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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -77 BOX 5 I ro 111, 11 MUM -.) IN r1 � L , HL: Cr ;m 00228 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 7 WELL COMPLETION REPORT Well Location Street Address: `]� �� e Town/Village: f• Tax Grid # Map Block 5 Lot(s) .q Well Owner: Name: Address: ncll Use of Well: 1- rimary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing -x- Open hole in bedrock Other Casing Details Total length OQ ft. Length below grade ft. Diameter 7 in. Weight per foot 7lb /ft. Materials: _ Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _ Cement grout j&Bentonite Other Drive shoe: C Yes No I Liner:_ Yes Y, No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test Bailed Pumped K Compressed Air Hours Yield gpm Depth Data Measure from land surface-static (specify ft) `z) tc During yield test(ft) ''-- ll 4 #v Wt of &A/% Depth of completed well in feet or K65- Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 0 36 y 6 kiffitsmahe. �- 2 7! l,J T If yield was tested at different depths during drilling,' list: Feet Gallons Per Minute Pump /Storage Tank InformatI& .y�r�s t<< � � Pu;np Type Capacity iv C,.-!vl Dept%u1 3ZO Model Voltage 23 u HP Tank Type Volume -3/ C-IA L, W� X7�Ca 1 ' u i Date Well Compl ted 0 Putnam County Certification No. 067 Date or t 0 Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent`landrfiarks to be provided on a separ# sheei/plan. Well Driller's Name t-T ft fi .� � , Address: Signature: Date: (� C White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 C. t.� SHERLITA AMLER, MD, MS, FAAP Commissioner'of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health April 16, 2009 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health Rick Stocklfield 61 Vista Lane Patterson, NY 12563 Re: Addition — Approval - Stockfield No Increases in Number of Bedrooms 61 Vista Lane (T)Patterson, TM #13. -3 -77 Dear Mr. Stockfield: I have received and reviewed the plans for the proposed addition to the above- mentioned residence. The proposal for the addition has been approved as per plans bearing the approval stamp from this Department dated April 16, 2009. The addition is approved with the following conditions: 1. The total number of bedrooms must remain. at rive without prior approval by this department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained: 3. All plumbing fixtures must be updated with water saving devices (i.e. new low flush toilets, restrictors for shower heads and faucets, etc.). 4. The approval is for the proposed changes only. This approval does not.validate any construction shown as existing that has not obtained proper approvals. Any.other- permits or variances required are:the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Very truly yours, JSP: lm oseph S. Paravati, Jr. cc: 'BI (T)Patterson Assistant Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing.Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 . ---•- _ Is�'H GRC- . bSnsn<jj (LC-6m Lsysn R.nvr*•s . CIO el 9 rt 8-76L n � :1 CC, PUTN M COUNTY DEPARTMEN OF HEALTH RO ITSE PLANS IAPPROVED FOR BEDROO COUNT 01VLYQ r UW %"vim/ !j $EDi�00 X73 � .�.3_ -7 -7 :AT T, SUBSEQUENT PEVISFON[A-TER A TIONS TO THESE HOUSE P1 ,1NS N!U,ST LL ":URI'villI I' D TO Tom__ "� JD i, t i •'JOt I'ia� tiI't`i�O /t AL IU =TUR.E & TITLE - - - -- DATE COCO% to"N L 711 71 AM COUNTY DEPARTMENT OF HEAI,,'Jy'!-T -__COUNT Dl 010-a e7. mmizooms, 7 -7 QG-vkor, i-1cvs;7— T REV ISIONF ALT EERATTONS T,) T"ES' Mu., SUBSEQUETP. 0 T ,; PLANS MUST BE SUBMITTED TO T11E PCD 1:1 1: �_ r L q TITLE `URE(G gedcsoam ... . ...... ............. ..... . . ro a (3 on cp CD PUTNAM COVINTYMPARTWNT OF HEALTH Tr!L,'S.T-E PLANS APpr,,OVFD FOR BFDIIOO-Nl COUNT ONLY, .174 ALL cl*Ul-,)SEQVENT TO Ti-ir,,SE Houst. PLANS MUST DE TO Till; PGFJOH FOR APPROVAL DATF4 ippq .... . ..... ...... . .... ... .. . ....... ..... .. .. .................. ro a (3 on cp CD PUTNAM COVINTYMPARTWNT OF HEALTH Tr!L,'S.T-E PLANS APpr,,OVFD FOR BFDIIOO-Nl COUNT ONLY, .174 ALL cl*Ul-,)SEQVENT TO Ti-ir,,SE Houst. PLANS MUST DE TO Till; PGFJOH FOR APPROVAL DATF4 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health • LORETTA MOLINARI, RN, MSN Associate Commissioner of Health . Health ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ADDITION APPLICATION STREET (ol, VISTA LAn6e NAME lktc . ST0CK6 =tSL0 RESIDENTIAL ONLY TOWN PATTeAS04 TAX MAP # 13 3 "t -1 (8ys) PHONE &'18 - 3 5 5 9 PCHD # y MAILING ADDRESS (a% VISTA LAWS , PATTE6Lsa0.I N4 12563 DESCRIPTION OF ADDITION F►ntsti flacy.cirea,homeoFFtce- NUMBER OF EXISTING BEDROOMS 3 PROPOSED # OF BEDROOMS O (FROM CERT. OF OCCUPANCY OF CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval I of plans (Construction Permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. r Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd., Brewster, NY 10509, Phone: (845) 278 -6130. # -E eooeavlly on eA Floor r badeoon►i �i� uSe 1. Certified Check or money, order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement) 3. Two sets of proposed floor plan (drawn to scale with name, street and tax map #) * Non- professional sketches are acceptable. 4. Copy of survey .showing well and septic locations to the best of your knowledge. Include date of installation if know. Label all wells and septic systems within 200 feet of the property line. Contact this office with any questions. 5. Copy of Certificate of Occupancy from Town or Certification from Building Dept. with legal bedroom. count of dwelling. OFFICE USE COMMENTS Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558. Fax (845) 278 -6026. WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 225 -2847 Fax (845) 225 -1580 /lG�r wu -A� C4,11 7 Led s: ,",-0 Sulm -j J� .,soWD r%Aqu %Q -a 0 CWP'� 1 l-%(�S� room �i t' •fY10.f � e r Co e N y I zs L- 3 Y L$ - 3SYI � 1 l i !�r•..1k.—J, (�3ac�oF ►lcvse� UP Si AIRS Se.6r so pM ew -Arco m /i . r s IP -J i Will tti ...... CERTIFICATE OF- OCCUPANCY AND COMPLIANCE No 1436, . . . . . . . . . . M man, 20 08 DATE ISSUEDSembeA 29, T Pir THIS IS TO CERTIFY THAT "tko Azzociatu ON THE PROPERTY OF Same LOCATED ON 61 Vista Lane HAS BEEN SUBSTANTIALLY CONSTRUCTED TO THE REQUIREMENTS OF THE BUILDING CODE, ZONING ORDINANCE AND LOCAL LAWS OF THE TOWN OF PATTERSON, NEW YORK AND MAY BE OCCUPIED AND USED AS Fours Bedroom, Sin .fie Famity Dwetting Wwinizhed So_6ement with Futt BathAoom Rears Deck,__S7_ ewich and Three Can Attached GaAage Building Permit 'Dated ... Permit No. .. Application, No. ....43.02 ............ SECTION ........13•.............. BLOCK .........3.- ....... FEE $ 50.00 BUILDING INSPECTOR .... ..... L OVERALL PLAN SCALE: 1' = 60" -WELL 10 11 12 iJ 14 A 4'0 HDP£ BOX AY DISTRIBUTION Z11 0 V - 1.250 GALLON SEPnC TANK 0 • "'N", T \ O,ps, YT. UNLESS UNDER THE DIRECTION IL ENGINEER, 15 A KOLA T1ON OF 15 OF WE EDUCATIONS LAW. 4'0 CIP 4 "I PVC SOR 35 2' WDE PRIMARY S ENCABSORP nav ®/ / 4 6 • 5 / / 7 / 2' WIDE EXPANSION SSTS / ABSORP77ON TRENCH ENLARGED PLAN SCALE.- 1' - 20' 9 1015' 10 95' 11 89' 12 l0J' iJ 108' 14 Ili, I 15 42" ��� ' ENG1P LAND& PROJECT.• AS ASTRO 61 NWA LAIMI;, PATH DRAWING.- AS -BU, PRDrECr 98105.3. N0. DATE 10-6- - SCALE AS SH01 i 1 a { I + APPI IC-ANT J?EQ= OWNER �' edge: 1.35 Ac. Astro Associates Number. • 13 -3 -77 C/o Louis Pescatore 92 -50 Queens Boulevard Rego Park, N. Y. 11374 i Is to certify that the Sewage Treatment System was constructed licated on this plan and that the system was observed by /nsite leering, Surveying, & Landscape Architecture, P.C. before it was ed over. The system was constructed in general accordance with. ndard Rules and Regulations of the Putnam County Deportment b1th and the New York State Department of Health. �cllltles existing; unless noted otherwise. �erty line and house shown hereon are based on field survey by Terry rdorff Collins revised August 31, 2006. AS —BUILT MEASUREMENTS A B C NO CORNER OF CORNER OF CORNER OF REMARKS DN+LWNG DWELLING DWELLING 1 40' 46.5' - 1,250 GALLON SEP17C TANK COWN 2 42.5' 48.5' - 1,250 GALLON SEPTIC 1'ANK MYER- - 3 615' 93' - 14 WAY DiSTR1OUPOW 4., X 4 81' ,;; " =,t,• - SW COINER OF WNW .. . - -. 6 90 66. - OF TRENCH END 7 95' ';' ��2'' �s -• r.: �`ND OF TRENCH 8 100' ;;> Gll .....;dRENCH / 9 105' ..:f B4' , : i SE CORNER OF TRENCH il" Y.w 10 95' Y X47'''' r° ti �, -.1 ... :+.(VYi! CORNER 'OF TRENCH 11 99' 150' - END. OF TRENCH - r; 12 103' 153' AND OF lR �s 13 1a8' 156 ►:. tt, 1 w lYa' tNtt iislV�i9Xy „• ++ ' i !� 14 113 59 j 15 42' - 22.5' WELL ' Putne.I County Department. of Health Division of - vironmentalealth Services F Approved as.noted or conformance with i NvR�'H S��A�ON 100' NY5 t7EG NSW Y0•� ,� „� N � EG DRIVEWAY PROFILE, , SCALE: 7" = 50' HORIZ. 1 " = 5' VERT. O / 1 7 � 1 / � AI2�A; I ,382 AGI2�5 i / ar r VI5''A PATIO / / -J n N� � 509.9 10.13 �� BOX L��, L- 104.60 r� -y3,o4 v�- 2I.5o�o6° a- rry.00 5uwrly Or- p120M12'CY BEING L'Of NO. 7 A5 SHOWN ON FILEV MAP ,,A5f120 A550CIA1E5,, SHEET 2 OF 3 FLeV MAP NO. 2646A F"V ON II -U6-00 51TLIAIE IN ''OWN OF FA1lr -,R50N FUMAM CO., N.Y. 5GA E. ; I” - 50' ALU6 r S, 2004 CC?I'1' ia-tr 0 2004 SMY MRtZN170WF: C.MLIN5, ALL la&R 'S M5eWl17 AWLISyr 31, 2006 ( rINAL) dm O CEMFICATION5 INVIGAS -12 MELON 54NIFY 1H5 SUMY WA5 PMPA12Et7 IN ACGOWANM WITH 1W EXI5nNG COVE OF MAC?IG>; FOR I-M V 5L VEY5 AVOMP BY ?FE NEW YORK 5rATe A550CIATION OF PWFE5510NA1- LAW 51,k'VEYQ0 5. INC. CEI211FICA1I0145 SHALL Ia914 ONLY t01FE FMON FOR WHOW THI5 5L12VEY WA5 PIMPAMP ANV ON HI5 BEHALF TO 1FB TITLE C.U. AN12 LENVING IN5TI- TunoN'LI5fEV mmoN, i GEI2TIFICAMON5 AM NOr TRAN51M ABLE t0 APM- 410NAL INSfh unON5 012 5L05EQLENf'0MMEIZ5. lfW 8 0WF GOLWNS 52 Srm t jva RbAv MW5rM, NEWYb$aK. 105 W 9fFrE %U.TEIZAt10N OF SLP2VEY MAPS BY ANYONE lpk TfVW 3VE,ORIGINAI.:PIMPAtMR 5 MIS - LP— WN0.40WL6ING At V NOr IN IM GENERAL WELFAM -AWWW1'r OF 1-C PUBLIC, LIEEtdbEV tAmv SlY2\/ yoR5 SHALL Nor Amin 5W&Y MAPS 9RVEY PLANS OR 5I VEY FLATS PI�1?A3�V.6Y DtFE1�.: • . LHNXHOtUV.:AL1M110N OR AMMO N r0 1H GrG ,770.9' C 5Li�GEY 6 A,vmAA m OF S iw*eMYDIa' StATE:EDGCAjm, LAW tiE �FXA001J OJ1�EF OLP IMPRUVE°MEN d12 ENt 3'JAGN TS IF, F: ANY E)05T 012 Fm w FAN, AID NQr G IZIIF V. AI.L. Ci '(CAF1m 5`HwoN AID VAw :FGx2 THI MAP `At�9? COIZS 1FOF ONLY IF SAIV MAP G GOP�501~AR.SFB IN55ED 5�lV- OF,1FB SUZVEYOIZ Wk05 514NU� qqt APFEPRS:POMON iM5'N1AP MAY,•NOtB�+I�SED,W',GON 1N . "5[Y /W�117�1,V�}''! {�JIZ SIMILN2 °�'C7M�IJM. S?ik1N5M�iJr 012 lalEGklAi�liS {k�ytv{RT/O�C�yrAlt�f ui o ® O b N b h DRIVEWAY PROFILE, , SCALE: 7" = 50' HORIZ. 1 " = 5' VERT. O / 1 7 � 1 / � AI2�A; I ,382 AGI2�5 i / ar r VI5''A PATIO / / -J n N� � 509.9 10.13 �� BOX L��, L- 104.60 r� -y3,o4 v�- 2I.5o�o6° a- rry.00 5uwrly Or- p120M12'CY BEING L'Of NO. 7 A5 SHOWN ON FILEV MAP ,,A5f120 A550CIA1E5,, SHEET 2 OF 3 FLeV MAP NO. 2646A F"V ON II -U6-00 51TLIAIE IN ''OWN OF FA1lr -,R50N FUMAM CO., N.Y. 5GA E. ; I” - 50' ALU6 r S, 2004 CC?I'1' ia-tr 0 2004 SMY MRtZN170WF: C.MLIN5, ALL la&R 'S M5eWl17 AWLISyr 31, 2006 ( rINAL) dm O CEMFICATION5 INVIGAS -12 MELON 54NIFY 1H5 SUMY WA5 PMPA12Et7 IN ACGOWANM WITH 1W EXI5nNG COVE OF MAC?IG>; FOR I-M V 5L VEY5 AVOMP BY ?FE NEW YORK 5rATe A550CIATION OF PWFE5510NA1- LAW 51,k'VEYQ0 5. INC. CEI211FICA1I0145 SHALL Ia914 ONLY t01FE FMON FOR WHOW THI5 5L12VEY WA5 PIMPAMP ANV ON HI5 BEHALF TO 1FB TITLE C.U. AN12 LENVING IN5TI- TunoN'LI5fEV mmoN, i GEI2TIFICAMON5 AM NOr TRAN51M ABLE t0 APM- 410NAL INSfh unON5 012 5L05EQLENf'0MMEIZ5. lfW 8 0WF GOLWNS 52 Srm t jva RbAv MW5rM, NEWYb$aK. 105 W 9fFrE %U.TEIZAt10N OF SLP2VEY MAPS BY ANYONE lpk TfVW 3VE,ORIGINAI.:PIMPAtMR 5 MIS - LP— WN0.40WL6ING At V NOr IN IM GENERAL WELFAM -AWWW1'r OF 1-C PUBLIC, LIEEtdbEV tAmv SlY2\/ yoR5 SHALL Nor Amin 5W&Y MAPS 9RVEY PLANS OR 5I VEY FLATS PI�1?A3�V.6Y DtFE1�.: • . LHNXHOtUV.:AL1M110N OR AMMO N r0 1H GrG ,770.9' C 5Li�GEY 6 A,vmAA m OF S iw*eMYDIa' StATE:EDGCAjm, LAW tiE �FXA001J OJ1�EF OLP IMPRUVE°MEN d12 ENt 3'JAGN TS IF, F: ANY E)05T 012 Fm w FAN, AID NQr G IZIIF V. AI.L. Ci '(CAF1m 5`HwoN AID VAw :FGx2 THI MAP `At�9? COIZS 1FOF ONLY IF SAIV MAP G GOP�501~AR.SFB IN55ED 5�lV- OF,1FB SUZVEYOIZ Wk05 514NU� qqt APFEPRS:POMON iM5'N1AP MAY,•NOtB�+I�SED,W',GON 1N . "5[Y /W�117�1,V�}''! {�JIZ SIMILN2 °�'C7M�IJM. S?ik1N5M�iJr 012 lalEGklAi�liS {k�ytv{RT/O�C�yrAlt�f ® PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # _ _%�� of - y Located at _ i� 1f'j lxL , ; 7 t-� Town or--411age- Owner /Applicant Name ;� ���;,_, -, r��.,� Tax Map i3. Block :�� Lot 7 7 Formerly Subdivision Name ,4__, r rn e_, Subd. Lot # Mailing Address q2 -a.,;> [ f S P_ n S , i r U,� ,-�.[ �� r_ , , /V ,V Zip _ U Date Construction Permit Issued by PCHD Separate Sewerage System built by CcAuc*t hr`s', Csyf, Address 5,taW Srez Consisting of %� 5-b?) Gallon Septic Tank and 62-7. C. F. of Z ' c rt�.� 465orzemo� Other Requirements: 0 -:Z A.0.(3, Ge-Avi , 1:'r&& r -&c e_-)e Water Supply: Public Supply From Address %vr8 km 3il or: X Private Supply Drilled by gi.,�r M, AYArr 6 5v.N5 ly Address ?qrTrr_, N .,rX C Building Type ge,5iden Has erosion control been completed? � 5 Number of Bedrooms S Has garbage grinder been installed? A/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 regulations of the Putnam County Department of Health. Date: 10/7-A 10 (o Certified by Address P.E. R.A. License # 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 or change is,necessary. White copy - HI) Title: - Building Inspector; Pink copy - Owner; - Design Professional Form C -97 Jun 13 06 04:06p TOWN OF PRTTERSO JUN -13 -2006 14:29 FROW INSITE ENGINEERING 8452259717 BRUCE R- FOLEY Public Health Dlrretor DEPARTMENT OF HEALTH 1 Geneva Road $rew.00r, Now York 10SO9 845- 878 -2019 p.2 70:6782019 P:2/2 LORMA M0L1NARI • RN.. M.S.N. Aasoerore Public fkallh Dtreetor ;hector of Parent Services F.eviroom entel Hertth (914)279-613(1 Fax (914) 279.7921 Nursing Servie" (014) 271-6S511 WIC (;14)178 -6676 Pnc(914) 27S .602S Ehrly Intervention (914)278-6014 Preschool (014)278-M Far(914)11R -6648 OWNERS NAME: TAX MAP NUMBER: /2j- - E911 ADDRESS: fs TOWN: AUTHORIZED TOWN OFFICtAt.: tSigoacure) DATE: 'o/// a � The Putnam County Department of health will not issue a Certificate of Construction Compliance unless the above form. is completed, ie., a legal E911 address is assigne4 by an authorized town official: This form is to be submitted with the application for a Certificate of Construction Compliance. CE91 I VERM" i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES !A#7 WELL COMPLETION REPORT Well Location Street Address: ,411 Town/Village: (—<15 In Tax Grid # Map Block 3 Lots) q Well Owner: Name: Address: Astl-o 0 t, I Use of Wells 1- rimary 2- secondary Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _,K_ Open hole in bedrock Other Casing Details Total length 106 ft. Length below grade _ffft. Diameter % in. Weight per foot �ib /ft. Materials: _ Steel _ Plastic _ Other Joints: _ Welded _ Threaded _ Other Seal: _ Cement grout K Bentonite Other Drive shoe: 'C Yes No, Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed Pumped K Compressed Air Hours Yield Rh gpm Depth Data Measure from land surface- static (specify ft) �f ec During yield test(ft) vb'► of we l Depth of completed well in feet Keels, Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface I Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 0 4 h 30 V 6 If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pulnp Ty ,e Capacity iu (, !vl DepT 3ZO Model 1005 -v+ Voltage Zg o HP '3/q Tank Type Volume Il C1A,l, Date Well Compl ted o_ Putnam County Certification No. 067 Date Wof e ort Well Driller (signature) IVU'i z: Exect location of well with distances to at least two permanent'lanc[Marks to be provided on a separr sheet/plan. Well Driller's Name 416crt ft -t- _TA , Address: 1MV Signature: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Building Constructed by TownNillage Location - Street Subdivision Name Re S Q. ^1 n � x 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: Month Day 09 Year ar, Signature: Title:�v�� General Contractor (Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) Address: Address: qz-5 -6 4�IaEeV5 eL-vD/ R15�0 State Zip State zip—!/ / 37T— Form GS -97 Owner or Purchaser of Building Tax Map Block Lot Building Constructed by TownNillage Location - Street Subdivision Name Re S Q. ^1 n � x 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: Month Day 09 Year ar, Signature: Title:�v�� General Contractor (Owner) - Signature Corporation Name (if corporation) Corporation Name (if corporation) Address: Address: qz-5 -6 4�IaEeV5 eL-vD/ R15�0 State Zip State zip—!/ / 37T— Form GS -97 Page 1 of 1 JASEnvironmental Services, Inc. �� 41 Kenosia Avenue 1�� tvATEA, SOIL AND AJA ANALYSIS Danbury, Connecticut 06810.1 Telephone 203 - 798 -2229 Hyatt Pump Service Mailing Information: Collector's Information: JMS ID: 019058 Name: Hyatt Pump Service Name: Madelyne Hyatt Address: 229 South Rd Address of site: Astro Realty Lot #7 City: Holmes City: State: NY Zip: 12531 State: NY Zip: Phone: (845) 855 -5136 Fax: (845) 855 -5136 Phone: Sample's Information: - Site: Outside Faucet Date Collected: 9/25/2006 Date Received: 9/26/2006 Preservative: HNO3 Time Collected: 11:00:00 AM Time Received: 1:00:00 PM Temperature: <4 Lab No.: J0609072 Matrix: Water Date Analyzed Test Name Result MCL Method 09/27/06 Manganese <0.05 ppm 0.3 ppm SM 3111 B 09/27/06 Sodium 8.2 ppm N/A SM 3111 B 09/26/06 pH 7.31 S.U. 6.5 -8.5 S.U. SM 4500 H B 09/28/06 Color ND' 15 Units SMWW 2120 B 09/26/06 Turbidity 0.45 ntu 5 ntu SMWW 2130 B 09/27/06 Hardness 300 mg/L N/A SMWW 2340 C 09/26/06 Odor ND N/A SMWW 2340 C 09/27/06 Iron <0.05 ppm 0.3 ppm SMWW 3111 B 09/28/06 Chloride 5.78 mg /L 250 mg /L SMWW 4110 B 09/28/06 Nitrate 1.86 mg /L 10 mg /L SMWW 4110 B 09/28/06 Nitrite <0.05 mg /L 1 mg /L SMWW 4110 B 09/28/06 Sulfate 21.9 mg /L 250 mg /L SMWW 4110 B 09/26/06 Chlorine Free Residual <0.1 mg /L N/A SMWW.45000IG 09/26/06 2:00 PM E. Coli Absent Absent SMWW 9223 B 09/26/06 2:00 PM Total Coliform Absent Absent SM WW. q2 ?3R Comments: At the time of the analysis the sample was Acceptable for Total Coliform At the time of the analysis the sample was Acceptable for E. Coll CFU = Coliform Forming Units MCL = Maximum Contaminant Level mg /L = milligrams per Liter N/A = Not Applicable I ND = None Detected ntu = Nephelopmetric Turbidity Unit ppm = parts per million S.U. = Standard Unit Units = Units Signature: �+� %��G� , Reviewed By Z r+, Michael Lapman Sharon Houlahan, Director President State #: PH -0218 ELAP #: 11715 CONNECTICUT, NEW YORK AND NELAC CERTIFIED Tog Free 888- JMS -5097 1 Corporate Fax 203 -798 -2408 I Lab Fax 203 - 798 -2107 I %vw%v.jnlsenvironrrental.com I -z4iA/NS/ T 777T ENGINEERING, SURVEYING & LANDSCAPEARCHITECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 TO: Putnam County Health Department 1 Geneva Road Brewster, NY 10509 LETTER OF TRANSMITTAL Date: 10 31.-06 Job No. 98105.100 Attn: Mike Budzinski, P.E. Re: SSTS for Astro Associates Lot 7 61 Vista Lane, Town of Patterson TM# 13 -3 -77 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via the following items: ❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of Letter ❑ Change Order ❑ COPIES DATE NO. DESCRIPTION 5 10 -06-06 AB -1 As -Built Drawing 1 10 -24-06 CC -97 Construction Compliance 3 1 10 -24-06 6 -13 -06 GS -97 Guarantee E911 Address Verification 1 9 -26 -06 Water Test Results 3 1 �_- 8 -20 -04 6 -14 -06 WC-97 35264 _$300.00 I Well Completion. Rep Fee THESE ARE TRANSMITTED as checked below: For approval []Approved as submitted ❑ Resubmit ❑ For your use ❑ Approved as noted ❑ Submit ❑ As requested ❑Returned for corrections ❑ Return ❑ For review and comment ❑ REMARKS: COPY TO: Iot2002.dot copies for approval copies for distribution corrected prints SIGNED: eJoM. son, P.E. ct Engineer, Associate IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health i Jeffrey Contelrrio Insite Engineering & Survey 3 Garrett Place ` Carmel, NY 10512 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health June 22,'2006 Re: Field Inspection — Astro Associates Vista Lane, Lot # 7 (T) Patterson, TM # 13. -3 -77 Dear Mr. Contelmo: A re- inspection at the above referenced property has been completed and found to be in compliance with the approved plans. There are no open comments to be addressed at this time. If you have any further questions, please contact me at (845) 278 76130 ext. 2261. . I Sincerely, Gene D. Reed Senior Environmental Engineering Aide GDR:kly Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 f„ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES / FINAL SITE INSPECTION Street Location kf ; 64-zx L ex v,, e Town Po.°l-y-er5on TM# 13; -3 —"77 1. Sewage Svstem Area Date: 'l Inspected by: Owner 46 1jr o Assoc . Permit # P — Subdivision Lot # `7 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 cpurse /wetlands ................... IL Sewage System z t / X x,..9...07 i e le !J - " A::. a. Septic tank size - 1,000. .....: , Y- .other. f. -:. . b. 'S eptic tank installed ley 1, .9::� ... .. c. 10' minimum from foundatlo .............................. ,. _ . . d. Distribution Box 2- /j 113 . 1. All outlets at same elevation -water tested........... 7' 2. Protected below frost ....................................... ..� :s P7 3... Minimum 2 ft. Original soil between box & trenches e. Junction Box properly set .......... ............................... 6. Trenches 1. Length required 602.6- Length installed /a �- 2. Distance to watercourse measured •}- / 0 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 - 1112" diameter clean ...............:...: 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe ends capped ...... ................. . .......... I ................... . g. Pump or Dosed Systems 1. Size of pump chamber ................. ............................... 2. Overflow tank ............................ ............................... . 3. Alarm, visual/ audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... 111. House/Buildhig a. house located per approved plans......... .. ....:.......... b. Number of bedrooms ..................... 1C. IV. Well Well located as per approved plans . ............................... b. Distance from STS area measured _/ 0 1 ' . ft........... c. Casing. 18" above grade ................ ............. ................... d. Surface drainage around well acceptable ....................... V. Overall Workmanshin . 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. 12/02 rr ,A - WMEI ' r�%a TWA ,!_ WKW WAIM rem �r E/ MOM M Z -2-S8 :131 BT :OT 3ni too2-92-i3o T 'd AO 1N3W1add38 AiNnoo WUHIFIJ: -140f K t? PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SEAVICES ATTENTION, El ADAiV1 GENE RRQQF,ST—FQR, KNAL jNSPEC-QQN For: Fill All infbrmafion must be fully completed prior w, any TrE inspections be419 made. PCHD Construction Permit Located: G' i%YTA LF%,\)� IFT M — --------- Owner/Applica'nt Name: —'OESta-1404 'f,,NA 13 Formerly: Subdivision Naine- —A3 -r Subdivision' Lot tr Is system fill completed? Date: gRT't ( 9- ("4 - ]Block -3— Lot rill :) A55v(.uncs Is system complete? Date: +-6-- J "-04 Is system constructed as per plans? - Is well driHed?' YE1 Date: 'ha- 17-1ti Is well located as per plans? Are erosion control measures Idplace? I certify that the ;system(s), as listed, at. the abovel)TeoEmses has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health. Date: Certified by pE RA .'Design . rofesk 1 Address: Inshe Eacaneerin�L Surveying Lie, 9 Landscape Architecture, PC- Comments, '3 Garrett Place 1 Carmel, New-York-i 12 Form FIR-99 TAT :d T26L8L2:01 !- - i*,;6-',�7St;,8 SNIN33NIEN3 311SFJI:W0d-J 2T :OT i/-002-93 -100 Q `t J LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 . Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 November 2, 2004 Jeffrey Contelmo Insite Engineering & Survey 3 Garrett Place Carmel, NY 10512 Dear Mr. Contelmo: .ROBERT J. BONDI County Executive Re: Field Inspection — Astro Associates Vista Lane, Lot # 7 (T) Patterson, TM # 13. -3 -77 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: 1. A bedroom count must be performed by this Department upon further completion of construction. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDR:km Sincerely, P Gene D. Reed SR. Environmental Health Engineering Aide _ 1 - PUTNAM COUNTY; HEALTH DEPT. '7 • 1 Geneva Road `: (845) 278 6130 0 2 6.4 2 1 � B ter, NY 10509 ' Received of I,-%'7�1�� The Sum Of?� Dollars $ yoo .Olo Fo'r . THANK YOU! r Ht tr 13 ❑Cash ❑Check 1 0 ❑ Credit Card By i y 1 i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION- OF ENVI .Or1 1�TAI� HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM ; Owner k5rA O Address RAG o ,04Ak , A Y 113 .61 Located at (Street) Tax Map 13 Block 3 . Lot 53 (indicate nearest cross street) Municipality �a,,. -,v 6F �i1 sc�e_j Drainage Basin ohs; Bie r// +-M-4A D SOIL PERCOLATION TEST DATA Date of Pre - soaking yfig zq-6 Date of Percolation Test )2: Hole No. Run No. Time Start - Stop Ela se Time Ain.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Drop la Inches Percolation Rate Min/Inch 30 �-S'l Y `s,� 3�i 10 3 3 ' — zi/ 4 5 7%6 1 tfc�— � / nl1 2�►1 _ Z�� 3 ;1 6 2 - 2 S'' — a A ,, 3, 9 3 1 0'43 1 13 30 1 ,� --1 j,r 3,� /0 4 5 1 • 2 3 4 5 iwL--j +u-ue repeatea at same aeptn 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 TEST PIT DATA _.w..:......... _...._..._.r DESCRIPTION 0T*`SQILS,.ENC:O.UN TEREDv IN,TEST.� OLES 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' HOLE NO._ . `HOLE NO. HOLE N0. Indicate level at which groundwater is encountered nr�A Indicate level at which mottling is observed NlA Indicate level to which water level rises after being encountered A.1%A Deep hole observations'made by: : 'dwV ,4 "47-5a,_, P, Date .y 3 Design. Professional Name: Jeffrey J. Contelmsl —P.E. Address: imite Fhgine6ring, surveying & , P.C. 3()At(tty J. Signature: m sr7 a j 1. 3 Desiga 9''�� ealjA�`\�: PUTNAM COUNTY DEPARTMENT OF `HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR.SEW GE TREATMENT SYSTEM '; tom• _ ��� PERMIT # a �� O � I .1 r _ 0 Located at G1 vtS fA L ANt- Gown or Village PA 1 t FArn A/ Subdivision name A rra 0 A rsac t Ar Es Subd. Lot # -7 Date Subdivision Approved to — S' -, 00 Tax Map i 3 Block 3 Lot -7-7 Renewal — Revision -- AsrRo Atdoc /o.9"E5 Owner /Applicant Name el-, cods MSCAfoR6 Date of Previous Approval — Mailing Address q L-So 0u6(W -c 'oovc6j/ARD R6eo PAkK tiY Zip 113711 Amount of Fee Enclosed Building Type R fS 1'D Fn1 i/A l Lot Area I.3 5, No. of Bedrooms Design Flow GPD 1,000 At Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of I , 90 0 gallon septic tank and 2 -7 L F o F I. wlp,E 48sojePf10AJ TR6JCH6:5; Other Requirements: 0 t Tv Z RD a G Xttv 6Z, Fcc., F*A, G XkP l 6t v GH t3 To be constructed by To BE 26 Dr ,k MIN a Address Water Suualy: Public Supply From Address or: Private Supply Drilled by -ro 6 n6rEieMtA16j> Address At 11A I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatments stem 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. K it-A. �cANnrcAPE ARcmw5crvR6, P.C. Au it , G c, z License # Date t- ljk - fo 61931 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage trea ystem has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w c sidered ne sary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe roved fo d' harge of domestic sanitary sewage o By: Title: / Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 VISION' 'T EN IRONMI NTAL :Ir P A IIH SEA. ICES .PPLICA T SON FOR A PPROVA:L OF PL_A.NS FOR A V- VASTEWA.TER TRE' AJMEI T SYST TVf I.- Name and address of applicant: q sry C , e 'r 15-C CIP Gods PEscA>o�8 C17.- ro Ou9r0.4JS 3odc6yo2k 1 R1;G0' PAR1ej t1Y 11374 2. Name of project: srrS Foq Afreo Assoc)args 3. Location D-\': ' PA MC-1 o�1 LOT W-7 Insite Engin= ing, Suz -eying & Landscax 4. Design Professional: Jeffrey J. coat lm, P:E. 5. Address: ; .- ,.,-2= P c 6. Drainage Basin: EAsr ag4A/cN WAYe RSNFn 3 Garrettew1York 10512 7. Tyne of Project: Privateaesidential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subje6f 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? ......................... NO 10. Has, DEIS been completed and found acceptable by Lead Agency? ............... —T A 11. Name of Lead Agency ,y /A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances ?, ............................ ............ S 13. If so, have plans been submitted to such authorities? ....................... 14. Has preliminary approval been granted by such authorities? . �° Date granted: /Vt. t5. Type 'of Sewage Treatment System Discharge ................. surface water groundwater 1.6. If surface water discharge, what is the stream class designation? .. :................. 7. Waters index number ( surface) ........... ................................. ......................... :..... .8. Is project located near a public water supply system? a 9. If yes, name of water supply � A . Distance to water supply '.0. Is project site near a public sewage collection or treatment system? ................ n10 1. Name of sewage system AIA Distance to sewage system .2. Date test holes observed Li -2 g- 4 g . .'23.. blame of Health Inspector ADaM , sfl, E�iNr :4. Project design flow (gallons per day) ...... .:...; I oom :5. Is State Pollutant Discharge Elimination' System (SPDES) Permit required ?... N� `.6. Has SPDES Application been submitted'to IoW DEC office? ........................... 27. Is anypoi�tion ofthis.project located within a designated Tov�•n or fate wetland? K 28. Wetlands"ID Number:......:..: ................................................ ............................... A& e DP -L�- 29. Is Wetlands Pei-nit required?. ........ ..............................' o Has application been made to Town or Local DEC office? ............................... -=-- 6A M. Does project require a DEC Stream Disturbance per nit?. .. ............:.................. iyo 31. Is or was project site used for agricultural activity invoIving application of pesticides to orchards or other crops, solid or hazardous waste disposal, Iandtillin& slug - application, or industrial acti,'iL3,? ....•.. ..... ... :.. Y es 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 kno-wri source of contamination? ............................... Ye51I0 /lo DESCRIBE: 3 3. Is there a local master plan on file with the Town or Tillage? ......................... uNic,�low,� 34. Are community water and/or sewer facilities planned to be developed within 15 years ;n or adjacent to project site? ................................ ............................... y,1►c9 vWd .5. Are any sewage treatment areas in excess of 15% slope? .................................. No 6: Tax Map ID Number ....................... ............................... Map f 3 BIock 3 Lot 7. Approved-plans are to be returned to ..... Applicant Z. Design Professional 'OTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP )proval of the &STS prior to final approval by the Department. Projects within the watershed may also quire DEP review and approval of other aspects of a project, such as storrriwateUlans or the crRion :o.f, ipervious surfaces, and the project applicant should obtain the appropriate forms for such activi�i from=: EP acid submit those forms to DEP for review and approval_. the application is signed by a person other than the applicant shown in Item I.,the applieatieB Ind s = accompanied by a Letter, of Authorization (Form LA -97). Failure to comply with this proYisiq' ,.y be grounds for the rejection of any submission. r,'w I hereby affirm, Wide vwIiy of perjury, that information provided on this form is true to the best Pf. n knowledge and belief. False state nie nts niade herein are punishable as a Class Misdemeanor pursuant to S'eefiofz 214.45 of the Penal Law. M TURES 4 OFFICAL TITLES. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Well Location: Street Address: illage Tax Grid # C1 V It fA L AA . PATf6e5oA/ Map l3' Block 3 Lot(s) -77 Well Owner: Name: Ar-/2o AssouA►�'Ef Address: I CIO LOVIs rEscAr0Jt . REGv PARK NY 11314 Use of Well: >< Residential Public Supply Air /Cond/Heat Pump Irrigation Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served 5— Est. of Daily Usage 30o 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 >,:f Is well located in a realty subdivision? ...................................... ............................... Yes >e No Name of subdivision 4s-rg o A Sso c r ATgs Lot No. -7 Water Well Contractor: To e 5 V97yAM1W617 Address: Is Public Water Supply available to site? .................................. ............................... Yes No >< Name of Public Water Supply: ,,�/.a Town/Village L%//A Distance to property'from nearest water main: Proposed well location & sources of contamination to a provided on separate sheet/plan. Date: �- ��- _ Applicant Signature: � 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. y revision or alteration of the approved plan requires a new permit. Well to be constructed by a wate we 1 driller ified by Putnam County. Date of Issue C� e6 V Permit Iss n aff Date of Expiration Title: Permit is Non- Transfer • e White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 LORETTA MOLINARI Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845)278-6130 Fax(845)278-7921 Nursing Services (845)278-6558 WIC (845)278-6678 Fax(845)278-6085. Early Intervention/Preschool (845)278-6014 Fax (845) 278 - 6648 Insite Engineering & Survey 3 Garrett Place Carmel, NY 10512 February 19, 2004 RE: Astro Associates 61 Vista Lane, Lot #7 (T)Patterson, TM #13 -3 -77 Reservoir Basin Dear Sir: ROBERT J. BONDI County Executive The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on January 14, 2004 is complete. The Department will notify you by March 10, 2004, 2004 of its determination. ❑ The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. X Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail; return receipt requested, The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of 'impervious surfaces, and the project applicant should L! Letter to: I site Engineering — February 19, 2004 -2- contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Ve ly y s, Robert Morris, PE RM:Im Senior Public Health Engineer WS2 March 2, 2004 Robert Morris, RE Putnam Co. Health Dept. 4 Geneva Road Brewster, NY 10509 Re: Astro Associates Sub. Lot 7 & 8. SSTS Vista Lane Patterson - Putnam East Branch Reservoir DEP Log # 12275(lot 8) and Log # 12276(lot 7) (Joint Review) Dear Mr. Morris: This letter is to inform you that the New York City Department of Environmental Protection (Department) has determined that the above - referenced application is complete. In addition, the Department has no objection to the approval of the above - referenced regulated activity. This determination is based on the review of submitted documents including the plans titled "SSTS for Astro Associates Lot 7" and "SSTS for Astro Associates Lot 8 ", both dated 01/08/04. The applicant must contact Sissy De La Ossa of my staff at (914) 773 -4416 at least 2 days prior to the start of construction of the SSTS so that a Department representative may inspect and monitor the installation. Sincerely, Danny Shedlo, P.E. Project Manager Engineering Design & Review xc: John M. Dunn, P.E., NYSDOH 14.16 -4 (11195) —Text 12 PROJECT I.D. NUMBER 617.20 SEOR Appendix .0 State Environnilerital Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION. (To be comDleted by A'bDlicant or Prolect soonsorl 1. APPLICANT /SPONSOR 2. PROJECT NAME 7 A -rrl?o Al o'C/A Ssrt Fok AS')Ca C PT'0 3. PROJECT LOCATION: Municipality A4 1"T6R s z N Count P✓ A/A M 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) SEE LoC A 1r'`oAv MAP oAl evvSt/41jc�to^J D2q,,J .nrG 5. IS PROPOSED ACTION: 'RNew ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: Q0Ai5 - r2vcf,oN of 01,1i C, FA Al y R. VC 7OWCE �A21✓GwAy� SsTS (16LCr ANV APP UP, 776UAV0ES. 7. AMOUNT OF LAND AFFECTED: l•31 ' Initially acres Ultimately1'�s acres 8. WILk PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ESYes ❑ No If No, describe briefly 9. WH IS PRESENT LAND USE IN VICENITY OF PROJECT? �Residentiai ❑Industrial ❑Commercial ❑ Agriculture ❑ ParklForestlOpen space d Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? Oyes ❑ No If yes, list agency(s) and permit /approvals Pe Rmif _ 10v J or- PAT`ft AC" 8J11.P#n1C pW11r -` -rowA) of OATT6A00d 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes 06 If yes, list agency name and permitlapproval i 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes M0 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE S1VStf6 l W a1,jC suRv�yl�tiG, 4 `an p.CeA 6 Ar2CN(r r ✓g�, P.C� Applicant /sponsor name: J6RAIA. JdA coN P- Date: /'7-0� f Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment. OVER 1 PART III— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD tN 6 NYCRR PART 617.4? If yes, coordinate the review process and use the FULL EAF. ❑ Yes ❑ No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative- declaration may be superseded by another involved agency. ❑ Yes ❑ No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly: C2. Aesthetic agricultural, archaeological, historic; or,other natural or cultural resources; or community or neighborhood character? Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain.briefly C.-.. _. . C5. Growth, subsequent development, or related activities likely to be Induced .by the proposed action? Explain briefly. a C6. Long term, short term, cumulative, or other effects not identified in C1 -05? Explain briefly. C7. Other impacts (including changes fn use of either quantity or t yp e of ener gy)? Explain briefly. - D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF -A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS:` For each adverse effect identified above; determine whether it is substantial, large, important or otherwise significant. Each effect should•be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of .occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes;,the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the Information and analysis. above .and any supporting documentation, that the.proposed action WILL .NOT result, in, any significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Of icer Signature of Responsible Officer in Lead Agency. Signature of Preparer (It different from responsible officer) Date PA /'NS/ T ENGINEERING, SURVEYING & LANOSCAPEARCN/TECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 TO: Putnam County Health Department 1 Geneva Road Brewster, NY 10509 LETTER OF TRANSMITTAL Date: 1 -12 -04 Job No. 98105.307 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates – Lot 7 61 Vista Lane, Town of Patterson TM# 13. -3 -77 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via ❑ Shop Drawings ® Prints ❑ Plans El Samples ❑ Copy of Letter ❑ Change Order ❑ the following items: ❑ Specifications COPIES DATE ! NO. DESCRIPTION 5 1 -08 -04 CD -1 Construction Drawing_ 1 -12 -04 i CP -97 ' Construction Permit 1 --------------------- LA -97 Letter of Authorization 1�a 12 -27 -00 CA -97 Corporate Affidavit 1 _ _ 1 1 -12 -04 1- 1.2 -04 PC -97 - -- - - ---- Application for Approval of Plans_ - Short EAF 12 -29 -98 DD -97 _ ,� Design Data Sheet (previously submitted with subdivision application) 1 1 3 -18 -03 1 27778 ! 00.00 Fee _ — _- 2 f - - - - - - - - - -- -- 5 Bedroom Modular House Plans 1� 1 -12 -04 j WP -97 Well Permit THESE ARE TRANSMITTED as checked below: For approval []Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑Returned for corrections ❑Ret urn corrected prints ❑ For review and comment ❑ REMARKS: 30(9 -00 p GS g L6*-"VZe we-c K 100 ,.00 F2 ASPS � op it- 58 R�`l Z 109 COPY T0: SIGNED: J hn M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE Iot2002.dot PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of_, A �l Ro Assoc�,AfE(; Located at N 5 &V j E 3 j I�V PAXTE Tax Map # .3 Block Lot 7 _ Subdivision of AZ J90 S ©CiA'��5 Subdivision Lot # -7. Filed Map # 2616 Date Filed /l 00 Gentlemen: This letter is to authorize insite Engineering, surveying & Landscape Architzcture, P.C. (Jeffrey J. Contelm, . a duly licensed Professional Engineer x o- &A=d9ffKhi1=xxxxxto 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 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 Count[,,��Code.. Countersigned: P.E.,1K A., # 6 3. co �O Ago 61931�`��� Mailing Address Lnsite & Landscape , P.C. >.uA,e1Z6Tr PJAC6 State New York Zip 10509 Telephone: ( 914) 278 -4990 Very truly y rs, Signed: , -U� (Owner of Property) A5 90 �{SScyCtA�"rS Mailing Address: C/O 1015 PEkATO &E q2--50 aUEN5 60ULE/AKD , AE60 P RK State V EV YORK Zip ] i 3?q Telephone: i �28 -2600 Form LA -97 PVTNAM COUNTY :DEPARTMENT OF HEALTH DMSION' OF ]ENVIRONMENTAL HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION FOR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: SRO A S SO C I A feS — L o T'7 I, LoujS ff5CATj2AF, represent, that Lam an officer or employee of the corporation and am authorized to act for: Name of Corporation: ASS 0 Q S50C/A f Having offices at: 92 - A Whose 0 fficers' Are: President - Name: OUI S i�ESC�'1'OR l Address: , SAMF Vice President -Name: Address. Secretary -Name: Address: Treasurer -Name: Address: M I and that I am and will be individually responsible for any and all acts of the corporation with respect to the approval requested and all subsequent acts relating thereto. Si p ed: Title: Sworn to before me this day of (year) Notary Public Noicjry Public, 51n1a of N w `("r! Corporate Seal No. 501013 Cluali4if rd in ' '.J � rs Cnunri Form CA -97 1�1 cn o" to \\ PROPOSED SS TS .LOT PER FILED M F2846 Ip�OPO ED WELL \ \ ,t . • 'y ``` PERT +FILED MAP-12846 I S644159 E i 289.45' A °A 510 Qcl ` L 1 mN V Aj - - -o °' `° 514 I a sue. � _ �', -�''` ' • �` �' 0' TO 2' R.O.B. ORA6£L FxL FOR GRAOINC'000 CYt) - Ar