Loading...
HomeMy WebLinkAbout0393DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -30 BOX 5 s L A elm le le I �� { 00202 elm le le I 00202 PUTNAM COUNTY DEPARTMENT OF HEALTH DIV3SION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEW E TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # f ' 10 - qq Located at DE�jAM 9-0 N4 Town or Village PA-1 Owner /Applicant Name PAULAVi M bLOa "p' Tax Map (� Block Lot '50 Formerly Subdivision Name Subd. �L./ot # Mailing Address p' Q ' 6P Cd w INL El ' Date Construction Permit Issued by PCHD 614M Separate Sewerage System built by Consisting of Other Requirements: Gallon Septic Tank and Ft Lk, Zip lo�oq Address °4 � LAMeF '4ZOOT1i' $mvey -%E 10 S Water Supply: Public Supply From Address or: Private Supply Drilled by p' �' ���1 -� �ON� Address Building Type P4h ki* A4 Has erosion control been completed? yv� Number of Bedrooms' A- Has garbage grinder been installed? r�0 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 the standards, rules and regulatior}s of the Putnam Count'y Department of Health. Date: 5 1. Certified by ,Z () P.E. X R.A. (Deftn Professional) Address �l� LLCA J'W06G� CoM►�oN� p NE bF&JT1��(�- License# COI�� �oSo� Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public, sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment. of the Public Health Director, such revocation, modification or change is necessary. By: Title: Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 m r.i y -s, OIO ;E DISPOSAL :CATED ON THIS JSPECTED BY ME !ACCORDANCE EGULATIONS OF THE NEW YORK Za ,21 is 1)E i 6 �4 13 8 cr Yp� 55.13�� d = ZO °53�90 22 , [)E VO N RO �d rgNK'r i a N� Put-, Diviaio Approi Sign DIMENSION CHART (in feet) Number A B I 3. 0, 49 .0' 2 Co2 .5 50 .0 3 roI O, 52 -.0 4 60 .0 54.0' 5 5D .0 ' 55 .0 co 50 .0 56 .0' 7 60 .0 , Co0 .5' 8 64 .0 , C06 .O 9 68 .5 70 .5' 10 T2.0 76 .0' 1 1 -75.0 80 .0 ' 12 5-1.0 75 .5' 13 I Iro .5� 113 .0 14 1 1-7 .0 115 .0' 15 11 7.0 IICo .0 1& 11-7 .0 117 .5 17 114.0 IICo,O� 16 it 4 .0 117.0 19 1 1 Co .0 120.O' 20 40 .0 53.0 21 33 .0 32 .0 ' 22 21 .0 ' 55.0 23 20 .0/ 41 .0 24 34 .0 40.0 25 43 .0 ' 56-0 2<0 50.5 ' G5 . 0' 27 5 ,0.0' 74.0 26 67 .0 82 . o � 6> `9 0 0� �I NI 0 z NE. NORTHEAST LABORATORY of DANBURY 39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404 LABS (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 LABORATORY REPORT -- WATER SUPPLY TESTING REPORT TO: P.F. BEAL & SONS DATE SAMPLE COLLECTED: 4/11/2000 4 PUTNAM AVENUE TIME COLLECTED: 3:25 P.M. BREWSTER, N.Y. 10509 COLLECTED BY: P.F. BEAL DATE RECEIVED @ LAB: 4/11/2000 TESTED BY: LAB# 11471 REPORT DATE: 4/14/2000 SAMPLE SITE: PALADINO, DEVON ROAD, PATTERSON, N.Y. SAMPLING POINT: HOSE BIB SOURCE: WELL TREATMENT: NONE TEST PERFORMED RESULT: MAXIMUM CONTAMINANT LEVEL BACTERIAL: Total Coliform (Bacteria) 0 per 100 ml 0 per, 100 ml PHYSICALS: Color 12 15 Odor ND 3 Units pH 6.99 no designated limit Turbidity 3.0 NTUs S N_ TVs CHEMISTRY: Nitrite N <0.005 mg/L as N 1 mg/L as N Nitrate N 3.90 mg/L as N 10 mg/L as N Alkalinity 342.0 mg/L no designated limits Hardness 520.0 mg/L no designated limits Iron 0.227 mg/L 0.30 mg/L Manganese 0.011 mg/L 0.30 mg/L [Note: Combined Limit for Iron plus Manganese = 0.50 mg/L] Sodium 19.4 mg/L 20 mg/L ** Lead 0.004 mg/L 0.015*** m1= milliliter mg/L = milligrams per Liter ND = none detected NTU =Units * *Notification Level ** *Action Level RESULTS BASED ON SAMPLES SUBMITTEDA /12/2000 SAMPLE, AS TESTED ABOVE: MOTABLE 417-11NOT POTABLE (PER NEW YORK STATE DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) asp d e t t : i,] j'• „1: Laboratory Director. *NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050 TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE "SE E TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # " Located at tD PEWV4 P-®!-\'P TowPA1 TOLE 1 Owner /Applicant Name PA -i'''i) HO b"N I 1�00-F ' Tax Map Block Formerly Subdivision Name C-044wWV Lot ' to Subd. L,iot # 1 Mailing Address P , Q ' zip.. 0 0� Date Construction Permit Issued by PCHD 614119 Separate Sewerage System built by BOTRM,-' �i'li. `S Ct� Address °� t-hHE Consisting of 49-1 00 Gallon Septic Tank and Other Requirements Water Supply: Public Supply From or: ')< Private Supply Drilled by ?if-, 60H� Building Type Pj�") 105 "4 Address Address P"MP Mi1= 11r� t J 1wgp Has erosion control been completed? Y Number of Bedrooms Has garbage grinder been installed? 14 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 the standards, rules and regulations of the Putnam CounW D partment of Health. Date: 5h d W Certified by Address 1% CPC V- .1bv3EV- Cp N410'+ P.E. X R.A. License # 156 1 1,4 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 subject to modification or change when, in the judgment of the Public Health Director, such revocatio , m dificati r change is necessary. By: Title: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Palladino Building Incorporated 13 - 3 - 30 Owner or Purchaser of Building Section Block Lot Palladino Building Incorporated P. 0. Box 501 Brewster, NY 10509 Building Constructed by 7 Devon Road Location - Street Patterson, NY Municipality q Residential Building Type Cornwall Ridge Subdivision Name #7 Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material,. construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to.accept as conclusive the determination of the Director of the Division of Environinental Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this 2 4 day of April- Signature Title -\/ Palladino Building Incorporated r^ 3eneral Z501 actor (Owner) - Signature,.�i� Corpora ion Name (if Corp.) P. 0. Brewster, NY A,0109 :o i n if Corp.) 'r e� S. -,-y Addres rev. 9/85 mk P[TINAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Palladino Building Incorporated 13 - 3 - 30 Owner or Purchaser of Building Section Block Lot Palladino Building Incorporated P. 0. Box 501 Brewster, NY 10509 Building Constructed by 7 Devon Road Location - Street Patterson, NY Municipality Residential Building Type Cornwall Ridge Subdivision Name #7 Subdivision Lot # GUARAt,1TEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage disposal system serving the above described property, and.that it has been constructed as sham on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environmental Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. 1 Dated this 24 day of April .2.000 Signature Title rAES V _ Palladino Building Incorporated ,51, General Cactor (Owner) - Signature . At, Corporation Name (if Corp.) P. 0. NY Co yem% �� i n if Corp.) ) es rev. 9/85 mk PUrNAM COUWY DEPARIMENr OF HEALTH DIVISIOLq OF ENVIRONMENTAL HEALTH SERVICES Palladino Building Incorporated 13 - 3 - 30 Owner or Purchaser of Building Section Block Lot Palladino Building Incorporated P. 0. Box 501 Brewster, NY 10509 BuildinT-Constructed by 7 Devon Road Location - Street Patterson, NY Municipality , Residential ' Building Type Cornwall Ridge Subdivision Name #7 Subdivision Lot # GUARANTEE OF SUBSURFACE SEWAGE DISPOSAL SYSTEM I represent that I am wholly and completely responsible for the location, workmanship, material,, construction and drainage of the sewage disposal system serving the above described property, and that it has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the.owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage disposal system, or any repairs made by we to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the system. The undersigned further agrees to accept as conclusive the determination of the Director of the Division of Environinrntal Health Services of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of the building utilizing the system. Dated this 24 day of April -2 0 0 0 Signature Title _Palladino Buildings Incorporated General Contgactor (Owner) - Signature Corporation Name (if Corp.) rev. 9/85 mk Harry W. Nichols Jr., P.E. 311 Clock Tower Commons Route 22 Brewster, NY 10509 Telephone (914) 279 -4003 Fax (914) 279 -4567 May 1, 2000 Mr. Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS Compliance Devon Road Cornwall Ridge Section 11, Lot 7 Town of Patterson Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -7, "As -Built Plan," dated 5 -1 -00. 2. "Certificate of Construction Compliance for Sewage Disposal System," dated 5 -1 -00. 3. "Guarantee of Subsurface Sewage Disposal System," dated 4- 24 -00. 4. Well Completion Report, dated 10- 26 -99. 5. Laboratory Report, dated 4- 14 -00. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. N ols Jr., P.E. HWN:JM:his 00- 087.00 i 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 3, 2000 Harry J. Nichols, P.E. 311 Clocktower Commons Drive Brewster NY 10509 Re: Palladiho Building Corp. Devon Road, Lot #7 (T) Patterson, TM #13 -3 -30 Dear Mr. Nichols: The above regarded application is incomplete 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. El $300 for a renewal of a Construction Permit. ❑ $150 for a revision of an approved Construction Permit. 1] $200 for a Certificate of Compliance. $100 for a Well Permit. ® Other Standard E911 Address Form. If you have any question regarding this matter, please call me at (914) 278 -6130 ext. 2152. Very truly yours, Theresa Nemeth Senior Typist BRUCE R. FOLEY Public Health Director LORETTA MOLINARI RN., 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 .1-W-1 1W.11 00 ' L OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: PC, lf�� ��a 130:1 i 13, -3- 76 A Wei AUTHORIZED TOWN OFFICIAL: (Signature) -'DATE: 5 f 24 r 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. (E911 VERFRM) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . FINAL SITE INSPECTION Date: o® Inspecte y. �; 77� Street Location yam/ �7�C,, Owner ?AU�4 y >�e/o 8vi�plAe -a Camp, Town I�' -�}TT F',z sue. Permit # 7:>- i o - 9 �2 TM # Subdivision Lot # 7 "cotr,(wgz,_ 1. Sewage 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 tank size - 1,000 ....... .1,25 .........other ................ b. Septic tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box &. trenches e. Junction Box - properly set ........... ............................... f. T renc es T-E-en-g-th requited . 6�� % Length installed 682 2. Distance to watercourse measured 'fi 10 O Ft.......... 3. Installed according to plan ......... ..............................: 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ....... :.................._ 8. Size of gravel 3/4 - 1 %2" diameter clean .................... 9. Depth of gravel in trench 12" minimum ................... 10. Pipe ends capped.....: .:................ ..........:.................... g. P,umR or Dosed Systems 1. Size o 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 Buildin a. House orated per approved plans ... .....................:......... b. Number of bedrooms ......................... �...�f.�R?i??....... . IV. Well a. Well located as per approved plans . ............................... b. Distance from STS area measured j- / O aft........... 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 7 OL 2 � ce sure v� IN V U UUMIVIL�,IN I J y/ • ` `JC � �h PV' �P ea r-5 v� CX7 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINAM R.N., .M.S.N. , Associate Public Health Director Director of Patient Services Environmental Health (914)278-6130 Fax (914) 278-7921 Nursing Services (914)278-6558 WIC (914)278-6678 Fax (914) 278-6085 Early Intervention (914)278-6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648 Date: To: Fax #: X 7 9` 7 From: Gene D. Reed Putnam County Department of Health For your information For your review As discussed No. Pages � . (Including. cover sheet) Please respond Attached as requested Please call r J iii M' I � L � � �► I . / � 4�� X, I In the event of transmission /reception, difficulties, please contact this office at (914) 278 -6130 ext. 2261. 4, .� V �� —�a� � 6 %�. r � '� �. � d � �- f �� � � � �� \ ,� l `� �\ of Y S. �' ° 7 � ' Sib o- �o �� �� � � ��� . �7� 1 �\ ,•. �� ;. APR -05 -2000 08:18 PM PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES REQ1 [EST FOR FINAL INSPECTION For: Fill Date: A, ` 00 Trenches PCHD Construction Permit # Located: , NVOM F0 AP (T) (V) ...ZATTjW_AoN Owner /Applicant Name: pA. A0040 tfJ10JJ4C4 09f' TM Block Lot '5o Formerly: "°° Subdivision Name: C.0aN WAt-k' Pa01�E Subdivision Lot # Is system fill completed? It's Is system complete? is system constructed ai per plans? Yes Is well drilled? Y�4 Is well located as per plans? Are erosion control measures in place? Date: '' 00 Date: S"00 Date: V; i`°o I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with Construction Permit and approved plans and the Standards, Rules and Re am County Department of Health. OQ Date: 41-00 Certified by: L PE X RA Address: it CiWor— 7- ©Sj S. ta��%��,ic. # Comments: FOR: 0 ADAM IQ GENE 1 (NAME) Form FIR -99 P.06 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ,pCONSTRUCTION PERMIT FO ATMENT SYSTEM PERMIT # / / % l �_ �, Located at 0 1=V ® H P4AP Town or Village PAT'rEMoH Subdivision name t-OP4 4WAI -L f4D'AE-:' Subd. Lot # Tax Map ' '1— Block ' % Lot Od Date Subdivision Approved Renewal Revision Owner /Applicant Name PUADi,Mo 6LDC1 , CO ", Date of Previous Approval Mailing Address p10 P10-A 601 Pfl-FW lT&12—. N K J6f67 Zip 104;61� Amount of Fee Enclosed Building Type f ZVW E� Lot Area' , 477 No. of Bedrooms + Design Flow GPD &0 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of /"61 gallon septic tank and Other Requirements: To be constructed by VJA-11 t N Address G6-7 VP Water Supply: Public Supply From Address or: i Private Supply Drilled by P -F - 1- 'f 617M Address PuTw mE bww in Sc� 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: FTqAA4. k, Address U I LC ©WN P.E. R.A. - 'i767a Ni IdSgl, ice Date 4 )11 # Jb(al�4 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 c sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe MI it proved discharge of domestic sanitary sewage only. By: Title: e-f� ' Date: jn White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # 1 1' Well Location: Street Address: Town/Village Tax Grid # Map ) Block Lot(s) Well Owner: Name: N-MlAt BLX L04 Address: N Boy ea0 ugVJSTE:(L NY t 0�0 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought 15t gpm # People Served Est. of Daily Usage $d0 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No X Is well located in a realty subdivision? ...................................... ............................... Yes X No Name of subdivision C,09-+A'%4 0,U-, 9-1040 Lot No. Water Well Contractor: f 4,,7 N5 Address: dh A kl4M kc Pi2sw' � N)' Is Public Water Supply available to site? . ....... ............................... Yes No l Name of Public Water Supply: Town/Village ^ Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: th % Applicant Signature: Pp g v v PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or Well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED_ FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a water w driller certified by Putnam County. c Date of Issue Permit Issu' al: Date of Expiration / Title: Permit is Non-Transferrokle White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 _ i PUTNA COUNTY HEALTH DEPT 4 Geneva Road `(914);278 -6130 fq: •� �� c 'f^--k ' S L. ; r s.,. .� s`*- t v�" t r -+' C r a BfeWStBr� 1058 7 s 1 L} ... r �t/ n 7 _ z 'Date �1 R t� t ASK r Gig e .� Received of ,_ "I"T TH r n ' "s K �.L /).y�A I Iff fi's_ Is x" Est L - ❑� -Cash ` � ❑Check .� Nf O � ❑- Credit Card � ` By - - 5 t; Loin PUTNAY COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of PAI -LAE)I No EjVjj p) Nc;j G p p� Located at -DEMON (LOAD Ofv PATTrz�L soH Tax Map r ith, Block Lot h Subdivision of C.OPkiwA L.L_ P-1 PC,9 A�i pArrEP-e,oN Subdivision Lot # i Filed Map r Date Filed Gentlemen- This letter is to authorize NI G 4dL5, a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permits) 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 treatment 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 Coq Sy anitary Code. Countersigne P.E., R.A., rr Mailing Add State Telephone: FAY Zip 0;0 0 Very truly yours�� Signed: of Properrj) Mailing Address: j -o� FJQ 'b p+'VJ ra'i" 5�L State Zip 10 P9 Telephone: I)H - 4Go ) Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT . STREET LOCATION �L bk\ ' NA::E F OWN R PALL Ab)Nt7 REVIEWED BY RM, GR, AS, MB, BH y TAX MAP # 13-3 Y DOCUMENTS PERMIT APPLICATION PCG1 WELL PERMIT _ PWS LETTER LETTER OF AUTHORIZATION DESIGN DATA SHEET (DDS) CORPORATE RESOLUTION SHORT EAF PLANS 2 THREE SETS H USE PLANS - TWO SETS 'VARIANCE REQUEST FEE . SUBDIVISION �3d% LEGAL SUBDIVISION SUBDIVISION APP OVAL CHECKED PERC RATE Si" , FILL REQUIRED 1' 3" .DEPTH uleURTAIN DRAIN REQUIRED ANDPIPES GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD P APPROVAL, IF REQ'D pp DEEP TEST HOLES OBSERVED r' PERCS TO BE WITNESSED EX- APPROVAL SSDS ADJ. LOTS TLANDS (TOWN/DEC PERMIT REQ'D ?) DATA ON DDS PLANS & PERMIT SAME RE 1969 NEIGHBOR NOTIFICATION ,JtETTER BI/ZBA .4400 YR. FLOOD ELEVATION R REQ'D PERMIT(S) REQUIRED DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) SSDS HYDRAULIC PROFILE GRAVITY FLOW �Y 1. EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN, GRAVITY FLOW, SUFF.SIZE LIMPED, PIT & D BOX SHOWN & DETAILED HOUSE - 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 NO BENDS; MAX.BENDS 45° W /CLEANOUT . FILL SYSTEMS 4�10 Y BARRIER - FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS "� FILL NOTES L CERTIFICATION NOTE DEPTH GAUGES ILL PROFILE & DIMENSIONS VOLUME FILL M EXPANSION AREA TRENCH LF TRENCH PROVIDED � 07 60 FT MAX: PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS v 14 10' TO P.L., DRIVEWAY, LARGES, TOP OF FILL 20' TO FOUNDATION WALLS _15' WELL TO PL 100' TO WELL, 200' IN DLOD, 150' PITS 0' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATERLINE (pits -20') INTERMITTENT DRAINAGE COURSE 7500' RESERVOIR, ETC. _150' GALLEY SYSTEMS CONSTRUCTION NOTES M'11141 15'MIN to CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -1° /x100' - <I% DESIGN DATA: PERC & DEEP RESULTS 20 'MIN to CD discharge /I00'with 182 cons day discharge vl CONTOURS EXISTING & PROPOSED SEPTIC TANK DRIVEWAY & SLOPES, CUT Fn10' 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 PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES t DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM C= Owner RAL 1-,4'n f/Vc Address V AE y.E N R-A Located at (Street) Gn•?,AZ-tA/,4L,, IjILL y;x, Tax Map 13 Block 3 Lot p (indicate nearest cross street) Municipality PATZE -P, n- At Watershed E,4 -7- BpAWz_j{ SOIL PERCOLATION TEST DATA Date of Pre - soaking -:Z Z 19 Date of Percolation Test :3 /0- 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 2 10 #1 a 0 °5 go 3 r 15- -- a- / a a 4 '00— '30 '3 C�' 5 ;. 1 y,'Sl - L1' 30 -- 2-5 .3 o 2 10 3 9 32 r/' 0 ;2 '— r l 30 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 F RECORD OF PHONE CONVERSATION P• Time: , 3 Date: 3 ZzA Person calling: L7— 4:F F p �,+�UQ Phone #: 170 — 6100 Reason O Inspection: KDeeps and/ Peres: Scheduled Field Meeting "Pre -t,7& Time: Date: 1'erc5 Y N Tentative /to be confirmed () ( ) Town: 24T.. s Road /Street:1�Vou RZ a Tax Map #: ' Comments: Kill _ Sheet Town= _State Zip PERSON IN CHARGE OR TNTFRVTRWF %f/M� Name and" Ti t le TYPE OF FACILITY.: - S° s + FINDINGS r�T}�� ,A.a%.. -5' a ►d �ee� �c�e�i AyOre r. - ire 5aaked' 6,3','99 v. .F ^b _ �r zI f �?SEErME: - ��-I TF.T : d2 % � :'613D Signature and Title I acknowledge receipt of this report: SIGNATUREc 71 OZ/96 Title: TV Rev. f TEST PIT PROFILES Hole # I- Lot # _ 7 Hole # Lot # 7_ Hole # Lot # _ Depth to water NotZ e-. Depth to water =1(/ -,� e Depth to water X1/0"1 e Depth to mottling ` r' o t �-G'' Depth to mottling Depth to mottling Depth to.rock/imp. Aloe Depth to rock/imp. 7 - D" Depth to rock/imp.. 6 G G.L. G.L. G.L. 0.5 �p��,�l 0.5 Ta�,S�,•/ 0.5 na r k 8"rown .1.0 s 5 = 1.0 1.0 eta yr y E3 rc7u�/1 2.0 2.0 2.0 3.0 3.0 s 5ll- 3.0 4.0 4.0 4.0 _ - 5.0 5.0 G�..�/i'Slrl #' ,�`r.� 5.0 1 6.0 8 r�tvh� F'rr e �� tea? 6.0 6.0 7.0 7.0 7.0 8.0�i. /c 8.0 '1'2ac IC B x 9.0oti 0 G '' 9.0 y - 9.0 -G 10.0 10.0 10.0 Hole #_ Lot # :_ Hole # Lot # Hole # Lot # Depth to water /✓V n Depth to water Depth to water Depth to mottling NO A- e Depth to mottling Depth to mottling Depth to rock/imp. G Depth to rock/imp. Depth to rock/imp. t G.L. G.L. G.L. 0.5 0.5 0.5 2.0 r dG 3.0 3.0 3.0. 4.0 G; � 4.0 4.0 5.0 5.0 5.0 6.0 ?a� 6.0 6.0 7.0 / p 4. h' G� 7�-a M 7.0 7.0 a r .� 8.0 _U 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 � _1� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner l`ALL. App V0 Address gy� t -pj, Located at (Street) GOR41WAL4 Ma z Tax Map 1 !�> Block Lot 3? (indicate nearest cross street) Municipality ATTEjL:, �N Watershed j FAFA6 ' BRAN6W SOIL PERCOLATION TEST DATA Date of Pre - soaking // Z3 o t�2 g Date of Percolation Test / ,Z1 Z5� s Hole Time Eta se Time ' Surface (Inches} : propp In Inches ..Rate hfa 1Zurt No Start Stop: In;} Start Stap MtuiInch > .: 2 4 5 1 1/� XL 2 r 3 4 7y 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 �. 12531 I # 64 ar s i Z • � � 311 :�,� _r 84 own t t ` 6 � 164 g May g Corn" @ k`r 311 U _ 46 --tea 91; 'ReInbeck ri 3 ! Bp 1 Pond; Corners I ,� t 8 ( l l � � � 22 I l rners as ®� "°gB►o� /qua Area HS •es e r "a9 rye• 1, Q' � � � � v ; L Bremunter,,, } ` q \ ernan t ms 1 ^ •. ` F Pc 311 57 .% Q.. �, n 312 2 `tViz, oNtw000 $ 8 \4e ?�'l�jt,. 9m am 1 Till W 1 I FoSt f, y t �yf �a xrS�3a�kal y: k. 1 rV. 12563 22 1 61 Pond " 164 t•1 Ct alneS Corn U _ 46 --tea 91; 'ReInbeck ri 3 ! Bp 1 Pond; Corners I ,� t 8 ( l l � � � 22 I l rners as ®� "°gB►o� /qua Area HS •es e r "a9 rye• 1, Q' � � � � v ; L Bremunter,,, } ` q \ ernan t ms 1 ^ •. ` F Pc 311 57 .% Q.. �, n 312 2 `tViz, oNtw000 $ 8 \4e ?�'l�jt,. 9m am 1 Till W 1 I FoSt f, y t �yf �a xrS�3a�kal y: k. Cr, - I acknowledge receipt of this report .SIGNATURE;, . 02/96` . Title Rev. RECORD OF PHONE CONVERSATION Time: Date: J /Tr7 Person calling. f 1 yr� �� Jr�-� Phone #: Reason () Inspection: Deeps and /o eres: Scheduled Field,Me_ etina 0 Ic > -rc j Dated =r Y N Tentative /to be confirmed Town: EA Road /Street: 7r � Tax Map #: 3D Comments: lo (10 OQ E RECORD OF PHONE CONVERSATION Time: q' Date: I_ Person calling: ,4y R n(Phone #: :�- 7 6 — 8 Reason () Inspection: Dee and /or Peres :e S Scheduled Field Meeting Date. Y N Tentative /to be confirmed () ( ) Town: P� `( 4 z Road /Street: 7) iE�7 ug-:7,� Tax Map #: 1 3 — 3 ^ S e2 Comments: RECORD OF PHONE CONVERSATION Timer Date: 1 / Person calling: �Z I FE f� 2 Phone #: K01063 Reason O Inspection: (.Deeps and /or erc . Scheduled F Time Date Tentative /to be confirmed () ( ) Town: P15a—`{� Road /Street: Tax Map #: Comments: A RECORD OF PHONE CONVERSATION Time: -J ; - _ - - =- Person calling: t= FE U re = Phone #: 2-76 —6 C 6 e Reason ( ) Inspection: Deeps and/qe er& Scheduled Field Meeting Time'. Date: F:2Qrc-5 Y N Tentative /to be confirmed ( ) ( ) Town: EP4!t --�- Road /Street: -Lp j= Vg-:: b(12�, Tax Map #: (-:� , — 3 — -3 n Comments: Pte-% z An,/ 1\11119 �id9 e r� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET SUBSURFACE SEWAGE TREATMENT SYSTEM Owner C'°p'P Address PO )�DX 601 O-F'W5TEF- 4 lu501 Located at (Street) p�VoM `'0rn ��" ' Tax Map ` ifi 'Block Lot *7d (indicate nearest cross street) Municipality �ATTI �N Drainage. Basin ��T BRANGN SOIL PERCOLATION TEST DATA Date of Pre - soaking Date of Percolation Test X11-4111 Hole No. Run No. Time Start - Stop Ela se Time Min.) Dep th to Water )E rom Ground Surface_(Inches) .. Start 'Stop Water Level Dropp In Inc es Percolation Rate . N in/Inch 1 1. q 5, 1W ► ll 4 9-411 2 .; 3 1-134� 214 4 11/411 5 10 mo 2 f o'�ti � t rho 5 2A" 014' 214" )W 1 3 �''� �2�'ti lea 14 26W 21/10 27l1 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, < 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 Indicate level at which groundwater is encountered NOME Indicate level at which mottling is observed MO ME Indicate level to which water level rises after being encountered Deep hole observations made by: JE moo ! OW 0 1 Hu,4+oL-6 Ja 1'E - AL�°•Date Design Professional Name: 14,4f-P -Y W • ),/I(, k0tf7 A -FE Address: 2-D 11 i tt- T O W N PP NY t0,501 Signature: _&,IA4, Design Professional's Seal of NEbyYQ� s r e- rI ua ['s � �;�• -mot ' Vj ���FESStO��� 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO. °/ G.L. 0.$' d -Co" ToP�oIL c�-Co" ToPSA {L —G" 1-oPl-10L 0-.6 z DU5 1.0' „-I -Cv ' ;`�� r{� Co "- I'-G," sR a� SI L ow>NV� 1.$' LMSE LOAM LOAN\ 6Pn1U1 qJN �p9v.IM 1 2.0' VV_ -o CAIW SA{ao`� 2.5 Film TFL% s ONM 1,ol�cs� 3.0' Sloy Lmm 3.$' 4.0' CAW �tR 4.5' q�'�n �I,`CO� or EES BNAD NN q��-Q'-T-0' G{1��,Slt VIA- FAME $.0' r� aLN F(prt V-60 FIM ;I'(� F {NE $.$' F Nl; PAP SANG 5Ars0 6.0' iAM 6.5'- �N -a��(a 7.0' S a Kp 4 6 6 7.$' 8.0' 8.5' 9.0' o��L 9.5' 10.0' Indicate level at which groundwater is encountered NOME Indicate level at which mottling is observed MO ME Indicate level to which water level rises after being encountered Deep hole observations made by: JE moo ! OW 0 1 Hu,4+oL-6 Ja 1'E - AL�°•Date Design Professional Name: 14,4f-P -Y W • ),/I(, k0tf7 A -FE Address: 2-D 11 i tt- T O W N PP NY t0,501 Signature: _&,IA4, Design Professional's Seal of NEbyYQ� s r e- rI ua ['s � �;�• -mot ' Vj ���FESStO��� 03 -31 -1999 05 :17PM FROM r TO 9786913 PUTNAM COUNTY. DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES P.01 AFFIDAVIT - CORPORATE OWAR APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM. COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: Anard of Health Approval for Devon Road,_ Patterson . NY. i ...Ay-- Palladino ......__�.__.._. _.._...... represent that I am'an officer or employee of the corporation and am authorized to act for: Name of Corporation: Pa11;ge; rn B 1; 1 j,C$_ Incorporated Having offices at: p _ o. Box 501 Brewster, NY 10509 Wtaase Off iicers _Are: President -Name; --A . Palladino Address: p� o, Box 501 Brewster, NY 10509_ Vice President - Name: nail ; P palladinQ .Address: j_ _Q. Box 501-Brewster, "NY 10509 �-.. Secretary - Name: .._j.,eG1 ; e palladi no _.... , Address: �, 0. Boy 501 Brewster, NY 10509 Treasurer - Nacre: adi.no Address: -p_ n_ _Rox_ Q Br ter, NY 10509 and that I am and will be individually responsible for any and all act� f the corporations with respect to the approval requested and all subsequent acts relating thereto l, � � n I Signed: alladino Title: ,�YL; gent /SS vvorn to before me this 1 day of 1 (year) L _fi t ry Public `*ELLIE.ANN BRATTESONI NOTARY PUBLIC MY COMMISSION EXPIRES MAY. 31, 2002 Corporate Seal MATH BEDROOM 4 DRESSING- BEDROOM 3 WALK' 13*1310' -0' 10*' I N CLOSET J- L Li r MASTER BEDROOM BEDROOM OPEN 13' 0- Is'-s— POT?' COW rY L.VARTRMT OF WA�,p <: -I COUNT 13 B 0 <1 SECOND FLOOR ?/ -k- 344S F Sicratur� & l t le Date L KITCHEN DINING ROOM MORNING AOOjA 13'0" % 12••0• FIT IN f 0 E' PEN ABOVE ► LIVING ROOM FAMILY ROOM 13.0.. -0 17.0.. FOYER �,y i FIRST FLOOR 4828 = 1.144.,Qf: i 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: PALL-,&D1 HO 2) 01 LD I k(A C/o pip . BRF-F -wr) �P- I NY . 1 b�09 2. Name of project:. LOT 1 IHDNIDVAL . `''✓ 16 3. Location @V: PATMR64i 4. Design Professional: RAF-P4) vy, N14Ao�i 4-965. Address: ao H1L- 1 -TdwH WO 6. Drainage Basin: E&t>� $a-AN L H BRPEW15tER- N1 1060 9 7. Type of Project: X 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 ' x Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... NO 10. Has DEIS been completed and found acceptable by Lead Agency? ............... N A 11. Name of Lead Agency N h 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ............................. .......:....................... ............................ AF5 13. If so, have plans been submitted to such authorities? ........ ............................... N b 14. Has preliminary approval been granted by such authorities? No Date granted: N h 15. Type of Sewage Treatment System Discharge ................. surface water 'i groundwater 16. If surface water discharge, what is the stream class designation? .................... N A 17. Waters index number (surface) ........................................... ............................... N A 18. Is project located near a public water supply system? ....... ............................... No 19. If yes, .name of water supply NA Distance to water supply NA 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system Distance to sewage system NA 22. Date test holes observed H I M % 23. Name of Health Inspector '1 EME lip 24. Project design flow (gallons per day) .................:............... ............................... 840 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... N0 26. Has SPDES Application been submitted to local DEC office? ......................... f Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? NO 28. Wetlands ID Number ................. ............................... ...... ............................... N A 29. Is Wetlands Permit required? ........................ N Has application been made to Town or Local DEC office? ............................... 1y0 30. Does project require a DEC Stream Disturbance Permit? .. ............................... N 0 31. 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/No Nu 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site; salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No N� DESCRIBE: 33. Is there a local master. plan on file with the Town' or Village? ..........:.. 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... �6 35. Are any sewage treatment areas in excess of 15% slope? . ............................... YE5 36. Tax Map ID Number .......................... ............................... Map ��i Block Lot OR 37. Approved plans are to be returned to ..... Applicant X Design Professional NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the .SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and.the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for -the rejection of any submission. I hereby affirm, 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 pursuant to Section,210.45 of the Penal I fwy/ SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... J,b IniLMwk /LOA -0 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORN1 For UNLISTED ACTIONS Only art 1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLICANT /SPONSOR: PALADINO 'BU141N(j C ,1 2. PROJECT NAME: gyp?- -1 1 NpjyI PV ��75 I. PROJECT LOCATION: Municipality County PVTH44 PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc„ or provide map) PROPOSED ACTION IS: %New OExpansion OModification /alteration DESCRIBE PROJECT BRIEFLY: AMOUNT OF LAND AFFECTED: Initially 2.477 acres Ultimately acres WILL PROPOSED ACTION COMPLY WITH EXISTING'ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ,Yes ONo If No, describe briefly WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Agesidential Olndustr)al. ,. OCommercial OAgricultural ❑Park /Forest /Open space OOther Describe: /VI DOES ACTIOilJ INVOLVE A PERINIIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNNIENTAL AGENCY (FEDERAL, STATE OR LOCAU? ]Yes ko If yes, list agency(s) name and permit /approvals DOES ANY ASPECT OF THE ACTION! HAVE A CURRENTLY VALID PERMIT OR APPROVAL? OYes 1gNo If yes, list agency(s) name and permit /approval AS A R`�SULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? Oyes �jNo . I CERTIFY THAT THE 11'..' ^N.IATION PROVIDED ABOVE IS TRUE TO THE 6EST OF f.,Y KNOWLEDGE Oq I' I. the action )5 in 3 Coastal Ar.a, vnd you ?r'a a state agency, co1T1,-:;e;e a procdeding wk'1 this a.SCSSmc:'.' HARRY W. NICHOLS JR., P.E. April 6, 1999 Mr, Robert Morris, P.E. 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS Cornwall Ridge - Lot #7 Devon Road Town of Patterson Dear Robert: Enclosed are the following: 1. Five (5) prints of SS -7 "Proposed SSDS," dated 4 -1 -99. 2. "Short EAF;" dated 4 -1 -99. 3. "Application For Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 4 -1 -99. 5. "Application to Construct a Water Well," dated 4 -1 -99. 6. `Design Data Sheet." 7. "Letter of Authorization," dated 8. "Corporate Resolution for Authorization." 9. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." 10. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:his 98028 LAURENT ENGINEERING ASSOCIATES, P.C. j \ MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)278.6108 - (FAX) 278 -2658 CONSULTING SITE ENGINEERS 1. Five (5) prints of SS -7 "Proposed SSDS," dated 4 -1 -99. 2. "Short EAF;" dated 4 -1 -99. 3. "Application For Approval of Plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 4 -1 -99. 5. "Application to Construct a Water Well," dated 4 -1 -99. 6. `Design Data Sheet." 7. "Letter of Authorization," dated 8. "Corporate Resolution for Authorization." 9. Two (2) copies of Residence Floor Plan(s), for `Bedroom Count Only." 10. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:his 98028 • ,v A ,;r - .,,�.,3 - :fit�r?'F .,;. .., , .. ?.. ,r n: :...��„ :,. 'S.d_� '-,� ,i� A'o �F €,aa e y.• i. ,.,...,.. ..- ..a:,ra�t,. ,-,..- »:., :... ,.. £"`-+§ 1, "• -.. „.> „v "., S[a .. .. ., x,:.. •P .. . ... ., ,,.e.,. -.� .'. mod':. fa":�° s, - w. PY -w - P , ..vim y,. • s:� i.. .. ..., t ,iY Kf »SF r $ ..; .- tvrfri. i _ . ,,,, s. • .- , -,. ,. s =,.,, ,,.,. s a ' a . ,... . a. _,.. +M. - „yam'',.. � :' .ro• � _?,.'- t n r .9:'.:r .. y- c. ,"i �.2 z -?A -<• 47.R.. .,r. -.ii -:;, �. .. {r.o ” L'�a . �r,, r•^r�sc `51 r'e,:' a- c 2 l' #. ,', _. _ Z'. ,_ *�_, 11 r . �:.,, -. c.,., i -. ��r «.: ,�. S ,: •.. r k c '.� y. , ....,. r" -�:F. .. � 3 .+,•?t. �. - ..a,} �: R -- ",C ', 2 ^.'yu, Y" _ 1�4. a ._ .z. ,- ,, _ '^ > ��' is>, :;• r. »..... .t r ..:., _.- > .Y. - _,. _..., ^T. :°?*�' _ 'o-'3. . Y 91 .:1• .. ...6 „(' s s -.y . r., . . , , . . . , .. . v• , , w b _ <,,,., .. tam .�'''. :: : �: _ �3� ,.r .. ♦ i - ” - .. .. ,1 -r f, �.,#.. -F•_...t,. .,:. . -- :. -.. r.� _,. �,. ,. .- -t ." - .mow. '..� ;. .'ti t ir-� ,�„ .r ♦��� ry �., 4 . - .. ,. i ...,+ ..: ., -. a.. ; a.., . ;•d -- +.. '. !.w . r:: , � .. ^:,,.� s ., n \, - o',�, �>t ' / . FW �l #P,w+W ti�ilf.�ldUl {{• _ a ,aM ._ -..., 4 . _'_ - __, - _:�•. .. -." � ... ., _ _ tt" ..« - ti.'- ^' x a -'-� �,._ � . - • - - �'S~_'+_..� -- - r� ., '#i . - _ -_ .�� .. � _.r... - v G. � s.c" - ., -�� ....>3- �� � .. _ dUt�YGbrOnF:. _ y' ,Fs } ht' S 3� t.' h Y^ f A �4 k � R•� -K tY wd, \ - { ry , a$ �T p r l •�.�' --".,d t �a 'u �+ �s�;'r•� 'R iii ° G cw f < i i 6 F °J' •, - >f v� :S5. :.fit � x •F. � , -1 �.� `, r rF -. , F � ° „- �''r`'TkFiolletgiad�icsihdi6c .. -. o }:• :.� _ ♦'i . .' -. r. r; � ,..s' , •...: •�. ,� -' �,�',o "?_ x ;2`�sr:Y"'oZlksl{141CPih,' -I F `�,�.zdaFt+t e 21 �i r S n 3� h � r� d ^v de FAN r a t r o-, , \ 1 ,. r 'y ..5 f r .....,.. .x ,,. . _ n,... .e. u.'Vr uk'.- ,A 5i .1:, •'. , �+ "~-�- �. ,tee. f. . ,rt -.�' '>„', � �' \' /•. . `�„ .� >:�p ,,,,, „RuAC���� +.t ,. ,.y s,. ..,t ...- .,. ,-ate. -�' A,., , \' ` -� �`-. '� ,,1•• C. - - '�+'� \.. €;!: - 6 .....I X, L% e „/• :. ^` /,' � 1 \...�. i. l4 �tt� ',.' AA NN E TJ/