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631- 589 -8100
14. -1 -7
BOX 6
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09/29/00 FRI 07:54 TEL 914 277 8210
...
BRUCE IX FOLEY
Public Health Dlncror
BIBBO ASSOCIATES LLP
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster. New York 10509
11001
LORMA MOLINARt R.N.. M.S.N.
Assaclata PtrWte Health Dlraetor
Director 4/ Patient Servlc"
REMST F011 FIELD TFS'rrfvC
ATTENTION: /ADAM STIEDELING )(GENE REED
Alt information below must be Cully completed prior to any scheduling. DATE: d
ENGtr ER OR FIRM: � .s Tf- P11ONE a 77 s`c3�s-
REASON:
DEEPS: PERCS: o PUMP TEST: D
TOWN: om 4ee,Tg TAX 1vI, O:
SUBDIVISION. % /�dJr{� LOT #.
OWNER; _Gi/'G'1'! CzreC s✓
YES NO
o Proposed SSTS within the drainage basin of West Branch or Boyds Corner Reservoirs.
o Proposed SSTS within $00 feet of a reservoir, reservoir stem or control lake.
o ( Proposed SSTS within 200 feet of a watercourse or a DEC wetland.
D Proposed SSTS design flow greater than 1000 gallons /day or SPDES Pcrmit required.
C3 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 ja to any of the questions, NYCDEP must witness the soil testing. This
Department will eoordiwe a mutually suitable time for field testing with the PCDOEI, the Design
Professional and NYCDEP.
It a project has been determined td 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.
2 "o C) Foit COUNlTY USE O3YLY
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ea ..
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290.23
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203�v 4 j
16.98 AC. CAL. s R s
f CARMEL CENTRAL Sf}IOOL DI51I
569.5 i
BREWSIER CEIRRAL SCHOOL DISTRICT
c�9'f2q
5 '*
_ \
�( 4.43 At - - - `.. 45e.1 i 1
( 10 _
1 i/ ti, 6 7" 8 9 �: \ \ \ \ 88.23 AC. CAL
► �� +re \ y 8.02 AC. .03 AC 5.05 C" '\ \\ \ s 9.05 AC. CAL
90.9.43 AC. CAL \
3 32aC _ _ J \ _ _ P/0 24.1 1
P/o - P/0 14 -1-6 I' P%0 P/0 Pa P/0 14 =1 -10� s \ - - - -- -� Y / ITN --°
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t I 1
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p �•� Y` r (+� 10.02 AC. CAL s
o I
a 56
o°c 40 to.stac. s \ Y s
J 4.65 % 0. G , ` I oOAC. t'�Lp \.� * TO
15.05 AC.
54
16.76AC. 58 +� \
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57 r 104 ;i�Lti,Qt: s
� • 9.63A;
< l
9.05 AC. N6'0
„�„ •uialo C4 "tot
JAL
48 .\
/.
10.47 ac. CAL � Ito 59 / �
'\ 4
11611 4
43 5 Ut
�/ \\ tN
rg00l OISiRICi 124.01 AC. CAL. �
I � Cp7tdEl CEN S � •\
1 52.33 AC. EAL. 49 53
1 '
I l 10.96 Ac. 32.47 AC. CAL s ,
47
34.87 AC. CAL nt3
\s ` X50
I -V C :. �t 52
I sl`' 1'13« �ma \•� /
9013) i3 ° 4 N'io � (5 � 999 f 769,19
nxsa• "-� 46 •� § r 41.�T )c "� Q RO ()TE - r6gyJ
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2.OAC- 21 * t r4
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Si ' / 2 6 oitoaC� � s 19 + 63.42 AC. CAL.
�. 1.09 1.86 A. II
s n 1 \s 26 42.65 AC. CAL
32.33 AC. CAL. I
19 a� xr
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. HOLE NO. 2 HOLE NO.
Indicate level at which groundwater is encountered '7 f — C.9
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered
Deep hole observations made by: c / :. Date
Design Professional Name:
Address:
Signature:
Design Professional's Seal
J
131660 ASSOCIATES LLP
589 Route 22 — Box 403
CROTON FALLS, NEW YORK 10519
(914) 277 -5805
FAX (914) 277-8210 .,G/ ,c
TO
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via
• Shop drawings ❑ Prints ❑ Plans
• Copy of letter ❑ Change order ❑
119ITTIgn @G5 4 ° aQ3W0 U ULQL4
DATE 7 y/ 7- 6;;,3
JOB NO.
ATTENTION
C�
RE:
C
❑ Samples
the following items:
❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
C
THESE ARE TRANSMITTED as checked below:
P-foor approval
• For your use
• As requested
❑ For review and comment
❑ FOR BIDS DUE
REMARKS
COPY TO
❑ Approved as submitted
❑ Approved as noted
❑ Returned for corrections
❑ Resubmit
❑ Submit _
❑ Return _
copies for approval
—copies for distribution
corrected prints
19 ❑ PRINTS RETURNED AFTER LOAN TO US
SIGNED: x_l �
If enclosures are not as noted, k1ndlV notify is at once.
0
■ ■ : 0 0 ■ ■
P
THE VARIABLE TONE BACKGROUND AREA OF THIS DOCUMENT CHANGES COLOR GRADUALLY AND SMOOTHLY FROM DARKER TONES AT BOTH TO AND BOTTOM TO THE LIGHTEST TONE
IN THE MIDDLE.
V
7 L
Jun 24 03 08:42a TOWN OF PATTERSO 845- 878 -2019 F -2
08/24/00 TUE 08:18 TEL 914 277 6210 BIBBO ASSOCIATES LLP 0002
C()
BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S.N.
Public Health Director 46' � �Q Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road'
Brewster, Ncw York 10509
[:nvirunmenlal 11calth (914)27B-6130 fax (9 W) 278 - 7921
Nursing Services (914)278.6558 1V1C (914)278 -667$ Fax (914) 278 -6085
Early Iulervenlion (914 }278.6014 1'rciehaol (914)278 -6082 !';x(914)278 -6648
OWNERS NAIVI,L,':
TAX ivLAP NUMBt;R:
14--/- 7
E911 ADDRLSS: /�y Cc �G %7 �a.y
TOWN: /%Z2� yfos7
AUTUbIUZED TOWN OFFICA,L-
(SigllatuI'C)
DATE:
� -7/ 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 assifined by an authorized town official. This form is to be submitted
willi the applivation fora Certificate of Construction Compliance.
(L•"911 VElU:1UA)
06/24/03 TUE 09:36 [TX /RX NO 66691 0002
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
160 Couch Road
Town/Village:
Patterson
Tax Grid #
Map 14. Block —1 Lot(s) —7
Well Owner:
Name: Address:
Karen Correll, 160 Couch Road, Patterson, NY 12563
Use, of Well:
1- primary
2- secondary
X Residential Public Supply Air cond/heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
X Rotary Cable percussion X Compressed air percussion Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock Other
Casing Details
Total length 63 ft.
Length below grade 62 ft.
Diameter 6 in.
Weight per foot 19 lb /ft.
Materials: X Steel Plastic Other
Joints: Welded X Threaded Other
Seal: X Cement grout _ Bentonite Other
Drive shoe: X 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 X Pumped X Compressed Air
Hours _6_
Yield 2-1_ gpm
Depth Data
Measure from land surface - static (specify ft)
60'
During yield test(ft)
280'
Depth of completed well in feet
355'
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
40
Drilling
in over
urden clay and boulders
Hit rock
at 40'
40
63
Drilling
in rock
set casing routed
63
355
Drilling
in rock
granite
-`
c:)- a,
C
6 -C
If yield was tested
at different depths
during drilling,
list:
``' Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type sub Capacity 7gp'n
Depth 300' Model 7GS07412
Voltage 230 HP 3/4
Tank Type Volume
Date Well Completed
6/5/05
Putnam County Certification No.
004
Date of Report
6/10/05
Well D ' signature)
C ristopher`Teal
NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet(plan.
Well Driller's Nam e Beal &Sons Inc. Address: 4 Putnam Ave., Brewster. NY 10509
Signature: Date: 6/10/05
zri.s op er ea
White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM
Building Constructed by
Location - Street
1%s, 01. ` 02 ., /P 141:5e el- 741e�
Building Type
TownNillage
,V/ , er \-r, ,� //
Subdivision Name
3
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 D�};,,r=� Year Signature:
GeneraYContractor (Owner) - Signature
Corporation Name (if corporation)
Address:
State Zip
Corporation Name (if corporation)
Address:
State Zip
Form GS -97
/'?,
7
Owner or Purchaser of Building
Tax Map
Block
Lot
Building Constructed by
Location - Street
1%s, 01. ` 02 ., /P 141:5e el- 741e�
Building Type
TownNillage
,V/ , er \-r, ,� //
Subdivision Name
3
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 D�};,,r=� Year Signature:
GeneraYContractor (Owner) - Signature
Corporation Name (if corporation)
Address:
State Zip
Corporation Name (if corporation)
Address:
State Zip
Form GS -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM
PCHD CONSTRUCTION PERMIT # 14WWI
Located at /�® 4! fi—W A ,ZIWI Town or Village
Owner /Applicant Name &6 e-4 Tax Map /f Block / Lot 7
Formerly
Subdivision Name s-
Subd. Lot # 1Y
Mailing Address "64 -1 /Pjrl, , /Gi
Date Construction Permit Issued by PCHD
Zip %r rg&
Separate Sewerage System built by ( 7 e sci %7G� Z Address
Consisting of S Gallon Septic Tank and i-3 Z62X/1 el-th ' --
Other Requirements:
Water Sunnly:
Public Supply From
Address
or: Private Supply Drilled by �X/ `5�i y4' %� Address
Building Type Has erosion control been completed? _ C-
Number of Bedrooms Af - Has garbage grinder been installed? Z7 e7
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: 7-17-O5 Certified by Q � � �, .' P.E. ✓ R.A.
/ (Design Professional)
Address : 5�5ocs=�ZLf ;jr'f ?/aPee-i- .7- Z License # 4az: %s��
Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary
to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage
treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval
of the private water supply shall become null and void when a public water supply becomes available. Such
approvals are subject to modification or change when, in the judgment of the Public Health Director, such
revocation, modifica ' mvr a ge 's necessary.
w
By: �� ` Title: �� Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
AN
u
N
r
112
1250 GAL P/C CONC.
SEPTIC TANK
Al
s�
II III "'
jj.II
1'
II II II II II
III
TRENCH (TYP.;
0
1000/6 EXPANSION)
{
(TYP•)
AREA
�C
�y
y
ITEM
"A"
"8"
tANKI
39'
27'4"
J82
60'3'
34'
i
J83
64'6"
35'6'
J84
69'6"
8'6"
.185
75'
42'6"
J86
8016'
47'
J87
66'61152`--511
J88
92' 6"
57' 8"
-�9
98'
63'
10
103'6"
6B'
J811'
'�12
II6'
97'6"
?1;13
117'
95'7'
-MI4
120'
98'
T�15
124'
101'
t�lb
IZB'6"
105'
1 17
133' 7"
108'
1MI8
138'9"
112'3"
1V19
142'
114'5"
20
144'
ib'B"
1>r21
129'6"
97'6"
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CONSTRUCTION PERMIT FOR SEWA.GGE TREATMENT SYSTEM
PERMIT # 2 - I " v
Located at Z62 ri>e,,CII AW, Town or Village / f Pr Sow
Subdivision name 17o� // Subd. Lot # Tax Map /I- Block _� Lot 7_
Date Subdivision Approved 1'7,R7 Renewal Revision
Owner /Applicant Name Zrar—ezr e Gy ye-%l Date of Previous Approval
Mailing Address /t<O 62, /zeG,(/1 M ,, A/` , zip /'es �, j
Amount of Fee Enclosed
Building TVDe r° 5'i'ri/ . Lot Area bqc, No. of Bedrooms Design Flow GPDM:7
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of gallon septic tank and
e sfe—A
Other Requirements:
To be constructed by 27; Address
Water Supply: Public Supply From
Address
or: Private Supply Drilled by Address
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
sQarate 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 /
License # * .
/ r 111$-J /v%.1- 16215-19
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 when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new permit. Approv gbrischarof domestic sanitary sewage only.
By: O Title: Date: 2 l
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design rofessional
.Form CP -97
PUTNA9i� C ®UP9T'Y HEALTH ®EP -
4Geneva Road (914)`'278 G130 T, -
Brewster, NYa10509 ` 4
S
z Yom, 0189fi5
f
Rece►ved - '
4
of
-� �:. 9
ate
z
The Sum Of
D $ j
FOr
ON ars
}
PUTNAM COUNTY DEPARTMENT OF HEALTH
'DIVISION OF ENVIRONMENTAL HEALTH SERVICES
LETTER OF AUTHORIZATION
d
RE: Property of f�/ 6 A2 0
Located at
T/V e2 -� Tax Map # //f Block l Lot 7
Subdivision of 4 C-5
Subdivision Lot # J Filed Map # Date Filed
Gentlemen:
This letter is to authorize 13,1" hAa S, G -G . /0-
a duly licensed Professional Engineer t-�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 conricction with this
matter and to supervise the construction of said wastewater treatment and /or water supply systems
in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
Countersigned•o
P.E., R.A., # -:�-
Mailing Address;
State
Zip .7
Telephone: j/� - „;? 7.7
Very truly yours,
Signed:
(Owner or Property)
Mailing Address: �pQ lvf l<_ C�cl�
4 61-eZ5 O A---
State Al
zip
Telephone: %<1,3 O
Forni LA -97
P UTNAM COUNTY DEPARTMENT OF HEA L'I'l [
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA.SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner Address AV,,ZZ , er-s eIVIZ231�3
Located at (Street) Tax Map Block / Lot 7
(indicate nearest cross street)
Municipality Drainage Basin
SOIL PERCOLATION TEST DATA
Date of Pre - soaking /fZ 2 7_1pD Date of Percolation Test8�p�
Hole No.
Run No.
Time
Start:- Stop
Ela se Time
(iVlin.)
Dc th to Water
-From Ground
Surface (Inches)
Start Stop
Water
Level
DropP In
Inches
Percolation
Rate
mill/Inch
4
5
12
1
/ :� - . s-�
3ca
Z
Sr
�2 -5r-4
3
,' s 6
3 o
s��
% 3�
17,1
4
Y
5
1
..
2
3
4[�^
NOTES:
4,2 �\ SUrCllll
at same depth until approximately equal percolation rates are obtained at each
(i.e. s 1 min for 1 -30 min /inch, s 2 min for 31 -60 min /inch) All data to be
to be made from top of hole:
Form DD -97
DEPTH
G.L.
0.5'
1.0'
1.s'
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. j HOLE NO. HOLE NO.
C�4A* 7k G'•�
�ev��rd�✓ti , f /:, e
A.; pal
s�;
Indicate level at which groundwater is encountered
Indicate level at which mottling is observed --
Indicate level to which water level rises after being encountered
Deep hole observations made by: T ,,;,5C Date
17/00
Design Professional Name:
Address:r,
Signature: `
Design Professional's Seal
N
CO r NA
e
4,,0 . 0559Za
gOF�8810N�
PUTNAM COUNTY DEPARTMENT OF REALTH
DIVISION Off. ENVIRONMENTAL HEALTH SERVICES
APPLICATION FOR APPROVAL OF PLANS FOR
A.WASTEWATER TREATMENT SYSTEM
1. Name and address of applicant:C
2. Name of project:.
4. Design Professional:,
6. Drainage Basin:
7. Tyne of Project:
3.. Location ., N, : ' ��� •�r .
�. ✓�'ha s sots L.L. /? 5. Address:
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).
. . .. , . ;. .. ExeT y e Status (check,one .........: ................... .... Type I mpt
Type II;. . Unlisted
9.. Is a Draft Environmental Impact Statement (DEIS) required? ......................... Pi
10. Has DEIS been completed and found acceptable by Lead A enc ?
g ..y
. ....
11. Name of Lead Agency y
• 12. Is this project in an area under the. control of local planning,, zoning, or other..
`officials ; ordinances. .. ..........................
13. Jf so have P lans been submitted 'to such authorities?
e
14. Has preliminary.approval.been granted by such: authorities. Date granted:
15. Type of Sewage Treatment System Discharge ................. surface water 4-"' groundwater
...::.......... ....
•
16. ;,If surface•water discharge,' what is the stream class designation. .
17. ` Wat6rs�index number (surface).:: :............... .. ............ AVA
18. Is project located near a public water supply system? ....... ............................... A Jv
19. If yes; name of water supply, Distance to water, supply
20. Is project site near a public sewage' collection or tr'eatm'ent-'system?
21. Name of sewage system Distance to sewage system-
22. Date test holes observed i oa 23. Name. of Health Inspector G'6?1.1VC__ �eeW
24. Project design flow (gallons per day) OCR
25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... ^o
26. Has SPDES Application been submitted to local DEC office? .........................
Pon» P(' -97
27. Is any portion of this project located within,.a: designated Town or State wetland ?' `
28. Wetlands ID . Number .......................... .......................................
: .........::........:...........
29. Is Wetlands Permit required? ............
Has application been made to Town or Local DEC office? .......................... ......
30. Does project require a DEC Stream Disturbance Permit? ................................. 410
31. Is or was project site used -for agricultural activity involving application of
pesticides to orchards or other crops, solid or hazardous waste disposal,
landfilling, sludge application or industrial activity? ........................ ..... Yes/No
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/N.o p
DESCRIBE:
33. Is there a local master plan on file with, the Town or Village?! ........................... . 5
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? p
36. TaxMap ID Number .......................... ............................... Map Block_ Lot 7 .
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.
I hereby affirm, widerpenalty of perjury, that information provided on this form is true
tolhe best of my knofvledge and belief. False statements made herein are punishable as
a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
SIGNATURES & OFFICL4L TITLES.
o s'socs_ 2—
Mailing Address: ................................... 15� 9
14-1e -4 (2187) —Taal 12
PROJECT I.D. NUMBER 617.21 SEQR
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. ROJECT NAME
C.i yy�� ,,((��
dddt°i / � ��CJ,1 , Ol / / / d'P%
J. PROJECT LOCATION:
/
Municipality �� County 07 y/ O
4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, otc., or provide map)
5. IS PROPOSED ACTION:
❑ New ,12q Expanslon ❑ Modification /alteratlon
6. DESCRIBE PROJECT BRIEFLY:
p2 �,GV ���T: �-, Ito G- f��`s7i�� 02 9- A7,
G?' `i0� C%X�! y Si o�y � � vX /. ;r%`i �,� Ss� .$' �!�• Q GGO�iG�� a7�
A`
7. AMOUNT OF LAND AFFECTED: p'
Initially � 4 acres Ultimately G acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
,Yes ❑ No It No, describe briefly
S. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
.151 Realdentlal ❑ Industrial ❑ Commercial Agriculture ❑ Park/Forest/Open space ❑ Other
mac❑
Describe: �i��i %� Geis. •7`y /'G.:S•C�.� / i G
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)?
.Yes ❑ No If yes, list agency(s) and perrnil/approva(s
tt. DOES ANY ASPECT OF THE ACT; ,1N HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
❑ Yes No II yes, list agency name and permit/approval
J�J
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION?
❑ Yes ❑•No lUlf
1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
9
Applicant/sponsor name: _ %ae / Dale:
L-P�.,x ?1e)
Signature:
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review piocess acid 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 b nother invQlve gency..
❑ Yes No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, 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 brlolly:
C3. Vegetatlon or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly
C5. Growthi subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other.eflects not Identified In C1-057 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 / If Yes, explain briefly
-e:' f5�c��,
PART III — DETERMINATION OF SIGNIFICAI(CE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identif led 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 (n magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed.
❑ Check this box if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and /or prepare 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 environmbntal imparts
AND provide on attachments as necessary, the reasons supporting this determination:
Print or Type Name of Responsi —o . is n ea Wiffil
v Signature of Responsible officer in Lead Agency
'Title of Responsi e O icer
Signature of Preparer (if different from responsible officer)
�G/
BIBBO ASSOCIATES, L.L.P.
Consulting Engineers — Planners
Putnam County Department of Health
1 Geneva Road
Brewster, NY 10509
ATTN: William Hedges
Dear Mr. Hedges:
January 31, 2001
John P. McNamara, P.E.
Joseph J. Buschynski, P.E.
Timothy S.Allen, P.E.
Leonard J. Bibbo P.E.
Robert A. B. Howe, B.S.
RE: Karen Correll - 2 BR Addition
Couch Road, (T) Patterson
Enclosed for your review in the above matter please find the following items:
1. Construction Permit Application
2. PC -97 Application Form
3. E.A.F.
4. Authorization Letter
5. Design Data Sheet
6. $300 Application Fee
7. Two sets of house plans
8. Four prints of an SSTS Site Plan
The owner proposes to construct an addition to her house which will increase
the number of bedrooms to four. The existing septic system was uncovered and was
found in good condition. No saturation was evident in any of the existing trenches.
Based on the 16 -20 min. /in. perc rate in the area adjoining the existing system, 420 I.f.
of new absorption trench is proposed which will precede and connect to the existing
150 ft. of absorption trench. The existing septic tank will be replaced with a 1250 gal.
tank.
Please call if you have any questions.
Very truly yours,
Joseph J. Buschynski, P.E.
JJB /bs
Enclosures
Planning o Site Design a Environmental
589 Route 22 - P.O. Box 403 - Croton Falls, NY 10519 - (914) 277 -5805 - (91,4) 277 -8210 Fax
7
0 REWSTER LABORATORIES
Box 224 - BREWSTER, N.Y.
WATER ANALYSIS REPORT .
SAMPLE NO. 5013
SOURCE: Virginia S. Half,
Coach Road
Patterson, NY
COLLECTED: January 189 1983
BY: Raymond E. St. Martin
BACTERIOLOGICAL EXAMINATION
Coliform Count, MF Method
Faucet - Well
Thir rorult i„dieater the rource of tht rampli war
of satisfactory raxitary quality wht„ thi raepli war colltcted.
0 per 100 ml.
CAt
mr f`Gs'
; ?,
� sew
-P January 23, 1983 C '�-,--
Bickwit P. E.
Director
4.
PUTNAM COUNTY DEPARTMENT OF HEALTH
Division of Environmental Health Services, Carmel, N. Y. 10512
CONSTRION PERMIT -FOR; StWAGE..- DISPOSAL SYSTEM.. pati:BrSOn
UCT
.1 t i Town or Village
Located at COl1Ch -Road . Tax Map 5 Block 2
- Subdivision Lot 2 Job S.O. 20.28
ti
Owner Virginia S. :Hal 1 Address n � .
Building .'type Fra.610, ' Lot Area 18, .9 _t_, _,cr*eS Ntte -son -N Y. ��,25�
Number of Bedrooms tWG Design Flow ''6OO (t(lree bedroom] Total Habitable -Space 1.84 Square Feet
1000. , 500t x 24 "`' Latera1 k:
Separate Sewerage System to consist of Gal.- Septic Tank and
Phlli St. `Martin Address HnImeS H _
To be constructed by � �-
Water Supply: Public Supply From - -
x Private Supply to be. drilled by LX4stfn6'.
Address
Other Requirements one ,
I represent that 1. am wholly. and completely responsible for the design and location of the proposed system(s); :1) that the. separate sewage d_ isposal system
above described• will be constructed as shown onthe_ approved amendment there to and in accordance with the standards, rules and regulations o t e u nam
County Department of .Health, and. that on completion thereof a "Certificate 'of Construction Compliance" satisfactory to the Commisslorier of Health 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, ;disposal systern during the period of two (2) years irrimediatelyfollowing thedate of the issu-
ance of the approval. of e' th Certificate' of Construction Compliance of the 'original system or'any repairs thereto;.2) that the drilled. well described above
will -be located es shown.on, the approved plan and that said well will be installed -in accordance, with the standards rules'and regulations of'. the ..Putnam
County Department of Health:
Date 10 "November 1982 signed P.E. R.A.
Address RD 9 :- Fair 'St. ,. C r ,_ N.Y. 051 license Iva. 29206
APPROVED FOR CONSTRUCTION: This approval expires one year from the 'date issued unle ;s ,construction of the building has been undertaken and is
revocable. cause or maybe' amended or modified when considered necessary by the Com s Toner of Health. 'Any change or alteration of construction
requves a new permit Approved for disposal of domestic y age or priv a
.Date ��c'S BY T
IF
y
K
r PUTHAM COUNTY.DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET - SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner... VjM I Lj ; d S. H3g I Address
Located at. ( Street ) (S (, U, I: .
oss
Hares
Block Z Lot Z
e
4
Municipality Watershed
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME P
PERCOLATION P
PERCOLATION
No. T
apse D
Deptti to Water W
Water Level
Soil Rate
ved
3 f ///7 u
u )
)'' i
ii -,So
2 /013 .1,047. 1
14 /
/
1047 /I /¢ z7
4 - 2-7
.1 COUN-Y
Notes: 1) Tests to be repeated at same depth until approximately equal soil
rates are obtained at each percolation test hole. All data to be submitted
for review.
2) Depth measurements to be made from top of hole.
TEST PIT DATA REQUIRED TO BE SUSMITTED.WITH APPLICATION
DESCRIPTION OF.. SOILS .- ENCOUNTERED''IN- TEST .HOLES
DEPTH HOLE N0. l .'.. HOLE. -No.l.
HOLE N0.
G. L.
6" �,foi� di 17.1;e5
12 "..... .
1811. .
2411 L-E. �row�► �
301' Lo. m .. .
36.1
42"
48
60" o
66..
7?
7811
8411
1J0 �.00eh
INDICATE LEVEL AT 9 II,CH GROUND WATER. IS. ENCOUNTERED.Poae
INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED AJOne A—P4w i- Ffiy
TESTS MADE_ BY
Date
DESIGN
Soil Rate Used2,1-30 MirVl "Drop: S.D. Usable
Area Provided �-
No. of Bedrooms 'rte Septic Tank Capacity p
Gals. Type
Absorption Area .Provided.,By.. L.F.x24. 5b"
width trench.-
_
hi V1 1TiFgY skI-P 1 eaaa
her IUone
101VR fESSIONA[ _
Name- - - - - . _ . --y � — y . .
Address QAW4r-1 %J
gnaturej
v.a V. V A ! W 1
THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY:
Soil Rate Approved Sq. R /Gal. Checked
0M
011
�o•
2920`0
�FrHE S10 �!X_ate
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL ABANDONMENT REPORT
I, undersigned, hereby certify that the abandoment of the above - referenced water well has been accomplished and
completed in accordance with the methods described in Permit.# AW15 -05 to abandon said water well.
Date: 6/28/05 Signature:
Print Name: Christopher Beal
Address: P. F. Beal & Sons, Inc.
4 Putnam Ave., Brewster, NY 10509
I S Z lid 0E Nnf S9)i
1
S3A8S 1i U AN3
All noo 6awand
CIA1333d
Form WAR -97
PCHD Well Abandonment
Permit # AW15 -05
please print or type
Well Location
Street Address:
Town/Village
Tax Grid #
160 Couch Road
. Patterson
Mapl4. Block —1 Lot —7
Well Owner
Name:
Address:
Karen Correll
160 Couch Road, Patterson, NY 12563
Well Type
_x Drilled Driven
Dug Gravel
Other
Depth of Well
Well Depth 150 ft
Static Water Level ft
Date Measured
Reason for
Abandonment
Well is collapsing
Description of
Filled well from bottom
to top with concrete.
Completed Work
I, undersigned, hereby certify that the abandoment of the above - referenced water well has been accomplished and
completed in accordance with the methods described in Permit.# AW15 -05 to abandon said water well.
Date: 6/28/05 Signature:
Print Name: Christopher Beal
Address: P. F. Beal & Sons, Inc.
4 Putnam Ave., Brewster, NY 10509
I S Z lid 0E Nnf S9)i
1
S3A8S 1i U AN3
All noo 6awand
CIA1333d
Form WAR -97
SHERLITA AMLER,-MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
P.F. Beal & Sons, Inc.
c/o Chris Beal
4 Putnam Avenue
Brewster, NY 10509
June 1, 2005
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
County Executive
Re: Proposed Well Correll
160 Couch Road
(T) Patterson
14.-1 -7
Dear Mr. Beal:
A field inspection was conducted on the above referenced lot by Brian Stevens, Public Health
Technician. The application to replace the existing well is approved with the following.
stipulations:
1. The existing well is to be abandoned within 30 days of the completion of the new well
construction. Please provide notice t6 this Department two days prior to abandoning the
existing well so that this Department may witness it.
A Well Completion Report (WC -97) shall be submitted no later than 30 days after the well
completion by the permittee.
Please contact the writer at (845) 225 -5186 ext.2235 if you have any questions.
cc: RM, File
Sincerely,
X-� t - i
Brian R. Stevens
Public Health Technician
Water Supply 3edim (845) 225 51 B6 Pax (845) 225 -5418
Environmental Health (845) 278-6130 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 WIC(845)279-6678 Fax(845)278-6085
Early Intervention/Preschool (845),278-6014 Fax(845)279-6649
6M'• - ,
PUTNAM COUNTY DEPARTMENT OF HEALTH
AV'SION OF ENVIRONMENTAL HEALTH SERVICES
OF
TO CONSTRUCT A WATER WELL
please print or type
PCHD Permit # Lk) 3p -O,!!�
Well Location:
Street Address: Town/Village Tax Grid #
160 Couch Road Patterson Map 14. Block -1 Lot(s)
-7
Well Owner:
Name:
Address:
Karen Correll
160 Couch Road, Patterson, NY 12563
Use of Well:
X 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 5 gpm # People Served -Est. of Daily Usage
gal.
Reason for
X Replace Existing Supply Test/Observation Additional Supply
Drilling
New Supply (new dwelling) Deepen Existing Well
Detailed Reason
Existing well is collapsing.
for Drilling
Well Type
X Drilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes No
Is well located in a realty subdivision? Yes No
Name of subdivision Lot No.
Water Well Contractor: P. F. Beal & Sons, Inc. Address: 4 Putnam Ave., Brmster, NY 10"
Is Public Water Supply available to site? .................................. ............................... Yes No
Name of Public Water Supply: Town/Village
M
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on separate sheet/plan.
7d „'
Date: 5/19/05 Applicant Signature:
.,
Christopher Beal
w =i
PERMIT TO CONSTRUCT A WATER WELL C) �?
This permit to construct one water well as set forth above, is granted under provisions of Article 1®cbf thy'
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. rvision or alteration
of the approved plan requires a new permit. Well to be constructed by a water 11 ler ed by Putnam
County.
Date of Issue rl"311"tl , Permit Iss
Date of Expiratio Title: '
Permit is Non -Trans ra le
White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
1, ' Form WP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO ABANDON A WATER WELL
please print or type
PCHD PERMIT # At J l5 -06
Well Location:
Street Address: TownNillage
Tax Grid #
160 Couch Road Patterson Map 14. Block -1 Lot(s) -7
Well Owner:
Name:
Address:
Karen Correll
160 CouchRoad, Patterson,
NY 12563
Well Type:
X Drilled Driven Dug Gravel
Other
Depth Data:
Well Depth 150 ft
Static Water Level ft I
Date Measured
Use of Well:
X Residential Public Supply Air /Cond/Heat Pump
Abandoned
1- primary
Business Farm Test/Observation
Other (specify)
2- secondary
Industrial Institutional Standby
Water Well
Name: Address:
Contractor:
P.F. Beal & Sons, Inc., 4 Putnam Avenue, Brewster, NY
10509
Reason For
Well is collapsing
Abandonment:
Description of Work To Be Performed:
rn
Fill well with concrete from bottom to top.
<—t
CD
� cn
Date: 5/19/05
Applicant Signature: `-
Christother Beal
PERMIT
This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam
County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR
and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall
submit to the Department a certified statement that the in a 'on delineated on the application for this
permit has been completed.
,313
Date of Issue Permit Issuing Official Title
White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WA -97
P.F. BEAL & SONS, INC.
4 PUTNAM AVENUE
ARTESIAN WELLS BREWSTER, NEW YORK 10509
WATER SYSTEMS
JET PUMPS &iaXI.,1 eon /B91 Over /447s &ell, Gompleled
SUBMERSIBLE PUMPS TEL. (845) 2794461D.- 2451
FAX (845) 279 -6613
COMPLETE INSTALLATION, REPLACEMENT AND REPAIR SERIVICE
Karen Correll
160 Couch Road
Patterson, NY
Tax Grid #14. -1 -7
px,ie- /(a LIT
WATER TANKS
COMMERCIAL WATER SYSTEMS
HYDROFRACTURING
WATER CONDITIONING EQUIPMENT
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!Eq3kT —7
FOR ASSESSMENT PURPOSES ONLY
NOT TO BE USED FOR .CONVEYANCES DATE DES
cunnam nu,.a.1: s �,..z+i
PREPARED BY
JAME) W. SEWALL COMPANY
147 CENTER STREET OLD TOWN MAINE
346
TOWN
VILL
,� • -- � 3 - o O'b' -P,ro r4 -1 -6 1 0 14.000
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I acknowledge receipt ofthis report SIGNATURE:
02/96 Title;—
'P.=-%
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AS BUILT" DATA
Structure located from survey by surveyor noted b a 19 '
Weil located:by: Surveyors survey.—
Well drillers report--
Engines rs rnf sure ment sjs— —rz.YL�Auqj 12zjj vq
Tank, boxes, pits, galleries alo.terals lo-cated by:Controctor.
tnotneer3
HeCitthdapt:
v \ N -
d Cie Field inspection. 'by: Health dept 1z dot a:—
Eng-i near Ej date
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A11A -.,f
V
Putnam County Department Of Health.
Division of Erri—rcnmental Health Ser7iaes-
Lpproved nz for conformance with
—Awl"1143 0 "d'-VN. nd Regulations of the
,1 -Pkutnamounty pealth Department.
NOTES: U.
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D I ME N SION S
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SANITARY 5Y21F.M DEStGN -"I&BUILT
OWNER:
_ _
LOCAT)PN Street:_ a,,.O,, tuj <9
eo,/—
Town*_
SUBDIVISION:
I'A 0. P
Block..
X LOT
Builde,76jo-"�Z, Q
S urve y or: L-&L—A/
Drawn: Date: -&
Job N-Sj.
SColfi: 11
JOHN H. .PR E. N T IS S. R E,
CONSULTrNG ENGINEER