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HomeMy WebLinkAbout0443DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13.07 -1 -8 BOX 6 00252 LE „ ., -. .. Ir ��- LIV 1 ` , ��; . , ., %3 A 14,16 00252 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANC TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 1 Located at � "� �` Town or Village PaTIW-60 H Owner /Applicant Name. Formerly cjkPJ C'0HV' AA Tax Map 1� 61 Block ' Lot 16 Subdivision Name Subd. Lot # VL Mailing Address r� Tul-i f P°AD b9-e' M Zip Date Construction Permit Issued by PCHD I J W - Separate Sewerage System built by JiN"%U�' Address PIP + k4 D ID; Consisting of 0-50 Gallon Septic Tank and Other Requirements: Water Supply: Cv " 2� VY Public Supply From Address or: 'A Private Supply Drilled by 61�D ��- PP41-L I H �► Address 10 �'� 'T S7- LAW, 04J l�S`11, Building Typed ���� Has erosion control been completed? Number of Bedrooms /' Has garbage grinder been installed? lG� HO 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: I 1 � -02, Certified by Address P.E. X R.A. ial _ 6 5 � 1 V r License # Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Public Health Director, such revocati ix m dificat* or change is necessary. By: / �/� Title: � � Date: Go u a Z White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 Cash ❑ Check M O ❑ Credit Card . By : //% . } Harry W. Nichols Jr., P.E. Patterson Park, Suite 106, 2050 Route 22 Brewster, M 10509. Telephone (845) 2794003 Fax (845) 279 -4567 September 16, 2002 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New.York 10509 Re: Individual SSTS Compliance - Conklin Crossroads - Lot # 12. (T) Patterson, NY Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing S -12, "As -Built SSTS,"' dated 8/14/02. 2. "Certificate of Construction Compliance for Sewage Treatment System," dated 9/16/02. 3. Three (3) copies of . "Guarantee of Subsurface Sewage Treatment System," dated 9/16/02. 4. Laboratory Reports, dated 8/27/02. 5. "Well Completion Report," dated 8/26/01. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Department. 7. "E -911 Address Verification Form," dated 1/3/02. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic Is Jr., P.E.. HWN:JM:jmm 00- 181.00s -I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: ► PAN kAQ (50 KKO-" f i& K Q) Town/Village: IJa {7t -g Q ✓7 Tax Grid # I�, O'l - i - I Map Block Lot(s) r Well Owner: Name: `, Address: �G C assoCta. es -%-a- vl i �' d �r�ursf� L a Use of Well: 1- primary 2- secondary k Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion )e Compressed air percussion Other (specify) Well Type Screened Open end casing V Open hole in bedrock Other Casing Details Total length eft. Length below grade r.1® ft. Diameter 6 in. Weight per foot _L9 _lb /ft. Materials: Y Steel Plastic Other Joints: _ Welded _A Threaded _ Other Seal: _ Cement grout _ Bentonite Other Drive shoe: -1 Yes No _ Liner Yes _X 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 S' gprh-* Depth Data Measure from land surface- static (specify, ft) 451 During yield test(ft) r7 50 Depth of completed well in feet 17 5o Well Log If more detailed information descriptions or sieve analyses are available,.Q please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface I? L Lt 11.mas4 -am e ; 5-D S' XO' S-40 W If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type < Capacity Depth G 0 0 Model Voltage L'-`' HP Tank Type Wy -3&2- Volume Date Well Completed $ -moo -off Putnam County Certification No. (003 Date of Report a Well ille (si nature) NOTE: Exact location of well withAistances to at least two pe ane t landmarks to be pro vi a on a se ara sheet/plan. �cJ� �o .�_. _ r Well Driller's Name sal 0, Address: 5 `'� �f 5Z C�u Signature: Date: ' -,2'7 --00- Los-L, White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921 Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085 Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648 WIC (914) 278 - 6678 Fax (914) 278 - 6085 PROJECT (Owners Name): . STREET: i p A�f 94 COVER SHEET J r3c ; %06o�v / CAA U040 i \,fL ICIPALITY: � �� TAX MAP NUMBER: DESIGN PROFESSIONAL: ��' Iv `� DATE:�lo� 11 REVISION X,._REQUESTED ADDITIONAL INFORMATION 11 OTHER S 2 f JI:3 0 o ;n N —w —0 C3 C' W r� W &J ' YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director ` LAB #: 93.203341 CLIENT Q 56023 NON STAT PROC PAGE 1. JGC ASSOC. DATE/TIME TAKEN: 10/09/02 11:17A 22 TULIP RD. DATE/TIME REC'D: 10/09/02 11:45A BREWSTER, NY 10509 REPORT DATE: 10/15/02 PHONE: (914)-760-7711 SAMPLING SITE: 1 PAN ROAD PATTERSON NY : COL/D By: SARY CONKLIN NOTES...: KITCHEN TAP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SAMPLE TYPE..: POTABLE PRESERVATIVES: NONE TEMPERATURE..: < 4C COLIFORM METH: MF ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHDD 10/09/02 CHLORINE, TOTA <0.1 PPM 10/09/02 MF T. COLIFORM ABSENT /100 ML ABSENT 1008 ' COMMENTS! BACT THESE RESULTS INDICATE THAT THE WATE (WAS NOT) OF A SATISFACTORY SANITARY Qt]ALITY ACCORD 'HE NEW YORK STATE AND EPA FEDERAL DRINKING WATER STANDARDS, FOR THE PARAMETERS TESTED, AT THE TIME OF COLLECTION. .^/ / SUBMITTED BY: DireAr ELAP# 10323 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., 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 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool .(845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: Conldin 1 Pan Road, Lot #12 (T)Patterson, TM# 13.07 -1 -8 Dear Mr. Nichols: September 23, 2002 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: 1. Water analysis results indicates a chlorine residual. Therefore, second bacteriological and chlorine residual analysis must be submitted. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Robert Morris, P.E. Senior Public Health Engineer RM:tn NE NORTHEAST LABORATORY OF DANBURY \,A ACCp94D 39 Miry, PLAIN ROAD - DANBORY, CT 06811 CT Cert: PH -0404 moo` °F (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471 u ¢ L"s www.NORTHEAST LABORATORIES.com a s LABORATORY REPORT REPORT TO: JGC ASSOCIATES 22 TULIP ROAD BREWSTER, NY 10509 FAX#845- 278 -1819 SAMPLE SITE: SAMPLE POINT: SOURCE: TREATMENT: TEST PERFORMED BACTERIAL: • Total Coliform (Bacteria) PHYSICALS: • Color (Apparent) • Odor • pH • Turbidity CHEMISTRY: • Nitrite Nitrogen • Nitrate Nitrogen • Alkalinity • Hardness • iron • Manganese DATE SAMPLE COLLECTED: TIME COLLECTED: COLLECTED BY: DATE RECEIVED @ LAB: TESTED BY: LAB I.D. # REPORT DATE: 1 PAN ROAD, PATTERSON, NY SPICKETT WELL NOT STATED RESULTS METHOD # 0 per 100 ml SM 9222B 5 - EPA 110.2 2- Chlorine - - 7.72 - ASTM- D1293 -99 1.4 NTUs EPA 180.1 <0.005 mg/L as N EPA 354.1 2.1 mg/L as N EPA 353.3 174 mg/L SM 2320B 240 mg/L EPA 130.2 0.08 ( <Q) mg/L EPA 236.1 0.01 ( <Q) mg/L EPA 243.1 09/03/2002 12:35 PM GARY CONKLIN 09/03/2002 LAB# 11471 & 11301 JGC ASSOC- NY1136 09/11/2002 MAXIMUM CONTAMINANT LEVEL (MCL) OR STANDARD 0 per 100 ml 15 units 3 Units No designated limits 5 NTUs 1.0 mg/L 10 mg/L No designated limits No designated limits 0.30 2 mg/L 0.30 2 mg/L 2 Combined limit for Iron plus Manganese = 0.50 mg/L • Sodium 48.4 mg/L EPA 273.1 No designated limits 3 • Lead 0.002 mg/L EPA 239.2 0.015 mg/L * ** • Chlorine Residual 0.3 mg/L - —_-- ml= milliliter mg/L--milligrams per Liter ND =none detected MCL = Maximum Contaminant Level TNTC =Too Numerous To Count <Q= Analyte detected below quantitation limits. Data deemed estimated. * *Notification Level ** *Action Level 3 =Water containing more than 20 mg/L of sodium should not be used for drinking by people on severely restricted sodium diets. Water containing n than 270 mg/L of sodium should not be used for drinking by people on moderately restricted sodium diets. COMMENTS: - Sample, as received, complies with aU State of New York regulatory guidelines. -All holding times (were) met. SAMPLE, AS TESTED ABOVE: OPOTABLE or ONOTPOTABLE (PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER) RESULTS BASED ON SAMPLES SUBMITTED: 09/03/2002 Quality Control Officer Laboratory Director •NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050 TOLL FRF,F WITHIN CT: 800 -826 -0105 •OUTSIDE CT: 800- 654 -1230 GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM.. Owner or Purchaser of Building Tax Map_ Block.; Lot Building Constructed by .. -- ?PH Location.- Street 0 6 H Building Type OH Town/Village 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 Depan trnent-of Health, and hereby guarantee to the owner, his successors, heirs or assigns; to place in good operating condition any pan 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 I Month I 'bay G Year �-- General Con ractor (Owner) - Signature Corporation Name (if corporation) Address: i ..... . ... . State �`-i Zip S Title: Corporation Name (if corporation) Address: to NM 747-0- .. State 1 .. Zip Form GS -97 BRUCE R. FOLEY Public Health Director a � LORMA MOLINARI- R.N., M.S.N. W Attoctate Public Health Director Director of Patient Servket , DEPARTMENT OF HEALTH.... _.. 1 Geneva Road Brewster, New York 10509. -... - Eoriroamental Health (914) 278 6130 Fax (944) 276.7921 Nursing Services (914) 278.6558 WIC (914)27$-6671 :Fax (914) 278.6085 Early'Ulerri4bu—(914) 278'• 6014 Preschool (914) 278-6082 Fax (914) 219'.6648 F911 ADDRESS VERIFICATION FORM OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: Go4 1H (Ck �"f L-�rl G, 1 004 A-, R d AUTHORIZED TOWN OFFICIAL: (Signature) DATE: The Putnam County Department of Health will not issue -a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This-form is to be submitted with the application for a Certificate of Construction Compliance. _.. (E91 I VERFRM) 10 E K c ST• �W E LL 20' 4 .9 0 ° Vol 3 0 M 0 d- D• NO 60 4S` 521t W 219.25' 5I n ` M V6 a` 12 IS 1 h 10 $S 5oN f 'I PROPOSEp 4 aED�M�, fCES 1DENC E A u t25o Ga�wN SEPTIC TANK 19 e0 21 22 23 JV .6c, . 38 q'p`Z� Solt °4�`52"E 482'3' it'd q0 N bo u1 O ODo �• M 2 6 t r f DIMENSION CHART (in feet) Number 1 15,5' 42,5' 3 4 (9T I1 100` V) 12 Al 14 15 HIS' 1(D q AS' 2a z\ �4% 34' 2�L 2cs.5' I -'n Z-3 30,c) ' 2u 24 -36' 23 5 1 25 42' 23,'3\ PUTNAbI COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION Street Location Town TM # 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 I T from STS area.......... e. 100' from water course / wetlands ...... ............................... II. Sewage System a. Septic tank size - 1,000 .......1250. ... other ................ b. Septic tank installed level ................ ........................ ........ c. 10' minimum from foundation ........... ............................... d. Distribution Box . All out ets at same elevation -water tested ................. 2. Protected below frost .................. ............................... 3. Minimum 2 ft.Original soil between box & trenches e. Junction Box - properly set ........... ............................... _- ..._... f. Trenches Date: ./o g Inspecte y: v. Owner /C�I,�dS Permit # F- 5_X - 0/ Subdivision Lot # 1�. 1. Len gt required 7/ Length installed 2. Distance to watercourse measured -fy pd Ft.......... 3. Installed according to plan ...................... : ........ ::.:...... 4. Slope of trench acceptable 1/16. -1/32" %foot....... ....... 5. 10 ft. from property line -20 ft.- foundations.......... 6. Depth of trench <30 inches from surface .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 -1 %:" diameter clean .........::.:....... 9. Depth of gravel in trench 12" minimum.......... ::....... 10. Pipe ends capped .................................. :.................... g. PumD or Dosed Svstems - Size ot pump c am er ................ ............................... 2. Overflow tank .........:................... ............................... -- - 3..Alarm,.visual/ audio .................... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled..... ..................... ...............::.........:.... 6.' Cycle witnessed by H.D.estimated flow /cycle:... -..... III. House/Buildin a. house located per approved plans .. ............................... b. Number of bedrooms ...................... ............................... IV. Well a. Well located as per approved plans ............................... b. Distance from STS area measured .......... 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 & dir -to exist watercm g. Footing drains discharge away from STS area............ h. Surface water protection adequate .........................:.:... i. Erosion control provided.,........ .:... .............................., ., a Z 'd AO 1N3W1ddd30 AiNnoo WdNifld : 3WdN �Z6L- 8LZ -Sb8 X31 �E ti 1 WM deed- �L- 1111* PUTNAM COUNTY DZPAXTUM 01 ELAL = DrMOS GF ENVMON WWAL EMTB SEKV1W :. ATTEN770N Q ADAM • ' i 1 ST F A FINAL. j SPEC1r'QN For:. Flu All iaforattdoa must be i1z11 lamplctod prior to any ?reochoe - inspections biWS made. PCHD Cos coon Permit # owaarraFpticaat Nerve: Qh&N r0C1NY—\—NN Tbi I - Block Lot ; — Formerly; Subdrnsbao Name: _ SubdMilon Lot # is system fj1 completed? "- Into; 1: synem complete? - I E5_ .._.r_ . ,- �.,:3.1- Q2 Is Lynam wnsun Vpd as pa plot? Is weft drilled? 7 S ISato: �., 7 -31 Is well loetmed as per plan=? ' Ara orosion coguol ttieMos !a plaoo? I oa*tbu the sY Cs% is btt4 At the above pro caisas bat bees ownctod tad i bavo wFected ad verified their completion io accordance with the Wood PCID - Coosttucdon parmh tad approved plus and the StAndudi, Butts ead Regulations of the'putm County D6putcueat of Health / ... ~ Due: 7 —114)2, C UAW by: i 1r Y ... -r,.. RA ' ' ' Dasi ofa�stonal aC505UOL _. cow; Form M -99 T 10'd L;Sb 61 Z Vt6 S10H3IN M J488VH Wei oz—,.ii Z00Z— i£ --inr BRUCE R. FOLEY Public Health Director August 7, 2002 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N.a 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 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection - Conklin Pan Road, (T) Patterson Lot # 12, TM# 13.07 -1 -8 Dear Mr. Nichols: The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field. No comments. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed GDR:cj Environmental Health Engineering Aide / / / / / pn5r. weu.1 +k67•o' /p G / / O I I � ; it � `• 3DR- 95`E J PROP• FiN- GRADE AMOK. BX15Y. GRADE) Putnam County: Division of Enviro .1 Wr d ae, notes aDPl ale c' Rule ; am - / 5 \ W \ \ \ 0) �� 61 J 3DR- 95`E J PROP• FiN- GRADE AMOK. BX15Y. GRADE) Putnam County: Division of Enviro .1 Wr d ae, notes aDPl ale c' Rule ; am - -s I I r r � CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT #'"°' �- �A - ►� Located at FAO Town or Village PATT'EP-eDOH Subdivision name 6P'9V'P -0P<>� Subd. Lot # 1�- Date Subdivision Approved l o j �41 Owner /Applicant Name " i",y-`i � Date of Previous Approval Mailing Address V� T%4-19 `-© P<0 Bp-e /--) 1 eR- W, TaxMaplo)oOl Block 1 Lot Renewal Revision X ,�11,,,Aol zip t ®gv`l Amount of Fee Enclosed t-N"� t Building Type ��Si M C-E; Lot Area 0`T'i No. of Bedrooms 4 Design Flow GPD X00 Fill Section Only Depth Volume PCHID NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Other Requirements: a �i - /� �" 06. To be constructed by EM M gallon septic tank and �� 1 pl" , N 1AP Water Sup"I : Public Supply From _ or: Y, Private Supply Drilled by T -M Address Address Address LF AB5 I represent that I am wholly and completely responsible for the design and location of the proposed systems) 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: 1� Address 9-060 P.E. X =T r?-re j, ; i fl S VO� R.A. Date -711.11 0I License # �jf�l � I 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 wpen ohsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe pproved discharge of domestic sanitary sewage only. I, l� By: Title: h\-''— Date: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 e� PUTNAM COUNTY DEPARTMENT OF HEALTH � DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # S— �-- O l 110-5A-01 Located at PINP �' Subdivision name Subd. Lot # 1'�- Date Subdivision Approved 10! Owner /Applicant Name Mailing Address 45 Amount of Fee Enclosed bra �' Town or Village Tax Map 1� n Block I Lot Renewal Revision Date of Previous Approval 19e'4P01)?' &j Zipdt -P(6 Building Type P-65 ci!&k -e Lot Area P,qq No. of Bedrooms -1 Design Flow GPD 800 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 11Z40 gallon septic tank and ,70" 71 Cpl% Other Requirements: a" ��LL To be constructed by 'T'f31) Address Water Supply: Public Supply From 'or: Private Supply Drilled by -'6f) Address Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the csparate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date 01 Z-6 Col License # � a 21q 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 wh c sidered ne essary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. ,A roved f ischarge of domestic sanitary sewage only. UT By: t- Title: �. Date: (2-- 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 SERVICESp APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # Well Location: Street Address: Town/Village ,�rye ��,, Tax Grid # j kH Rn1 �QHHET kN YhTre -',J� i�,01131ock 6 { Map Lot(s) Well Owner: Name: Address: _ 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 f gpm # People Served H'% Est. of Daily Usage Dr4 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 C (u 5 � �- m- P 4 Lot No. 11, Water Well Contractor: -T g p - Address: ~- Is Public Water Supply available to site? ........................ Yes No _ Name of Public Water Supply: '� Town/Village �- Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate s eet/ Ian. Date: bi , ,d Applicant Signature: MA PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water we d 'ller cert' ied by Putnam County. Date of Issue 3 h 2 Permit Issuing O#*- l: Date of Expiration t 2 f ) 2J 6-J Title: Permit is Non -Tra White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 February 21, 2001 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS Crossroads Subdivision, Lot #12 Pan Road & Sonnet Road Town of Patterson Dear Robert: In response to your review letter dated February 14, 2001, we offer the following: 1. Enclosed please fmd two sets of house plans with room opening dimensions shown. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nichols Jr., P.E. HWN :his 00- 181.00 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279 -4003 Fax (845) 279 -4567 January 26, 2001 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS t`xossroads Subdivision, Lot #12 Pan Road & Sonnet Road Town of Patterson Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SS -12, "Proposed SSTS," dated 1- 26 -00. 2. "Short EAF," dated 1- 26 -01. 3. "Application for Approval of Plans for a Wastewater Disposal System. 4. "Construction Permit for Sewage Disposal System," dated 1- 26 -01. 5. "Application to Construct a Water Well," dated 1- 26 -01. 6. "Design Data Sheet." 7. "Letter of Authorization." 8. Corporate Owner Application. 9. Two (2) copies of residence floor Plan(s), for bedroom count only. 10. Review Fee in the amount of $300.00 If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. r s Jr., P.E. HWN :his 00- 181.00 w 14.164 (9/95) —Text 12 ` PROJECT I.D. NUMBER 617.20 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) SEQR 1. APPLICAyT /SPONSOR / 2. PROJECT NAME 3. PROJECT LOCATION: t� P!"�J PJ Municipality 1 County A. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) , an 5. IS PROPOSED ACTION: WNew 0 Expansion ❑ Mod lfication/aIteratlon 6. DESCRIBE PROJECT BRIEFLY: VJ5�:-E�J ►�� 7. AMOUNT OF LAND AFFECTED: 0 ' " Q' Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR -OTHER EXISTING LAND USE RESTRICTIONS? 9 Yes 0 No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? u Residential 0 Industrial 0 Commercial 0 Agriculture 0 Park/Forest/Open space 0 Other Describe: 'S tjt(a_��m,LJ 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? 0 Yes ,&NO If yes, list agency(s) and permltlapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? 0 Yes 9No If yes, list agency name and permit/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? 0 Yes 9No I CERTIFY THAT PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE /THE ,'INFORMATION � �CA HT Applicant/sponsor nam : Date: Signature: Z U If the action is In the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment OVER 1 PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617,4? If yes, coordinate' the review process and use the FULL EAF. Cl 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 handWrillen, If legible) Ct. 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 speCles, 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 by the proposed action? Explain briefly. C6. Long term, short term, cumulative, or other effects not Identified In C1•C5? Explain briefly. C7. Other Impacts (Including changes In Usa of either quantity or type of energy)? Explain briefly. 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CEA? ❑ Yes ❑ No E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATEb 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 affect Identified above, determine whether it Is substantial, large, Important or otherwise significant. Each effect should be assessed in connection with Its (a) setting (i.e.•urban or rural); (b) probability of occurring;•(c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. If question D of Part II was checked yes, the determination and significance must evaluate the potential Impact of the proposed action on the environmental characteristics of the CEA. ❑ Check this box if you have identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration. ❑ Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any significant adverse environmental Impacts AND provide on attachments as necessary, the reasons supporting this determination: Name of ea Agency Print or Type Name of eeponsi a Officer In ea Agency Title of Responsible Officer Signature of Responsible Officer In Lead Agency Signature of reparer (If different from responsible o ricer) Date PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,:OF=:ENYIRONMENTAL HEALTH. SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: - .W Ay Ma VAH b)PY GT 0� 81 � ,. 2. Name of project: 1 1-Q V' 12- * 3. Location TN: 4. Design Professional: \L°Jt -5. Address: 0 ��-- 6. Drainage Basin: 7. T net of Protect; . Y, 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 Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Exempt Unlisted x H0 10. Has DEIS been completed and found acceptable by Lead Agency? ............... 11. Name of Lead Agency M�2 12. Is this project in.an area under the control of local planning, zoning,. or other.. ....officials, ordinances? .... .......:.:.:: ........................................ ............................... � �i 13. If so, have plans been submitted to such authorities? :.:.......... MD 14. Has preliminary:pproval beezi granted by such authorities? NO Date granted: WA 15. Type of Sewage Treatment System Discharge ................. surface water1 _ groundwater 16. If surface water discharge, what is.the stream class designation? .................... NA 17. Waters index number ( surface) :...................:.:.. ........:...................... A 18. Is project located near a public water supply system? ........................ No 19. If yes, name'of water supply H A- Distance to water supply 20. Is project site near a.public sewage. collection or treatment system? ................. ' RIO 21. Name of sewage system Distance to sewage system N f 22. Date test holes observed a - i 1 - 01 23. Name of Health Inspector 6 EMG- 1;1J 24. Project design flo w (gallons per day) ................................. ............................... � 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?.... ND 26. Has SPDES Application been submitted to local DEC office? .......................... -/� r__ nn n^. 27. Is any portion of this project located within a designated Town or State wetland? H 9 28. Wetlands ID Number .........:................................................. .....................:.. :..,... NA 29. Is Wetlands Permit required? ............................................... ..........:.................... NA Has application been made to Town or Local DEC office? .............................. 30. - Does project require a DEC Stream Disturbance Permit? .. ............................... lye 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? 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous. waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination. Yes/No 0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be developed within. 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 1`4� 36. Tax Map ID Number ....... . ............................... ................... Map Block Lot 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 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 form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal kaw;, . SIGNATURES & OFFICIAL TITLES: Mailing Address: BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., 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 Early Intervention (845) 278 - 6014 Fax (845) 278 - 6648 Preschool (845) 228 - 5912 Fax (845) 228 - 6113 July 30, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Conklin Patsy Road / Sonnet Road, Lot #12 (T) Patterson, TM# 13.07 -1 -8 Dear Mr. Nichols: 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: 1. The minimum of additional percolation test and deep hole must be witnessed by a representative of this Department. The testing is to be performed at the south end of the system. The revised plans proposed trenches 90 plus feet from the location of the existing test holes. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, R�oj 4119.0 Robert Morris, P.E. Senior Public Health Engineer RM:tn 3e of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner k,q k 67:5 Address PA Ai 1c d, Located at (Street) 5�.), V-2--7 t,4 AI, Tax Map 3, v Block �_ Lot i' (indicate nearest cross street) Municipality Watershed,.--s7 T�7c'tJ�tc.N SOIL PERCOLATION TEST DATA Date of Pre - soaking ie, c'Z Date of Percolation Test NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 2 rf;o'a 4 5 2 3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. 1 HOLE NO. a HOLE NO. VAC. �lC OWN ca1 8!L, o) 1,41 -oitz 6) 17 Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered -7 2 " Deep hole observations made by: ,�; Tc'��� �.�, pie-,T7, H, Date t i Design Professional Name: Address: Signature: Design Professional's Seal b PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A..GENERAL INFORMATION - Name of Project K,4 k c -5 (T)(V) P,4 15o y County Re/T,,vAm Site Location N 17a l Building construction begun rA62— Extent r' Is prorty within NYC Watershed ? ................. ❑'`Yes ❑ No SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1.. Hill R911in Stee slope........ entle slo e — =—= Flat --- -- --- 2. Evidence of wetlands ❑ Low area subject to flooding ❑ Bodies of water Drainage ditches ❑ Rock outcrops 3. Property lines or comers evident ...................................................... ❑ Yes �No 4 —Do water courses exist on or adj&Ln the property? ...........:........:.....:... ❑ Yes No 5. Will these affect the design of the sewage system facilities ?............ ❑ Yes �No watershed regulations apply in tlns development ............. ........ .......... Yes _ No . - - - -- g ary .. ............................... 7 —Will extensive grading be necess - .4 Yes ❑ No 8. Will extensive fill be necessary for SSTS ? ........................... ❑ Yes �No,, 9. Do filled areas exist within the SSTS area? ........ ............................... ❑ Yes �No If yes, what is. the condition of the fill? ti SECTION C. SOIL OBSERVATIONS Appearance -of soil: Sand Gravel Loam Hard an Mixture, , ❑...: ❑ ❑Clay.:.:.❑ P -- 11. Observed from: ❑ Borings ❑ Bank cut E2"'Backhoe excavations 12. Soil borings /excavations observed by G, D -1:�, c, n, N'," on / o 13. Depth to groundwater z /G : on - 14. Depth to mottling _5 11 roW/.,,,��- on r 15. Are test holes representative of primary & reserve areas ...... ............................... ED Yes No 16. Soil percolation tests made by ;7`� F rn ��► N. �/ n/tG No s on f 17. Soil percolation tests witnessed by �, 7c ,,_r G p Vic, D, N , on SECTION D (on back) Form ST -1 4 2 SECTION D. DRAINAGE 18. Will proposed grading materially- alter the natural drainage in this or adjacent areas? ❑ Yes �o 19. Will groundwater or surface drainage require special consideration? ............... ...... ffYes F_� No. 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... 0 Yes ffNo SECTION E. REMARKS 21. - If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ..................... ............................... Inspection data .......... � Yes No 22. Do adjacent wells and/or sewage systems exist ? :::::::.:.::. - - -- ...... - - Yes D No 23. Additional comments 24. Site observer /inspector and title D ME E 0 5 „g c � 25-. 7- of observation(s)inspection(s) TEST PIT PROFILES - - - Hole # Lot # :_-^dole # -- -Lot # - - -- Hole # Depth to water Depth to water . Depth to water - - - - -- -- - -- Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. - Depth to rock/unp. Depth to rock/imp. G.L. G.L. G.L. 0.5 - 0.5 0.5 1.0 - - - -- 1.0 _:1,0. -- ... 2.0 . :. 2..0. .12.0 3.0 3.0 - . 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 20 r•i 4.21 AC. ' -- . _ �� sa bo 21 I o ,., 22 w N 24 � •° 1510 . 6000 61 j6 26 111 . y., 1p142 TA 15061 J 14 v 27 1.00 AC. CAL. D x.10 0 29 g ;; 655 1.02 AC e3 F s� e� s zotsi ,az 6� 1.03 AC. __. .. .._ / c -may _.__ N..- __— _ -._... ... __ /Q _ J. .-. ___ _/� — _ ._ ... -_.._ _.__.__ •_V _ 6 30 I mob' r � • r� H rl • B ,( . A I .. - eta 5 1.99 AC. CAL l l01 J 4 \� I ~--- %- �-•- -- 156 per_... - � .... _.. -..• .....__ ..____. ... .. _.. .._. .. 1.01 AC.. CAL 1.04 AC. CAL QUO 1.18 AC. CAL. 69 to 1.02 AC. CAI. 1>b�o 69 158151 �,+ 150 / / / / / 13 1 N V4= ... DEC -19 -2000 11:31 AM HARRY W NICHOLS BRUCE R. FOLEY Public Health Director ?ATTENTION: 914 279 4567 P.02 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 o ADAM STIEBELING GENE REED LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Service$ All information below must be &l v, completed prior to any scheduling. DATE: 12-1 tl10 ENGINEER OR FIRM: i'"R`1 w . �L5 PHONE #: 2-1 1' 4.00n. REASON: DEEPS: PERCS: x PUMP TEST: o ROADISTREET: PAH 4�9 TOWN: TAX MAP #: SUBDIVISION: GF- o55�pA�flS LOT #: OWNER: DlLY— AQ l4 aN 'CDFPSRITERIAFOR JOINT REVIEW AND WITNESSING OF SOIL TE TS ING YES NO ❑ ) Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs. ❑ or Proposed SSTS within-500 feet of a reservoir, reservoir stem or control lake. ❑ 19 Proposed SSTS within 200 feet of a watercourse or a DEC wetland. ❑ . it Proposed SSTS design flow greater than 1000 gallons /day or SPDES Permit required. ❑ Qt Proposed SSTS for a Commerical Project. It is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (.Joint or Delegated) based on the response. If you answered xes to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the soil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE ONLY l CQ\f \[EATS: (FIELDTEST) Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 July 17, 2001 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS - Revision/Name Change Crossroads Subdivision, Lot # 12 Pan Road & Sonnet Road Town of Patterson Dear Robert: Enclosed are the foll owing: 1. Five (5) prints of Drawing SS -12, "Proposed SSTS," revised 7/17/01. 2. "Construction Permit for Sewage Disposal System," revised 7/17/01. 3. "Letter of Authorization." 4. Two (2) copies of residence floor Plan(s), for bedroom count only. 5. Review Fee in the amount of $150.00. 6. Pump Calculations. If there are any questions concerning the enclosed, please call. . Very truly yours; Harry W. Nichol s Jr., P. E. HWN:JM:jmm 00- 181.00 july PUTNAM COUNTY DEPARTMENT. OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of LETTER OF AUTHORIZATION 669 C_QHY L-! iii Located at N T/V ?N'Tr59-A>1'H Tax Map # ► y ° Block ! Lot Subdivision of LP4"" °6 Subdivision Lot # ��- Filed Map # ,o °`�- Date Filed Gentlemen: This letter is to authorize �� '� N 1�1��j J a duly licensed Professional Engineer ,� or Registered Architect _ to apply for the required wastewater treatinent and/or water supply permits) to serve the above =noted property in accordance with the standards, rules or regulations as promulgated by the Public lfcalth Director of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the prov ins of Article 145 and/or 147 of the .Education Law, the Public health Law, and the P itn QuA, �i�tary Code. Any- NICNp� Countersigned:. " P.E., R. A., # ��', i�o.56124 ~9D SIU�� Mailing Address �V_FVJ1�i 6G_' State ' , zip Telephone: 1'1�- 400-� Very truly yo t", Signed c2L (Owner of? ) Mailing Address: M, T-UW9 �-OfO State Zip (OS A9 Telephone:1�� June 28, 2002 Mr. Robert Morris, P.E. Department of Health One Geneva Road Brewster, New York 10509 Re: Proposed SSTS: Conklin Pan Road/ Sonnet Road, Lot # 12 (T) Patterson, TM # 13.07 -1 -8 Dear Robert: Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279-4003 Fax (845) 2794567 In response to your letter dated July 30, 2001, we offer the following 1. Additional percolation and deep hole tests were performed in the south end of the system, results of these tests are attached. In addition to the above, the pump system has been omitted from the design due to the constructed location of the house, which now provides for gravity flow as previously approved. It is now proposed to move the well to the front of the property, as shown on the attached plan. Please review the design for this revision. If you have any further questions, please call, Very truly yours, Harry WnNic ol s Jr., P.E. HWN:JM:jmm 00- 181.00 PUTNAM COUNTY DEPARTMENT OF HEALTH.... DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner C'l�k¢� G � L11-� Address `'T j Located at (Street) �RrJ I ��N�1 �'C Tax Map -0i0l Block Lot (indicate nearest cross street Municipality k Of" Watershed ���? ►� %�-1- SOIL PERCOLATION TEST DATA Date of Pre - soaking 2 Q2 Date of Percolation Test G71-7/02, Hole No. ,...:Rut►.No.:; Tirim .:Strt�:;'Stop Elapse Time (1v1in. ) Depth to Water Ground Surface (In bes) Start Sto p Drov In pp Inches PerRate on NIigIInc6.;.... 1 lo; go )0,0� 24 2 24 -2-7 3 10;j3 10; 4 O; 2-S X32 9" 2 s .2. 3 4 1 2 __... 3 _. 5 NOTES: 1. 'Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation.test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review: 2. Depth measurements to be made from top of hole. Fnrr„ nn.o� - DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0- 4.5' . 5.01- 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO 1 _ HOLE NO. HOLE N0. 2 M F - 1Z. NV- DNS S Q C- f` Indicate level. at which - groundwater is encountered ON; Indicate level at which mottling is observed NA_ - -- Indicate level to which water level rises after being encountered ±� Deep hole observations made b y C�.E �_ D A� G Date I Design Professional Name: ��� 1� �,Jlt✓i�at,� ;�I "- fit; Address:---- U l o 'i.. Signature: Design Professional's Seal 1�QFNEWro NICyO� �. 1 � , Uj �+ ESS Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 (&45) 279-4003, Fax 279-4567 CONSULTING SITE ENGINEERS JOB No. � , I a I SHEET No. I .. - OF -2, COMPUTED BY im --DATE ®1 -0 -b1 CHECKED BY 44v4m A. P -YAP L�X 1)1,,�TR1$uTi _T .... L6.... +04,001 pump C k 4 115- 00 TI F01pp- -bi P 1'rT I /Y 6V,6,L qU.LV1jr .LF 7- F --- --- --------- ---- ------ T Tb 14 To* FT. . ....... ... ---------- DATE ®14- _ M Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 (9-0 279 -4003, Fax 279 -4567 CONSULTING SITE ENGINEERS - - -- JOB -No: - --- USA--- :. :_:_.:. -- SHEET No. '2. OF 2 COMPUTED BY- 01 _.. J_�'i_ -- .DATE �'1- 1'i -_ CHECKED BY - - _ DATE .0-)-=1"1° O "i - D05146- yoi-vAtE ' 67S` /o d S`f5'TEM UOL.W�IE� - — - -- ZD05E. AvMP ChAMMER S iziNG -; , -- d p -- - -- —d N— E D `'3_ STORA6 -M boo - -- --- - - - - -- -- o ��6�• ®° - - - - -- -- - - I- - -L@ --- ._....- - - - - -- -- -- - - - -- Goulds JA Submersible _ `� 5 Sewage �', 6 Pumps "BP and "BHF" Models "B" Models r—MODEL 3887 Goulds MODEL 3887 Performance Curve METERS FEET MODEL 3887 16 - 50 SIZE 2" SOLIDS —I 12 I I r I ( i w , = 10 (- 30�._..._ L I OMB eF .. C i.. - I - I I ' 20 . ( ! I 0 20 40 60 80 100 120 140 160 180 GPM 0 0985 Goulds Pumps, Inc. 10 lN to 0"I 20 30 CAPACITY 40 m3 /hr Effective July, 1985 PUTNAM COUNTY DEPARTMENT OF HEALTH .DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner —Address Located at (Street) H R / CnUN-A0 FOM9 Tax Map 'l'�, el Block­ I Lot 67 (indicate nearest cross street) Municipality PAf TLZ;79,�, gj Watershed SOIL PERCOLATION TEST DATA Doe of Pre..,;nakinv 0i -14- .01 Date of Percolation- Test OJ-0-01 "a I .... . .... .... 1 4., .., ­ :. , '. 11 .. P I NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates -are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 1 Iq I q1, I 2 t�Y 4 5 2. A 3 4 5 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates -are obtained at each percolation test hole. (i.e. :5 1 min for 1-30 min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5. 5.0'... 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' ..TEST PIT DATA DESCRIPTION OF'SOILS ENCOUNTERED IN TEST HOLES k HOLE NO. HOLE NO. HOLE NO ©�11 -" TOIASO1L -.. Mal - �(1 ©tV-0,r DF i OUILss Qf- W W W �ft- S AM Indicate'level at which groundwater is encountered -(o Indicate level at which mottling is observed. `:70(1\ 06'tY►Hb Indicate level to which water level rises after being encountered Deep hole observations made by: eA r- -Ii-- Design Professional Name: AEW W M1 GN- at_..r ,J(L P& Address: Signature: Design Professional's Seal 2 BRUCE R. FOLEY Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 LORETTA MOLINARI R.N., 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 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 February 14, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: Application to Construct a Subsurface Sewage Treatment System Kakos Pan Road / Sonnet, Lot #12 (T) Southeast, TM# 13.07 -1 -8 Dear Mr. Nichols: The Putnam County Department of Health (Department) has determined that the above referenced application, received by the Department on February 2, 2001 is incomplete. Please be advised that the following information is required before the Department may commence its review. • House plans submitted are not adequate. I have repeatedly requested that room opening dimensions must be provided on stock house plans. The review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed Regulations and Putnam County Department of Health regulations. Should you have any questions or care to discuss this matter, please contact me at (845) 278 -6130 ext. 2166. Very truly yours, Robert Morris, P. E. RM:tn Senior Public Health Engineer PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of WAY NC t P P'TY Located at A M 0 eD 0�4 NO_� P4 kD Tax Map # Subdivision of I, /�, ge, Block "" Lot Subdivision Lot # I z— Filed Map # (dl2? Date Filed Gentlemen: This letter is to authorize �'Q-� � - NI C f-oL,5, fe 1012co 1 134 a duly licensed Professional Engineer 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 Directbr of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions -of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam County,S.anitary Code. Y N Y0 Countersigned: P.E., R.A. # q �_ Mailing Address ,1 2� B IZIFw psi I� Very truly you7/0 igned: (Owner of roperv) 1 . Mailing Address: ►P 6 U State i� Zip State Zip N81 Q - - Telephone: � � ZZc 4-at, 92 Telephone: r Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DMSION OF ENVIRONMENTAL HEALTH r INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEM REVIEW SHEET FOR CONSTRUCTION PERMIT �o NAME OF OWNER: STREET LOCATION: REVIEWED BY: RM, GR, AS, SRDATE: Y DOCUMENTS (� PERMIT APPLICATION )WELL PERMIT OR PWS LETTER PC -97 LETTER OF AUTHORIZATION U(�DESIGN DATA SHEET (DDS) U CORPORATE RESOLUTION SHORT EAF (_J(_JPLANS -THREE SETS LJLJHOUSE PLANS - TWO SETS UUVARIANCE REQUEST ®� SUBDMSION (�( JLEGAL SUBDMSION 4d (_)USUBDIVISION APPROVAL CHECKED (_JLJPERC RATE L -)LJFILL REQUIRED DEPTH L_J(_}CURTAIN DRAIN REQUIRED GENERAL .00ATED IN NYC WATERSHED 'LANS SUBMITTED TO DEP )ELEGATED_TO PCHD )EP APPROVAL, IF REQ'D )EEP TEST HOLES OBSERVED 'FRCS TO BE WITNESSED ',X- APPROVAL SSDS.ADJ, LOTS (_�)L _)WETLANDS (TOWN/DEC PERMIT REQ'D ?) (!% DATA ON DDS PLANS & PERMIT SAME )PRE 1969 NEIGHBOR NOTIFICATION �( 1F` )LETTER BI/ZBA � /xa )100 YR. FLOOD ELEVATION W/I200' (�( _)SOIL TESTING LOTS >10 YEARS OLD REQUIRED DETAILS ON PLANS Ce!��SEWAGE SYSTEM PLAN - (NORTH ARROW) ( Al / )SSDS HYDRAULIC PROFILE GRAVITY FLOW . CONSTRUCTION NOTES 1 -15 DESIGN DATA: PERC & DEEP RESULTS 2' CONTOURS EXISTING & PROPOSED DRIVEWAY & SLOPES, CUT FOOTING /GUTTER/CURTAIN DRAINS USDA SOIL TYPE BOUNDARIES TITLE BLOCK; OWNERS NAME ADDRESS TM#, PE/RA; NAME, ADDRESS, PHONE# DATE OF DRAWING/REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS AKES,WETLANDS WITHIN 200' OF P.L. (­d(::�,LPROPOSED FINISH FLOOR AND BASEMENT ELEVATIONS L�(l-J-WELLS & SSDS'S W/IN 200' OF SSTS U PROPERTY METES & BOUNDS �L__)_ EROSION CONTROL FOR HOUSE, WELL & SSTS, EROSION CONTROL NOTE COMMENTS: (REVSHEET)09 /01/00 TAX MAPR: (CONFIRNIED) Y (REQUIRED DETAILS ON PLANS CONT'D) () HOUSE SEWER-14" FT. 4"0'; TYPE PIPE CAST IRON __ �NO BENDS; MAX BENDS 450 W /CLEANOUT RENEWALS �USITE NOTE (NO CHANGE) FILL SYSTEMS 10' HORIZONTAL; PAST TRENCH SLOPES 3 :1 TO GRADE (� FILL SPECS/ FILL NOTES 1 -5 FILL PROFILE & DIMENSIONS UL�FILL IN EXPANSION AREA FILL GREATER THAN- 2 FEET CLAY BARRIER FILL CERTIFICATION NOTE DEPTH GAUGES VOL. ON PLAN FOR R.O.B., UNCLASSIFIED & IMPERVIOUS SEPARATION DISTANCE FROM TOE OF SLOPE TRENCH LF TRENCH PROVIDED LOFT MAX. PARALLEL TO CONTOURS tlK 10 0% EXPANSION PROVIDED TAILMUST FREE CRUSHED STONE OR WASHED GRAVEL :EOTEXTILE COVER SEPARATION DISTANCES ON PLAN - FROM SSTS 0' TO P.L. DRIVEWAY, LARGE TREES, TOP OF FILL 0' TO FOUNDATION WALLS 100' TO WELL, 200' IN DLOD,150' TO PITS 100' TO STREAM, WATERCOURSE, LAKE (inc. expan) L _XL_ -)50' TO CATCH BASIN, 35' STORNIDRAIN, PIPED WATER L!)C_)10' TO WATER LINE (pits - 20') C_�)C_)50' INTERMITTENT DRAINAGE COURSE 0200' /500' RESERVOIR, ETC. _ 150' GALLEY SYSTEMS L�(_J10' MIN TO LEDGE OUTCROP SEPTIC TANK FROM FOUNDATION; 50' TO WELL WELL DIMENSIONS TO PROPERTY LINES CC.� (:L jLOCATION OF SERVICE CONNECTION UL _)MIN 15' TO PROPERTY LINE SLOPE SLOPE IN SSTS AREA (920 %) *l REGRADED TO 15 %, IF REQUIRED DOSE/PUMP SYSTEMS PUMP NOTES DOSE 75% OF PIPE VOLUMEMOSE VOLUME NOTED C_JVJDF,TAIL FOR FORCE MAIN, (PIPE TYPE, ETC.) U PIT AND D -BOX SHOWN & DETAILED U 1 DAY STORAGE ABOVE ALARM CURTAIN DRAIN STANDPIPES, 5' BOTH SIDES, DETAIL T15' MIN to CDS = >5 %, 20' -4 %, 25' -3 %, 35' -1 %,100 % -<1% 20' MIN to CD DISCHARGE /100' with 182 cons day discharge (—J10'MIN to NON - PERFORATED PIPE PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICE q� L ®% DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM /2 Owner GoA),g L[n/ Address -FAA1 Located at (Street) �j ®ivnl�� Tax Map 13, 07 Block �_ Lot (indicate nearest cross street) Municipality f E725,o Watershed ,5 ¢# SOIL PERCOLATION TEST DATA Date of Pre - soaking 412 6 2 Date of Percolation Test 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 lti epth to !Water Water n r G ou d F.;om e L. vel ti Percoia an Hale V o Ruff No Time „Start Stop Eia se Time (�iVLn) �. Surface riches) Start Staff drop In Inches hate M�n/Ineh 0:00 -00y � 2f — .-? � l,3 2 lo;0 5 -/0,,j 2 7 3 2 `3 3 100 3 --012 2 F :5 3 4 10,7- 3 - /0i 3 2. Zel 3 3 5 1 2 3 4 5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97 DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. / — HOLE NO. 4 _ O . HOLE NO. Indicate level at which groundwater is encountered ,d Q i Indicate level at which mottling is observed uoAjl—� Indicate level to which water level rises after being encountered Deep hole observations made by: p jet G, Date 6 z 7 o-2 Design Professional Name: Address: Signature: Design Professional's Seal s8� 60-NA/Er 2 MAY -10 -2002 12:51 PM HARRY W NICHOLS BRUCE R. FOLEY M11c Healh.. Director 914 279 4567 P.02 DEPARTMENT OF HEALTH I Genova Road Brewster, New York 10509 LORETrA MOLIAIAM RN„ M.S.N. Arexiolt Mile Health Director L%irectef ,qf .., Pgf(ra►Il "Sirv(cet .aTT) MON: 0 ADAM STIEBELING GENE RUD AW information below must be MIX completed prior to any scheduling. DATE: ENGINEER OR FIRtv1: "lroToNj, ii' MILV: 41 fi pe PHONE #: REASON: DEEPS:, PERCS:X, PUMP TEST: (3 —. ROA) /STREET: TOWN': F Af rOi DO TAX MAP #: M�4�" I —$ SUBDIVISION: C416 kns LOT #: 11" OWNER: Ge1- 10.1AM YES N D Proposed SSTS,within the drainage basin of West Branch or B.oyds Corner Reservoirs. 0 Proposed SSTS within $00 feet of a reservoir, reservoir stem or control lake. a Proposed SSTS within 200 feet of a watercourse or a DEC wetland. o Proposed SSTS design flow greater than 1000 gallons/dayor SPDES Permit required, 0 t Proposed SSTS for a Commerical Project. _. It is the responsibility of the design professional to provide the above information priitir to soil testing, This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. It you answeredya to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate it mutually suitable time for field testing with the PCDOH, the Design Professional and NYCDEP, If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP is required to witness the Moil testing, it will be the sole responsibility of the design professional to schedule re- witnessing of the soil testing with NYCDEP, FOR COUNTY USE ONLY r c ®® TOM /00� 7L"�� / / // / (MLDTEST) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION.A. GENERAL INFORMATION Name of Project Cody >e L�,A1 Site Location -'PAAI 26041 T/P'l, ! 3 r 0 7 — / 0-4 42 Building construction begun " Extent /-Ese--,-4* ey Is property within NYC Watershed ? ................. Yes (No SECTION B. TOPOGRAPHY (Please .check all appropriate boxes) 1. Hilly . 0 Rolling E Steep slope Gentle slope Flat 2. Evidence of wetlands 0 Low area subject to flooding 0 Bodies of water 0 Drainage ditches 0 Rock outcrops 3. Property lines or corners evident ....................... ............................... Yes 0 No 4. Do water courses exist on or adjoin the property? ............................ 0 Yes F2/No 5. Will these affect the design of the sewage system facilities ?............ Yes �No 6. Do watershed regulations apply in this development ? ....................... Yes F--J No 7 Will extensive grading be necessary? ................. ............................... Yes No 8. Will extensive fill be necessary for SSTS? ......... ............................... a Yes No 9. Do filled areas exist within the SSTS area? ........ ............................... Q Yes F No If yes, what is the condition of the fill? s SECTION C. SOIL OBSERVATIONS 10. Appearance of soil: ZSand [7 Gravel F-� Loam PBackhoe Clay Hardpan Mixture a a 11. Observed from: a Borings Bank cut excavations 12. Soil borings /excavations observed by zg ggj G %> /5; on %2711 13. Depth to groundwater _A/pA.0; on 14. Depth to mottling 4 /nom 6 on 15. Are test holes representative of primary & reserve areas ...... ..............:................ 16. Soil percolation tests made by 7),VAl /J/ZZ/, &/, Ildl, .5 on 17. Soil percolation tests witnessed by ,��,� on SECTION D (on back) 0 Form ST -1 a SECTION D.. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? Yes N 19. Will groundwater or surface drainage require special consideration? ..................... a Yes 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... Yes E10 SECTION E. REMARKS 21. If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ............ :.................................................. Yes rNo Inspection data 22. Do. adjacent wells and/or sewage systems exist? ..................... ............................... Yes No 23. Additional comments 24. Site observer /inspector and title �s f tai -;V 25. Date(s) of observation(s)inspection(s) TEST PIT PROFILES Hole # Lot # Hole # Lot # Hole #. Lot # Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. 0.5 0.5 0.5 1.0 1.0 1.0 2.0 . 2.0 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7:0 7.0 8.0 8.0 8..0 9.0 9.0 9.0 10.0 10.0 10.0