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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 15. -1 -12 BOX 6 'Irs ' I I a 7- " Ll jr J Lr Tr rz Adiji, 00503 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: M, , co& Town/Village: ter Tax Grid # Map le?, Block Lot(s) �. Well Owner: Name: U Ari ' Address: 5G Use of Well: 1- primary 2- secondary Residential Business Industrial OPublic Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing _)L Open hole in bedrock Other Casing Details Total length _4pQ�L_ft. Length below grade gadft. Diameter 7 in. Weight per foot lb /ft. Materials: Steel _ Plastic _ Other Joints: Welded Threaded Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes Y No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield a gpm Depth Data Measure from land surface - static (specify ft) C50 Ti During yield test(ft) � L � lv c Depth of completed well in feet 76' Well Log If more detailed information descriptions or sieve analyses are available, please attach.'a, Depth From Surface Water Bearing Well Diameteron) Formation Description ft. ft. Land Surface 725 (% If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 66LJ S Capacity M Depth Model /345 �s- Voltage HP / • 5' Tank Type�S610kdvolume � 646A Date Well Co leted Putnam County Certification No. 007 Date of Re ort `/�7�3 Well Driller (signature) A�& NOTE:/Exacf location of well with distances to at least two permanenrandmftks to be provided on a separ rheet/plan. Well Driller's Name r' Signature: Address: 126 40' 3I% 6 4�3 Date: n White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 AM COUNTY DEPARTMENT OF HEALTI N OF ENVIRONMENTAL HEALTH SERVI CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMEN PCHD CONSTRUCTION PERMIT it P~ Located at M 61-AW 6M(A 10N91 Owner /Applicant Name �`PLI AHI'l V,46011 Formerly Town or Village RTr 5 F-6 01-4 Tax Map i�) ° Block 0 Lot L Subdivision Name ' J {�bf ! � Subd. Lot # �1 Mailing Address HA )tN 14J A41; - off W 41 iFF" Zip 1001 Date Construction Permit Issued by PCHD 01) '� 6 C Separate Sewerage System built by A FAdlI KWOi gL i Address 44 ` 6� Pi's Consisting of � 00 0 Gallon Septic Tank and i Gt O L Other Requirements: I'I L I ��� iNL� L71 Pl +#H Water Supply: Public Supply From Address, or: X Private Supply Drilled by H 1 VTDO 1l 1 All- Address IM Building Type F-65 10 ( HLG7 Has erosion control been completed? Number of Bedrooms -7 Has garbage grinder been installed? _ VF� 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 regulatic)#s of the Putpam County Doartment of Health. Date: ® .) 1 Address P.E. � R.A. 661,24 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 ubject to modification or change when, in the judgment of the Public Health Director, such revocatio }n dificatio change is necessary. By: Title: White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; W ?WS9 Date: Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: i jf0a 6 ('per Ka Town/Village: ter'5a\Map Tax Grid # 1�5. Block I Lot(s) Well Owner: Name: U ri Address: ) ir&S ' SG M -y i �►�� t� Use of Well: 1- primary 2- secondary Residential Business Industrial OPublic Supply Air cond/heat pump Irrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) ZZ Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length —4��ft. Length below grade _jaLft. Diameter �7 in. Weight per foot lb /ft. Materials: _y Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: Cement grout _ Bentonite Other Drive shoe: Yes No Liner _ Yes K 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 gpm Depth Data Measure from land surface - static (specify ft) C50 - During yield test(ft) 4t%hLj;,, df k e Depth of completed well in feet 766 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 V ' If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type 124jdg Capacity J3 '' l Depth �5fb_ Model �yLC7J /J, Voltage _4�6 HP / • s Tank Type jSO,01��Volume ,I�Q 6-alldn Date Well CZ leted // Putnam County Certification No. 007 Date of Re a /� d7 63 Well Driller (signature ' NOTE:/Exacylocation of well with distances to at least two permanenrandm#ks to be provided on a separpfteet/pl.an. Well Driller's Name Signature: Address: Date: White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 MAR -12 -03 0845 AAM PAT 4148786343 P'Q3 .TERSON TOWN HALL ' BRUCE 1t, FOLEY T LONMA MOLMAM itN,, M.S.N. �� ' i,f;`� tr4ltc H�altb Dlnao�� • �. ,. •.�� Aiteotrw l�ltp „Xtal�,,l� tor, # ... .. Director (f per &A*” I. �._,...�� ...... _..� DEPATt'rivWT OF - HE ' ...... 1 GenaYa - Road Broweter, New Yo* i0S09 .;....•..r„ .,._..., . •Wtlr IMUW Hod* (911)271.6110 t1s�9U) t!1 7921 y • • NOrdM air en (9N)371r6058 •w1C (911)X78.1671 .� 14) 271.6083 r ' . , � ',,,� ftu{7'liktvea�oe'(414) S7f'• 6411 Pracboo{ (91 ;} =8.6012 F (910} 17i'• 6448 ., E211 ADDRESS YERIFICA11 0'Wk S NAM: R-� )-R) cR� ( 5rft'&d l,eS" E911 ADDRESS,-, • . TOWN: �Ti" 4.5oH ............... , 1 � AUTa0AiZXD T0W. N._0MC1AL:. :._.....__...,. (Sfgn>,Cure} ~� DATE: .... .... . , •. �' I� ��. i. ..... ... >. .... •o •i I � The Putnam County Department of Health wW not issue a 'Ceirttficate 'of ' Construction Compliance unless the above form is coml leted; Le,, a legal E911 r address is assigned by an authorized town official. This 'arm is to be submitted with the application for a CertiFcate of a -:: 0% September 9, 2005 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 2050 Route 22 Brewster, NY 10509 Tel: (845) 279 -4003 Fax: (845) 279 -4567 Email: hnengineer @aol.com RE: Proposed Compliance: KRASNIQI Stage Coach Road, Lot 27 (T) Patterson, T.M. # 15.1 -12 Dear Mr. Morris: The following is a response to your March 25, 2005 review letter: 1. The system has been flushed and the water retested. Results of the new water test is enclosed. Very truly yours, Harry W. N' hols Jr., P.E. HWN:gav 00- 011.27 Page 1 of 1 liffiEnvironmental Services, Inc. //ii 41 Kenosia Avenue S WATER, SOIL AND AIA ANALYSIS 1i J� Danbury. Connecticut 06810 I Telephone 203 - 798 -2229 Date Analyzed u Hyatt Pump Service Mailing Information: Collector's Information: JMS ID: 005197 - Method 08/17/05 Name: Hyatt Pump Service Name: Madelyne Hyatt Address: 229 South Rd Address of site: Krasniqui /Main House 08/17/05 231 Stage Coach Road City: Holmes City: State: NY Zip: 12531 State: NY Zip: Phone: (845) 855 -5136 Fax: (845) 855 -5136 Phone: Sample's Information: -.— Site: Kids Bath Tub Date Collected: 8/16/2005 Date Received: 8/17/2005 Preservative: HNO' Time Collected: 1:00:00 PM Time Received: 3:00:00 PM Temperature: <4 Lab No.: J0508817 Matrix: Water <0.05 mg /L Date Analyzed Test Name Result MCL - Method 08/17/05 Color ND 15 Units SMWW 2120 B 08/17/05 Turbidity 0.1 ntu 5 ntu SMWW 2130 B 08/19/05 Hardness 60 mg /L N/A SMWW 2340 C 08/17/05 Odor ND N/A SMWW 2340 C 08/19/05 Manganese <0.05 mg /L 0.3 mg /L SMWW 3111 B (NY) 08/19/05 Sodium 6.26 mg /L N/A SMWW 3111 B (NY) 08/19/05 Iron <0.05 ppm 0.3 ppm SMWW 3111B 08/19/05 Chloride 9 mg /L 250 mg /L SMWW 4500 Cl C 08/17/05 pH 7.4 S.U. 6.5 -8.5 S.U. SMWW 4500 H B -NY 08/19/05 Nitrate 1.21 mg /L 10 mg /L SMWW 4500 NO3E 08/19/05 Nitrite <0.1 mg /L 1 mg /L SMWW 4500 NO3E 08/19/05 Sulfate 37.2 mg /L 250 mg /L SMWW 4500 SO4F 08/17/05, Chlorine Free Residual . <0.1 mg/L N/A SMWW 4500CIG 08/17/05 4:00 PM Total Coliform Absent Absent SMWW 9222B Comments: At the time of the analysis the sample was Acceptable for Total Coliform CFU = Coliform Forming Units MCL = Maximum Contaminant Level mg/L = milligrams per Liter N/A = Not Applicable ND = None Detected ntu = Nephelopmetric Turbidity Unit ppm = parts per million S.U. = Standard Unit Units = Units Signature: ���l+til''�iCC� . Reviewed e l Michael Lapman Sharon Houlahan, Director President State #: P14-0218 ELAP #: 11715 CONNECTICUT. NEW YORK AND NELAC CERTIFIED Toll Free 888 - JMS -5097 1 Corporate Fax 203 -798 -2408 1 Lab Fax 203 - 798 -2107 I wwwirnsenvironmental. corn SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health Harry Nichols, P.E. Patterson Park, Ste 106 2050 Route 22 Brewster, NY 10509 Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 March 25, 2005 ROBERT J. BONDI County Executive Re: Proposed Compliance: KRASNIQI Stage Coach Road, Lot 27 (T) Patterson, TM # 15.1 -12 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 water sample results exceed the parameters outlined by this Department in PH and Iron. It is suggested that you flush the system and resample. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:kly Ver ly yours, AA-- Robert Morris, P.E. Senior Public Health Engineer Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 ,� °. PUTNAM COUNTY DEPARTMENT OF HEALTH V ?/O—y DIVISION OF ENVIRONMENTAL HEALTH SERVICES FINAL SITE INSPECTION ' �-- 115:106- Date: Inspected by: Street Location JAMMU fT &, c�d Z T_ Owner kaSffla j Town p4ELE 6adl Permit # 3 TM # -/�, - /.- 1.1- Subdivision Lot # 2- 7 1. Sewage System Area a. STS area located as per approved a :...... �...... b. Fill section - date of placement 3:1 barrier Lgth. Wivptrr� c. Natural soil not stripped ................... ............................... d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course / wetlands ................... :................. II. Sewage System a. Septic tank size - 1,000 .......... 1,250 ......... other..,:<2.o �P b. * Septic'tank installed level ................ ............................... c. 10' minimum from foundation .......... ............................... d. Distribution Box ,� 1. All outlets at same elevation -water tested........... �; 2. Protected below frost .................. ............................... 3... Minimum 2 ft. Original soil between box & trenches e. Junction Box - properly set .......... ............................... 6. Trenches 1. Length required / 6 S,5-Length installed / 6 s 2. Distance to watercourse measured,�v c, 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.......... bb Depth of trench <30 inches from surface .................. Pre,je,1 7. Room allowed for expansion, 100 %..641......... 6'1 i A,,Iej 8. Size of gravel 3/4 - 11/2" diameter clean ............... �` V411 9. Depth of gravel in trench 12" minimum ....... :........... 10. Pipe d ...................................................... g. Pump o Dose S stems 1. Size o mp chamber .............................. ...........� 2. Overflow tank ............................. ............................... 3. Alarm, visual / audio ........:........... ............................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................... ............................... 6. Cycle witnessed by H.D.estimated flow /cycle........... III. House/Buildidg a. Mouse located per approved plans........., b. Number of b&drooms ...................... , � ............ IV. Well °lCemdr 1G,'FcLle�►^mw� ,��,� a Ge II aI' Well located as per approved plans . ......:........................ b. Distance from STS area measured f / e :�? ft........... c. Casing 18" above grade ................ .............:................. d. Surface drainage around well acceptable ....................... V. Overall Workmanship . a. Boxes properly grouted ................... ............................... b. All pipes partially backfilled ............ :............................. c. All pipes flush with inside of box ... ............................... d. Backfill material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall protected & dinto exist watercour g. Footing drains discharge away froze. STS area ............. h. Surface water protection adequate.,* ....:......................... i. Erosion control provided ............... ............................... Rev. 12102 F1i/ �e YES r 1N C;U1VllV1L+ 1V "1'S QVIW_ e to c,_ c{n v, ;2 40re a S 14er+q _. Al, de it cc vnc 02 i, 4e .5 •'d: �X L link .. w 4, b,. e e In e0 i we '69�ea1Y S Q (C X 0s r , Form -? F1i/ �e DEC -30 -2003 10:10 AM HARRY W NICHOLS 914 279 4567 P.01 A% ...� PUTNAM COUNTY DEPARTMENT OF HEALTH VIS DIION OF ENVIRONMENTAL HEALTH SERVICES P QIM Al, INSPE110N For; Fill Date: 121 �4 �' Trenches X PCHD Constructioa Permit # P ` $" Located;... 'STi�L I -na[hH P.o app } FA Ott Owner/Applicant Name: AN #'I< TM «• Block Lot • IL Formerly: "Subdivision Name: 157hWE U" Subdivision Lot• # 9-1 Is 'system fill completed? 'yl+J' Date: �2ftlo� Is system complete? : - S _ Date: (tiIZ�°l1a'� Is system constmcted as per plans? 'Yes, Is well drilled? `t!ES'_ _ -. _. _ _ Date; l2Sti� (on, Is well located as per'plans? AS Are erosion control measures in place? I certify that the system(s), as bted, at the ab ve premises has-been constructed and I have inspected and -verified their Completion in accofdauce with the issued PCHD Construction Permit and approved-plaas and the - Standards, Rules and Regulation tun County Department of " Health. � /1 _ ti r -v .rte SENDING CONFIRMATION DATE JAN -5 -2004 MON 15:32 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES START TIME : JAN -05 15:31 ELAPSED TIME : 00'44" . MODE G3 RESULTS OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a w x *. 1AR87TA MOLINARI R_Y -, M.S.N. ROBERT J. DON DI Pvblre H_&h Dlraror Y�Q- .. County E a- DEPARTMENT OF, HEALTH 1 Geneva Road, Brewster, New York 10509 xnvlronmeatal IWO (845) 278.6110 Pat (845) 278-7921 Nursln88erv$m(845)278.6558 WIC(945)278 -6678 Fez(845)276 -8085 Each IntervehtlaNPrmnaenl (x45)278 -6014 Fm(84S)270. 6648 lanuary 5, 2004 IIazry Niohol9, PE Patterson Palk, Suite 106 2050 Rare 22 Brewster, New York 10509 Re: Field inspection — Kraslugi Stage Coach Road, (T) Pal(crsea Lot 027, TW 15. -1 -12 Dear MW Nichols: - i An inspection at the above referenced lot haa< ecn completed. The following comments must be correotod in the field. i i 1. it appears the SSTS area has been cut. I 1 II appears the upper portion of the septic mtcm does not have two feet of fill depth. 3. Pipes from the dicaibutioa box moat be levoled up to eliminate dips and low points. 4. It appears the expansion area fill is not installed in accordance with the approved plan. S. Required erosion control measures have not been installed. Please note that all erosion control measures must be properly installed prior to the start of any construction. . 6. The footta8 drain outlet was not found upon hnpection. 7. A bedroom court needs to be performed by this Department upon further completion of construction. 8. The pump pit needs to be completely sealed. 9. A dose test needs to be performed and witnessed by this Department. If you have any Htnher questions, please contact me at 845- 278.6130, ext. 2261. Sincerely, . - Genc D. Reed i Sr..Environmontal Health Engineering Aide j GDR:cj i i 0 r. a' LORETTA MOLINARI R.N., M.S.N. Public Health Director DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648 January 5, 2004 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Field Inspection — Krashigi Stage Coach Road, (T) Patterson Lot # 27, TM# 15. -1 -12 Dear Mr. Nichols: ROBERT J. BONDI County Executive An inspection at the above referenced lot has been completed. The following comments must be corrected in the field. 1. It appears the SSTS area has been cut. . 2. It appears the upper portion of the septic system does not have two feet of fill depth. 3. Pipes from the distribution box must be leveled up to eliminate dips and low points. 4. It appears the expansion area fill is not installed in accordance with the approved plan. 5. Required erosion control measures have not been installed. Please note that all erosion control measures must be properly installed prior to the start of any construction. 6. The footing drain outlet was not found upon inspection. 7. A bedroom count needs to be performed by this Department upon further completion of construction. 8. The pump pit needs to be completely sealed. 9. A dose test needs to be performed and witnessed by this Department. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, j?eA Gene D. Reed Sr. Environmental Health Engineering Aide GDR: cj SHERLITA AMLER, MD, MS, FAAP 'A', Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health January 14, 2005 Harry Nichols P.E. Patterson Park, Ste 106 3050 Route 22 Brewster, NY 10509 )Dear Mr. Nichols: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 . ROBERT J. BONDI County Executive Re: Field Inspection — Krashigi Stage Coach Road, (T) Patterson Lot #27, T.M. #15. -1 -12 A re- inspection at the above referenced lot has been completed. There are no further comments to be addressed at this time. If you have any further questions, please contact me at (845) 278 -6130 ext. 2261. GDW:cw Sincerely, "04 0, - lzz� Gene D. Reed Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845)278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 March 9, 2005 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Harry W. Nichols Jr., P.E. Patterson Park - Suite 106 . 2050 Route 22 Brewster, NY 10509 Tel: (845) 2794003 Fax: (845) 279 -4567 Email: hnengineer@aol.com Re: Individual SSTS Compliance — Permit P -8 -93 Stage Coach Subdivision —,Lot #27 233 Stage Coach Road Patterson, NY 12563 Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of Drawing S -27, "As Built SSTS ", dated 01/17/05. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 03/09/05. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 03/09/05. 4. Laboratory Report, dated 02/16/05. 5. "Well Completion Report", dated 11/27/03. 6. Application Fee in the amount of $300.00 ayable to Putnam County Health Department. 7. "E -911 Address Verification Form ", dated 03/12/03. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Ni ols Jr., P.E. HWN:gav 00- 011.27 -PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF. ENVIRONMENTAL HEALTH SERVICES I GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM APA<Hvr K_ 9— 60 Owner or Purchaser of Building Tax Map Block Lot Building Constructed by Vd)*b 606� DA, 0 kPT Location - Street Building Type.' TownNillage Subdivision Name 2� Subdivision Lot # I represent that I am wholly- and completely responsible for the location, workmanship, material, constructiori and -drainage of the sewage#reatment system serving tlie'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 cotis'lructed by ' me which fails'to operate fora 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 �Pei Day d� Year �.' Signature: Title: General Contractor (Owner) = signature F Corporation Name (if corporation) Address: (-; (v State Zip Corporation Name (if corporation) Address: 5L P 1� Aid W�5- State IJ�`!'1 Rio Zip .M: Form GS -97 imSEnvironmental Services, Inc' �1 WATER, SOIL AND AIR ANALYSIS Mailing Information: Name: Hyatt Pump Service Address: 229 South Rd City: Holmes State: NY Telephone: 845 - 855 -5136 Client: 41 Kenosia Avenue I Danbury, Connecticut 06810 1 Telephone 203 - 798 -2229 Zip: 12531 Fax: 845 -855 -5136 Collector's Information: Name: M.H. Address of site: 231 Stagecoach City: State: Telephone: Zip: COMMENTS: *ABOVE MCL * *BELOW MCL At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Reviewed b Sharon Houlahan, Director Signature. State #: PH -0218 Michael Lapman ELAP #: 11715 President CONNECTICUT, NEW YORK AND NELAC CERTIFIED Toll Free 866 -JMS -5097 I Corporate Fax 203 - 798 -2408 1 Lab Fax 203 - 798 -2107 1 www.jmsenvironmental.com Sample's Information: Site: Kitchen Tap Date Collected: 2/14/05 Date Received: 2/15/05 Preservative: HNO3 Time Collected: 3:00pm Time Received: 11:0.0am Temperature: <4C Filter: Not Present Lab No.: J0501106 Date Analyzed Test Name Result MCL Method 2/15/05 14:00 Total Coliform ;,.:. ; .,,. .. Absent Absent SMWW 9222B 2/15/05 Chlorine Free Residual <0.1 mg /L N/A 8MWW.45000IG 2/15/05 Color ND 15 Units SMWW 2120 B 2/15/05 Odor ND 3 TONs SMWW 2150 B 2/16/05 Iron *0.314 mg /L 0.3 mg /L .' SMWW 3111 B 2/16/05 Manganese 0.083 mg /L 0.3 mg /L SMWW 3111 B 2/16/05 Sodium 14.9 mg /L N/A SMWW 3111 B 2/16/05 Chloride - 2 mg /L 250 mg /L SMWW 4500 Cl C 2/16/05 Hardness 36 mg /L N/A SMWW 2340 C 2/16/05 Nitrate <0.1 mg /L 10 mg /L SMWW 4500 NO3E 2/16/05 10:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 2/15/05 pH * *5.53 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 2/16/05 Sulfate 18.7 mg /L 250 mg /L SMWW 4500 SO4F 2/15/05 Turbidity 0.7 NTU 5 NTUs SMWW 2130 B COMMENTS: *ABOVE MCL * *BELOW MCL At the time of analysis the sample was acceptable for total coliform N/A = Not Applicable mg /L- milligrams per Liter ND- None Detected S.U.= Standard Unit NTU- Nephelometric Turbidity Unit MCL- Max. Contaminant Level TON- Threshold Odor Number ug /L- micrograms per Liter Reviewed b Sharon Houlahan, Director Signature. State #: PH -0218 Michael Lapman ELAP #: 11715 President CONNECTICUT, NEW YORK AND NELAC CERTIFIED Toll Free 866 -JMS -5097 I Corporate Fax 203 - 798 -2408 1 Lab Fax 203 - 798 -2107 1 www.jmsenvironmental.com z Z AYE �1 0 L cXIR�LSLDE BrDQOO —,� ..� o •. NGF x. Q i� 2000 (SAL. A SUM: TANK ,10 SOLID P40 SITE LOC SDa As ' SCALE: / y SHI�MON GHAIY OfiR can PROPERTY SHOWN ON TAX MAP: 15.- 1 - 12 4'm5.L+D PJCSDQ•35 i rDLST box / / 4 SoLID PJC (Ty?) � PROJECT: AS -E �Oct c� STAGE COACH Pf STAGE C oeF' \ TOWN OF PATTFRSO 0 �5 \ �)-box (TYP) C'_ -EuT : .. �a ARIANI 56 M 3o BREWSTER IVAV t � L LA 1� \ Lt 1.` 10 C DRAWING. TITLE Putnam county Department of Health AS -BU Division of Environmental Health Bervioss LO' noted Por aonformanae eith npp Oab Rul nd Regulations of the H th Depart � NEW r49 �ol �Q• Slgmture A Title bate o i 4t � r DIMENSION CHART (in feet) Number A. 1 29 80 2 27 94 3 99 160 4 168 212 5 173 214- 6 1`17 215 7 162 217 8 187 219 9 192 221 10 19? 223 1 1 202 22G, 12 201 228 13 2 12 23 1 14 218 235 15 223 238 16 229 241 17 234 244 is 240 247 19 246 251 20 278 3 0 21 274 3 15 2t 270 313 23 266 311 24 262 310 25 258 308 . 26 255 301 27 252 306 28 249 305 29 246 304 30 243 303 31 240 302 32 237 302 33 235 302 34 233 302 35 230 302 D15i. Box 176 210 PA R `/ N 59 ` o Y55 V N 7C 04 N 7 O /V i © N7 V N 7 ® .5 7 O SG „) s a /V/ ,g /V D S/I is S B i6 57 0 $7 ® 57 .0 S G, ® 55 (v 5(, t1 N 0 © N' ® N O 0 N PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERM QR �k VAGE TREATMENT SYSTEM . E!W2�j;j PERMIT # ' Located at �T��� � ��N �c �� Town or Village p��pH I - Subdivision name 6F P�i� 60" Subd. Lot # ` l Tax Map 16+ Block I Lot Date Subdivision Approved i � i1 114 Renewal Revision X Owner /Applicant Name AP -IAH1� �' �� Date of Previous Approval +I 10 Mailing Address 54o Nia�y1 %EVE . t `1 Zip I a5o 1 Amount of Fee Enclosed Building Type RED' 10�H i� Lot Area 2��� %No. of Bedrooms I Design Flow GPD � 00 Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of Gov® gallon septic tank and I GOO I-F A6:5 Other Requirements: e' FI V t') V0120-4(4 To be constructed by ��� Address Water SuopW Public Supply From Address or: 9 Private Supply Drilled by -rBO Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the Separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion the- of a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the D� "Cartment, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said der will place in good operating condition any part of said sewage treatment system during the period of two (2) years t hediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original m or any repairs thereto. Signed: 91ki AAA1 P.E. R.A. Date 5 3 ��- Address- riv ZZ P jze W�'j y1i'� i�70 `� License # 6 G 1,� 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 whe co idered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permi Ap roved for charge of domestic sanitary sewage onl . By: ��i�^ Title: Date: �L White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # — �— 93 Well Location: Street Address: Town/Village Tax Grid # lmpw GPN,4 FWQ ?�rfi�rof4 Map Block Lot(s) 12- Well Owner: Name: AWir 046�41 af Address: 56 -MANN A45' B9LeW67'NQ- P'j tp�-01 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 5f- gpm # People Served 5-1 Est. of Daily Usage) 00 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 %C No Name of subdivision STPtAe (,oAVJA Lot No. 2.1 Water We11.Contractor:p Address: Is Public Water Supply. available to site? .................................. ............................... Yes No X Name of Public Water Supply: r' Town/Village �-- Distance to property from nearest water. main: —� Proposed well location & sources of contamination t be provided on separate heet/plan. Date: 5� fil ©� Applicant Signature: v� i V PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water ell filler certified by Putnam County. Date of Issue Permit Issuing icial: � Date of Expiration o Title: Permit is Non - Transfer bl White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 L e yr -5 oN -P,4-r TV1z -51 f -5 7-,46 c v,4c H reX � % 9 F, , TEST PIT PROFILES____,,.----,-,--- i'on Hole # Lot # a'L 7 Hole # Lot # ;Z 7 t Hole # Lot # 'Z Depth to water 410 Depth to water ./C2 y! Depth to water. ' Depth to mottling . Ala I:e Depth to mottling, Mqn e- Depth to mottling Depth to rock/imp. 3 ' -,1 '' Depth to rock/imp. 0 " Depth to rock/imp.. p G.L. G.L. � 0.5 .TL{Va 0.5 � 0.5 t3^vL;.ev� %ea'!7 f� 'Br�•r n , 0, �- 1.0 1.0 �� z. le : `. -s�1 �, jQ, 1.0 Fine- �/oG.►o'1 y/ ravel 2.0 r 2.0 , a 2.0 Nle f 'E3roev4 _ :. 3.0 .., o.�wf � z 3.0 ; n o 3.0 �� s r 4.0 3�0 l� 3 -'� 4.0 �cayh cv/ yet ve.j A0 5.0 5.0 �oifa;✓t =r'" -�� 5.0 1 � 6.0 6.0 06.0 7.0 7.0 7.0� -v" 8.0 8.0 8.0 `J 9.0 9.0 9.0 10.0 10.0 �'. 10.0 m,.. ..,..�..._. Hole # Lot # 9, 7 Hole # Lot # Hole # 2 Lot # Depth to water Ivy n e Depth to water Depth to water Depth to mottling /VD )j 0 Depth to mottling Depth to mottling i� Depth to rock/imp. �' - f3 " Depth to rock/imp. = e;�' Depth to rock/i :L - zi ' -e" G.L. G.L. G.L. G, i 4„ r5 6" .TS D 0.5 0.5 0.5 M�dt 1.0 1.0 , do w 1.0 BY-0 4 ° 2.0 2.0 e i-i ►� 2.0 F %n 5G ' S 3.0 /,Oex yn 3.0 ZOA 3.0 !'°• w7 Do a �� `o 4.0 4.0 4.0 5.0 5.0 L 5.0 6.0. ', 0 0 6.0 c k 6.0 k o-h` 5 7.0 8 �� 7.0 l y 7.0 i2oc �c _G v 8.0 8.0 8.0 -6'' 9.0 9.0 9.0 10.0 10.0 10.0 ! i kbl 345 -73; I 2 _ 4 SCAU IN 1110 OF AN INCH N �J ----------- P/0 4.1.71---- • - -• - -- --• -� ` -- -.- I - I a 18 v 11 u1r 6.89 AC. n( I 1 • y I I y� 17 20 I IzaS) 18.28;C.�CIcc y ti w I I�. i� I I / r� .SIO.i7 ``1 16 144.19 AC. CAI. a �y / 'mH . T. 8 26.09 AC CAL I 7 4y 8.03 AC. CAL .g 1 29 Lx 27 16.14 AG CAI. 5 6 3.99 AC..;�•' CAL 29 20.0 A y 33 32 :4.70 AC. 31 1 CAL. 25.50 AC. CAL. 18.26 AC. 25.56 1 y, La At tv} Ii11 110 111. `ian�. �• �• �1 ,srHAVILAND „� 21 L� `• tiY � i 5 / a` .. 10.00— — >�. -_ V � 23 y tee ac % 22 �• I 24 95.11 AC. � 1 ^4.94 AG` \ • ` _ - 1i11r.� I �J4a a 2.49 AC. _ N Ao r 2 ' 1.04 A tm� -naa' s `� 10 1.10 AGE 9Q p a>A O 30.14 251 dC i,o 9 a 53.73 AC. CAL. Q� 30 AC: (DEED) a �y / 'mH . T. 8 26.09 AC CAL I 7 4y 8.03 AC. CAL .g 1 29 Lx 27 16.14 AG CAI. 5 6 3.99 AC..;�•' CAL 29 20.0 A y 33 32 :4.70 AC. 31 1 CAL. 25.50 AC. CAL. 18.26 AC. 25.56 1 y, La At tv} Ii11 110 111. `ian�. �• �• �1 ,srHAVILAND „� w R 11RICT =2— 20.37 AC. CAL: —.7 28.44 AC, M. a o At 78 AC. CAL. 4 AC. CAL. 19 AL - WL 1.0 ZOG At. CAL. cc 2.59 AC.. '44.11 .0 7.89 • D 11.94 AC. CAL /- 7r---j—. P/O 4-1-71 xl 540 ST C..) ro • 144.19 AC. CAL. —all 72 LOS 42 $ 4 40.70 AC- CAL' E: PUTMM SCH _r — — — — — — — — — — — 1006.50 Mn 89 &29 43 16.1CAL.\ 1 AC L1a- - -- --- - — — — — 7:- ,,� o o> 96 41 45 2T.5c '04: 92.77 AC. 2:4 AC) 15-1-19 39•.43 139 1e9 AC. 3l. JL 2 AC.�CJJCL 201s) !f ? Note maca At 9511 AC. 23 ( "" L6 2 k 4 2,3 A' 2 4 1.84 A. 4 AC. 49 '. 0 RECORD OF PHONE CONVERSATION Time: :3, Date: Y 7 Person calling: Phone #: 2 % Reason () Inspection- () Deeps and /or eres: Scheduled Field Meeting Time r�G Date x n. ', Xan � oZ Y N Tentative /to b confirmed ( ) ( ) Town: -PATT Road /Street: c w R e, Tax Map #: Comments: 2 e y;6d n Z_ mr-f-t-:, �2_ RECORD OF PHONE CONVERSATION Date: "V2 f5 Person callinc- f Phone #: Reason Scher ( ) Inspection: �41)eeps and/or Peres: �PYC:!�2d efe 5 Tentative/to be confirmed ( ) ( ) Town: T163 4 11 �-:2- 24CL 1!5 < !�� n <_ b Road/Street: Tax Map #: Z, C Comments: 7 IN :!:5 W � �unu:, 4r /67/;Zo RECORD OF PHONE CONVERSATION Time: 12 c cD D Date: Z6: Person calling: L ay1^Pyl tPhone #: 8 % Reason () Inspection: eeps nd /or Peres: Scheduled Field Meeting Time: L1= Date: F `- Y N Tentative /to be confirmed ( ) ( ) Town: ?Irx --, Road /Street: Tax Map #: Comments: 0 'V -r RECORD OF PHONE CONVERSATION Time: / f " ( "--? Date: Person calling: r- � d e Phone #: '9, % (LO Ga u)l &tip Reason ( ) Inspection: () Deeps and /or Peres:G> -� Scheduled Field Meeting Time: �f �ica 1 yn 1� -PYCS P7 74 Date: Y N Tentative /to be confirmed () ( ) Town: Road /Street: Tax Map #: C 7 Comments: PUTNAM COUNTY DEPARTMENT OF HEALTH... DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET'- SUBSURFACE SEWAGE TREATMENT SYSTEM Owner A-P -kAH\T KKN5N� Q), Address % TALE COACH R_OR� Tax Ma 1�.E Block 1 Lot Located at (Street) S p (indicate nearest cross street) Municipality WatershedI SOIL PERCOLATION TEST DATA Date ofPre- soaking Date of Percolation Test `' 6 _QZ Hole No. Run No.':. Time: Srt Stop Ela se Time n.) De th to Water F- o rr m Ground Surface (Inches) Start :Stop, Water e L vel Dropp In Inches Percolate. on Rate �IioJlnch..:: IA 1 1i312,o1 0 2:o� 3 4 -- 5 2. _ 3 4 5 1 2 _. .3 4-- 5 _...__ UbLb w oe repeatea at same oeptn unm approximatery equal percoianon rates are omamea at eacn 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. DEPTH G.L. 0.5' 1.0' 2.0' 2.5' 3.0' 3.5' 4.5' 5.5' 6.0' 6.5' 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. HOLE NO. Indicate level.-at which - groundwater is encountered 0 0 W -- R- Indicate level at which mottling is observed - - Indicate level to which water level rises after being encountered N� Deep hole observations made by: GZ tj� N b, CON, N DCZ- Date Design Professional Name: }-I-AW V, r lWmVS A, PE Address: ti +3F NEW y NICH ....5 °iii Signature. 0 � � � - W No: 56124 Design Professional's Seal A9QFESSIO' 2 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 279-4003 'Fax (845) 2794567 July 18, 2002 Mr.. Robert Morris Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Proposed SSTS: Krasniqi Stage Coach Road, Lot #25 Town of Southeast T.M. #15 -1 -12 Dear Robert: In response to your May 22, 2002 review letter, we note the following: 1. TP #2 is located greater than 10 feet outside of the SSTS area. 2. Septic tank size has been corrected. 3. An additional deep test and perc test were performed in the primary SSTS area. Results are enclosed and have been added to the plan. Kindly continue with your review and issuance of the Construction Permit Very truly yours, Harry W: Nich s Jr., P.E. HWN:jm 00- 011.00 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 May 22, 2002 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster, NY 10509 Re: Proposed SSTS: Krasnigi Stage Coach Road, Lot 927 (T) Southeast, TM# 15 -1 -12 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. Deep test hole #2 notes an impervious boundary at 4' 6 ". Therefore, fill plans must . be submitted. 2. Septic tank size is to be noted as 2000 gallons in the plan view. 3. Due to the size and boundary conditions addition deeps and percolation tests are to be witnessed in the primary SSTS area. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Ve ly yours, Robert Morris, P.E. Senior Public Health Engineer RM:tn MTAT =m A mwil& May 8, 2001 Mr. Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 2794567 Re: Proposed SSTS (Revision of P -8 -93) Stagecoach. Subdivision, Lot #27 Stagecoach Road Town of Patterson T.M. #15. -1 -12 Dear Robert: Enclosed are the following: 1. Five (5) prints of drawing SS -27, "Proposed SSTS, ".revised 5 -3 -02. 2. "Short EAF," dated 5 -3 -02. 3. "Application for approval of plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 5 -3 -02. 5. "Application to construct a Water Well, dated 5 -3 -02. 6. "Design Data Sheet." (Submitted w/ previous Submission) T "Letter of Authorization," dated 5 -3 -02. 8. Two (2) copies of Residence Floor Plan( for `Bedroom Count Only." 9. Review Fee in the amount of $150.00. We appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. Nicho Jr., P.E. HWN: JM: jm 00- 011 -27a (695)—Tul 12 _ S EQ R PROJECT I.D. NUTABEA • ' • ,. >, elm Appendix C _ State FAVtonmental Quality. Rwl w ` -'— _ _. SHORT ENVIRONMENTAL ASSESSMENT FORM.. For UNUSTHP �rONS Only PART I— PROJECT INFORMATION (To be completed by Applloant or Pro)eot SP004,00 1. APPLICANT XPON$OR 2. PROJECT N---- AIaE 3.. PROJECT LOCATPt. PLA HANI _ . _....._ tJun,clpallty county 4. PREWE LOCATION (stmt addro" and road Intuaaotlona, prwWAsnt tandnuuka, ao, a proud. "N 51-Nt CpA $:-13- PROP06ED AGTKft''. . 1hr .._O ❑ ModllloatloNaltaralbn 5. DESCR,BE PROJECT WYZI LYt JNpNlDlP�l. :- 7. AWOUNT OF LAND ECTMDC U11104 acm WY s. mLL PRO 665 Agnom OONPLY wmr PunNo ZONING OR4 MER EX1Ma LANG Us6 RFATWOT OM. Ayes O -No II No, dada w trwy ~ ► _ v. WKAT IS PRESF,NT UWD YU L mEGGtt N )RUSidonu., O Wuauw O Cantu rolal O Agrloulturn , O ParWFaaUOpw� apace -CJ OUw . Dscr,o« J' pow o��rri'. �IH�� ��>✓a' . -.. .. . 10. DOES ACTION IHVOLV1 A 'PtRW APPROVAL, OR FUNDING, NOW OR uLnmATFLY room ANY OTNEA oOVtUW1AMAL AGENCY (FEDEFUI, STATE OR LOCAQ? O Y" ZINo U Y04141 apaooy(i) and pwaUUap maw -: „. DOES ANY . OF THe MT19N HAW A CUR URMY VAUD PgWT OR APPROVAL? O YN ,... u r•s wtw.�or !um. a+td v«�+Iwva�+I. .... __..._ ............. ...:- ......::•.:. 12. AS A RESULT Of *T.10N WILL UWING PUWT PPROVAL R6gWRE t,IQO r"Tw O Ysio I ca:imrY THAT THa INFORWITION PR"D90 A80VE 13 TRUE To THt etVT OF YY•KNOWLEDCiE ADpku t /sponaa nmw m-'p'7✓ td lu�i l ' FE, A6• A6FAIr S19ntturK "w If the actlori Is In the.Coastal Area, and you are a state agency, complete the Coastal -Assessment Form before proceeding with 'thls assessment r'AH 1 II— tNVIMVNMrn1A6 a0SOM01MG11I tIV VV VVrnywwv Vr nyvw�r A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 1 NYCRR, PART 611,11' II yea, 000rdlnaN'tIN rwlew process and use thr FULL lsA. O Yes ❑ No 5. WILL ACTION RECEIVE CO MNATgo Rt:MW AS MVI{1E0 fCR VNUSTED ACTIONS IN 6 NYCRR, PART 017,67 It Not i 111494 tNe d9clartttlon may w superseded by anoow.loyplved apenoyt O Yes ❑ No CouLo ACTION RESULT IN ANY ADVERSE EF►EOTS ASSOOIATED WITH THE FOLLOWINO; (Mowe(• MY b9 handwrlNm, II 19910'9) C1. Eslsung. air Quality; +lirtaoi or growldwat}r gVallly or quantity, nolo9 19v91a, 9461in9 u911.19 pat)aQ +,. !s wsot� produatic!► -a Wsposab: poisnUa) for erosion, dralrw" or flooding pnweclal.Uplaln brlelly; C2. Aostnotic, agricultural, archaeological, historic, or other natural or cultural r960urc91; Or community or nelghbort00 character? Explain brtolly: CJ. Ynotatlon.vr fauna, ilah, sholfth or *11411114 op9c1e41, signfloanl habitat&. or threatened or sn4ang.er9d 1041 s? Eiiplaln br1911y: C.. A community's exlsting plans Oro We as officially adopted, or a change In use or Intonaity of use of.WW or.otder ii txleuy C5. Growth, w049puent dw9lopment, or tolMod acttvltla IIMIY to 09 induced by the propow lotion? Explain tNNlty, O C4. Long term, short term, cwtluI&Uv9, Or other elfects not IdenUfled In 01-061 Explain bdolly. - — Z.—U ==� ! C~ C7. 01ner Impacts (Including changes In use of either quantity or type of energy)? Explain briefly, ; _"70' �° �'�•. _ l 1• 11 C. WILL THE PR04tsCT HAVE AN IMPACT ON THE ENVIRONMENTAL. CHAMCTERISTICS THAT CAUSED THE ESTABUSHMENT OF A CEA1 . OYes . ONo . ' ISrnTTHERE, OR IS THERE LIKELY TO BE, OOKIiROVERST RELAT TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? " J Yea No It Yea, ixplaui Ixlelly — . .... __... .._ .:.... . ' 7- aRT III — DETERMINATION OF SIGNIFICANCE (To be completed by'Agency) INSTRUCTIONS: For each adverse efleot Identified above, determine whether It Is substantial, large, Important or otherwise slpnl (icon I. Eacn e1t9ct should be- aaaesaed In oorule Illon with Its 0) setting 0.0. urban or ruralk.4 bLProbeblllty .ol.00aijtTlnp;.:(o� 0unuon; (d) irreverslblllty; (9) 9eogrophlo aoope; and M magnitude, If neoeiaary, add attacilmente or referenos supporting materlsli. Ensure that explanallons contain sufficient detall to show thal all relevant adverse Impacts hive Dean Identifled•and adequately addressed. It quostlon D of Part II was cheoked yes, the determination and slgnlfidance must evaluate the potentlal Impact of the proposed action on the envlronmenta) characteristics of the CEA, O Check this box If you have Identified one or more potentially lame or significant adverse Impacts which MAY occur, Then proceed directly to the FULL EAF and/or prepare a positive declaration. O Check this box If yO'V,7havo.determinsd, aced on the informatlon and- analyNs •above and I any supporting documentation,. that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on attaFhments as necessary, the reasons .supportln" this determination: _._. ame 01 lead Ayency tint « Type Hanw wr• In L*ad AjAnq irnatury of es y is Wr9 npuer pent roar tespons e o KK MI PUTNAM .COUNTY DEPARTMENT OF HEALTH. :. DIVISIONOF, ENVIRONMENTAL- HEALTHSERVICES`�`�' "' ' • " • •; APPLICATION FOR APPROVAL OF PLANS FOR . A. WASTEWATER TREATMENT- .SYSTEM 1. -.r !�..1�1 ✓V�'1�1'UL� ' �.j' i i "s 1. Name and address. of,applicant: ._ ...... .:.. .. ..,. .. DY�j��l �I �, � V V V �•. .I'i .: •.t'.� - ]irV'i .i�} �•� i •l.. Z: Name of project. 1. � r 2� i 5 � 3. Location T/V Q 4: Design Professional: N� c tJl(�b t 5. Address: 6. Drainage Basin:fy1'. -�� �1?GS -, ►�i -!) ©S 7. Tyne of Project:; 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 F.: ,,,..;:.,, ;Exempt1a t: • . ................ , ... ;Type =:Unlisted..; x 9. Is a Draft Environmental Impact Statement (DEIS) required? ...................... i.,.. T0. Has.DEIS been'completed and found acceptable by Lead Agency? N, 11: Name of Lead Agency !. 12 Is this ro ect in an area under the control of local lannin g , p � planning, zonin , ;or. other • • � - , � � t �• . t ' 1✓ officials; ordinances? .. ilr - yj 13: If so, have•plans; been, submitted to such authorities?'... - 14. Has preliminary; approval been;granted by such authorities? f�� 0 Date'granted 15. T yp e of Sewage Treatment System Discharge ................... surface water Xgroundwater 16.. If surface water discharge, what is.the stream class designation? N'A 17:: Water's index number (surface) .............. 18. Is project located near a public water supply system? . ........................................... 19. If yes, h" e ' water supply D,istanceiio,water;snpply;!' + +N 20. Is project site near•a public-sewage collection of treatmentsysiem ? °n:....:.'........ IUD'' 21. Name of sewage system 22. Date test holes observed 23. Name of Health Inspector 6;ENE 24. Project design flow (gallons per day) ........................... .. ........................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... Form PC -97 P1, 27. Is any portion of this project located within a designated Town or State wetland? �1R 28. Wetlands ID. Number ........................ :................................................................... NP 29. Is Wetlands Permit required? .............................................. ............................... N Q Has application been made to Town or Local DEC office? ............................... 30. Does project require a DEC Stream Disturbance Permit? .. ............................... I So 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 active Yes/No 0 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source of contamination? ............................... Yes/No DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... Y6 34. Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... PO 35. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. Tax Map ID Number .......................... ....:.......................... Map 1 Block 1 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 projeet-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 8e creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such Wtiv ttesrfrom DEP and submit those forms to DEP for review and approval." ' c If the application is signed by a person other than the applicant shown in Item l .,the apf)9caf 5: ust, be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with tfis ' pi}t on � may be grounds for the rejection of any submission. :6° •• < 74 n� I hereby affirm, tinder penalty of perjury, that information provided on this form is MueCID to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Sectio 210.45 of the Penal yaw. SIGNATURES & OFFICIAL TITLES: bailing Address: ............................... 110 �p Eoy_ �Iq l a�cI PVTNAM COUNTY DEPARTMENT OF ' HEALTH DIVISION OF ENVIRONMENTAL HEALTH,.$EICES I�V LETTER OF AUTHORIZATION -- RE: Property of Located at i ��E TN Tax Map # I E5 ° Block Lot Subdivision of Subdivision Lot # �'� Filed Map # Date Filed 5 '9 q� Gentlemen: This lever is to authorize 1�W) w • H\ 040 V--) J �- a duly licensed Professional Engineer or Registered Architect _�to apply for the required wastewater treatinent and/or wattr supply p=lt(s) to serve the above =noted "property in accordance -wi th the standards, rules or regulations as promulgated by the Public Ifcalth Dhcfor of the- Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this maser and to supervise the construction of said wastewater tretrnent and/or water supply systems in conformity with the...provislons of Article 145 and/or 147 of the Edueatlon Law, the Public 1-iealth Law, and the Putnam Cou=—Sanitary Code. Countersigne P.E., R.A., # Mailing Adds State L.zip Telephone: VOW) Very truly yours, Signed: (owner of PMPCM) Mailing Address: 5C WNW ANN State Telephone: `�`���. �-' ✓ i y 1 i i 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # P 8 D Located at '71-X&5 0 "' � �" . Town or Village ptrTsp-tso`I Subdivision name 'STf1(aE co" fQTY Subd. Lot # �� Tax Map 'IS - Block f Lot Date Subdivision Approved Owner /Applicant Name h4-�AH %T- Mailing Address J56' MhP -Nik ME' Amount of Fee Enclosed W 1h A)111- Building Type P65nw- Renewal X � Revision G Date of Previous Approval Zip 10 SIDy Lot Area 1116 No. of Bedrooms 4 Design Flow GPD W Fill Section Only Depth Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 4 gallon septic tank and I DO LF �NfiW . Other Requirements: 12 Fi1 -1-) 0 0 4,�I' H6 6 i P 4° N To be constructed by Water Supply: Public Supply From Address Address or: X Private Supply Drilled by TOP Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment s,, stem described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: ` J Address .E. X R.A. Date - 11- d, r 10 15 ° Cl License # 6 i 2 4- APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of' the sewage trea t system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified w en c nsidered ecessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe discharge of domestic sanitary sewage onl . 971 By: Title: J�V�- Date- O _ White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Des gn Professional Form CP -97 Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax(845)279 -4567 March 29, 2001 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 Al 1: Robert Moms, P.E. � I RE: Proposed SSTS Krasnigi Stage Coach Road, Lot #27 Town of Patterson T.M. #15 -1 -12 Dear Robert: In response to your review letter dated March 16, 2001 we note the following: Spot grades have been added to ensure a minimum of two feet of fill over expansion trenches. We believe the above adequately addresses your concerns, and we request the issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry W. ichols Jr., P.E. HWN:his .:Hang W. Nichols Jr., P:E. Patterson Park; Suite 106 2050 Route 22 Brewster, NY 10509 zz Telephone (845) 2794003 Fax (845) 2794567 March 29, 2001 Putnam County Health Department 1 Geneva Road Brewster, NY 10509 ATT: Robert Morris, P.E. RE: Proposed SSTS Indian Wells Road, Lot #19 Southeast, NY T.M. #47 -3 -98 Dear Robert: T RE In response to your review letter dated March 26, 2001 we note the following: 1.. Footing/Gutter Drain now discharges below the SSTS. We believe the above adequately addresses your concerns, and we request the issuance of the Construction Permit at your earliest convenience. Very truly yours, Harry . Nichols Jr., P.E. HWN:his 00- 076.19 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 March 16, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Krasniqi Stage Coach Road, Lot #27 (T) Patterson, TM# 15 -1 -12 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: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regards. 1) Two feet of fill is to be provided for the entire SSTS, i.e., the upper part of the expansion area does not show any fill in the plan view. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. RM:tn Very ours, Robert Morris, P.E. Senior Public Health Engineer t� i , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL _ P please print or type PCHD Permit # Well Location: Street Address: Town/Village Tax Grid # eE4 'N f 2 6rA65 (,o► H 0 Pl rf f Map CJ' Block Lot(s) Well Owner: Name: AP-1 PMrr 1-1141 Address: 5(o rimy -WI R Pt v Use of Well: �K 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 h gpm # People Served 01 ' Est. of Daily Usage 8 0o 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 X Is well located in a realty subdivision? ...................................... ............................... Yes A No Name of subdivision J5Th &'5 U N"A W%"E 3- F1.06 Lot No. �L7 Water Well Contractor: 1"l5p Address: Is Public Water Supply available to site? .................................. ............................... Yes No x Name of Public Water Supply: i Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate s et/pl Date: Applicant Signature: PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED, FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. revision or alteration of the approved plan requires a new permit. Well to be constructed by a water e 1 iller certified by Putnam County. 1�411 Date of Issue Permit Issuing 0 Date of Expiration 1 3 Title: Permit is Non- Transfe •ra e White copy - HD file; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well' driller Form WP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HE, ALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner A� I A k it 4— *AS H, W Address NyE K�1"� 4zPA Located-.at-(Streqt)'6t�15 C0110k Tax Map 151 Block" Lot -i;(indicate nearest,cross street) Municipality. P NIT �—A � i-A Watershed 5M-1' bP--N}& H SOIL PERCOLATION TEST DATA Date of Pre-soaking. Date of Percolation Test Hole'N ..... T1 mc, •- . D e- 't . P.xo m ro..1ill 10 Al -a e ty�.ercala''' 11C. 2 3 4 5 To L-N) Pg-F.% 2. \JbMM 3 4 5 2 3 4 a V4 %Q 11%0 W I V 6%1F%,Q W Q11 aamv uVFu, u1m, vpvAuummy quai percolation rates-are obtained at each percolation test hole. (i.e. s I min for 1.40 min/inch, s 2 min for 31 -60 m''Winch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. 'r f� ,r r DEPTH G.L. 0.5. 1.0' 1.5' 2.0' 2.5' 3.0' 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. l - HOLE NO. � A- HOLE NO. 5- :1 lt6- HNE L-� WvN U.1Alr 1� Ptr NONE I11MEU �1b1� Indicatelevel at which groundwater is encountered �'Nt= Indicate level.at which mottling is, observed. KaHE Indicate level to.which water level rises after being encountered McrC - Deep hole observations made by: ' Je'ff moat / 01:115 tPL- ! Date Design Professional Name: VkftQ Y%J - Address: Signature: dA Design Professional's Seal 2 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of LETTER OF AUTHORIZATION Located at T/V F(�ttEP—/tooK Tax Map # Block 1 Lot (2-- Subdivision of '5rN (AE C G NC 4 ER-1' l I Mc, 5E Subdivision Lot # �� Filed Map # - 4916 Date Filed Gentlemen: This letter is to authorize HAW W, H l G �A 0L,, JV M 5 - % -% a duly licensed Professional Engineer_ or Registered Architect to apply for the required wastewater treatinent and/or water supply permit(s) to serve the above =noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers'on my behalf in connection with this matter and to supervise the construction of said wastewater 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 CQ.unta! Sanitary Code. Countersigne P.E., R.A., # Mailing Addi State 1"AY zip i p�co°\ Telephone: C� �5� 'L1 °i" A'Cjv Very truly yours, Signed:.;' (Owner ofProperty)'� Mailing Address: GL MNPYIN Me State Zip Telephone: ( %45} 2-1 - 6I Cal 14164 M" —Text 12 PROJECT I.D. NUMBER 617.20 Appendix C State Environmental Quality Review SF�DRT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART 1— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) SEAR 1. APPLICANT /SPONSOR .. AHAW ri I! PLA5 N► 01 2. PROJECT NAME Lor 9_11 3. PROJECT LOCATION: pJTIiRP(\ Municipality County 4. PRECISE LOCATION (Street address and road Intersections, prominent landmarks, etc., or provide map) 5r,4GE Ga,A{iH PA J7 6. IS PROPOSED ACTION: 0 New ❑ Expansion ❑ Modllloatlon/alteratlon 6.•.DESCRIBE PROJECT BRIEFLY: Il- t➢I,IIDOM' 65T"7, Vj&�� 7. AMOUNT OF LAND AFFECTED: 141,14 Initially acres Ultimately acres 6. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING.OR•OTHER EXISTING LAND USE RESTRICTIONS?- 8Y83 ❑ No If No, describe briefly 9. W��HyyyAyT IS PRESENT LAND USE IN VICINITY OF PROJECT? JCI Residential ❑ Industrial ❑ Commercial ❑ Agriculture ® Park/Forest/Open space ❑ Other Describe: 5lH &L:9 FAMIL )l 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL47 ❑ O list Yes No If yes, agency(s). and permit/approvals 11. DOES ANY PECT OF THE ACTION HAVE A CURRENTLY VAUD PERMIT OR APPROVAL? C1 Yes No If yea, list agency name and permlt/approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITUPPROVAL REQUIRE MODIFICATION? 11 Y03 ICI•No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE On t r IO IjArW � I 1 �r`' p�C` Appllcant/sponsor name: � Date: 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 3 jt . .� r I .i 1„ r ,_' t't PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION,.,OFSENYIRONMENTAL HEALTH. SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER .TREATMENT SYSTEM 1. Name and address of apprcarX, AP'1 AH li V9—AS HI 2. Name of project: 3. Location TN:"' P� � 4. Design Professional: R"46'- 5. Address: �-`l- 6. Drainage Basin:%' 7. Type of Project; X Private/Residential * Food Service Commercial Apartments.... Institutional Mobile Home Park ' Office Building Realty Subdivision Other (specify) 8. Is this project subject to State,Environmental Quality Review (SEQR)? TypeStatus (check one) ....................... .......................:....... :Type I Exempt !�,,, . Type II Unlisted x 9. Is a Draft-Environmental Impact Statement (DEIS) required? ......................... Ht 10. Has DEIS been completed and found acceptable by Lead Agency? ............... laA 11. Name of Lead Agency la A 12. Is this project in an area under the control of local planning, zoning, or other.. officials, ordinances?"..; .......................... .................. ............................... 13. If so, have plans been submitted to such authorities? -: :...... ............................... 14. Has preliminary �ppioval been granted by such authorities? AO Date granted:. �! 15. Type of Sewage Treatment System Discharge..............:.. surface water % groundwater 16. If surface water discharge, what is:the:stream class designation? .................... N A 17. Waters index number (surface) . .... ..........:.... ................ ............................... 18. Is project located near a public water supply system? 1ao 19. If yes,.name ofwater supply NAB Distance to water supply N N 20. Is project site near a public sewage. collection or treatment system? ....... .:......: No 21. Name of sewage system NA Distance to sewage 'system 4 22. Date test holes observed 23. Name of Health Inspector 6665 F-6 6P 24. Project design flow*(gallons per day) ................................. ............................... 00 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... ILIA 26. Has SPDES Application been submitted to local DEC office? .......................... N& z 27. Is any portion of this project located within a designated Town or State wetland? - HQ 28. Wetlands ID Number ........................................................... ............................... NA 29. Is Wetlands Permit required? ..............................:............. ..........I.................... A Has application been made to Town or Local DEC office? ............................... N A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... �c 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, - ... is p 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/No, t4 D DESCRIBE: 33. Is there a local master plan on: file with the Town or Village? ......................... YD'S 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? . ............................... Kb 36. Tax Map ID Number .......................... ............................... Map 15, Block 1 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. I hereby affirm, underpenalty 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 Law,,, _ SIGNATURES & OFFICIAL TITLES: \J$6�1Gt OV5, j� q1; ("A' �'( A6 ENT Mailing Address: .............................. 205,0 2� PUTNAM COUNTY DEPARTMENT' OF.-HEALTH. DIVISION OF ENVIRONMENTAL RE.AiLTH SERVICES �. '' 7 DESIGN DATA SHEET - SUBSURFACE SEWAGE•TREATMENT SYSTEM Owner (�,¢ tV'1 I Address S. C -_OA� Located at (Street) Tax Map Block ^ Lot /,;2 (indicate nearest cross street) ' Municipality T,A::�_Z S vnu Watershed s 1?-7 A I C # .SOIL PERCOLATION TEST DATA. Daie. of Pre - soaking Date' of Percolation Test d .. ...,....... .....:..............:... ...:........:.....:............ .. ::... �3e .th :Io'i; .. at. �t<><:' �;: >.�1~�' > +� >..,. <��.•����`.�< ....y.. ...:...::.... :.::.::..... '. ;.:.J::::.:.:..'..:.:'..:::.: �::: :.:::.::::::.....:: . ?:J::<.JJ:: >:.;;:J:........... ......�om� � .r'u:uud::;:::� ' ?.;:. ?L:•vel•::•.��::.::;:. ;eccolaht�t��':: :...:...:.:.: :..::...::...:... p.s�e Time .. -' •.: is F•i••i ... ..:., e. ... ..... .. '.:i: ? ?: tart''::: ><: >Sto •••�<:�'> �a� •es'.: � �`'; >���' �nf.Itic1�::<:: . n S ..�........:::.. ::M. . yy • 3 g q� 3 4 2 -. 3 4 5 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. 4 2. Depth measurements to be made from top of hole. Form DD -97 A TEST PIT DATA,. 2 DESCRIPTION OF SOILS ENCOUNTERED IN.TEST HOLES DEPTH . HOLE NO. f ' HOLE NO.-' HOLE NO. G.L. 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' Indicate.level.at which groundwater is. encountered Indicate level at which. mottling is observed Indicate level to which water level rises after being 7:5 ountered Deep hole observations. made by: V , _Pe- Lo- U Date Design Professional. Name:. . Address: Signature: Design Professional's'Seal Q'I'l DINING BOOM 14'11 .X 13'1" '0 KITCHEN 12'2" X 13'1 " .j FAMILY ROOM 194" X 13'1 " . oVH'!a STUDY LIVING ROOM 13'9" X 131 " 17'3" X 13'1 " , , 12;1 c NT OF AEA,TH ZSM NAM APPROVED FOR BEDROOM COUNT ONLY, .I a. v v BATH f2 13'4• X 99' • -- : J ' EDROOM #1 713" X 1618".. —'&kWibZ'•?i'`'�',,.LTERATIONS TO THESE HOUS2 i', "D I - THE PCDOH FOR APPROVAL co BEDROOM #4 N �X 12'0 "X9'9' �r 0 x O a OPEN TO FOYER • BEDROOM #2 1319" X 1312" Q 7 IN. 12 AIS rZ March 13, 2001 Mr. Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Proposed SSDS (Renewal of P -8 -93) Stagecoach Subdivision, Lot #27 Stagecoach Road Town of Patterson T.M. #15.4 -12 Dear Robert: Enclosed are the following: Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 . 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 1. Five (5) prints of drawing. SS-27, "Proposed SSDS," revised 3- 13 -01. 2. "Short EAF," dated 3=13 -01. 3. "Application for approval of plans for a Wastewater Disposal System." 4. "Construction Permit for Sewage Disposal System," dated 3- 13 -01. 5. "Application to construct a Water Well," dated 3- 13 -01. 6. "Design Data Sheet." 7. "Letter of Authorization," dated 3- 13 -01. 8. Two (2) copies of Residence Floor Plan(s) for "Bedroom Count Only." 9. Review Fee in the amount of $300.00. We appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, A- Harry W. Nic ols Jr., P.E. HWN:JM jm 00- 011 -27 MAY -80 -2002 09:45 AM HARRY W NICHOLS BRUCE R FOLEY Publtr Health.. Director 914 279 4567 P.01 LORETTA' MOLINARI R.N., M.S.N. Associate Pubfk Health Director Dlnetor Q/- patient Servlees DEPARTMENT QP HEALTH 1 Oeneva Road Browstar, Now York 10509 REQUEST FOR,` ELD TESTING ATTENTION: a ADAM STIEBELING )(GENE REED .-Ji information below must be fl 4 completed prior to any scheduling. DATE: ENGINEER OR FIRM: ,�t"�''1- ' @� PHONE N; REASON: DEEPS,,, PERCS:V, PlJNiP TEST: ❑ ROAb /STREET: TOWN: Q ""!� TAX MAPN: SUBDIVISION: P� G4�y� LOT #: ` YES NO o Proposed SM- within the drainage basin of West Branch or B.oyds Corner Reservoirs. o Proposed SSTS within $00 feet of a reservoir, reservoir stem, or control lskkp ._ o ld Proposed SSTS within 200 feet of a watercourse or a DEC wetland. �• Proposed SSTS design flow greater than 1000 gallons/day-or SPDE_S Permit,required. Proposed SSTS for a Commerical Project. — It is the responsibility of the design protassianal 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 j= 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 1s 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 cotiky u3z ONLY CS - --r ,,. -..� !_..�.. ..`. nLDTEST) ni 1Tl VAM -r-d IA ITV MC000TMX=WT nr P- 1. NF= WIN L 12 563 T Rl I Pond 164 a as Ines Corners �HKTM� I I ru � tembeck Corners Lake tteirnbeck Corners n harles 22 lque Area Mount Ebo LA Corner oer *ES CIP AM Pond Brewste der / — m ' | ----| 1 28 1907.03 Md | rn 23 22 95.11 AC. 144.19 'AC. CAL Z49 AQ lip 33 ^ 14.70 AC. | CAL. | _-^~~'- ` | ./ 325.17 AC. CAL. ( \ oAil 46 _ � i ^ 43 omxmC- � ~�a�------------------------------�----- '----------- \.���71.92 ^%� � BRUCE R. FOLEY Public Health Director Date: (o Zi -T 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) 278 -6082 Fax (845) 278 - 6648 To: 5S5Y let LL 6551 Fax #: "7 `7 -3 From: Gene D. Reed Putnam County Department of Health _ For your information For your review As discussed Notes/Messages ? f—:; 7 L S No. Pages (Including cover sheet) Please respond Attached as requested Please call 7 06(_0 /; 3 0 M - E 0710-M, - I In the event of transmission /reception difficulties, please contact this office at (845) 278 -6130 ext. 2261. SENDING CONFIRMATION DATE : JUN -19 -2002 WED 21:17 NAME : PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 -278 -7921 PHONE : 919147730355 PAGES : 4/4 START TIME : JUN -19 21:14 ELAPSED TIME : 02'29" MODE : ECM RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... HRUCH R. FOt" LORMA MOLINARI R.N., 1.i3.N. Patin. )&,M DD.aro. 1V A.. A- P..Wk N.*b De..hr D"&.r eJ Pala, 61..6+.. DEPARTMENT OF HEALTH oelwva Rood 61ea6ter, New Yodc 10509 a.rh..m.al Haigh (16S)171.6170 Pa(/15)271.7911 Nand.. S d- (1451272 - ISSS WIC (1611 271 -6 6 76 Fa.(166)271 -dad Z.1, a.Wwrli a (615)271 -011 rams.al (666)17{6061 ra(tIr)27/ -6611 PAX COV)PR A ..T Date �i0 2 ro:.Lii6�;^ &I tX Fa:a- -7 -7 3 No. Pagc. 5� (Including cover sheet) From: Gene D. Bred /Putnam County Department of Health For your information Pleaso respond ' T For your review Attached as requested As discussed Please call Notes/Mer.egn 7>�aes Ve -ef`l oAy '9/i6 @ /:30 l�irlfl'E12SonlE �✓��. C� r</ ll� In the Event of transmisslonlr"tion difficulties, plalte contact this office at (815) 27 86130 art. 2261. VIVI&TNAM COUNTY DEPARTMENT OF HEALTH ION OF ENVIRONMENTAL HEALTH SERVICES w° CONSTRUCTION PERMIT FOR S E TREATMENT SYSTEM n PERMI # p' 0 �b � 1 s t jU4 aq 3 Located at `7r k � C-0" 9-9 Subdivision name Subd. Lot # ,� Date Subdivision Approved Owner /Applicant Name Nwa Mailing Address 10 Amount of Fee Enclosed ®0 Building Type p- 1�'60Dt'1 -+(. ` Town or Village Tax Map 1':�- Renewal X N Block I Lot �- Revision Date of Previous App oval 01 MP P'DH" h4 Zip Lot Area No. of Bedrooms 4 Design Flow GPD $0O Fill Section Only Depth V Volume PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED � g - 09 allon septic tank and '500 LF- PSG NW Separate Sewerage System to consist of p Other Requirements: f)% r-1N. To be constructed by Water Supply: 'T Ab Q Public Supply From Address Address or: Private Supply Drilled by ' %&Q, . Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: Address R.A. Date is 11,119b License # 56, 114 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 7 modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe it. Approv or discharge of domestic sanitary sewage only. By: Title: U- Date: 112f White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 / �' • � 1' �' ' 1� Y• I �• Mme. DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner 9 ruf f Lr—.v \.^ S o^ Address 0?, P Gro�cof, << W Located at (Street 0-CZ0,LA,� �CO� dj -(, o� �r�'� Sec. Block Lot S� (indicate nearest cross street) Municipality 7/0 Watershed SOIL PERCOLATION TEST DATA RDQUIRED TO BE SUBMITT.ID WITH APPLICATIONS Date of Pre- Soaking �S�?.�nCQZ.. :�1" t Date of Percolation Test 6 1 A? Z HOLE NUMBER_ CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water From Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 2 c� :Z1- q =34 7 3 10 :Lla 4 Io =�s - It =o7 la a� a� jZ 5 Il:0'6 - ,i:� ��. a� �5 1 i z 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. 4 CY • !S -ak 4 �3 5 9:S9 - 16-.ro I Ci 2 9= 31Dt - 3 g e 4 z 4 qa 3 3 2 v : Al - 10= �r� Cl� 3 10 :Lla 4 Io =�s - It =o7 la a� a� jZ 5 Il:0'6 - ,i:� ��. a� �5 1 i z 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 SUBMITTED WITH APPLfCATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. Z HOLE NO. G.L. o 2' scMa S� l� o sca�T�'1 tS� 3' P),, C.(ti 4 , 5'OG� 6' 7' 8' 9' 10' 11' 12' 13' 14' VA INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED IJ(A INDICATE LEVEL, TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED N �� DEEP HOLE OBSERVATIONS MADE BY: J O S-t DATE: 13 DESIGN Soil Rate Used 12- Min /1" Drop: S.D. Usable Area Provided (?jam„ 50�C;f. No. of Bedrocros Septic Tank Capacity �, gals. Type Absorption Area Provided By - — L.F. x 24" width trench Name '5 o�E.Q V � •�.� �1 � 'mil, SPACE FOR USE BY HEALTH DEPARTMENT ONLY: SEAL Soil Rate Approved sq.ft/gal. Checked by Date PC -1 I., PUT NAM C OUN TY D E PARTMEN T 1 2. 1 4. 1 3. A O F HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM Name and Address of Applicant: �U y ( "6�0 11 ;:L01 1 N%1 O 5 o q, Name of Project: L � � \ � S ol� SOS 3. Location T /V /C: G. ^ Project Engineer,: 7b4;F per- 5. Address: 33 L1" Vl 1n License Number: 0 69 ( 3L] Phone: 91q 41/ 73,Z,3 Type of Project: _�— Private /Residential Food Service Commercial Apartments, Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) Is this project subject to State Environmental Quality Review (SEQR)? Type Status (Check One) Type I.. Exempt Type Ii. Unlisted - '!i<_ Ic. Is a Draft Environmental Impact Statement (DEIS) required? Has DEIS been completed and found acceptable by Lead Agency? ........... kJ IPA I,. Name of Lead Agency . Is this project in an area under the control of local planning, zoning, or other officials, ordinances? ......... ............................... If so, have plans been submitted to such authorities? LD�-vj Has preliminary approval been granted by such authorities ? PA Date Granted: E o Type of Sewage Disposal System Discharge...... S,urface'Water _Ground Waters If surface water discharge, what is the stream class designation ?........ %1 A . Waters index number (surface) ........................ .......••........ A , . Is project located near a public water supply system? NO . If yes, name of water supply N-A _ Distance to water supply . Is project site near a public sewage collection or disposal system ?..... L Co . Name of sewage system Date observed: Na 23. Distance to sewage system _WIN- Name of Health Inspector: Project design flow (gallons per day) ...... �RQQ..QP.Q................. I 2. 5. Is State Pollutant.Discharge Elimination System ( SPDES) Permit required ?.. �D 6. Has SPDES Application been submitted to local DEC Office? ............... _ N 7. Is any portion of this project located within a designated Town or State wetland ? ............. ................... ............................... 8. Wetland ID Number ........................ ............................... `�i.4 9. Is Wetland Permit required? .............. ...... .......................... Has application been made to Town or Local DEC Office? AA J. Does project require a DEC Stream Disturbance Permit? ................... 1. 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 or NO 2. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site orC5 any other potential known source of contamination? ..............YES or NO _ DESCRIBE: 3. Is there a local master plan or file with the Town or Village? ........... � s ;. Are community water, sewer facilities planned to be developed within 15 years? i. Are any sewage disposal areas in excess of 15% slope? ........................ i. Tax Map ID Number ........................................................ A PP ro`ed P� -Lans are to be returned to: Applicant � Engineer .�,. Y ,� t:; o'. the"applJ.cat_j.on is signed by a person other than the applicant shown in Item 1, the )pliccati:Qn,_.must - be accompanied by a Letter of Authorization. Failure to comply with this ovis;ion:':m'ay be) grounds for the rejection of any submission. I hereby affirm, under Pena ]ty 'of perjury, that information provided on this form`" s,, -trU& 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 Law. GNATURES & OFFICIAL TITLES: ILING ADDRESS: I ,ter I DESIGN DATA SHEET- SUBSUFACE SEWAGE DISPOSAL SYSTEM FILE NO. Owner Address • F3 oX 6 4 t ( 6r 04.0 ids Located at (Street) Sec. Block Lot (indicate nearest cross street) municipality 717 25:. �-r• ®I'%, Watershed SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATIONS Date of Pre- Soaking `S �?�0 �- " �("� Date of Percolation Test e, l ''l Z _o 3 10:L12 4 1=07 I a all, c� S 1z S 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 frcin top of hole. rev. 9/85 HOLE NUMBER CLOCK TIME PERCOLATION PERCOLATION Run Elapse Depth to Water Fran Water Level No. Time Ground Surface In Inches Soil Rate Start -Stop Min. Start Stop Drop In Min /In Drop Inches Inches Inches 1 t=t =7o C?:2 fp 4 Ll _ 4 5 °�•s� plo:ro ► ! t co = Z. 2 q =3°t 9--41 3 9 w�ta° " r�� l 4 a 'BALI Z5 3 5 o t,�q CQ -�5a 3 :R LI a!5 3 Ito 1 1cl:2-3 " I0- Z 'Y &l( as -7 3 2 10 :3I R. 10 :Lrg) 9 (,L{ C9. 1 _o 3 10:L12 4 1=07 I a all, c� S 1z S 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 frcin top of hole. rev. 9/85 TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLfCATION DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. I HOLE NO. Z HOLE NO. G.L. 1' j rJ j�) 5 o 11. "r._ n .; 0 �e =--� 2' C�� 3' 4' 5'4G� 6' 7' 8' 9' 10' 11' 12' 13' 14' INDICATE LEVEL AT WHICH GROUNDWATER IS ENCOUNTERED N (A INDICATE LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: o S-� �. c,- DATE: L4 3 DESIGN Soil Rate Used �_ Min /1" Drop: S.D. Usable Area Provided (3 s0�1 No! of 'Bedrocros Septic Tank Capacity ��_ gals. Type ' = Ab "so6tion Area Provided By L.F. x 24 width trench -Other Ll U-3 - .:Name - 4 - �5�� �'} Signature Address 3 SEAL, THIS SPACE EAR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gala Checked by Date November 17, 1998 , Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS Bruce Levinson '& Louise Katzin Stagecoach Subdivision, Lot #27 Patterson, N.Y.' Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -27 "Proposed SSTS ", dated 11/17/98. 2. "Short EAF" , dated 10/27/98. 3. "Application For Approval of Plans For a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 10/27/98. 5. "Design Data Sheet ". G. "Letter of Authorization." 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 8.. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the construction permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. 0 Harry W. N ols, Jr., P.E. HWN:JDM:bd 98023 -27 . j j LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE / j \ Route 22 & Milltown Road Brewster, New York 10509 (914)278-6108 -(FAX) 278 -2658 HARRY W. NICHOLS JR.. P.E. CONSULTING. SITE ENGINEERS November 17, 1998 , Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSTS Bruce Levinson '& Louise Katzin Stagecoach Subdivision, Lot #27 Patterson, N.Y.' Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -27 "Proposed SSTS ", dated 11/17/98. 2. "Short EAF" , dated 10/27/98. 3. "Application For Approval of Plans For a Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 10/27/98. 5. "Design Data Sheet ". G. "Letter of Authorization." 7. Two (2) copies of Residence Floor Plan(s), for "Bedroom Count Only ". 8.. Review Fee in the amount of $300.00. We would appreciate your review, approval and issuance of the construction permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. 0 Harry W. N ols, Jr., P.E. HWN:JDM:bd 98023 -27 . DEPARTMENT OF HEALTH Division Of Environmental Health Services Geneva Road, Brewster, tiew York 10509 (914) 278-6i'30 JOHN KARELL Jr., P.E., M.S. Public Health Director Re: C.� v1iL�° KJ Dear Your application has been received by this department on The application is considered incomplete and,the following items must be submitted. ( ) Fee should be paid by Certi`ied Check or Money Order only. ( ) Fee is not enclosed or incorrect amount. Fee due is: Tax Map designation should be provided. ( ) Other: If you have any questions, please contact Robert Morris, ext. 166 or William Hedges, ext. 168 of this office. Thank you for your cooperation. Very truly yours, Christine Johnson Intermediate Clerk DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #/ !-'f� WELL LOCATION Street Address Town/Village/City Tax Grid Number AAaV. WELL OWNER Name Mailing Address I40< Le..�j os -,^ 3cX G 6zio n, F-, I-v P-4 ®Private 1 os-19 o -19 0 Public USE OF WELL 1 - primary 2- secondary ® RESIDENTIAL 0 BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP 0 ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify O INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT J gpm /li PEOPLE SERVED /EST. OF DAILY USAGE*g2o gal 0 REPLACE EXISTING SUPPLY O TEST /OBSERVATION GE ADDITIONAL SUPPLY R-NEW SUPPLY NEW DWELLING) D DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING o WELL TYPE 11DRILLED DRIVEN DDUG C] GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: %Zotr_'V-e.D Lot No. 2_54 Z WATER WELL CONTRACTOR: Name &-Ak Address: L...., IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES '>< NO NAME OF PUBLIC WATER SUPPLY: M1111 TOWN /VIL /CITY .DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH b SOURCES OF CONTAMINATION PROVIDED S-1 !@ON SEPARATE SHEET (date PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt3, (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the Department attached to this permit. 3. Submit a Well Completion Report on a form requirements of the Putnam County Health provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or 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. Date of Issue: 19 Date of Exp' tion 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date to (G Z Re: Property of r�VQ'e �_eU kr-S o.^ Located at La+ -a- 'S E( ZC Section Block Lot Subdivision of P��SC 1 5_kAG COQ-0, �' Ct �eS �� UDC F Z4 2 Subdv. Lot # ZS 2,j(� Filed Map Date Gentlemen: This letter is to authorize PC�� a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary.papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned • P.E. , R.A. , # - ::Z;� ( L^ Address Q(3 U Telephone Very truly yours, Signed Owner of Property Address, Town Telephone :V BRUCE LEVINSON P.O. Box 644 Croton Falls, NY 10519 -0644 May 4, 1993 EXPRESS MAIL Mr. Bill Hedges Putnum County Health Department 4 Geneva Road Brewster, NY 10509 Dear Mr. Hedges: Our engineer, Joseph Berger, has you the two enclosed forms, an application well and a construction permit for sewage Please let us know if anything further is BL \ic Enclosure requested that we send to construct a water disposal system. needed. to j2,z:1C4 Z- C"v .0- lid Ommir lz i i BRUCE LEVINSON P.O. Box 644 Croton Falls, NY 10519 -0644 March 25, 1993 EXPRESS MAIL Putnam County Health Department Attn: Bill Hedges 4 Geneva Road Brewster, NY 10509 Re: Septic Approval Dear Mr. Hedges: Pursuant to our recent discussion, enclosed is an application for a septic system at our Patterson property on Stagecoach Road. Also enclosed are a certified check in the sum of $300, two (2) copies of the house plan, the PC1 form, and a letter of authorization. I understand from our engineer, Joe Berger, that you already have the other paperwork, including the original plans prepared by him. If you need anything further; please_giye me a call. Thank you very much for BL:ic Enclosure ration Sincgrely Levinson P.S. My telephone number during the day is (212) 935 -0900. If I am unavailable, you can speak to my wife during the day at (914) 277 -8024. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date (p Cq 2 Re: Property of�"��- .Ci+��S Located at L©+ (T) j Section Block Lot Subdivision of pIn�SC L 42 Subdv. Lot # 25 ? ZICm Filed Map # 2`{�� Date Gentlemen: This letter is to authorize _)C::OS1ea i 3_ -' a duly licensed professional engineer or registered architect (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Very truly/'YourA) Signed �� 0wnT of Property Countersigned • u ��_ P.E. , R.A. , # Add 'Q 6�6�� a ��'� ess Telepnone Co. +a Town 7,11. -93-�' -0900 Telephone PC -1 U PUT NAM C OUN TY DEPARTMENT O V HEALTH _ APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM 1. Name and Address of-Applicant: �t -11�p_ �..,evV "S40 y �C) 2. Name of Project: +z�+ k SOS 3. Location .T /V /C: ' 4. Project Engineer: 5. Address: �evC l�tas. s� N Ia6o/ License Number: C) 6 C 6 3V Phone: 914111L -7-3 3 3. Toe of Project: Y ^ Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) r. Is this project subject to State Environmental Quality Review (SEAR)? Type Status (Check One) Type I.. Exempt Type Ii. Unlisted - '>e_ 3. Is a Draft Environmental Impact Statement (]EIS) required? ............. d Has DEIS been completed and found acceptable by Lead Agency? ........... �). Name of Lead Agency . Is this project in an area under the control of local planning, zoning, t_�- or other officials, ordinances? ......................... ............. If so, have plans been submitted to such authorities? .................. kptovc S� b 6IVIJ Has preliminary approval been granted by such authorities? PA Date Granted: ��....� �. Type of Sewage Disposal System Discharge...... Surface Water X _Ground Waters If surface water discharge, what is the stream class designation ?........ _I�1 A . Waters index number (surface) ....... ... ............................... Is project located near a public water supply system? .................. N O . If yes, name of water supply IJA Distance to water supply g Is project site near a public sewage collection or disposal system ?..... Name of sewage system A Distance to sewage system Date observed: 23. Name of Health Inspector: Project design flow (gallons per day) ...... QQ ..apm ................ M . 2. 5. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. 6. Has SPDES Application been submitted to local DEC Office? 7. Is any portion of this project located within a designated Town or State wetland ? ............. ................... ............................... 8. Wetland ID Number ........................ ............................... N!4" 9. Is Wetland Permit required? .............. ......:........................ A- Has application been made to Town or Local DEC Office? / jA 0. Does project require a DEC Stream Disturbance Permit? ................... M 1. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid'or hazardous wast$ disposal, landfilling, sludge application or industrial activity? ........ YES or NO 2. Is project located within 1,000 feet of existence of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or ,� t� any other potential known source of contamination? ..............YES or NO fv DESCRIBE: 3. Is there a local master plan or file with the Town or Village? ........... 4. Are community water, sewer facilities planned to be developed within 15 years? i f0 3. Are any sewage disposal areas in excess of 151 slope? ........................ 5. Tax Map ID Number ......................................................... F. Approved Plans are to be returned to: Applicant Engineer F the application is signed by a person other than the applicant shown in Item 1, the )placation must be accompanied by a Letter of Authorization. Failure to comply with this - ovision may be grounds for the rejection of any submission. I hereby affirm, under penalty 'of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A Hisdemeanor suant - -too Section 210.45 of the Penal Law. ti :GNATURES & OFFICIAL TITLES: AILING ADDRESS: �oF 6`F ��C�'� , �• _ _�a'�l RE LAURENT ENGIN_ERI,VC ASSOCIATES. P.C. j \ MILLSROOKE OFFICE CENTRE /I 1 / \ Rout• 22 6 Milltown Road Brr.rstV. Now Yortt 1 05C HARRY b•I. NICHOLS JR., P.E. V \\ (914)2741-61Cd • (FAX) 27a -2ia CONSULTING SITE ENGIY _cERS January 22, 1999 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Proposed SSTS Levinson Stage Coach Road, Lot #27 Town of Southeast Dear Mr. Morris: In response to your review letters dated January 11, 1999, we offer the following: 1. All expansion trenches have been revised to 50' in length, except for the fifth row with 2 @ 45' for a total reserve length of 890 L.F. 2. 2' minimum R.O.B. Fill is now shown over the entire system. We trust the above adequately addresses your concerns and request the issuance of the Construction Permit at your earliest convenience. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:hs 98036 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 January 19, 1999 Jeff Moore n • Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSTS: Levinson and Katzin Stage Coach Road, Lot 27 (T) Southeast, TM# 15 -1 -12 Dear: Review of plans and other supporting documents submitted at this time relative to the above - regarded project has been completed. Comments are offered as follows: The construction of this sewage disposal system may be subject to local wetlands regulations. You should contact local wetlands officials in this regard. If percolation tests were not witnessed by a representative of the New York City Department Environmental Protection on this lot, percolation tests must be witnessed by a representative of this Department. 1) All expansion trenches should be shown at lengths of 50 feet. 2) The minimum of 2 feet of R.O.B. fill is to be provided for the primary and expansion area trenches. Upon receipt of a submission, revised to reflect the above comments, this, application will be considered further. Ve ruly yours, Robert Morris, P.E. Senior Public Health Engineer RM:tn PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL Q please print or type PCHD Permit # e Well Location: Street Address: TownNillage Tax Grid # 45'�A(4f' cON 0 �OMD FA 0�4 Map 1�) % Block Lot(s) Well Owner: Name: &ux LeNio r,,, ! Address: L0-JJ ' 1LKT 2'1 N ID MT , *ASCU -y Q -0KG L - V-KVDf mA 0�' tO ra'(p 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 O;Pl' gpm # People Served 15 - 5 Est. of Daily Usage 00 gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type `yL Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes — N o S: Is well located in a realty subdivision? ..................................... ; ............................... Yes A No Name of subdivision '5TN,,,\S "eOA Lot No. 11-'0 Water Well Contractor: rAO Address: Is Public Water Supply available to site? .................................. ............................... Yes No X 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. heet/plan. Date: 101--14 cA� Applicant Signature: AA !/ v PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or well driller shall take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED. FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit. Well to be constructed by a watejell, iller certified by Putnam County. Date of Issue Z. /If Permit Issu' Official: Date of Expiratio 1 Title: Permit is Non- Transfe able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 b6fi J Credit rd By FA�J�A#4TA �AJAAJAAIM �AIAW yl i PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SHEET FOR CONSTRUCTION PERMIT STREET LOCATION 1V C.U1Sr'N ^ 6,41 NAME OF OWNER Lu msa-A1 .� eA T 4 iAl REVIEWED BY RM, GR, AS, MB, BH TAX MAP # J6.'- % -/a Y DOCUMENTS )ESIGN DATA: PERC & DEEP RESULTS 'MIN to CD discharge /100'with 182 cons day discharge PERMIT APPLICATION SEPTIC TANK DRIVEWAY & SLOPES, CUT PC -1 FOOTING /GUTTER/CURTAIN DRAINS WELL IVELL PERMIT _ PWS LETTER / Vz eETTER OF AUTHORIZATION / P DESIGN DATA SHEET (DDS) )ATUM REFERENCE CORPORATE RESOLUTION / SHMT EAF j J, PLANS -THREE SETS / HOUSE PLANS - TWO SETS VARIANCE REQUEST FEE SUBDIVISION LEGAL SUBDIVISION + SUBDIVISION APPROVAL CHECKED v.4 PERC RATE - / a. H ;r',/ern, FILL REQUIRED DEPTH CURTAIN DRAIN REQUIRED ' > b STANDPIPES GENERAL LOCATED IN NYC WATERSHED - Eas't' S SUBMITTED TO DEP Branch DELEGATED TO PCHD. EP APPROVAL, IF REQ'D DEEP TEST HOLES OBSERVED FRCS TO BE WITNESSED - X- APPROVAL SSDS ADJ. LOTS TLANDS (TOWN/DEC PERMIT REQ'D ?) ATA ON DDS PLANS & PERMIT SAME 1969 NEIGHBOR NOTIFICATION TIER BI/ZBA 0 YR. FLOOD ELEVATION , OTHER REQ'D PERMITS) DETAILS ON PLANS SEWAGE SYSTEM PLAN - (NORTH ARROW) IMREQUIRED SSDS HYDRAULIC PROFILE GRAVITY FLOW ✓ EROSION CONTROL:HOUSE,WELL, SSDS PERC & DEEP HOLES LOCATED 3 REPRESENTATIVE OF PRIMARY & EXIyAI±I iQN ' � k LOCATION MAP Z_ EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF PUMPED, PIT & D BOX SHOWN & DETAILED v'rjHOUSE - NO.OF BEDROOMS _ WELLS & SSDS'S WAN 200' OF PROPOSED SYS. v cc,!►�t c a 4,�C PROPERTY METES & BOUNDS USE SETBACK NECESSARY (TIGHT LOT) HOUSE SEWER -1/4" FT. 4 "0; TYPE PIPE NO BENDS; MAX.BENDS 45° W /CLEANOUT FILL SYSTEMS CLAY BARRIER 10- FT. HORIZONTAL;SLOPE 3:1 TO GRADE FILL SPECS 7. FILL NOTES FILL CERTIFICATION NOTE f�_ %.�c�1�w*f EPTH GAUGES FILL PROFILE & DIMENSIONS VOLUME - 700 FILL IN EXPANSION AREA Ypa e�Ga{`e+rI leaytM TRENCH /�a�_Cbee ri c"sy >c�Y�ea LF TRENCH PROVIDED k/ PARALLEL TO CONTOURS 100% EXPANSION PROVIDED SEPARATION DISTANCES SPECIFIED ON PLAN - FROM SSTS t/20'TO O P.L., DRIVEWAY, LARGE TREES, TOP OF FILL FOUNDATION WALLS 15'WELL TO PL 4 WEIR _ 200' IN DLOD, 150' PITS 0 SWATERCOURSE LAKE (inc. ex an O CATCH BASIN, 35' STORMDRAIN, IP O WATER LINE (pits -20') TERMITTENT DRAINAGE COURSE 00' RESERVOIR, ETC. _150' GALLEY SYSTEMS " ONSTRUCTION NOTES IN to CDS= >5 0/o,10'- 4 %,25'- 3 0/o,30'- 2 0/o,35' -1 0/o,100' - <I% )ESIGN DATA: PERC & DEEP RESULTS 'MIN to CD discharge /100'with 182 cons day discharge !'CONTOURS EXISTING & PROPOSED SEPTIC TANK DRIVEWAY & SLOPES, CUT m i0' FRO1v15F UIVDATION,. ;50'TU FOOTING /GUTTER/CURTAIN DRAINS WELL TOIL TYPE BOUNDARIES DIMENSIONS TO PROPERTY LINE FITLE BLOCK; OWNERS NAME,ADDRESS LOCATION OF SERVICE CONNECTION TM #,PE/RA; NAME,ADDRESS,PHONE# DATE OF DRAWING/REVISION )ATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL. COMMENTS: r BATH—) l.� i = U —� j BEDROOM 4 ;�� •�� DRESSING Si'•8:' : 12'4" . BEDROOM WALK* 13' -0" x 10'-0' IN CLOSET _as• T }. i 1 � • r�IH. j MASTER BEDROOM BEDROOM 2 j _ OPEN N 17'-0 16••8" 11' O' x 15'•8' — 1 : ' Y DEPA MENT OF • .. ► FIE,Qy�Tgp . � HOUSE PLANS APPROVED F f BEDROOM COUNT ONLY; 1, SECOND FLOOR 4828 = .•1344SF f 112, 3 Lsilct Lure T'i'le Date KITCHEN DINING ROOM MORNING 1400M 13' 0" w 12'•0" C•.:j .�i 1. de OPEN j ABOVE } LIVING ROOM ' w FAMILY I100M 13.•0.. 1 t. 0.. 13' 0" ■ 17' 0.. FOYER �. op FIRST FLOOR 4829 1 nprasant; that 1 am wholly and completely responsi0le for tM design and location of the proposed system(s)- 1) that Eha sep rate saw .disposal system abova described will W constructed* at shown on the'approvedamendnient there to and in accordance 'With the standards. rules a requ , o Putnam County; Oepartment of „4"Kh. and that on completion.theiaof a "Certificate, of Construction Compliance" satisfactory to the Commissioner of Haalthwill be submitted to the Opartment aril 4-written guarantee wih . be furhishW the owner, hit; Su c .SMS. hehs or assigns by the builder. that said builder will pMce N good .OperatMmg condition ..gray part of_: saw aawa4e disposal system during" the period of two (2) yews lmmedlebly followiim/;tMdatst Of the iou- ana of tM approval of tlu Certificate Of Construction COrnplia'nci of the original System or any repaNS thereto; 2) that the drilled well described above wile be located as shown on the approved pun aMahat said Well will be instal in accordance with time standards. rules and roe- UMEns: of the Putnam County OM efithent of feslth / Daft. Zj �j`3' an Signed P.E. �f X PA. Address ?� '� /a'�it� L1� C� License No 6c? 6 a APPROVED FOR CONSTRUCT ION- approval expires two ywr±s /romn,ths data .issued unless construction of the building Ass bee undertake and is revocable for cause or may be a 1 necessary 'try . the CommissioMi Of MMlth. Any Change or 'alteration of construction requires a w Permit. Approved for disposal of domestic sanitay,iWwage. and /or private water supply 'only. Rev. `Ca r c /J 1��88 By - Title 617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED. ACTIONS Only Dart.1 - PROJECT INFORMATION (To be completed by Applicant or Project sponsor) GI, iEVIH1r%t 1. APPLICANT /SPONSOR: L�Oir �MN 2. PROJECT NAME: 2, I `v e 3. PROJECT LOCATION: Municipality County 4. PRECISE LOCATION: (Street address and road . intersections, prominent landmarks, etc., or provide map) 5. PROPOSED ACTION IS: Ablew OExpansion ❑Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND AFFECTED: Initially acres Ultimately ti�"1�acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? Xes ONo If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑Industrial...,. ❑Commercial ❑Agricultural OPark /Forest /Open space 00ther Describe: 5✓111CAX 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL. AGENCY (FEDERAL, STATE OR LOCAL)? OYes Ao If yes, list agency(s) name and permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes- ado If yes, list agency(s) name and permit /approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑Yes &O I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE , , , _ na Sic: fure �i' NIA 19- M A-,7 AA047 If the action is in a Coastal Area, and you are a state agency, complete a Coastal Assessment Form before proceeding with this assessmec;; ,I PUTNA41 COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of �PWC-fE �-ENrN '50N �006E Y-ATz,fN Located at �t'PC.sE~t -o�GH RnRf� TIV PA77'Eig-5ON Tax Map r.-) Block Lot � �^ Subdivision of 5i Acid C°RCK 1'�S�T( `? ► 1NG Subdivision Lot 9 2I Filed Map # A Date Filed Gentlemen: This letter is to authorize HPV -94 V4 - HIUKM L_� ' ,J�L, a duly licensed Professional Engineer _ >4, or Registered Architect to apply for the required wastewate- treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or rcgulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health Law, and the Putnam Cou�o i ary Code. Countersigne P.E., R.A., # Mailing Acid State N� zip Telephone: (91�) q-1b - 6�0& Very truly yours, Signed: (Owner or Mailing Address: iti MT' KOL4� 4' F' State Telephone: Zip 10c� (1111 JAI_ - Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES { APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 8;4J&9 L,64 iN� � t,, 0Z 0-f� ,.4 10 IV1DJOT ftli . R n FPC49T WWNIY�; HE`S � 44-- 1 oS S(o , 2. Name of project: LO-1'M IKWIOUK, z5-:,T� 3. 4. Design Professional: �' N�,Ntti~�S� i�E 5. 6. Drainage Basin: 7. Tvpe of Proiect: Location TN: Address:�LoW� 10GO n Form PC -97 Private/Residential Food Service Commercial Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one)....... ................. ............................... Type I . Exempt Type II Unlisted 9. Is a Draft Environmental Impact Statement (DEIS) required? ..... �d 10. Has DEIS been completed and found acceptable by Lead Agency? ............... NA 11. Name of Lead Agency N A 12. Is this project in an area under the control of local planning, zoning, or other officials, ordinances? .......................................................... ............................... % 13. If so, have plans been submitted to such authorities? ........ ............................... Mo 14. Has preliminary approval, been granted by such authorities? NO Date granted: 15. Type of Sewage Treatment System Discharge ................. surface water .X groundwater 16. If surface water discharge, what is the stream class designation? .................... 114 17. Waters index number (surface) .................. .....:......................... N A 18. Is project located near a public water supply system? ....... ............................... N 0 19. If yes, name of water supply itA Distance to water supply NA 20. Is project site near a public sewage collection or treatment system? ................ No 21. Name of sewage system k Distance to sewage system �a 22. Date test holes observed 23. Name of Health Inspector G•® , 24. Project design flow (gallons per day) ........................ 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... NQ 26. Has SPDES Application been submitted to local DEC office? ......................... NA Form PC -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? .. ............................... 2 N� 114 �fl No 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 40 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 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ......................... Nti 34 Are community water and/or sewer facilities planned to be developed within 15 years in or adjacent to project site? ................................ ............................... _ No 35. Are any sewage treatment areas in excess of 15% slope? . ............................... N4 36. Tax Map ID Number .......................... ............................... Map L'� e 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 storrnwater,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, 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 Law. SIGNATURES & OFFICIAL TITLES. H\bml� , Jv Mailing Address :.... ............................... �LL;�ct.oc�p 10 DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM 57A4,F c0AC,,4/ ZGT #e?17 Owner &c►GE Zr- 0wSa.✓ Address 14K-w ogh- Rk Located at (Street) 5% A(�E�Df�L �� (FOA1�) Tax Map i� Block Lot (indicate nearest cross street) . Municipality SQA/ Drainage Basin BR-AHG µ SOR, 7'ERC0L, .T1ON TEST D A'1:'� Date of Pre- s -oaking Date of Percolation Test 1r % Hole No. Run No. Time Start - Stop Ma se Time (p11,n.) Depth to Water rom Ground Surface (Inches) Start Stop Water Level Dro In Inches Percolation Rate Min/Inch �A- 2 3 ll:ao -fi:su 30 4 -3o 30 5 2 )P 03.3 6 0 � �� l pi Z-g 4 5 1. 2 3 4 5 _L NOTES: 1. J ests to be repeated at same deptn until approximateiy equal perco►a<<un 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. �* ` �Q �/4z 124 —0 Form DD -97 T� •e — DEPTH G.L. 0.5' 1.0' 1.5' 2.0' 2.51 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. o -d r 1-6 M Eb }�-� I✓I KE '-(o HOLE NO. Indicate level at which groundwater is encountered Indicate level at which mottling is observed Ply Indicate level to which water level rises after being encountered MA Deep hole observations made by: (Rood -C C wn Date Design Professional Name: µAl -n1' Address: wrQ F NEW NCHO Signature: � OA9�P\' � Design Professionals Seal 0FESSO L V1 -S oN _Pd1 r-;V`TZSoN 5 Ti4G C c of{G4i recf It / ! 9 $ 9-7,.,,l Hole # }: ? Lot ff , ;c Depth to water t'1 g F. Depth to mottling Depth to rock/imp... 5 f 1 ,� 0.5 ,. b gel 1. 1.0 lV e A �v �vrJ 2.0 - � F:vl e- 3.0 4.0 'f 0' 6.0 :::17 - 0 A) 8.0 ' 9.0 i 10.0 TEST PIT PROFILES: - �xp�y�tot► Hole # Lot #. off. 7 Hole #' Lot # Hole # Hole # � Lot # 7 Hole # Lot # Depth to water 4/��k1 Depth to water } Depth to mottling -41& :1 Depth to mottling. N' Depth to rock/imp. 3 ` -q'' Depth to rock/imp. i G.L. G.L. V V 0.5 L,I p SCIi/ 0$ e, Tr�lJSo; Depth to rock/imp. 5 - o'' Rc��fsh `3^v�.tv� . �c�l�h 8r�y � 1.0 1.0 Fine- 2.0 �c.�.1j� /o�.►+'1 r✓ /gravel 2.0 / g. � M�A Br,�:vn F:nN leoSN 0.5 5" -Fop 5.0 ./1e 8.•s.v�! rl 1 3.0 I '"�� -� 4.0 Boo� -.j " 4.0 1.0. �aC , t 0 bv*1 �Q 5.0 5.0 2.0 r4c 6 1`►- 6.0 6.0 S �. 7.0 7.0 ®o a ►h �0 8.0 8.0 9.0 9.0 4.0 s 4 5.0 10.0 10.0 0`' � 6.0. 9-7,.,,l Hole # }: ? Lot ff , ;c Depth to water t'1 g F. Depth to mottling Depth to rock/imp... 5 f 1 ,� 0.5 ,. b gel 1. 1.0 lV e A �v �vrJ 2.0 - � F:vl e- 3.0 4.0 'f 0' 6.0 :::17 - 0 A) 8.0 ' 9.0 i 10.0 o�,y Hole # Lot #. off. 7 Hole #' Lot # Hole # Lot # Depth to water. /VP n e Depth to water Depth to water Depth to mottling Ng ),7 p Depth to mottling Depth to mottling N Depth to rock/imp. Depth to rock/imp. 5 - o'' Depth to ock/' . C G.L. G.L. G.L. 0.5 5" -Fop 5.0 0.5 � / cP.50;/ 0.5 d „ T� I '"�� 1.0 1.0. �aC , t 0 bv*1 1.0 ° 2.0 r4c 6 2.0 F' e rl'Ne 2.0 PA 54 S 3.0 0 3.0 0 3.0 J oA ®o a ►h �0 4.0 4.0 4.0 s 4 5.0 5.0 5.0 0`' � 6.0. 6.0 6.0 Rock B30 Q 8.0 8.0 8.0 6' 6 9.0 9.0 9.0 10.0 10.0 10.0 o�,y 0 r.a 't ; (40"rt + v ,r0 jel �v ►t�,�e� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner � ����/ Address �-M6E roc* Located at (Street) 151=g. Mil-y- R.J� Tax Map Block �_ Lot (indicate nearest cross street) Municipality Watershed 4� , - SOIL PERCOLATION TEST DATA Date of Pre - soaking /1 /1 %70, Date of Percolation Test /�X %-1 .7 0 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 1 _ ► �® ate _ �.�` � �� 2 /0 - Icy 3 o - 50 ' ` '3 .o �. �'- I d 4 ,5a- wag., 30 5 2 � 3 ;55- ,567 60 43 - �;-6 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 Signature and T acknowledge receipt of this report: .02/96 .. , .} v j�T(P vel PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES z7 DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner 5� Address 67A6 Located at (Street) J-3jjZ(jj &LI jjZ Tax Map 15- Block �_ Lot 2— (indicate nearest cross street) Municipality ?4 = -gSo& Watershed SOIL PERCOLATION TEST DATA Date of Pre - soaking loll g/qg Date of Percolation Test / o/, C.9 Z 9� NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolatiop 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 ..:.::> .... D epth to Water ater ......... F G o un d IX- L e veoti Percoiau ' TameIa se Time ' . Surface (Inches) : Start Stop Y?r0pp In Rate Hole No Run No Start StogyVLn) Inches .: lYin/inch- � 2 3 4 -1t�8 3 5 1 12:0 5- -g 3,;3/./ /U 2 3 1,'14 -- O'K '30 2- 1 x# 9' 13 � 4 11'g7 —x,17 % .5 1 2 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolatiop 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 Sheet Of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLH SERVICES FIELD ACTIVITY REPORT ADDRESS', STAG oAelj %U. TATTe925 Street Town . State .. Zip PERSON IN CHARGE � OR TNTF.RVTF.WF.T): ✓ 11 /a� %��' nntP_ Name and Title TYPE OF FACILITY : S 1v��1� �� r'(.�ub- 50 r-Ax �e '5, 7, I !S . FINDINGS: "Twn 2>PrG �, /e-S 3� (f We e14 A/ e e Q r� ScaQ��rp O ?A'O p �l ,h- e7f=1� 14 ales 00 1c2LZ 19 / 9b Signature and Title I acknowledge receipt of this report: SIGNATURE: 02/96 Title: