The URL can be used to link to this page

Home My WebLink About0420DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13.-3-79 BOX 5 1 rm "NJ II ii .L 1 I � J� V �� . 00229 SHERLITA AMLER, MI), MS, FAAP Commissioner of Health LORETTA MOLINARI; RN, MSN Associate Commissioner of Health October 12, 2005 John & Amy Kleine 51 Vista Lane . Patterson, NY 12563 Dear Mr. and Mrs. Kleine: DEPARTMENT ' OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Addition — Kleine 51 Vista Lane (T) Patterson, T.M. 13. -3 -79 ROBERT J. BONDI County Executive I have received and reviewed the plans for the proposed addition at the above mentioned residence. Based on the information submitted, the above mentioned addition cannot be approved for the following reasons: 1. The legal bedroom count for the dwelling is five. The potential bedroom count of your proposed addition is seven. 2. The addition of potential bedrooms requires this Department's approval of a revised septic system plan from a professional engineer. Please revise the proposed floor plan to reflect no more than five potential bedrooms, or have a professional engineer or registered architect design a sub - surface sewage treatment system meeting present code requirements for seven bedrooms. If you have any questions, please contact me at your convenience. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:cw Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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 OCT -12- 2005 09:00 FROM :PUTNAM COUNTY DEPART 845-278-7921 70:919149236147 P:1 /1 SHERLITA AMLER, MD, MS, FAAP Cotnmkvioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health October 7, 2005 John & Amy Kleine 51 Vista Lane Patterson, NY 12563 Dear Mr. and Mrs. Kleine: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Bxecmdve Rc: Addition — Application Incomplete - Kleine 51 Vista Lane (T) Patterson, T.M. 11-3 -79 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. The following was not submitted with your application: 1. Sketches of existing floor plan (drawn to scale, all living area including basement). 2. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #). Non - professional sketches arc acceptable. All living area must be shown even if changes are not being made. (ie. basement, first floor, second floor) Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Wiew Sincerely, we Gene D. Reed Environmental Health Engineet;ing Aide Environmental Heeltd (845) 278 -6130 Fax (845) 278.7921 Nursing Servleea (845) 278 -6SS8 Fox (845) 278 -6026 WIC (845) 278.6678 Nursing Home Care Fax (845) 278 -6085 Early Intervenden/Presebool (845) 278.6014 Fax (845) 2784648 c JBH ARCHITECTURAL YESIGN,PLLC ARCHITECTURE - PLANNING October 12,2005 Mr. Gene Reed 1 Geneva Road Brewster, New York 10509 Re: Kleine' Resideance — Addition; 51 Vista Lane, Patterson +1 Dear Mr. Reed, In response'to your October 7d' letter on the above noted project/property, attached please find the revisions as requested. Please contact us with updated information on the application. Our office number is (914) 9443377, Fax (914) 923 -6147, and my Cell Number is (914) 879 -3887. Sincerely,; emandea, R.A., A.I.A. P cipal 1A CROTON DAM ROAD j OSSIIYING, NY 10562 Phone: (914) 944 -3377 Fax : (914) 923 -1794 A SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health ROBERT J. BONDI County Executive DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ADDITION APPLICATION RESIDENTIAL ONLY *C) 0 STREET/ �,�� TOWN TAX MAP# - NAME fl' _PHONE PCHD# (J-7 MAILING ADDRESS�� DESCRIPTION OF - ADDITION NUMBER OF kXISTING BEDROOMS PROPOSED # OF BEDROOMS —0 (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUILDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, Brewster, NY 10509, Phone: (845) 278 -6130. Certified check or money order for $100.00. 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 known. Label all wells and septic systems within 200 feet of the property line' Contact this office with any questions. 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 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention/Preschool (845)278 -6014 Fax (845) 278 -6648 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Town Legal Bedroom Count ROBERT I BONDI County Executive Re: x4t (Owner's Name) Tax Map #: Address: Town:, Year Built: o?GYJ,S According to records maintained by the Town, the above noted dwelling, is in compliance with Town Code. is not in compliance with Town Code. The Legal Bedroom Count.is: This information has been obtained from: Certificate of Occupancy: y Other: Date Environmental Health (845) 278 -61.0 Fax (845) 278 -7921 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 r SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health November 5, 2005 John and Amy Kleine 51 Vista Lane Patterson, NY 12563 Dear Mr. and Mrs. Kleine: DEPARTMENT OF HEALTH Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Addition — Approval - Kleine No Increase in Number of Bedrooms 51 Vista Lane (T) Patterson, T.M. 13. -3 -79 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 the Department dated November 3, 2005. The addition is approved with the following conditions: 1. The total number of bedrooms_ must remain at five 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. GDR: cw cc: Building Inspector, Town of Patterson I Very truly yours, oox'k Gene D. Reed Senior Environmental Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 =6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 II0I 1 FMW .oken �vos 8a�'B'ISbl3'I$15Q .i 529 °59'45 "E', 241.LL' m REQUIRED SETBACKS - -- -------- LOT 49 LOT 49 50.315 50. FT. 1 1. I 1. I ut Mean P,yTAIWG ( 0 •r i 498s /WALL OR EQUAL i h [O'f +4% ( 111 01 191- . < i DECK a. 902. 45 0 PROP09E:D' P Z Kclo ONE FA111LY ( TWO STORY 1 QI ` FRAME. E.'- - P.P.PL 501.0 1 s� GAR.;2 L.5030 40s-"-- a ' a R=.215.0' L=104.&4' VISTA LANE SITE MAN IN & CONSTRUCTION CONSULTANTS • awmr t+tt ear ea "m erelra; o w wet au ai m aw BASEMENT RENOVATION KLEINE RESIDENCE PROPOSED FLOOR PLAN f l JJC CONSTRUCTION CORP. P. O � BOX 487 BALDWIN PLACE, NEW YORK 10505 84541628-0225 FAX 8451628-0348 TO: Putnam County Dept. of Health 1 Geneva Road Brewster, New York 10509 LETTER OF TRANSMITTAL DATE: November 2, 2005 ATTENTION: Gene D. Reed RE: Klein Residence 51 Vista Lane, Patterson, New York Tax Map No. 13. -3 -79 WE ARE SENDING YOU XXXAttached _Under separate cover via the following items: Shop drawings Prints Copy of letter Change order _ Plans , Samples _ Specifications THESE ARE TRANSMITTED as checked below: , XXX For approval _ Approved as submitted _ Resubmit copies for approval _ For your use _ Approved as noted _ Submit copies for distribution i _ As requested ; Returned for Corrections Return corrected prints For review and comment FOR BIDS DUE _ PRINTS RETURNED AFTER LOAN TO US REMARKS: We made the corrections as discussed. SIGNED: Donald Zanfardino, Pres. 5ESCRIPTION Revised basement floor plan THESE ARE TRANSMITTED as checked below: , XXX For approval _ Approved as submitted _ Resubmit copies for approval _ For your use _ Approved as noted _ Submit copies for distribution i _ As requested ; Returned for Corrections Return corrected prints For review and comment FOR BIDS DUE _ PRINTS RETURNED AFTER LOAN TO US REMARKS: We made the corrections as discussed. SIGNED: Donald Zanfardino, Pres. Y O a ti o� 7 sT!t 204.5 270.55 COM N, : = L -20'0 p I ' �8'25 44„ r —�o o7 N fit 4 a> o t, 9 c»�v,wvcoto moo z ro 1 Iro E` SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health October 7, 2005 John & Amy Kleine 51 Vista Lane Patterson, NY 12563 Dear Mr. and Mrs. Kleine: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 ROBERT J. BONDI County Executive Re: Addition — Application Incomplete - Kleine 51 Vista Lane (T) Patterson, T.M. 13. -3 -79 Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. The following was not submitted with your application: 1. Sketches of existing floor plan (drawn to scale, all living area including basement). 2. Two sets of proposed floor plan (drawn to scale — with name, street and tax map #). Non - professional sketches are acceptable. All living area must be shown even if changes are not being made. (ie. basement, first floor, second floor) Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. GDR:cw Sincerely, Gene D. Reed Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 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 � !��fflv PUTNAM COUNTY DEPARTMENT OF HEAL ISION OF ENVIRONMENTAL HEALTH SER CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 0 �-- Located at _ (�cS}c LQY\k— own r Village P AQ. s an Owner /Applicant Name c-1 o 1 _,,, .L,,s Atsc a_�®r.e Tax Map 13 Block _� Lot _2 Formerly Subdivision Name &4u) dsu jaLe S Subd. Lot # 0% Mailing Address } Are Pe v k, ley Zip 13 Date Construction Permit Issued by PCHD f a9 10 Separate Sewerage _System built by tJV -C AFr 6v+GVv,-t,S Address VW- A-to K(µS _9'V J I Consisting of j, r c7C7 Gallon Septic Tank and 5 S G L. E 6 L 211 Wide Other Requirements: I ' - t, A �O R' A rave l Fill (3�5 4/- cu ) Water Sunoly: Public Supply From Address or: ( Private Supply Drilled by li�nc � _ �a Address lot g 0.:-sa Building Type P P s i a! mh Has erosion control been completed? V Q 5 Number of Bedrooms 5 Has garbage grinder been installed? N o 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: b l(0 0"Or Certified by P.E. V R.A. Mrxs i k E iY�e�rtnta,, 5kw -� Design Pro ss' nal)"(5C4{x A*.{ukJU!T' P L. Address � r �� y License # ! g.31 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 a bject t modification or change when, in the judgment of the Public Health Director, such revocati ificati 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 �lay 28 04 08:12a i BRUCE R. FOLEY Public Health Dlrectar TOWN OF PRTTERSO 845 -878 -2019 p.2 LORETCA MOLINARI R.N., M.S.N. ristociale Public Health Director Dbeclar of Patient Sorvlcaa DEPARTM NT OF EALTt� 1 Geneva Road Brewster, New York 10509 lr nvlrenmmual Health (914) 27a -6130 Fax (9,14) 273 -7921 Nurdog Servlcoa (911) 278.6578 WIC (914) 278.6678 Fac (914) 279-6081 Far17 Interwatlea (914)273-6014 preae600l (914) 318.6082 Fax(914)213.6649 E911 ADDRESS VERIFICATION FOP Vvt OWNERS NAMT, TAX MAP NUMBER: E911 ADDRESS: TOWN: k-c�Lo A55� t�A�irS C/O Lo -11S Q �.SCA�u 2t 13- 3-19 51 \]tSTa Oe%MC r AUTHORIZED TO" OFFICIAL: (Signature) Z HATE: 7 2 rl D The Putnam County Department of Health will not issue a. Certificate of Construction Compliance ubless 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 VERFRIv1) £l2 :d 6TWaS :01 LLL6522Sb8 ENI833NISN3 31I5NI:W08d 2£ =£0 b002-52 -AtiW (d/LCCc t rt'fC- �.- rjc,(6 D t v t S c ^.� �'Z i r.✓C�c F dti c � cti� Gorl7 d� FccE �� PGH D PUTNI0`I COUNTY DEPARTMENT OF ffili.LTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES �� 9 WELL COMPLETION REPORT Well Location Street Address: )96 Town/Village: Aa&e o Tax Grid # Map 1'� Block Lot(s) Well Owner: Name: i�sfry Address: Use of Well: I- primary 2- secondary Residential Business Industrial Public Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length Length below_ grade Diameter Weight per foot ft. ft. 7 in. 17lb /ft. Materials: _ Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _ Cement grout k Bentonite Other Drive shoe: Yes No Liner _ Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped ✓ Compressed Air Hours j6' Yield � gpm Depth Data Measure from land surface - static (specify ft) e During yield test(ft) 60 Acv; Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface 3(0 30 3 6 d L!l If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type EID�j, Capacity LOA. Depth 3, �o Model cxo,x & Voltage a3D HP Tank Type In1at1 -�r-j {o,Uolume _Qa g Date Well Comple d Putnam County Certification 007 No. Date of Re or i(13h,7 Well Driller (signature) �. NOTE: Eltact location of well with Well T)rillar'e Hama NJ '-4 M JUL -1 -2004 10:22 FROM:INSITE ENGINEERING 8452259717 TO:2787921 P:1 /1 PMAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ATTENTION 13 ADAM GENE BE C .0 .N For: Fill All idormation must be fully completed prior to any Trenches inspections being made. Q PCHD Construction Permit 4. ` A - v� Located: A+i ,311 )414 i�j h Lb') IL . (V) WT Ema es Owner /Appli•ca, game: �„QSS�� +rartE� q& Laj +s Qt:scv*A F L1• Block Is _Lot S5. Formerly; _ _ Subdivision Name: _. Ag fQ _Kfj$r g TES Subdivision Lot 0 9 Is system fill completed? , ;r �5 Date: Is system complete? YES Date: °y Is system constructed as per plans? fS Is well drilled? : y E. 5 Date: 3 y Is well located as per plans? yrs Are erosion condo! measures 1]1 place? e I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordauce with, the issued PCHD Construction Permit and approved plazas ao,d the Standards, Rules and Regulations of the Putnam County Department of Health. Date: 01 Certified by: PE / r"h-!221_ IWO FEngineering, Surveying & Design rofess n 'Landscape Architecture, PC, A•ddr•ess: 3 Garrett Plane Lic. # C 10 1 Carmel, New York 10512 Comments: Form FIR-99 -1 -2004 THU 10:23 TEL:845 -278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P JMS ENVIRONMENTAL SERVICES, INC. 1500 SUMMER STREET • STAMFORD, CONNECTICUT o6905 NELAC, CT and NY State Certified Environmental Laboratory Mailing Information: Name: Hyatt Pump Service Address: 229 South Rd City: Holmes State: NY Telephone: 845- 855 -5136 Sample's Information: Site: Preservative: HNO3 Temperature: <4C Client: Astro Realy Zip: 12531 Fax: 845 - 855 -5136 Collector's Information: Name: MH Address of site: Lot #9 City: State: Zip: Telephone: Date Collected: 6/3/04 Date Received: 6/4/04 Time Collected: 16:00 Time Received: 14:00 Lab No.: J045829 Date Analyzed Test Name Result MCL Method 6/4/04 16:00 Total Coliform Absent Absent SMWW 9222B 6/4/04 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 6/4/04 Color ND 15 Units SMWW 2120 B 6/4/04 Odor ND 3 TONs SMWW 2150 B 6/7/04 Iron <0.050 mg /L 0.3 mg /L SMWW 3111 B 6/7/04 Manganese <0.050 mg /L 0.3 mg /L SMWW 3111 B 6/7/04 Sodium 16.1 mg /L N/A SMWW 3111B 6/7/04 Chloride 21 mg /L 250 mg /L SMWW 4500 CI C 6/7/04 Hardness 374 mg /L N/A SMWW 2340 C 6/7/04 Nitrate 1.41 mg /L 10 mg /L SMWW 4500 NO3E 6/7/04 10:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 6/4/04 pH 7.36 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 6/7/04 Sulfate 34.7 mg /L 250 mg /L SMWW 4500 SO4F 6/4/04 Turbidity 0.43 NTU 5 NTUs SMWW 2130 B 6/7/04 Lead <1.0 ug /L 15 ug /L SMWW 3113 B At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Reviewed b Sharon Houlahan, Director Signature. State #: PH -0218 Michael Lapman ELAP #: 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 imsenvironmental.com JUL-12 -2004 17:16, FROM:INSITE ENGINEERING 8452259717 TO:17184584191 P:3/4 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 62ro Aksyqe. Aieg V° Lou, ,.S kscahw % 3 7� .b Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Towz,,,,�'. Village Location - Street Subdivision Name Building Type Subdivision Lot # I represent that l: 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 farther agrees to accept as conclusive the dete=Anation 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 � Yeaap fA General Contractor (Owner) = Signature A , 4 Corpbration Name (if-corporation) Address: State A� zip ^1��,�� J L��-To2 C> cu : p e Corporation Name (if corporation) Address: �Z_'s ftomz i9el) State ip I ' Form GS -97 0 ENGINEERING, INSITE SURVEYING & ANDSCAPEARCHITECTURE, 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: 8 -16 -04 Job No. 98105.100 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates Lot 9 51 Vista Lane, Town of Patterson TM# 13 -3 -79 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via ❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Copy of Letter ❑ Change Order ❑ the following items: ❑ Specifications COPIES i DATE NO. DESCRIPTION 5 8- 10 -04 B -1 As -Built Drawing 1 8 -16 -04 CC -97 C�onst-r- ucctti Compliance 3 7 -12 -04 GS -97 -on Guarantee 1 1 1 1 5 -28 -04 —_�� 6-3-04 11 -13-99 i 04�- ( -- WC-97 068740 31261 E911 Address Verification Water Test Results Well Completion Report - - -�~— j $ 0002 0 Fee i 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: t jn i M . . Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: ' -7 e 7 °EL Inspected by: 1 Z - CD Street Location Town Pay-r, TM # r3, - 3 1. Sewage System Area a. STS area located as per approved plans ........................... b. Fill section - date of placement 3:1 barrier Lgth. Width . Avg.Dpth c. Natural soil not stripped .................... ............................... d. Stone, brush, etc., greater than 15 from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage Septic size p -- 1,000 .......... 1,250 ......... other. . /..-:2.q42, b. 'S eptic'tank installed level ...... ............................... ..... c. 10' minimum from foundation .......... ............................... d. Distribution Bog 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 .......... ............................... 6. ref nc! es 1. Length required ,g-6 Length installed 6- 2. Distance to watercourse measured-}- i o a Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property he - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - Ilk" diameter clean ...................: 9. Depth of gravel in trench 12" minimum....... ............. 10. Pipe ends capped ........................ ............................... g. Pump or Dosed Svstems 1. Size of pump chamber ................. ............................... 2. Overflow tank ............................. ............................... 3 Alarm, visuaUaudio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Building a. House located per approved plans ... ....:...............:.......... b. Number of bedrooms ........................ ..TJ. ................ IV. Well Well located as per approved plans . ......:........................ b. Distance from US area measured -t 1 o a . ft..... :..... c. Casing 18" above grade ................ ............. ................... d. Surface drainage around well . acceptable ....................... V. Overall Workmanship . a.. Boxes properly grouted ................... ............................... b. All pipes partially backfilled .... :..................................... c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain &standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercourse g. Footing drains discharge away from STS area ............... h. Surface water protection adequate ........ :...................:...... i. Erosion control provided ................. ............................... Rev. 12/02 Owner A57-x,, A_4,,c , Permit # P - / S - 92 Subdivision Lot # 9 LORETTA MOLINARI Public Health Director ROBERT J. BONDI County Executive 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 Jeffrey Contelmo Insite Engineering & Survey 3 Garrett Place Carmel, NY 10512 Dear Mr. Contelmo: July 8, 2004 Re: Field Inspection — Astro Association NYS 31 UVista Lane Lot #9 (T)Patterson, TM #13. -3 -55.9 The above referenced separate sewage treatment system can be backfilled. There are no open comments to be addressed at this time. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, VQ4 GDR: hn Gene D. Reed Environmental Health Engineering Aide y. MMT. it T T PUTNAM COUNTY. HEAL--TH DEPT ' 0 2 3 317: t 1 Ga -Roa d , (845) 278 enev 6130 y &evrster, NY 10509 , ?t ' , � r - Date �9'��,Q " R" ceived of �Tfe Sum Of l n B o p0� Dollars $ z3o �, oo :t TPAIVdt YOU► ❑Cash Q Check ref Card/ i i i a i i !, a l i i i � i•1 � �\ � DIVISION OF ENVIRONMENTAL HE LTH SERVICES CONSTRUCTION PERMIT FOR SE GE TREATMENT SYSTEM PERMIT # f 0 � C D Located at IYS 31/ V l -SrA ANE Qown or e Villa � II Subdivision name ASfRo A3�Faci6r" Subd. Lot # I_ Tax Map ) 3 . Block 3 Lot Date Subdivision Approved I,, S-oo Renewal '— Revision AsrRv .AsroctAr6f Owner /Applicant Name 54, 'buts PG1cc -ATOPE Date of Previous Approval Mailing Address qZ —S"b (s?vE&._►s eu „tF yAg. , g C&o PAku _ I_JY Zip 11 3-74 Amount of Fee Enclosed * 3 679 00 Building Type iC6S1DEAW` /At Lot Area 7, .C41-No. of Bedrooms ,5 Design Flow GPD l006 Ae, Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System.to consist of 1, roo gallon septic tank and rS 6 L , F. d; 2 ' w 10 G .A 8j:o ”. P -r,' o a/ Tm E,vaHag s Other Requirements: 1' -o" r►1N. A-0,6, G2Ay6L F)ci -3'5-}/ eY) To be constructed by IS Address N/A Water Supply: Public Supply From Address or: K Private Supply Drilled by ,4r rb,v yXA Ti Address eA7F6Aso,y 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: P.E. X R_�r' Date 5_"; aS1rC- �GIW 1 eAN7>.CeAPC MUIlr cn"R P r, Address c AA E t vy 110-07. License # C/13/ 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 whpwqpnsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe rt prove r discharge domestic sanitary sewage only. By: r Title: CrA__ Date: rInz, Z White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 2 27. Is any portion of this project located within a designated 'i ow.-D or State wetland? No aCZ- 28. Wetlands ID Number............. yip. ... ': i .... ............................... ' jvt-(� Siiov-o -j 29. Is Wetlands Permit required? . ................:.............. .... No Has application been made to Town or Local DEC office? ............................... N 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 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? "�..J �U Yes o 1 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 !y0' DESCRIBE: 33. Is there a local master plan on .file with the Town or Village? ......................... O- �AN,'vkf 34. Are cormnunity water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ...............:................ ............................... ULJtWowtv 35. Are any sewage treatment areas in excess of 15% slope? . ............................... !J� 36. Tax Map ID Number .......................... ............................... Map_ Block 3 Logo q 37. Approved plans are to be returned to ..... Applicant 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 y 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 1.,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 affrrm, under penalty ofperjury, 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 misdemeanor pursuant to Section 210.45 of the Penal Law. SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... Carmel New York -iAs': BRUCE R. FOLEY Public Health Director TO: PROJECT: 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 DEPARTMENT OF ENGINEERING AND DESIGN REVIEW DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED TOWN: C SE P K PV DATE SUB'D APPROVAL: 'sue U U NOTICE OF COMPLETE APPLICATION DATE: S Zrj' p Z PUTN•A.M COUNTY DEPARTMENT OF HEALTH ION ME MEAL HEALTH DIVO T .. 1 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM q.,7 3-a a�v�f�S G�c %s_Er.�/3.�✓ Owner A-37W, 0! /� s5i�G Address RAG o 04,Ak iv' Located at (Street) vyS Al- 311 A s Tax Map 13 Block 3 . Lot 53', � ;(indicate nearest cross street) Municipality ;ar•,v. mF ��lTSc��% Drainage Basin Lffs; ,gx1hyci/ a✓ATEAS/E/� SOIL PERCOLATION TEST DATA Date of Pre - soaking «/y All Date of Percolation Test i2:,1.2_ /wi g Hole No. Run No. Time Start - Stop Ela se Time (Min.) De th to Water rom Ground Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Incb 2 tO�sv -, ►In�1 Z3. — Z6 .f 3 3 11 3c 2.3 yG " 3 4 5 2 2 -14 3 I`L'K 6 3 L� it - 2 3 ► 4 . i 5 l - �,• 2 3 4 5 INO IE6: 1. "Pests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. .2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' 2 TEST PIT DATA t DESCRIPTICSN, O SODS ENCOUNTERED IN TEST I30LES HOLE NO. R A 'HOLE NO. g TW v so;•G- RED dAen -A; 3,ZL —rna s A4 G Aoek HOLE N0. Indicate level at which groundwater is encountered Al Indicate level at which mottling is observed Indicate level to which water level rises after being encountered ti 1A Deep hole observations made by: j d NrJ M. Date�.,iy Design Professional Name: Jeffrey J. Contelmo, P.E. . Address: Incite. Engineering, Szveying & Landscape Architecture, P B ,.ICJ ✓ [o; rz- re� +'s�e�, �leti�r �e�k- 1.fl.5.09 � / Signature: Design Professional's Seal /'NS/TE c 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: 5 -3 -02 Job No. 98105.309 Attn: Robert Morris, P.E. Re: SSTS for Astro Associates — Lot 9 Vista Lane, Town of Patterson TM# 13. -3 -55.9 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via ❑ Shop Drawings ® Prints ❑ Plans ❑ Copy of Letter ❑ Change Order ❑ the following Items: ❑ Samples ❑ Specifications COPIES DATE I NO DESCRIPTION 5 5 -3 -02 ( CD -1 Construction Drawing 1 5 -3 - -02 CP -97 Construction Permit 1 ' ------------------ ---- LA -97 Letter of Authorization 1 — _..____.._______ 12= __27 -00 —� CA -97 Corporate Affidavit 1 1 I --------------- - - - - -- 5 -3, -02 PC -97 --------- Application for Approval of Plans Short EAF -� 1 12 -23 -98 DD -97 Design Data Sheet (previously submitted with subdivision application) 1 j 2 -20 -02 --- - - - - -- $300.00 Fee 2 ----=---------- - - - - -- --- - - - - -- 5 Bedroom Modular House Plans 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 ❑ Return corrected prints ❑ For review and comment ❑ REMARKS: COPY TO: SIGNED:. hn M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE lot2002.dot PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL, HEALTH SERVICES AFFIDAVIT - CORPORATE OWNER APPLICATION 1~OR PERMIT APPLICATION SUBMITTED TO PUTNAM COUNTY HEALTH DEPARTMENT To: Public Health Director In the matter of application for: AS Ro-_ S 50 C I 5 •-` w _F 9 I, Lori 5 f f 5CA � oA E_ represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: A520- A sT -M,5 Having offices at: 50 MEWS NS 80 UL VaU U_�a P Whose Officers Are: President - Name: OU) Q _ SCA'�o� E Address: SAME Vice President - Name: Address: Secretary -Name: Address: Treasurer -Name: Address: 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. ` hjj",� Signed: VUL } Title: ` Sworn o before me this day of (month) JAoo, (year) Notary Public %•luiai Corporate Seal tJo. G %CJ�� 3 ;aii4ied in Cju „eeo:c Crum, . Form CA -97 i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of LfR0 ASSOC 're; Located at N Y 5 604F, 311 &V Aft E4 50 Tax Map # 13_ Block 3 Lot 'Subdivision of Q UD- ASSO6 Af 15S Subdivision Lot # Filed Map # Date Filed - ' - o 0 Gentlemen: This letter is to authorize incite Ehg neerinq, 'slZrvey�sig & Landscape Architecture, P.C. (Jeffrey J. r_onteamo a duly licensed Professional Engineer x c»f�a�d�t�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 County $anitary Code. Countersigned: P.E., X.A., # Mailing Address �. & Landscape:AArdtitedt , P. C. ..)y /091'& B—ellsber, New State clew Yorx'; Zip 10509 Telephone: i (914) 278 -4990 Very truly yours, S igned: ) (Owner of Property) 040 ASSO 'Arr5 Mailing Address: V -0 Lov►S taC400kE R2- �Q QvEE45 bOULE�/ARO �t� ' t'A�K State NEW ft K Zip 113?? Telephone: I - 71 - L 7 8 -2600 Form LA -97 14 -16.4 (2187) —Text 12 PROJECT I.D. NUMBER 617.21 SEAR,- Appendix C State Environmental Ataality Review SHORT .ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant,or. Project sponsor) 1. APPLICANT /SPONSOR. 2. PROJECT NAME. gs-rPo A SS'oc I A'!'CS Ssts Fo,e As-rko Lo-r q 3. PROJECT LOCATION: A pp Municipality i' 7-rr/� S o^/ County pI)1NA M 4. PRECISE. LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map) SEE COCA -rlaV NIAP •o,✓ r��.v�rlo�/ i%PAwi✓�'r. ' 5. IS PRO30SED ACTION: PR New ❑Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: _ e CojAJ -rRVQT. ID \1 or un/l: FAMI 1 I ESrP.CA10E•�.117R1ve -AY, - (S7`Cj I CL(, J ANA APP 00, AJ q VCCS. 7. AMOUNT OF LAND AFFECTED: Initially 9 1 54 +�" acres Ultimately • �9 4.1 acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? 1;aVes []No if No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial '❑ Commercial ❑ Agriculture ❑ Park]Forest/Open space ❑ Other . Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL) ?, f;byes ❑ No If yes, list agency(s) and permlVapprovals tv�J^j orA4TT CA-C*4 WELL r SrTS (UTNA&,, CovNt`J HEALT D'r IN ILDIN Q1 RGRAq fT — fOWN vt' PATC•CAsoAj 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT-OR APPROVAL? ❑ Yes ZNo. It yes, list agency name and permiUapprovai 12. AS A RESULT OF P OPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? ❑ Yes XNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1� NS�tE NGi�GGRivG s�ev�rivGr � CAYT>SaA It Agcq 11'6CTUR E � P. C', ApplicanUsponsor name: i 30 '"M M - WkfON Date: Signature: lithe action is in the Coastal Area, and you are a state agency, complete'the Coastal Assessment Form before proceeding with this assessment vvtm 1 PART 11— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. (DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? 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 C5. Growth, subsequent development, or'related activities likely to be induced..b the proposed action? Explain briefly. Q f-n L T, C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly. C� C rn t1),C -4 C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly.• ljo fn D. iS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes ❑ No If Yes, explain briefly PART 111 — 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. ❑ ..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 appositive 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: Print or Type Name of Responsible Officer in Lead. Agency Signature of Responsible Officer in Lea Agency Name of Lead Agency Date r� Title of Responsible Officer Signature of Preparer (If different from responsible officer) PU TNAM COUNTY DEPAR'T'MENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES i APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM[ 1. Name and address of applicant: 2. Name of project: ��; : N� �`''O" ��` �r,Voyt 43. Locatior(3rV. T-T 0.50 & Insi.te Engineering, surveying & Landscape 4. Design Professional: Jeffrey J. Contelmo, P.E. 5. Address: A dbitecture, P.C. ROAL0 22 3 < dA P A E PLAOj 6. Drainage Basin NAM-4t; y 7. Tvi)e of Proiect _ PrivatAesidential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to.State Environmental Quality Review (SEQR)? Type Status (check one) ......................................................... Type I Exempt Type II Unlisted K 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... wo 10. Has DEIS been'completed and found acceptable by Lead Agency? ............... _— f 11. Name of Lead Agency I fIA 12. Is this project in an area under.the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... YE S 13. If so, have plans been submitted to such authorities? ........ ............................... (� 14. Has preliminary, approval been granted by such authorities? Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water / groundwater 16. If surface water' discharge, what is the stream class designation? .................... 17. Waters index number (surface) 18: Is project located near a public water supply system? ....... ............................... �0 19. If yes, name of 'water supply / Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ AJO 21. Name of sewage system NA Distance to sewage system _ ... . ............. 22. Date test holes observed 23. Name of Health Inspector A p Si� 24. Project design flow (gallons per day) /1000 25., Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... klo 26. Has SPDES Application been submitted to local DEC office? ......................... WA Form PC-97 0204 c.rtit. ;g0t,cvlS c-, -��i r.✓CZL dt c 6 c,r.tt c.�7 0� FGG� w� t GE-t b PUTNVI COUNTY DEPARTMENT OF H ',e-LTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES 9 WELL COMPLETION REPORT Well Location Street Address: /96 Town/Village: �e qyi Tax Grid # Map Block Lot(s) 7q Well Owner: Name: Address: Use of Well: 1- primary 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 Open hole in bedrock Other Casing Details Total length ft. Length below_ grade ft. Diameter -7 in. Weight per foot _17 lb/ft. Materials: -V/ _ Plastic _ Other Joints: Welded Threaded _ Other Seal: _ Cement grout _V Bentonite Other Drive shoe: y Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed Pumped ✓ Compressed Air Hours 6 Yield gpm Depth Data Measure from land surface - static (specify ft) 7u -re-ell During yield test(ft) B0Alin Depth of completed well in feet 3� fee Well Log If more detailed information descriptions or sieve analyses Depth From Surface Water Beating Well Diameter(in) Formation Description ft. - ft. Land Surface j(, 7`i ( Arch 190 3 6 d 4J are available, please attach. If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type C 0,,i, Capacity Lk6rto- Depth ?)(,,o Model e-tos : d Voltage;L2)D HP A Tank Type WVr o,V/olume 12a_ .S Date Well Comple d Putnam County Certification No. Date of Re ort Well Driller (signature) NOTE: Etact location of well with distances to at least two permanenFianamartcs TO De proviaeu on a separate sij$cvpian. Address: l6 IV Pile. 311 /C 7f(L `-f ME // // 10, loe loe 50' %moo \\ Ss 60// /i /y 6 6. \ cJ �0'5 5• N o � , 1p w 000 0 � R c D'2 �P� 4� 2 'o r y R 4 ' t �Y" ^ f > t. x d'.: �c .F 1 $ 1 C ? � Y'. S _ _ , ♦ , f S t� 2 f h S. lG 4 n �, 1 ,�y � 4 f x r '' ND �Gi�7' 3 �: K N r ',tL h i " Y'"` t r V "`-v Y d r r 1 THIS �/S TO CERTIFY 7Hi 1. v f AS 'JNU/CA IEII , THJS' `,F ENGYNEERlNG� SURVEY/N .K ' COVERED OVER 1HE `SJ ALL STANDARD RULES x � ,OF,HEAL> TH AND THE N 1. jog , d j Y 3 5 `� .. �, ° a -r 11 ra a '> } Z-'ALL FACILITIES EXJSTINC t Z4, , 3 PROPERTY `UAIE AND FL v _ L_r ;. Z. ai PREPARED BY TERRY B .� 1, c ,, H :',{ 1, �.. :. "Mm" % , A j ' 4 5 Mj:. Y rF �, 5 1 '_ M . fi r _ E w ' - 4 Y - -, x., ,yJ, s. ��- t. . r-z z . �,.. u,� Y- i 4 x r-- r ) , y r n w x �. 9{ a _Y t `5 "�' Kati ^. „,.i 1 i; �N 't M ll� r� r k ,, y F ?, F• it .e - .per ,,. �. : n t 11 ,�5, ^l,� 4 F.' i, �'n9 t M";'�` vie S "�y' L z f a r i s � m f 3x, r ,r ,,4 x k a , 5 2 ? s x ii, r [ 1" ! .y a r .r *.. r A A, is � a r 1 L , L r y r - r a �,.. $hie } V is - t a ": •A ,� W * ,, ; L L ..' *r 4 W Z r F. , yr mss' 3 ` ya kS L• i X ' 2 ik L r-^ Y -p, � r a , _ r—,-- . ,q�HM1 X,y k x} .J J, :. { 4 5 7 > P b L S r lE 5 'WAGES ,'MtA TMENT,SY51 tk WAS 'CONSTRUCTED ti - 11 I AAlD THAT THE SYSTEM WAS OBSERVED BY. �l 98J -'- LAkDSCAPE ARCHJTEC7,VR&- P,C- �BEFOREEITIMAS I �(WA "5 J 0 STRUC'TFD IN`- ;GENERAL ACCORDANCE WJ *% � A REWLA77ONS OFD7 t- ,P&:INAl1�2�: "0 Y DEPARTMENi- ORK `STA,TEGDERARTMENT OF HEttLIH x d `,' `, ,} r ,_ � s i - LESS NOTED OTHERW> x 41ZON LOCH °TTON TAKEN fROM_,SURVEY:OF PROPERTY NDOfRFF COCUNS, DATED AU(�JST 8J 2D04 5, r m �' i x:. of ` Y,: t P �, �. Y y e' y } ,� ' fit., 7r $. �,4 GL K ��.5 Y,.f. a43. �' y . d J >v . '�s �. s `x � " �"- M z s f 3 L 2 Y ,4, F � k it Z- .1 .Y° �` 1. c A., Y a 3 i- S s Y k r I � t t,: ' k l 4 F 5 r y 1� 11 - t x 5 2 'S .,�4 T 6 r F C 3 3 _ t k . air 1. V f 7 i Z Y T X C. �, ,F 'Kati e S b1 1 P - C `' fi i i ' I, 8 7Q' # 89' - ' naow sa�r 9 76 T I 5'w , .'-"m, It i ' �" 9ox %_z` 4- } .. &1082 $' Ft.QB' END tJl� 1RF7Yla'!�x ,11 X96 ,5 140 5'4 K aNV a� 12 Y °64' � 126' am T + j - 1 ! - / F. e-i;- -'- 13 45' 51 5'p nq ava aFi€rrar 14 80' r SRS' r k - of nay ..'Jf5,. ?.,..:fix 1.�..3d i'.. -.:. G -, y k� f0 x t C 5 S.. F ,. 7 4 } 3 �, ` G s , e� �v t f. V - f 4 }t r s `1 k v a ° 5 itn) a. Division �;, _,.. _ _ � ' ., _ _ .- _v�p,. ,... . s " f s '�'.,�, u:a .r� 4 � ,,' 4 - t }" I it. a �` ;. r Y,F & a � z e a ., Vw . L I. aunty Department of ;Health EnvronmentalHealth Servioes r k noted for oonformanceWth ..` . ... ry. Zip iiF a -' R REMARKS NO Z arm arx - "D� tJ�l6 > i ilAAOfOIE x x 1 X X2224' x� 8 865' s sr�aaucar sync r 2 X na f f �^J r. s s�,1 ,, - . X23«.`,' . . , 3 4 4Q' X s+°',. X90' : :F„ 4�y:,claw s L 8 x 4 • •'46 5' L 89 5' x �Fl 5 5 52 4 488 5 t , V/�f/T $ - -. 5 , , _ V 6 5 -. _ M " "W s X X7 6 64' 8 88 5' o oYeex 4 -, y k� f0 x t C 5 S.. F ,. 7 4 } 3 �, ` G s , e� �v t f. V - f 4 }t r s `1 k v a ° 5 itn) a. Division �;, _,.. _ _ � ' ., _ _ .- _v�p,. ,... . s " f s '�'.,�, u:a .r� 4 � ,,' 4 - t }" I it. a �` ;. r Y,F & a � z e a ., Vw . L I. aunty Department of ;Health EnvronmentalHealth Servioes r k noted for oonformanceWth ..` . ... ry.