Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0437
DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -110 BOX 6 1 rm In m 0 1 BIN �� T I 4 , - 6 �� �. '` �' , d 1. 6' 1 �'. ,I r -, � . �, % h, - h ILL I 00246 PUTNAM COUNTY DEPARTMENT OF HEAL o DIVISION OF ENVIRONMENTAL HEALTH SER CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Q- 40 - 01 Located at 170 So Acf se4 'U%vt own r Village Owner /Applicant Name b MM p j L L c Formerly (.*c,J %J AV. H,%\ [S-TATES 9asTiRS,zd Tax Map 13 Block 3 Lot I" Subdivision Name 4nXPA0. Lc ( CcActa -rA.., $Ll. W"Tf s) Subd. Lot # 14 Mailing Address a �g�aGi� ROAD ) goREuSSE(Z ay Zip 1050-1 Date Construction Permit Issued by PCHD la -10 -01 Separate Sewerage -System built by 0,xr0o*& C.o,jctss Address tA(FIaS LRosS 2oAo , AWACS )I Consisting of 1, d 5o Gallon Septic Tank and goo of a W%OE J pbSoR9 -%10 4 - r&EFJc,ks Other Requirements: I' o G R , 0. b. , RpJ (c 1!i Water Supply: Public Supply From. or: x Private Supply Drilled by hLbt" 1AyAS1 t Son)s Building Type 0E01IAL Address Address 'o1% K,111 ?ATT(&S -,J a-I, 1a56I Has erosion control been completed? 0'0 Number of Bedrooms y Has garbage grinder been installed? 00 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: 9 -Z-7 - 04 Certified by � *SastrE En►(,uvEiR.nl(,, 5V9.,►E1, Address P.E. X R.A. License # 61 q S I CA%,-%tL N1 o S+ person occupying premises served by the above system(s) shall promptly take such action as may be necessary cure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage ent system shall become null and void as soon as a public sanitary sewer becomes available and the approval �rivate water supply shall become null and void when a public water supply becomes available. Such s bject to modification or change when, in the judgment of the Public Health Director; such h�o r fica ion change is necessary. ' Title: %-� Date: l0 1116 I rile; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy. - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: t Ac ✓ Town/Village: Pe rz� C-L, Tax Grid # Map t 'z.) Block 3 Lot(s) t t O Well Owner: Name: Address: C Rd. S li czj,3 Use of Well: rimary 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 ft. Length below grade ft. Diameter in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: Welded A Threaded _ Other YY Seal: _ Cement grout X Bentonite Other t 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 Yield &8 gpm Depth Data Measure from land surface- static (specify ft) VT During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface Q If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type ev7jj Capacity Depth O Model .V 01 t o4q 15 Voltage 1_3 C tFT 1 Tank TypeCH ume Date Well ompl ed Putnam County Certification No. Date of R ypol /,-�/ /I �? Well Driller (signature) 1V0'1X: Exact location of well wttn atstances to at least two permanent taRUMarxs to oe proviaea on a separc snucupian. // Address: �/ Date: 4/__)-A2 Well Driller's Name 4 6cr -f -o ,s Signature: White copy: HD File; Yellow copy- Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 Aug 20 03 07:29a BRUCE R. FOLEY Public Xcolth DIPactor TOWN OF PRTTERSO 845- 878 -2019 p.4 LOPE TA MOLINAR3• RN., M.S.N. Aupdaro Public Neahh Dirocror Director of Pa1W Services DEPARNT OF HEALTH 1 Geneva Road Brewster, New York 10509 Eavlronmeaml Hclth (914)278 -6190 Fax (914) 275 -7921 Nurilag Services (9 14) 273 - 6558 WIC (914) 273 - 6673 Fez (914) 278.6085 Early Inkrveadon (914)271 -6014 preschool (914) .118.5082 Fmc(914)278 -6648 E911ADD ,SS, —WRIFTCAT ON V'ORNI OWNERS NAME; b�nn+0; LL L GoQ,4v1wA 41�t>'f,StA *6�r �r %` TAX MAP NUMBER �3• -3 -1t� E911 ADDRESS: 110 & A1ERS E-r vt wl TOWN: 4>R� Ee. S owl AUTHORIZE, D TOWN OFFICIAL: '(Sibnature} ' DATE: G 3 The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town. official: This form is to be submitted with the application fora Certificate of Construction Compliance. (.911VERM" bzb:d 6T028L8:01 LUGS229VS 9NI833NI9N3 31ISNI ;l408d L2:17T OM2-61 -9f1t1 o / YML ENVIRONMENTAL SERVICES " 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director - ' - BMMD LLC ' DATE/TIME TAKEN: 06/28/04 10:O0A 2 TANAGER RD DATE/TIME REC'D: 06/28/04 11:30A BREWSTER, NY 10509 REPORT DATE: 07/13/04 PHONE: (845)-279-1771 SAMPLING SITE: 170 SOMERSET DR LOT 14 : PATTERSON NY ` COL/D BY: BRUCE MAJOR NOTES...: BASE FAUSET DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLlFORM METH: Ml::' RESULT NORMAL - RANGE METHOD - PUTNAM CNTY PROFILE 06/28/04 MF T. CDLIFORM ASSENT 1100 ML ABSENT 1008 06/28/04 LEAD (IMS) <1 ppb 0-15-ppb 9101 06/28/04 NITRATE NITROG 2.58 MG/L 0 - 10 9139 06/28/04 NITRITE NITROG <0.01 MG/L N/A 9146 06/28/04 IRON (Fe) <0.O60 MG/L 0-0.3 mg/l 2037 06/08/04 MANGANESE (Nn) <0.010 MG/L 0-0.3 mg/1 2037 06/28/04 SODIUM (Na) 149 MG/L N/A 06/28/04 pH 7.0 UNITS 6.5-8.5 9043 `06/28/04 HARDNESS,TOTAL <2 MG/L N/A 06/8/04 ALKALINITY (AS 238 MG/L N/A 06/28/04 TURBIDITY (TUR <1 NTU 0-5 NTU COMMENTS: BACT THESE RESULTS INDICATE THAT THE W WAS NOT) OF A SATISFACTORY SANITARY QUALITY ACCORDI����6��THE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. 6/Cu LEAD limits for public schools are set at 15 ppb. EPA Lead & Copper Rule for Public Systems requires that no more than 10% of their distribution points have a LEAD value of more than 15 ppb and a COPPER value of 1.3 mg/Lv else water treatment must be undertaken to reduce the waters corrosive potential. Pe/Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg/L. Na. No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg/L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg/L of Sodium is suggested. ' YML ENVIRONMENTAL SERVICES ' 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAD *t 93.401394 CLIENT #: 561721 NON STAT PROC PAGE -. 2 BMMD LLC DATE/TIME TAKEN: 06/28/04 10:0OA 2 TANAGER RD DATE/TIME REC'D: 06/28/04 11:30A BREWSTER, NY 10509 REPORT DATE: 1 07/13/04 PHONE: (845)-279-1771 SAMPLING SITE: 170 SOMERSET DR LOT 14 : 'PATTERSON NY COL'D BY: BRUCE MAJOR NOTES ... : BASE FAUSET ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE ' TEMPERATURE..: < 4C COLlFORM METHr Ml'--" ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ RESULT NORMAL - RANGE METHOD pH pH SCALE IN WATER RANGES FROM 1-14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE NORMAL RANGE OF pH IS 6.5 TO 8.5. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM Sx MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG/L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG/L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0-70 MG/L VERY HARD WATER: ABOVE 300 MG/L MODERATELY HARD WATER: 70-140 MG/L MG/L = MILLIGRAM PER LITER HARD WATER: 140-300 MG/L (1 grain/gallon = 17.2 MG/L) SUBMITTED BY: Director ELAP# 10323 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM. Owner or Purchaser of Building Building Constructed by Location - Street Building Type (3 3 <(0 Tax Map Block Lot Tow�jnNillage /f Subdivision Name 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 _ q Day Year Ge ral ontractor Owner) - Signature Corporation Name (if corporation) Address: 1'7&*?-v State IV 4 Zip ( Z' Signature: Title: Corporation Name (if corporation) Address: State Zip Form GS -97 /NS/ TE ENGINEERING, SURVEYING & LANDSCAPEARCHITECTURE, P.C. 3 Garrett Place (845) 225 -9690 Carmel, New York 10512 Fax: (845) 225 -9717 TO: Putnam Countv Health Deoartment 1 Geneva Road Brewster, NY 10509 LETTER OF TRANSMITTAL Date: 9 -27 -04 Job, No. 99147.314 Attn: Robert Morris, P.E. Re: SSTS for Cornwall Hill Estates Lot 14 170 Somerset Drive, Town of Patterson TM# 13 -3 -110 WE ARE SENDING YOU ® Enclosed ❑ Under separate cover via ❑ Shop Drawings ® Prints ❑ Plans ❑ Samples ❑ Copy of Letter ❑ Change Order ❑ the following items: ❑ Specifications COPIES DATE I NO. DESCRIPTION v5 8 -17 -04 AB -1 As -Built Drawing - 1 _ 9 -27 -04 CC -97 Construction Compliance 3 ; 9 -23 -04 I GS 97 Guarantee 1 -1 i 8 -20 -03 7 -13 -04 - -�- i --- - - - - -- - - - - ----- _� E911 Address Verification Water Test Results 6 -2 -03 WC -97 Well Completion Report 1 _ — 8 -3 -04 V 4996 i 87376 $300.00 Fee 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 1 ❑ As requested ❑Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ REMARKS: COPY TO: lot2002.dot SIGNED: d�j�z ":*� J n M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE I /NS/ T ENGINEERING, SURVEY ING & LANDSCAPEARCH/TECTURE, P.C. 1485 Route 22 (845) 278 -4990 Brewster, New York 10509 Fax: (845) 278 -6392 TO: Putnam Countv Health Department 1 Geneva Road Brewster, New York 10509 WE ARE SENDING YOU ❑ Shop Drawings ❑ Copy of Letter LETTER OF TRANSMITTAL Date: 11 -19 -01 Job No. 99147.314 Attn: Shawn Rogan Re: SSTS for Cornwall Hill Estates - Lot 14 Somerset Drive, Town of Patterson TM# 13 -3 -34.14 ® Enclosed ❑ Under separate cover via ® Prints ❑ Plans ❑ Change Order ❑ the following items: ❑ Samples ❑ Specifications COPIES ! DATE NO. i DESCRIPTION 1 - 6 -20 -00� Design Data Sheets T f % 4 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: Shawn - The enclosed application is submitted as requested in your 11 -16 -01 comment letter. Please call if you have any questions. - John COPY.TO: _..._._ copies for approval copies for distribution corrected prints SIGNED: hl (yohn M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE I01:2000.dot • tr D UT `i-r9M COUNTY DEPARTMENT O.F BsuALT DINISION OF EN-VIRONYDEWTAL HEALTH SERVICES DRSIGN DATA SHEET - S BSMA•CE SEWAGE TREAT- N.�ENT SYSTEM Owner 9;M D , L. Address s x-x� -- Located at (Street) f ra %1 ` j�,� �vr >,� nz�'a ;Map [:� Dlock �. Lot 3'f (indicate nearest cross stet) R P`.funicipality Drainage :Basin 4 X r� ' ... . .SOIL PERCCLAT i(?N -T -EST DATA . , ......... . Date of Pre- soakin P A ; Date of Percolation Test WrrpJc AS 91.4 torrM q� Hole No. Run No. Time Start - Stop Elapse Time (Min.) De_pth to Water k'rom Ground Surface ( Inches) Start Stop Water Level Drop In Inches Percolation . Rate Min/Inch SA Ag -9,56 AS ai ALf 3 9,S 3 cry 2 9LJr; 3 I����.. l4r ��f A� p2 a-. 91 3 4 3 j0zXq -1&58 �.q aay� �-5� .3 4 5 1 • 2 3 4 ' 5 n v ^ �; i. tests to be repeatea at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 minlinch, s 2 min for 31 -50 minlinch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 � TES T+ YIT DATA: DESC iON OF S0!B 'E-NCOi.T- NTERFD LN TEST NODES q Al DEPTH "HOLE NO. +HOLE rro. HOLE 1,10. G.L. 0.5' 1.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.01 8.51 9.0' 9.5' 10.0' J Indicate level at which groundwater is encountered . N oN 6' Indicate-level at which mottling is observed n) onj 6� Indicate level to which water level rises after being encountered Deep hole observations made by: 0A-CS v � Date 'Z- �� n Design 1?rofessianal Name; Jexfrey J. Contel.mo, .P.E. Address: nisite n)g' —re--ring, sun=-yvng & i ndscalm— P. 1:54'875'= Route 22 Brewster, New York. 10509 Signature: U Design Processional's Seal ENG /NEER /NG, SURVEY /NG & LANOSCAPEARCH/TECTURE, P.C. 1485 Route 22 (845) 278 -4990 Brewster, New York 10509 Fax: (845) 278 -6392 TO: Putnam County Health Department 1 Geneva Road Brewster, New York 10509 WE ARE SENDING YOU ❑ Shop Drawings ❑ Copy of Letter LETTER OF TRANSMITTAL Date: 11 -07 -01 Job No. 99147.314 Attn: Shawn Rogan Re: SSTS for Cornwall Hill Estates - Lot 14 Somerset Drive, Town of Patterson TM# 13 -3 -34.14 ® Enclosed ❑ Under separate cover via ® Prints ❑ Plans ❑ Change Order ❑ the following items: ❑ Samples ❑ Specifications COPIES 1 q _ DATE _ I — �M— — 11 -07 -01 — ; NO. —PC-97 CD -1— DESCRIPTION Application for Approval of Plans Construction Drawing ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ 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: Shawn - The enclosed application is submitted as requested in your 10 -23-01 comment letter. Please call if you have any questions. - John COPY TO: SIGNED: /IV,7N (./7ohn M. Watson, P.E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE I0t2000.dot BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI RN., M.S.N. Associate Public Health Director Director of Patient Services Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 October 23, 2001 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Jeffrey Contelmo, PE Insite Engineering Route 22 Brewster, New York 10509 Dear Mr. Contelmo: Re: Proposed SSTS: BMMD, LLC Cornwall Hill Road, (T) Patterson TM# 13. -3 -34.14 Review. of plans and other supporting documents submitted at this time relative to the above regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative -of the New York City Department of Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. Provide Aemgrr �sheqj,and Pith original signatures. Photo copies are not ac ptable. �- Provide a cleanout between the septic tank and the first junction box. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. Sincerely, Shawn Rogan Public Health Technician SR:cj PUTNAM COUNTY DEPARTMENTOF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and.address of applicant: T;r4N1 L L 2 'OrA N C-68 P o Ab 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... yr's t✓i✓IS 10. Has been completed and found acceptable by Lead Agency? ...�1 11. Name of Lead Agency '!'ow,y of PATr6 5o v P&A ynli,v a 87aA/2n 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? ........ ............................... �F4� 14. Has approval been granted by such authorities? 6S Date granted: 2ouv 15. Type of Sewage Treatment System Discharge ................. surface water -�< groundwater 16. If surface water discharge, what is the stream class designation? .................... AIIA 17. Waters index number ( surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... NO 19. If es name of water. supply y pp y Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ A✓o 21. Name of sewage system -=At A Distance to sewage system ?LE S �►. � f ��v8 22. Date test holes observed Sacs '23.. Name of Health Inspector A bAA f 68 FU�f/G . 24. Project design flow (gallons p era/ of g�3foo„ : Y g P .... 25. Is State Pollutant Discharge Elimination Systein (SPDES) Permit required ?... Na 26. Has SPDES Application been submitted to local DEC office? ......................... Farm PC-97 (_ C W S9' N y I orcl 2. $ Name of project: 021voALL HILL 6S -%rL'S .08"DI✓ts4. Locationd>j: A- TT6,P-So N Insite Engineering, Surveying & Landscape 4. Design Professional: Jeffrey J. Gontelm, P.E. 5. Address: Architecture, P C 6. Drainage Basin: E2 A s7 0 A a,, c H , Route 2z -I�� A3aar V--t� 19so� 7. Type of Protect: X Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building . Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... yr's t✓i✓IS 10. Has been completed and found acceptable by Lead Agency? ...�1 11. Name of Lead Agency '!'ow,y of PATr6 5o v P&A ynli,v a 87aA/2n 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? ........ ............................... �F4� 14. Has approval been granted by such authorities? 6S Date granted: 2ouv 15. Type of Sewage Treatment System Discharge ................. surface water -�< groundwater 16. If surface water discharge, what is the stream class designation? .................... AIIA 17. Waters index number ( surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... NO 19. If es name of water. supply y pp y Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ A✓o 21. Name of sewage system -=At A Distance to sewage system ?LE S �►. � f ��v8 22. Date test holes observed Sacs '23.. Name of Health Inspector A bAA f 68 FU�f/G . 24. Project design flow (gallons p era/ of g�3foo„ : Y g P .... 25. Is State Pollutant Discharge Elimination Systein (SPDES) Permit required ?... Na 26. Has SPDES Application been submitted to local DEC office? ......................... Farm PC-97 L 27. Is any portion of this project located within a designated Town or State wetland? CS 28. Wetlands ID Number ............ ............ .................... J............. ............................... Al. 29. Is Wetlands Permit required? ...... .................... .:....... ............................... A10 Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... Ne 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 activit3,? ............................ Yes/No 4/0 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? ............... /1/6 ................ Yes/No DESCRIBE: KCf0AAl ANPr(LL /t A. -rsrD,5 OF' rop—di'MLLPlr_C R°A SALT 3120 ILG %104TTI�RS -nl F 16G;JWA'1 LO-'J% -AIP., ee 33. Is there a local master plan on file with the Town or Village? ......................... yt%S 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... 1 AIM)WAI .35. Are any sewage treatment areas in excess of 15% slope? . ............................... & -36. Tax Map ID Number .......................... ............................... Map 13 Block -3 Lot Lq j1 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 NVatershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit Viose forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must. be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. 1 hereby affirm, under penalty of perjury, that information provided on this forin is true( to the bestvf my knowledge and belief. False statements made Herein are punishable as,`W a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. C" SIGNATURES& OFFICIAL TITLES: r BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 ' Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 October 23, 2001 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Jeffrey Contelmo, PE Insite Engineering Route 22 Brewster, New York 10509 Re: Dear Mr. Contelmo: BMMD, LLC, Cornwall Hill Road (T) Patterson, TM# 13. -3 -34.14 Reservoir Basin - East Branch The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on _ October 10, 2001 is complete. The Department will notify you by November 12. 2001 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. ❑ 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 would 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 New York City Department 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 contact the Department of Environmental Protection regarding such activities to see if DEP review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2159. Sincerely, Shawn Rogan Public Health Technician SR:cj (I3aHSA32I) Sall Qd 17l>1WN S2I3NM0 `3io0 S Z T C —)(—.--1 Qa2 mbau dI ` %SI O.L aaQvH!)31t (7C--) s Q S3I1idQNflOg 3dAS'IIOS `�QSr1C�CT) ( %OZS� yM S.LSS ha 3dOZS( -C�>> /� sNI�QAIId.L2iIL ma.L.Ln!)/om.LooiM(7) ols . ED `Sad aARiQ O'IS T8 AbM C�� aNI'I A.L1I3dO1id 01 ,51 i' '(�k -- - Qasoaoua v ONLLSIx3 MOIAOO ZMC,7) NOMANNOO aou'aaS 30 NOLLyoO'IC I � SIISai daaQ8 Oi3d dL�Q 4IQC ----- -------- AllaadO2id 01 Voism3I ST-I S3ZON NOLLOr1WKTo -3( 7) IMA IAWI3A AYY o((7) 'I'IaM OI.OS `NOLLyQ)vflOd I1O2i3 ,OiC-)C7) a'Iuoua oI'I ydaAH SQSSC .7) (MOuu Hi?ON)-N a Lams 3 YAiasM� dOifO 9Q3 OImOtC spaiSAS Aa' iYo ,OSI �'o.La `uioA1iasalI BOOS /,OOzC�(7S S Z )v0 SZI 3Q Q32Ilfl 3 (� _ aS2TllOO. �0�'NPd2iQ iN3i.LII�lT2i3.LNI ;OSC� Q'IO.SuaA OT <SIO'I `J TIvIIS3I'IIOS(;7)n 1 V S V ,00Z UM NOIIYA3'I3 QOO'I3 ZIA 0OIC —)� (, OZ - qjd) ah'I i3IyM OI SOT dgZQg ZialZ3'IC�C� - -aaldM QadId `NM(HAM0iS ,S£ `NISVg H31YO OI ,OS �) NOLLYOLH.LON UO8B0I3N 6961 32id /C—)i7 (ued=a a'a) a�'I `a52Ir1OO1IaIbM `I�lYa1TIS OI.00T(��% awys IIIU1iaa v Smvia saa NO Yiva(�C. r ) sua OZ .OSI `QO'IQ NI AOZ `'I'IatA OZ ,OOIC�� Qaba2I jngaad o3Q1.4MO.I) SQAI� II3M�)C ) S'ITV NOIIVmmOd OI.OZC� sio'I rQy sass'IyAOxady-x3C�� . 'iui 30 aOi `saaul a-D ay i `AdMaAiva ''ra OI ,OI � Q3SS�tiT LIM 3S OI So2I3dC�C� S . S wO - O Sao ,ISI !�0 a3S QaA2taSg0 S37OH IS3I d33Q(�n 1I�11OO 3'IIIX3ZO39(�C� (ibu.H `TfAOujay Z?AV95 MRSdM 110 aNOIS QaHSRUD 33213 lSr1Q/'I vi3QC� - QHOd OI Q3I�93I3Q( )n daQ O Q3iLIICal1S S\ hac-�C j� SunolNOO OI'I3'I'I�+'2iYd( � Q�Sggi�M OA.'d !�I Q3i�'JO IC —)C� X�'I1t 1309 r- allGAO2Id HOMUI 3'IC—(� a9. aclo IS d0 aol IIiOUA 3OKVILSICI NOI a2IIRa32i NI�1iQ l ilillOnn SflOIATNU Z 7 Q3LHSSY'IXm `'S' UO3. \0 "IOAC�C� HZdaQ It L°/ (Imnbn TII3C�n, S HId3Q(�C� 4 -7 3i�'2T O1T3dC�Cii Qa�IOM TVAOU(TaV \OISIM(Iff ISC�C~i a N NOI H I3I�� C�C� \OISIAIQSl1S �O3'IC�(� ) RO S� IAMEMS 3 Z1 �2IJ IS .LS3fIbnao \ytayACWC� da2lir NOISN�ddX3:�'I'II3C�(� SI3S O.ili- S)d�"Id 3Sf1OHC�n SNOISNaI�TIQ �' $'IIdO2Id'I II3C�C� Si3S arau-SATT�Zdi�(7) S-i SalON'I'IId /SO3dS'I'II3C�� 3Y3 i1iOHSC�� aavao OZ T £ Sa(lols Homi. ISvd ''IvINOZRiOH ,Ol NOLLl1' osau a.LvuOa- ao:)MC;7) SWIMS Till , S*r''�r y1d (S(iQ) Hans Y.L Q NOIS3QC�C7� (3ON��IO O!U aiO\ 3lIS NOI YZMOHJnY 3O 1i3ii31C�(� S I M mod" ate, L6-od( )(7-) inowa'IO /M oSb SQNI MI 'samaa 0!,()(7 1I3llal SAW 110 I111T1i3d ZZ3 T--)(% 3 NO1II ISdo Adld aau l,O,,t- 'L3 «' /,.-MUS 3SflOHC—)C%7 KouyJrldav jmk aC-n .I AO0 S. Z t�0 SII 3Q Q3 3 \ A. S �31U1oO \ l (Q OO) :O�dWq kbi ►�� Ql ulvaesv `do lu :Afi Q3.'il31 n 6V Il / ' :IIOUVO01 i332I.IS ..� q v *2i3NMO 30 �'�IdIQ tJ t1v m4lu3d wuor1 usL 00 2IO3 Iaans MaIAa2I SIvi3ISAS INaIAjIy3III nyms 3oyd2Insafis TS A'Iddf1S 1IaiYM'Idr1mmwa HllY3H'IYL \3IC\O2IMa 30 NOISIAIQ HI'IY3H 30 L %MVll2Itd3Q AlAR0O I1TyN.Lfld - �S.LN3I4I10O ddId aaJVUOdUad- N N Oj a3icgaSCp sup Saw Z81 gIpd SOOT /3O)Ma:)SI Q QO of NIIq ,OZC)C--) SQNnOff `8 SUZIM Ai1iiaOIUC--)��) %T>- %OOT ` %T-.S£ ` QO oI NII1I Sine S sirs 10 JOOZ NUM Mass v STIaMC�C� 'Ilum ` SNOLLYAa'la DMA13SY8 Q I S QNV UOOU HSINI3 Q3SOdOUd(�C/� Qa'IIT�iaQ HS g g-Q Qkv iIdC�C� . Td 30 �OOZ NIH LIM s(imr l3M`Sa vi ('oIa `adAl adld) ` dTAi a 3 . T SQNOd `S3S2i(lOOlIaidM d0 NOI.L�OO'IC — QalON M f1'IOA 3SOQ/ 'I0 d 30 %SL 3soaMM 3 3oN31i33ad O a.Ly(l — S3ION allnaC'�C� N #3NOHd SSa1iQQd 314VN'VW3d-lgI S AS d/aS0 # Qa2 mbau dI ` %SI O.L aaQvH!)31t (7C--) s Q S3I1idQNflOg 3dAS'IIOS `�QSr1C�CT) ( %OZS� yM S.LSS ha 3dOZS( -C�>> /� sNI�QAIId.L2iIL ma.L.Ln!)/om.LooiM(7) ols . ED `Sad aARiQ O'IS T8 AbM C�� aNI'I A.L1I3dO1id 01 ,51 i' '(�k -- - Qasoaoua v ONLLSIx3 MOIAOO ZMC,7) NOMANNOO aou'aaS 30 NOLLyoO'IC I � SIISai daaQ8 Oi3d dL�Q 4IQC ----- -------- AllaadO2id 01 Voism3I ST-I S3ZON NOLLOr1WKTo -3( 7) IMA IAWI3A AYY o((7) 'I'IaM OI.OS `NOLLyQ)vflOd I1O2i3 ,OiC-)C7) a'Iuoua oI'I ydaAH SQSSC .7) (MOuu Hi?ON)-N a Lams 3 YAiasM� dOifO 9Q3 OImOtC spaiSAS Aa' iYo ,OSI �'o.La `uioA1iasalI BOOS /,OOzC�(7S S Z )v0 SZI 3Q Q32Ilfl 3 (� _ aS2TllOO. �0�'NPd2iQ iN3i.LII�lT2i3.LNI ;OSC� Q'IO.SuaA OT <SIO'I `J TIvIIS3I'IIOS(;7)n 1 V S V ,00Z UM NOIIYA3'I3 QOO'I3 ZIA 0OIC —)� (, OZ - qjd) ah'I i3IyM OI SOT dgZQg ZialZ3'IC�C� - -aaldM QadId `NM(HAM0iS ,S£ `NISVg H31YO OI ,OS �) NOLLYOLH.LON UO8B0I3N 6961 32id /C—)i7 (ued=a a'a) a�'I `a52Ir1OO1IaIbM `I�lYa1TIS OI.00T(��% awys IIIU1iaa v Smvia saa NO Yiva(�C. r ) sua OZ .OSI `QO'IQ NI AOZ `'I'IatA OZ ,OOIC�� Qaba2I jngaad o3Q1.4MO.I) SQAI� II3M�)C ) S'ITV NOIIVmmOd OI.OZC� sio'I rQy sass'IyAOxady-x3C�� . 'iui 30 aOi `saaul a-D ay i `AdMaAiva ''ra OI ,OI � Q3SS�tiT LIM 3S OI So2I3dC�C� S . S wO - O Sao ,ISI !�0 a3S QaA2taSg0 S37OH IS3I d33Q(�n 1I�11OO 3'IIIX3ZO39(�C� (ibu.H `TfAOujay Z?AV95 MRSdM 110 aNOIS QaHSRUD 33213 lSr1Q/'I vi3QC� - QHOd OI Q3I�93I3Q( )n daQ O Q3iLIICal1S S\ hac-�C j� SunolNOO OI'I3'I'I�+'2iYd( � Q�Sggi�M OA.'d !�I Q3i�'JO IC —)C� X�'I1t 1309 r- allGAO2Id HOMUI 3'IC—(� a9. aclo IS d0 aol IIiOUA 3OKVILSICI NOI a2IIRa32i NI�1iQ l ilillOnn SflOIATNU Z 7 Q3LHSSY'IXm `'S' UO3. \0 "IOAC�C� HZdaQ It L°/ (Imnbn TII3C�n, S HId3Q(�C� 4 -7 3i�'2T O1T3dC�Cii Qa�IOM TVAOU(TaV \OISIM(Iff ISC�C~i a N NOI H I3I�� C�C� \OISIAIQSl1S �O3'IC�(� ) RO S� IAMEMS 3 Z1 �2IJ IS .LS3fIbnao \ytayACWC� da2lir NOISN�ddX3:�'I'II3C�(� SI3S O.ili- S)d�"Id 3Sf1OHC�n SNOISNaI�TIQ �' $'IIdO2Id'I II3C�C� Si3S arau-SATT�Zdi�(7) S-i SalON'I'IId /SO3dS'I'II3C�� 3Y3 i1iOHSC�� aavao OZ T £ Sa(lols Homi. ISvd ''IvINOZRiOH ,Ol NOLLl1' osau a.LvuOa- ao:)MC;7) SWIMS Till , S*r''�r y1d (S(iQ) Hans Y.L Q NOIS3QC�C7� (3ON��IO O!U aiO\ 3lIS NOI YZMOHJnY 3O 1i3ii31C�(� S I M mod" ate, L6-od( )(7-) inowa'IO /M oSb SQNI MI 'samaa 0!,()(7 1I3llal SAW 110 I111T1i3d ZZ3 T--)(% 3 NO1II ISdo Adld aau l,O,,t- 'L3 «' /,.-MUS 3SflOHC—)C%7 KouyJrldav jmk aC-n .I AO0 S. Z t�0 SII 3Q Q3 3 \ A. S �31U1oO \ l (Q OO) :O�dWq kbi ►�� Ql ulvaesv `do lu :Afi Q3.'il31 n 6V Il / ' :IIOUVO01 i332I.IS ..� q v *2i3NMO 30 �'�IdIQ tJ t1v m4lu3d wuor1 usL 00 2IO3 Iaans MaIAa2I SIvi3ISAS INaIAjIy3III nyms 3oyd2Insafis TS A'Iddf1S 1IaiYM'Idr1mmwa HllY3H'IYL \3IC\O2IMa 30 NOISIAIQ HI'IY3H 30 L %MVll2Itd3Q AlAR0O I1TyN.Lfld (Q OO) :O�dWq kbi ►�� Ql ulvaesv `do lu :Afi Q3.'il31 n 6V Il / ' :IIOUVO01 i332I.IS ..� q v *2i3NMO 30 �'�IdIQ tJ t1v m4lu3d wuor1 usL 00 2IO3 Iaans MaIAa2I SIvi3ISAS INaIAjIy3III nyms 3oyd2Insafis TS A'Iddf1S 1IaiYM'Idr1mmwa HllY3H'IYL \3IC\O2IMa 30 NOISIAIQ HI'IY3H 30 L %MVll2Itd3Q AlAR0O I1TyN.Lfld . jo i-,,W K tairm PUTNAM COUNTY DEPART'MEN'T' OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET e SUBSURFACE SEWAGE TREA.TM15NT SYSTEM Owner 13H M, , LL G Address o2 7wur, t? r2 oAP L 305Hs j Located at (Street) LoeNd ALL ILL p.-p SonerSst'.pp,Tax Map 13 Block Lot (indicate nearest cross s(eet) Municipality PA P 5 O _Drainage Basin 4$r tor 1� : SOIL PERCOLATION TEST DATA Date of Pre - soaking (o J D� Date of Percolation Test ra Bole No. Run No. Time Start - Stop lEla se Time (pMin.) De • th to Water rom Ground Surface (inches) Start Stop Water Level Drop In' Inches Percolation Rate 'Min/Inch ' � s 2 9:57 - 1 C' 3 17 a l %a a .q !x 3 6. 4 5' . 9,q3 �rJ 2 .9 :5 ]"P; 15". �/ a' o2.y 3 �, 15 3 1�,i8— 10:3 19 a� aq 3 �, 3 4 a 5- 1 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. ,s I min for 1 -30 min/inch, s 2 min for 31 -60 mWinch) All data to be submitted -for review. t t 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' T'ES'T PIT DATA ' DESCRIPTION OF SOILS ENCOUNTERED IN TEST . HOLES HOLE NO. HOLE N0. J fjl- HOLE NO. 2 3.0' L OA M 3.5' LdA�t 4.0' H1 �vie-L 4.5' 5.0' 5.5' TAN 6.0' SA�J� �i c ► r c 1`r %177 6.5' 7.0' 7.5' 8.0' 8.5' 9.0` 9.5` 10.0' Indicate level at which groundwater is encountered NoPg' Indicate level at which mottling is observed Indicate level to which water level rises after being encountered /1) .Deep hole observations made by: 3o'gd yl , cJ*-6&,3 Date Z-16-00 Design Professional Name: _Jeffrey J. Contelmo, P. E. Address:znsite Engineering- & Surveying, P.C." - P,atlt-p- 22 Brewster, New York 10509 r 4, `Signature: Design Professional's Seal °- � in 3 14 -16-4 (2/87) —Text 12 PROJECT I.D. NUMBER 61721 SEAR ;# Appendix C State Environmental Quality Review SHORT .ENVIRONMENTAL ASSESSMENT FORM - For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant-or Project sponsor) 1. APPLICANT /SPONSOR 2. PROJECT NAME , 5S) S F04 Co ALL i I tE i t S LOT . 3. PROJECT LOCATION: Municipality eAmsmf County 4. PRECISE LOCATION (S reet address and road intersections, prominent landmarks, etc., or provide map) SCE LOCAFION1 MAP oNf C0V5rrvc -TfP\r A4wldcll 5. IS PROPOSED ACTION: New • ❑ Expansion ❑ Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: CoOliI`:i Coal Or" ON'C r'AMit� RrSiViFkcF- ..DAIvEt✓N SSI "S, WELL � AW A PPS ►2 i EVA IVcr 7. AMOUNT OF LA �D,A�FFFECTED: 00 Initially acres Ultimately .- acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? .Yes No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? kesidential ❑ 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) ?. KYes ❑ No If list yes, agehey(s) and permlUapprovals Ptivi;w;t`t P�ti�1�T - 7G.�N' �r f�lTtE1;Sc� 5srs -*WELL - PC NS, O1lALA V( 11AM45Ck( 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes I& If yes, list agency name and permltlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes (&o I- CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1,SSli�E1�'GInIE``1Ek'11�''C -, SU����Y�r�l &� U�f�sujPE q�J;rllrEc�u ^L,Pi;: / Applicant/sponsor name: J�A� M = WATSCN Y. G Date: 8— o r Signature: M 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 r' PART If- ENVIRONMENTAL ASSESSMENT (ro 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 goats as officially adopted, or a change In use or intensity of use of land or other natural resources? Explain C5. Growth, subsequent development, or'related activities likely to be Induced..4y the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not identified in C1-05? Explain briefly. C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly. D. 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. ❑ Check this box if you have identified one o� more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL E4 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 Signature of Responsible Officer in ead Agency Date Title of Responsible Officer Signature of Preparer (it different from responsible officer) t P UrNAAl COUNTY DEPARTMENT OF HEALTH' DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A. WASTEWATER TREATMENT SYSTEhrl 1. Name and address of applicant: �-��- i i 2. Name of project: i1t�i. t-; -V4r6 T ocatlo%A) liisite !Yngineering, Surveying S Landscape 4. Design Professional: Jeffrey J. contelm, P.!:. '5. Address: ply *t-- P. C. -- Route 22 6. Drainage Basin: 7. Type of Project: Private/Residential Food Service Commercial Apailments Institutional Mobile Home Park- Office' Buildirig _ _ 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 _�L 9. Is a Draft Environmental Impact Statement (DEIS) required? ......:.................. qc$ Fi�:t5 . 10..Has'BE 8 been completed and found acceptable by Lead Agency? ..... .� l �� ''����- t �`l -3 11. Name of Lead Agency '%o n) or ��rtr5 �u.�! ✓1:� �� 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......................................................... ............................... 13. If so, have plans been submitted to such authorities? ........ ............................... 14. Has pin�approval been granted by such authorities? qc5 Date granted: 15. Type of Sewage Treatment System Discharge ..............:.. surface water X groundwater 16. If surface water discharge, what is the stream class designation? .................... A; 1A- 17. Waters index number (surface) ..........................:................ ............................... ,) / A- 18. Is project located near a public water supply system? ....... ............................... 19. If yes, name of water supply ,-� I A- Nc Distance to water supply 4) 20. Is project site near a public sewage collection or treatment system? ................ ,moo 21. Name of sewage system ,J i A-. Distance to sewage system - 22. Date test holes observed peu�,.- —u..'oo p 23. Name of Health Inspector kpAv-.-,, (Zi � 3 aO 24. Project design flow (gallons per dayS ................................. ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? .......................... ✓� � -- Form PC -97 27. Is any portion of this project located within a designated VWA Dr, 'Sfiate'vN,et Ian d? 28. Wetlands ID Number ............ ............................... J...................... .........NS�EG Q °2Z 29. Is Wetlands Permit required? . .................................................. I........................... /� d Has application been made to Town or Local DEC office? 30. Does project require a DEC Stream Disturbance Permit? .. ............................... fJ 31. Is or was project site used for agriculivral activity involving application of pesticides to orchards or other crops, S01101. or hazardous waste disposal, landfilling, sludge application or industrial activit)'? ............... J 32. is project located within 1,000 feet of or abandoned landfill; hazardous waste site, salt stockpile: landfill.. sludge disposal site or any other potentially lrnoi;m source of contamination? ..................... U' DESCRIBE: "<s. '-5 -4-A'tb 51 7 ��GIG,r✓�GE' /, ycs�n! ff (r ,c�zL� j P&Y — 33. Is there a local master plan on. file with the Town or Village? ....... � "�'� 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent. to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... /Jb p Map i -� Bloc/: 3 Lot f� 36. Tax Ma ID Number ............... ............................... 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 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 I .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 o �4 t� 1 Law. ��/� S1"GNATURES & OFFICXAL TITLES.- .......... . Mailing Address: ................................... .- 1-'�")"e Y'f' A0.171J PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION 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: Cornwall Hill Estates Lot # I, Bruce Major represent that I am an officer or employee of the corporation and am authorized to act for: Name of Corporation: BMMD LLC Having offices at: 2 Tanager Road, Brewster, NY 10509 Whose Members Are: John Boyle Bruce Major Bruce Major John Dale 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 Signed: / . Title: -Manager Sworn to before me this / day of (month) V.4. (year) Zoo / Notary Public .@31UVM PARSOM N0.01 PAQ24M In Putt" Caine . . Corporate Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of BMMD LLC Located at Cornwall Hill Road T/V Town of Patterson Tax Map # 13 Block 3 Lot 340 Subdivision of Cornwall Hill Estates Subdivision Lot # � �' _ Filed Map # 2856 Date Filed 04 -04 -2001 Gentlemen: This letter is to authorize Insite Engineering Surveying & Landscape Architecture, P.C. Jeffrey J. Contelmo, a duly licensed Professional Engineer X or Registered Architect_ to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law; the. iblic Health Law, and the Putnam County Sanitary Code. �• OF NEW, P.E., # 61931 Mailing Address &`E'afidsc �eArchitecturc 1485 Route 22, Brewster State New York Zip 10509 Telephone: (845) 278 -4990 Very truly yours, Signed (Owner of Property) 2g Mailing Address: 2 Tanager Road P.C. Brewster State New York Zip 10509 Telephone: (845) 279 -3613 Form LA -97 TE LANDSCAPEARCHIrECT-URE, P.C. ENGINEERING, SURVEYING a 1485 Route 22 (845) 278-4990 Brewster, New York 10509 Fax: (845) 278-6392 TO: Putnam County Health Department 1 Geneva Road Brewster, New York 10509 LETTER OF TRANSMITTAL Date: 10 -8-01 Job No. 99147.314 Attn: Robert Morris, P.E. Re: SSTS for Cornwall Hill Estates - Lot 14 Somerset Drive, Town of Patterson TM# 13-3-34.14 WE ARE SENDING YOU 0 Enclosed ❑ Under separate cover via ❑ Shop Drawings 0 Prints ❑ Plans ❑ Copy of Letter ❑ Change Order ❑ the following Items: ❑ Samples ❑ Specifications COPIES DATE NO. 1 DESCRIPTION 5 10-8-01 CD-1 Construction Drawing 1 10-8-01 CP797 Permit 1 6-8-01 WP-97 -Construction Well Permit 1 LA-97 Letter of Authorization 1 5-1-01 CA 97 ftt Corporate Affadavit 'o 1 PC-97 Application for Approval of Plans 1 10-8-01 Short EAF 1 6-20-01 DD-97 Design Data Sheets (previously submitted with subdivision application) 2 ___._..._._ --_-1- _4 Bedroom Floor Plans 1 9-6 -01 john 1 $300.00 Fee M. Watson, P. E. THESE ARE TRANSMITTED as checked below: 0 For approval ❑ Approved as submitted ❑ Resubmit copies for approval 0'For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return In f.-I corrected -prints; -v ❑ For review and comment REMARKS: r,.. CD, COPY TO: SIGNED: john M. Watson, P. E. IF ENCLOSURES ARE NOT AS NOTED, KINDLY NOTIFY US AT ONCE lot20OO.dot / PtTNAM COUNTY DEPARTMENT OF HEALTH • DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Date: o e Inspected by: 6, Street Location if ogAIzdAL L/ -1L /_L a /i5AMEK3 Owner g &,y L L C Town Permit # p — yip -O/ TM # !3 - 3 - 3 if, l Subdivision Lot # / ze 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 ...... ............................... 11. Sewage System a. Septic tank size - 1,000 ...:.. ::1,2 ........other ................ b. * Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box 1. All outlets at same elevation -water tested ..............:.. 2. Protected below frost .................. ............................... 3... Minimum 2 ft. Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. renc Fes 1. Length required X00 Length installed 11op 2. Distance to watercourse measured -� / o a Ft.......... 3. Installed according to plan ......... ............................... 4. Slope of trench acceptable 1/16 - 1/32" /foot ............. 5. 10 ft. from property line - 20 ft.- foundations.......... 6. Depth of trench <30 inches from surface ...:.............. 7. Room allowed for expansion, 100 % ......................... 8. Size of gravel 3/4 - 11/2" diameter clean ...................: 9. Depth of gravel in trench 12" minimum .......:........... 10. Pipe ends capped ........................ ............................... g. 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........... M. House/Buildiiig a. House located Der approved Dlans .. ...........................y.., Well located as per approved plans ................................. b. Distance from STS area measured + top 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. Backf l material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected. & dir.to exist watercourse g. Footing drains discharge away from STS area ............... Rev. .« y i �a M. rte= MOM N"Irs Film IFIMMIN VIEW ,MU, NAM RAJ .« y JUL -24 -2003 15:40 ' FROM:INSITE ENGINEERING 8452259717 TO:2787921 P:1/1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL. HEALTH SERWES ATTENTION 0 ADAM. � GENE REQUEST FO&UNAL INSPECMB For: Fill All information must be fully completed prior to any Trenches inspections being made. PCH'D Construction Permit Located: C or nvia -0 _ } l�t� ►2f�a At a;�n�.,Pr •� (� {u_ , (f (V) ' k+ie-r sc-n Owner /Applicant Name: _ 2*-,am � , �. �- C. TM Block —,3— Lot 2&A4 Formerly: Nlfi Subdivision Name: Cox nwrftQ MU &��_ _ Subdivision Lot', 1 4 Is system fill completed? A/.1A Is system complete? y s Is system constructed as per plans? IS s Is well drilled ? , Is well located as per plans? Ic S Are erosion control measures in place? 30 Date: Date: Date, - 7/zz)6:: I certify that the system(s), as listed, at the above premises has been constructed and I b.ave inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans ud the Standards, Rules and Regulations of the Putnam County Department of Health. Date: _ C).a Certified by: PE _X RA Insi a E=ngineering, Surveying & ign Pro sional Landscape Architecture, P.C. Address: 3 Garrertt Place Lic. # 1 `� r M T . Form FIR -99 15:43 TEL:845 -278 -7921 NAME COUNTY OF LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneya 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 July 31, 2003 Jeffrey Contelmo Insite Engineering 3 Garrett Place Carmel, New York 10512 Dear Mr. Contelmo: ROBERT J. BONDI County Executive Re: Field Inspection — BNEV D, LLC Cornwall Hill Road /Somerset Drive (T) Patterson, TM# 13 -3 -34, Lot 14 The above referenced separate sewage freatment system can be backfilled. The following comments must be corrected in the field. 1. The cast iron pipe connection from the house to the septic tank needs to be installed. g,i 2.`Y, If house building plans exist, they must be submitted to this department for a bedroom count. At this time our records show a generic house plan which does not match the existing structure. 3. Additional erosion control measures must be installed at the upper construction area, per the approved plan regarding the house and well. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, ., 4 � 4!/, -(/? Gene D. Reed Environmental Hdalth Engineering Aide GDR: cj SENDING CONFIRMATION DATE AUG -1 -2003 FRI 08:24 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92259717 PAGES : 1/1 START TIME : AUG-01 08:23 ELAPSED TIME : 00r 23" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a LORF19'A MOLDIARI ILK, M.S.N. ROBERT J. BONDI Aefna PWI. Kush I one BET BaaeDO Dbterar of fthmt Sklv6'b D—EP`ARTIv(ENT OF HEALTH 1 (Ie+u^+ Rafd, Brewster, New York 10509 900MM."l -Rolfe (84S) 278.6170 F"(945)278-7921 NurAhl 9aNm(14S) 271.6558 WIC(845)278 -6678 Fn(145)271.6015 Early IuferKOanNReetpol (845) 271.6014 Foe (145) 271.6648 July 31, 2003 Jeffrey Contelmo Inane Engineering 3 GarrcttPlace Carmel, New York 10512 Rc: Field Inspection — BMMD,LLC i Cornwall Full Road/Somerset Drive M Patterson, TMN 133-;4, Lot 14 Deer Mr. Contalmo: The above referenced separate sewage treatment system can be backfi(led. The following comments toast be corrected In the field. i 1, The cast iron pipe connection from the house to the saptic tank needs to be installed. 2.aK, If house building plans exist, they trust be submitted to this department for a bedroom count. At this time our records show a generic house plan which does not match the existing structure. 3. Additional erasion control measures must be Installed at the upper concoction area, per the approved plan regarding the house and well. If you have any further questions, please contact me at 645 - 279 -6130, en 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:aj LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 GenO'va 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 July 31, 2003 Jeffrey Contelmo Insite Engineering 3 Garrett Place Carmel, New York 10512 Dear Mr. Contelmo: ROBERT J. BONDI County Executive Re: Field Inspection — BNIlVID, LLC Cornwall Hill Road/Somerset Drive (T) Patterson, TM# 13 -3 -34, Lot 14 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. 1. The cast iron pipe connection from the house to the septic tank needs to be installed. 2. Additional erosion control measures must be installed at the upper construction area, per the approved plan regarding the house and well. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR:cj W' 0 L`. k a CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # - �? ,f II e� v Located at O f ta! G( i I o A o vn e�-S f ��e Town or a I�s,� Subdivision name 9!,11 ��� f ttar Subd. Lot # Date Subdivision Approved -01 Owner /Applicant Name 'S /y)1Y,-D L L e Mailing Address -f9,h a q 0 A" R 0&. Tax Map 13 Block' 3 Lot '31. I Renewal - Revision Date of Previous Approval Zip / o1-3 Amount of Fee Enclosed `� 00 Building Type % eV,zt, Lot Area 5, 00 No. of Bedrooms Design Flow GPD ��(7 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to-consist of �, Z- S gallon septic tank and H ®a L F 2 ' tv e- - Ct 6 s V r-2 Other Requirements: (' - • 0 - - UayeA r � To be constructed by �o bQ delp't1 rh.C'A Address Water Su 1 : Public Supply From Address or: Private Supply Drilled by °r0 Gej�rjnin4 Address 1� 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 'ihereof 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 S A ate 10- 8-0t Am 'Je tvre- License # 61831 APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w n c nsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe proved ischarge of domestic sanitary sewage n y By: Title: Date: Iddol White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL . / please print or type PCHD Permit Well Location: Street Address: Town/e Tax Grid # CDrnW#A H-,11 WhAarsrd 1` (iv I lerfov,. Map 13 Block 3 Lot(s) Well Owner: Name: Amm LLB Address: �h� �n G�- ���, Aly 1 o-4--o9 Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served S Est. of Daily Usage ' a gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling ( New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type Drilled Driven' Gravel Other Is well site subject to flooding? ............................................... ............................... Yes No Is well located in a realty subdivision? ................................ ............................... Yes_)< No Name of subdivision COQ A if,ll / Lot No._ Water Well Contractor: -1 � P ��►}j p rvry �,�_ Address: �.�I Is Public Water Supply available to site? ................................. ............................... Yes No Name of Public Water Supply: Town/Village 1st Distance to property from nearest water m in: /U Proposed well location & sources of contamination to a provided on separate sheet/plan. Date: 10- 'V ° ( Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam.County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Di recto w Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a wa r ll driller certified by Putnam County. Date of Issue 1 Z C a O f Permit Is icial: Date of Expiration / ! a Title: Permit is Non - Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT — � r� Act)4A Well Location Street Address: I 10 �or�e"066— be(A V Town/Village: PXfc C 5 61-, Tax Grid # Map -tom Block 3 Lot(s) t L O Well Owner: Name: Address: /, & . g6rca -3 ►1 M q Use of Well: rimary 2- secondary Residential Public Supply Lj 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 21 ft. Length below grade 96 ft. Diameter :Z in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded =A Threaded _ Other. Seal: _ Cement grout X Bentonite Other; Drive shoe: Yes No _ Liner Yes 'N& Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped X Compressed Air Hours6T Yield gpm Depth Data Measure from land surface - static (specify ft) During yield test(ft) &6)n' 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 Sail V I -o h, e. E Jul If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type j&cLiZ Capacity Depth 7—i © Model V f C'04q Voltage Z3 U ��FI"P j Tank TypeQh(�Ft�NVolume Date Well ompl eed 109 1 Putnam County Certification No. 56-2 Date of po 6 433 Well Driller (signature) nj��^ A&e NOTC: Exact location of well with distances to at least two permanetdt latldmarks to be provided on a separ2sheet/plan. Well Driller's Name /`'/ ZICL r' . -,"UtJils Signature: ✓ Address:/6/9_._ 6 e6" 6n Ay. Ives Date: 6 () White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 DROP BOX (T?P. EXPANSION ABSOJ TRENCHES (TYP.) 100% EXPANSION PROVIDED . / 7 6` t/ / / 4 O l 11 2 a 1,250 GALLON SEPTIC TANK PRIMARY ABSORP77ON TRENCHES (TYP.) le. OR 1,161, AS -BUILT MEA Ts NO. A LU7 CORNER DKEWNG B R10fr CORNER OF DKELLiNG C CORNER OF DC£ D CORNER, OF DRS NG REMARKS 23' .41' 1.250 GAUaV SEPnC TANK 2 64' 74 DROP BOX 3 70' 78' DROP BOX 4 76$ 831 DROP BOX 5 820 88' DROP BOX 6 88' 93, DROP BOX 7 94' .98' DROP 86X a 100' 103.6, I DROP BOX. 9 101' 103' END OF- n?ENCH 10 118, .92' BVD OF 65, 72' END OF n?fN0f 12 89' 56' 1 END OF n?ENCH 11 30' 32' aEAWUT 14 58, mu I NO. I DATE I REVISION 1 6Y 1 Af T ENGINEERING, SURVEYING & LANDSCAPE ARCHI TEC TURF, P C. PRO . JECT SSTS FOR BA4MD,, LL C COMWAL HILL UTA IFS WT #11) 170 SWOMET DR K TOW OF PA"VnM, PUTNAM COUNTY, NEW MRK DRA WING: 3 Garrett Place Carmel, NY 10512 (845) 225-9690 (845) 225-9717 fax www.insite—eng.com OF NE4, A, 3 C 0 Co ui Cl! C