUM (Na) l3.6 MG/L N/A 07/23/9$ pH 6.4 UNI•TS 6.5 -8.5 9043 07/23/98 HARDNESS,TOTAL 18.0 MG/L N/A 07/23/98 ALKALINITY (AS 14.0 MG /L N/A 07/23/98 TURBIDITY (TUR <1 NTU, 0 -5 NTU COMMENTS: .'T THESE RESULTS INDICATE THAT THE WATER WAS) (WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDIN THE NEW YORK STATE. AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. 'Cu LEAD limits for pi EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. sblic schools are set at 15 ppb. Rule for Public•Systems requires that no more distribution points have a LEAD value of more COPPER value of 1.3 mg /L, else water undertaken to reduce the waters corrosive Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the, water should contain no more than 20 mg /L of Sodium.' For those on a moderately restricted diet, a-maximum of 270 mg /L of Sodium is suggested. :%Q lo)18 It. A. A YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245 -2800 Albert H. Padovani,. Director AB #: 93.800901 CLIENT #: 9401 NON STAT PROC PAGE 2 NNNNNN NN N N N NNN N NN N N N N NN N NNNNNN N N NN NN NN N NNN NN N N N N NN N�iNN N NNN NN N N NN N NN N NNN NNNNNN ARMONY MOBILE HOME PA DATE /TIME TAKEN: 07/23/98 08:OOA .0. BOX 282 DATE /.TIME RECD: 07/23/98 11:00A ATTERSON, NY 12563 REPORT DATE: 07/30/98'* PHONE: (914) -878 -7529 ;MPLING SITE: RT. 311 SAMPLE TYPE..: POTABLE PATTERSON PRESERVATIVES: NOW IL ' D BY: P. OHARA _ _ _ _ TEMPERATURE._.. 7TES...a WELL #2 COLIFORM METH: MF VN NNN N N N NNN NNN N N N N NNN N N N NNN N N N N N N NN NN N N NNNNNNN N NN NNNNNN N N N NNNNNNN NN N N NNNNNNNN DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD MITTED BY: Albert H. Padovani, M.T.(ASCP) Director PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property" of Located at Subdivision of Subdv. Lot # Date 1- Section Block Lot Filed Map # Date T. MICHAEL D.ALY, P.E. Gentlemen: CONSU INi"i EWNEER P. 0. BOX 2.43 This letter is to authorize SHENOROCK, N. Y. 10587 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 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. Very truly yours, Signed . Countersig Owner of Property P.E.,' R.A. , # �a 7'"[D 7/ Address T. MICHAEL DALY, P.E. Address LUMULTINC ENGINEER P. ®. BOX 243 SHENOROCK, N. Y. 105$7 91,11 4ze 6'qCS-01--- Telephone AJ Town i Telephone PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: i 2/Pe Inspected by: G er Street Location f', 31/ Owner PeyLey d' � ,41Z Town _ ;7,- 1jj7:ACi SMj Permit # P — S' °7 TM Subdivision Lot #- 1. Seiv_ aae Svstem Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lath. Width Avg.Dpth c. Natural soil not stripped.......... .......... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 1.00' from water course/ wetlands ...... ............................... II. Sewage Svstem a. Septicltafik size - 1,000 ....... .1,25 ....other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribtuion Box All outlets at same elevation- «-ater tested ................. 2. Protected below frost-., ............................................... 3. Minimum 2 ft.Origi. al. soil between box & trenches Junction Box •properly set .... :.................. ............................... engtFi required sp o Length installed 2. Distance to watercourse measu.red-�-,2 oo Ft.......... 3. Installed according to 4. Slo��'o �tjr�6 acceptab e 32" /foot ............. 5. 10 o property, line o dations.......... 6. Deha nc < ncv 7. R m foe ansion, 100 % ......................... 8. Siz )/4 - 1 2" diameter clean .................... 9. De of gravel in trench 12" minimum ................... 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Systems 1. Size o pump c am er ................ ............................... 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio .................... ............................... 4. Pump easily accessible, manhole to grade.: ............... 5. First'box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildin a. House located per approved plans ... ............................... b. Number of bedrooms ....................... ............................... IV. Well a. Well located as per approved plans . .........:..................... b. Distance from STS area measured o o ft ........... c. Casing 18" above grade .................. ............................... d. Surface 'drainage around well acceptable ....................... V. Overall Workmanship a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ........... ............................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ............................... i. Erosion control provided ................. ............................... Rev. 1/97 Form -.3 . 6040N • I DI• • • ID, 0 • . DESIGN DATA SHEET- SUBSUFACE,SEWAGE DISPOSAL SYSTEK FILE NO. owner <�� Address Located at (Street) N U \ 3 t I Sec. Block Lot (indicae nearest cross street) mmicipality ��d�✓ Watershed Date of Pre- Soaking Date of Percolation Test HOLE NUMBER CI= TIME PERCOLATION PERODLATION Run Elapse .. Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches l q` Ili q 'i8 2 R 41-- 361 9 4 5 1 9 ` 9 yy 30 4r 3 o _ I �V �d 3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal soil rates are obtained at each percolation test hole. All data to*be submitted for review. 2. Depth measurements to be made from top of hole. rPV_ 9 /RS TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. I HOLD No. �° HOLE NO. G.L. ? so c� j o i , 1 2' 3' 4' 5' 6' 7' 8' 9' 10' 11' 12' 13' 14' 1,1101111111 M 11,111111111, 111MOIC0,61IN00 No N* oil INDICATE LEVEL TO WHICH DATER LEVEL RISES AFTER BEING ENCOUNTERED �+ DEEP HOLE OBSERVATIONS MADE BY: i� DATE: d 7 7 DESIGN Soil Rate Used Min /1" Drop: S.D. Usable Area Provided V q��Z%!!Fw No. of Bedroams Septic Tank Capacity gals. Type ON&I 1 Absorption Area Provided By §270 L.F. x 24" width trench Other Name Signature 1M 'k'! Address SEAL THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date PC -1 PUT NAM COUNTY DEPARTMENT O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM i 1. Name and Address of Applicant: 'y " 2. Name of Project: 3. Locatioovc: 4. Project Engineer: ��Gk �CS,(�/ 5. Address:�)K ZP � License Number: ��iv?'? Phone: 6. Type of Project: 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 (SEAR)? Type Status (Check One) Type I.. Exempt Type II. Unlisted 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. 9. Has DEIS been completed and found acceptable by Lead Agency? ............ 10. Name of Lead Agency 11. Is this project in an area under the control of local planning, zoning, -D60- or or other officials, ordinances? .......... ............................... 12. If so, have plans been submitted to such authorities? 13. Has preliminary approval been granted by such authorities? Date Granted: 14. Type of Sewage Disposal System Discharge::�i35 Surface Water Ground Waters 15. If surface water discharge, what is the stream class designation ?........ 16. Waters index. number (surface) ........... ............................... 17. Is project located near a public water supply system? .................. 18. If yes, name of water supply Distance to water supply 19. Is project site near a public sewage collection or disposal system ?..... W b 20. Name of sewage system Distance to sewage system 21. Date test holes observed: S L ¢ 22. Name of Health Inspectors. `. 23. Project design flow (gallons per day) ....... 6404/ ......................... 11/93 2. 24. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. k) b 25. Has SPDES Application been submitted to local DEC Office? ............... 26. Is any portion of this project located within a designated Town or State wetland? .................................. ............................... 27. Wetland ID Number ....................................................... 28. Is Wetland Permit required? .............. ............................... Has application been made to Town or Local DEC Office? .................. 29. Does project require a DEC Stream Disturbance Permit? ...................�% 30. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, ,,(( landfilling, sludge application or industrial activity? ........ YES or NO 31. Is project located within 1,000 feet of existence of abandoned landfill,: hazardous waste site, salt stockpile, landfill, sludge disposal site or FJ a any other potential known source of contamination? ..............YES or NO Iv DESCRIBE: 32. Is there a local master plan or file with the Town or Village? ........... 33. Are community water, sewer facilities planned to be developed within 15 years? k10 34. Are any sewage disposal areas in excess of 15% slope? ........................ �L b 35. Tax Map ID Number ......................... ..............................: 36. Approved Plans are to be returned to: Applicant ? L", 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 provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursuit to Section 210.45 of the Penal Law. . -.11 .. , ) SIGNATURES & OFFICIAL TITLES: MAILING ADDRESS: a�eJx 1'Y._-) DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Tom Daly Box 243 Shenorock, NY 10587 9 BRUCE R FOLEY Acting Public Health Director May 15, 1997 Re: Proposed SSDS: O'Hara Route 311 Trailer Park_ (T) Patterson Dear Mr. Daly: Review of plans and other supporting documents submitted at this time relative to the above - captioned project has been completed. Comments are offered as follows: "The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard." "You are referred to Article 128.1 of the official compilation of Codes, Rules and Regulations of the State of New York, Title 10, relative to the need for approval of individual sewage disposal systems by the City of New York. You should contact city Officials in this regard." 1. Tax map number has not been noted on application. 2. The proposed water line location must be shown from the well to the proposed trailers. 3. Neighbor Notification is required. 4. A letter from the Building Department or Zoning Board of Appeals is required stating the above referenced proposal is acceptable under current codes. 5. The invert elevations are to be shown on the SSDS profile, furthermore, the SSDS profile for both trailers is to be shown. -2- 6. Erosion control measures for the well is to be shown on the plan along with a note stating all erosion control measures are to be installed prior to the start of any construction. 7. Locationmap is to be provided. 8. Trench detail is to note cover as geotextile material or equivalent 9. Deep hole data notes ledge at 6 feet in deep hole 2, therefore, the minimum of one foot of ROB fill is required. Upon receipt of a submission, revised to reflect the above, this application will be considered further. RWJP Very truly yours, ?&V 41."— Robert Morris, P. E. Public Health Engineer PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME ADDRESS 173 " /4 ;? // TH No. MAILING ADDRESS P.O. Box Post Office Zip Code PERSON IN CHARGE OR INTERVIEWED �� �' '/7 ✓ivloe Name and Title DATE TYPE FACILITY Ni Ja,4e /p is TIME ARRIVED TIME LEFT FINDINGS: r /lam it Orig. Routine Orig. Complain Orig. Request Compliance Complaint Comp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference _Other 1� ' /tiD�e�S, Explain INSPECTOR: TELEPHONE: 7�-� /�J c?.✓D�a?Ey� /9:�Lsignature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: 1 1 i a 3 i FMT M COUNrr DEP = -= OF F=-'a.LTH - DIVISICN OF EWCRCN Ems- l .L E-_,UTH Sc�..,T,naS D I�� Ua_ , WISER SUPPLY SU SLTRFAC ED&CE DISpCcar SYST*P+S r - Fr r-n INSP= —CN REPORT 7x I "t P 4-r (Na-_= of Cumer) (Street •Lccticn) INJI -ML SITE LNSPE'•`?'ICN- YES NO PietlarO_c en /or proximate_ to prcperty . .......:...... Prccr--r -,,r lines or corners found ................... .:�. I Can �t=r�t: hce lcticn . ...................... y;; i 1 Gr?ve'NGy nE- cat ................... _ ......... i ha_ct. tr=-5 be- rewvd - note these ................ i reep holes repr = =c. ^,i -tive of e_ntiTe SUS axea ...... I Maticr. I. deep holes r. =ed........... I Suf- ki -e-nt SUS area ava fable canside_ -2nc dr3,va -; v cat, hcusa lccticn, Fdjac-�t wells /septics ............................ Acc to urcra =d well lccaticn for drilling..... I D. H. 1 LC L)e th to-G.W. � repel to rccc ft. SaL D5cr3.13ticn 0 ft. !f rawr� '01 3 ft. Jj 6 ft. Sc••� !oli s,� svm2. .7' 9 ft. f�. FDD -1., Sim LNSPL'CTICN D. E. 2 Lct De_ tz to G.W. Uept1 to rccc So>> D==crir°,cn 0 ft. zaizl y uhKIT�: INS•P.BY: I Y=S NO Ects_e SSDS lccatd per approved plan ............. Iprgth of t?'e_rxGi r °—a -urEd vidtz of trench average Slcce of tile lire and trench acceptable......... Roan a? lcwd for eransicn trenches ............... Cver 100 ft. fran water-ccurse .................... ltab= l soil not s t riFrd or SDS area uine_e_`se.rly cracdt ................... 10 ft. m*itained fran prcoe_*-ty line and 20 ft. fran hcuse ...............' _........... Mishap -ce well to SSDS (ft.) ...................... Rmm er of bdroars cie✓;s ........................ stones, brush, s, rubble, etc_, gre=te_r then 15 ft. fran ne =rest trench ................ 15 f:.. of peripne+ -� soil horizanta—Ily f_aa trench.................................... %xe_s properly set ............................... C:,u?d surface runof= f_an driveway, rceus, - crc=d surface, etc. , G-i,annel ne =r "-DS are:.. . rce_= lot ci* -aimce ap-ge=T CK-jn* ara_. of SDS:...... . V 1-7 L/'.:_ I') DPI: INSP. BY: D.H. - Ceep Hole G.SV.--G CL"&' atE D.E. 3 Lct Demtz to G.W. Depth to rcpt 0 ft. 3f 6 ft_ 9 ft. 12 ft. Sail t_=cir,t;cn CC�1ri5 3 ft. !f rawr� '01 9 ft. 12 ft. uhKIT�: INS•P.BY: I Y=S NO Ects_e SSDS lccatd per approved plan ............. Iprgth of t?'e_rxGi r °—a -urEd vidtz of trench average Slcce of tile lire and trench acceptable......... Roan a? lcwd for eransicn trenches ............... Cver 100 ft. fran water-ccurse .................... ltab= l soil not s t riFrd or SDS area uine_e_`se.rly cracdt ................... 10 ft. m*itained fran prcoe_*-ty line and 20 ft. fran hcuse ...............' _........... Mishap -ce well to SSDS (ft.) ...................... Rmm er of bdroars cie✓;s ........................ stones, brush, s, rubble, etc_, gre=te_r then 15 ft. fran ne =rest trench ................ 15 f:.. of peripne+ -� soil horizanta—Ily f_aa trench.................................... %xe_s properly set ............................... C:,u?d surface runof= f_an driveway, rceus, - crc=d surface, etc. , G-i,annel ne =r "-DS are:.. . rce_= lot ci* -aimce ap-ge=T CK-jn* ara_. of SDS:...... . V 1-7 L/'.:_ I') DPI: INSP. BY: D.H. - Ceep Hole G.SV.--G CL"&' atE D.E. 3 Lct Demtz to G.W. Depth to rcpt 0 ft. 3f 6 ft_ 9 ft. 12 ft. Sail t_=cir,t;cn CC�1ri5 TEST PIT DATA REQUIRED TO BE SUBMITS WrM APPLICATION DESCP=ION OF SOILS ENCOUNTERED IN TEST HOLES 0 DEPTH HOLE NO. . - HOLE NO. HOLE NO. G.L. O® `u,14 A -ice 11 911,10 61 461, 2' YD 3' n 5' `7 ►' l �� g " % lix % 7' . 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WRIC H CROUNDWA= IS ENC OUNT= INDICATE LEVEL TO WHICH jtz,TER LEVEL. RISES AF'T'ER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: DATE: DESIGN Soil Rate Used. Min/I" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity gals. Type Absorption Area Provided By L.F. x 24" width trench Other Name Signature Address - SE' THIS SPACE .FUR USE BY FMALTH DEPARRAF.NP ONLY: Soil Rate Approved sq.ft /gal. Checked by Date APPENDIX 3 PUTNAM COUNTY DEPARTMENT OF HEALTH - DIVISION OF ENVIRONMENTAL HEALTH SERVICES INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS REVIEW SHEET for CONSTRUCTION PERMIT t STREET LOCATION NAME OF OWNER t-4A X44 BY B. HEDGES R.MORRIS_,OTHER DATE S / N/ 9 7TAX MAP # - -_ DOCUMENTS. APPLICATION _' Y Rat *A% PC -1 WELL PERMIT W PWS LETTER tNGINEERS AUTHORIZATION DESIGN DATA SHEET(DDS) �ORPORATE RESOLUTION PLANS THREE SETS HOUSE PLANS - TWO SETS m VARIANCE REQUEST / SUBDIVISION li L SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED =STANDPIPES GENERAL APPROVAL SSDS ADJ. LOTS TLAND ( TOWN/DEC PERMIT REQ? ) DDS PLANS & PERMIT SAME - 1969 NEIGHBOR NOTIFIFICATION BI/ZBA 100 YR. FLOOD ELEVATION REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) fSSDS HYDRAULIC PROFILE = GRAVITY FLOW ONSTRUCTION NOTES (GRINDER NOTE) ESIGN DATA: PERC AND DEEP RESULTS WO -FOOT CONTOURS EXISTING & PROPOSED RIVEWAY &SLOPES CUT OOTING /GUTT DRAINS = EROSION C TROL; HOUS ,WELL, SSDS ROSION C PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY AND EXPANSION LOCATION MAP INOXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE PUMPED PIT & D BOX SHOWN & DETAILED OUSE - NO. OF BEDROOMS ELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM OPERTY METES & BOUNDS OUSE SETBACK NECESSARY (TIGHT LOT) OUSE SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE BENDS; MAX. BENDS 45° W /CLEANOUT FILL SYSTEMS YBARRIER 0 FT HORIZONTAL: SLOPE 3:1 TO GRADE ILL SPECS CIS FILL NOTES FILL CERTIFICATION NOTE DEPTH GAUGES FILL PROFILE & DIMENSIONS IN EXPANSION AREA TRENCH LF TRENCH PROVIDED =60 FT MAX �ARALLEL TO CONTOURS 100% EXPANSION PROVIDED 10' TO P.L., DRIVEWAY, LARGE TREE��Sf TOP OF FILL 20' TO FOUNDATION WALLS T 15' WELL TO P.L 100 TO WELL, 200' IN D.L.O.D., 150' PITS 100 TO STREAM WATERCOURSE LAKE (INC.EXPAN) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (PITS -20') 50' INTERMITTENT DRAINAGE COURSE 200 FT. RESERVOIR, ETC.= 150 FT. GALLEY SYSTEMS 15' MIN TO C.D. S=>5%,20'-4%,25'-3%,30'-2%,35'-I%,1001<1% 20' MIN TO C.D. DISHARGE /100' WITH 182 CONS DAY DIS. 10' FROM FOUNDATION; 50' TO WELL COMMENTS: DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PO PCHD PERMIT #! VS5 -� WELL LOCATION Street Address 3l or Village City Tax Grid Number WELL OWNER Name Mailing Address 1'2, 0rivate OPublic OE OF WELL primary 2 - secondary --// 0_6SIDENTIAL ❑ PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP 0 BUSINESS 0 FARM . O TEST /OBSERVATION 0 INDUSTRIAL b INSTITUTIONAL ❑ STAND -BY ❑ ABANDONED 0 OTHER (specify O AMOUNT OF USE YIELD SOUGHTgpm /# E3 RE ACE EXISTING SUPPLY VeW S PLY NEW DWELLING PEOPLE SERVED 9 /EST. OF DAILY USAGE (,gal 13 TEST/ OBSERVATION 13 ADDITIONAL SUPPLY Ll DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE RILLED DRIVEN ODUG OCRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? IYES 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 & OURCES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (signature, 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: l.. 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 drillin operations be contained on this property and in such a manner as not to degrade or otherw contam' te,surface or groundwater. Date of Issue: 19�_ Date of Expiration 19_ PermiCrssuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller A 4" 0 5 A. 93 19 414. 1V'06%0 oe ,W. .:F574,1. Az -SVS TZF/­7 V Putnam County Department of Health Division of'Environmental Health Se*r—wice3 Approve " noted for conformance with ulos and Regulations of t th De;,a 2tl Y, 7 'ALA PIZ, ao le� 1� Xlz 77e 4 4) Z S H / 1G 147 f - f - -. � W9T�Z Gi�!E Ja • BY!STi tX� W IM /o �9L, flSa�l�Y SE ?�L'_. 7-.Aj.K . Gt 7 /�.✓ FT of Z� T�'h' ' ` �� ✓SC !;R/�,C'rri7flf77Jn/ TH.t�c'ir/ .' ''1 /. 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