Loading...
HomeMy WebLinkAbout0548DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www. s ca n y o u rd o cs . c o m 631- 589 -8100 22.84 -2 -19 / 22.84 -2 -20 BOX 7 Dom L '. ' ■, , Ir ' ' ' r ri ! ', i- , �;, , 1 f = r Phi } it Dom CHAS. H. SELLS, INC. 555 PLEASANTVILLE ROAD BRIARCLIFF MANOR, NEW YORK 10510 TEL: (914) 747 -1120 FAX: (914) 747 -1956 www.chashsells.com TO Putnam County Department of Health 1 Geneva Road Brewster NY, 10509 LETTER OF TRANSMITTAL DATE 5/14102 JOB NO. ATTN: Bill Hedges RE: Rios Septic repaired 50 Concord RD. Patterson NY 5/14/02 WP -97 Application To Construct A Water Well WE ARE SENDING YOU KAttached Under separate cover via The following 14tl items: ❑ Shop Drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of Letter ❑ Change Order n COPIES DATE NO. DESCRIPTION 1 5/14/02 WP -97 Application To Construct A Water Well THESE ARE TRANSMITTED as checked below: ❑ For Approval ❑ Approved as submitted kResubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Return for corrections ❑ Return corrected prints ❑ For review and comment n ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS Regards, COPY TO: SIGNED- T: \FORMS \Transmittal.doc DEPARTMENT OF HEALTH I Geneva Road Brewster, New York 10509 Ea-virommewil Heiiltb (845) 278 - 6130 Fax (845) 279 -7921 faCs im le ttal. To: Fax: From: Date: Re: Qr Pages: CC, A.. ------- -#,;iMrgen,� -----13ForReVleyi 13 Nease Comment ❑ Please Reply - E3 Please Recy�le- 4. �X' . .. . ....... ...... MK ol . . . . . . . . . . ,/d, Z t-2 .7. zz -77 3 ev In the event of transmittal difficulties, please contact this office. 0 0 0 0 0 0 0 0 4 0 0 0 0 0 a 0• 0 0 0 0• 0 0 DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 En-vironmental Health (845)278-6130 Fax (845) 278 - 7921 a faeshRe transmittal To: Fax:4� 7? - 4o74 5--6- 7 From: AS /#?x Date: Re: Pages: rc• . ,cam p G a 1001 5.- � o Os�C� �rii il�si• In the event of transmittal difficulties, please contact this office. ............................ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL l �� please print or type PCHD Permit # Well Location: Street Address: Town. Tax Grid # �(j GQ rJ Map '�, • Block Lots) q- w Well Owner: Name: $ Address: q V,, <'gG�- w • vet, Use of Well: Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Retailed Reason �y 1 �� r� ao G oSQ. �0 ar r�c¢v1� V ' e-�a q S /x.,17. G `�l for Drilling Well Type Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? .............. Yes No Name of subdivision Lot No. Water Well Contractor: &���� �i Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: l� _ Town/Village -4� Distance to property from nearest water main: ,> �o ©t� l . Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: 6 c o a 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. APPROVER 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 water well driller certified by Putnam County. Date of Issue Permit Issuin Office Date of Expiration./ " Title: Permit is Non -Tra® err le White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller ✓ G �._3i`2�./c'� �/ Form WP -97 sX PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO ABANDON A WATER WELL please print or type PCHD PERMIT # LZ lob -02 -- Well Location- . Street Address: TownNillage Tax Grid # *0 &1--e> 4:�6 ® 6rL-VV Map ZZ ock 2 Lot(s) 11 42.0 Well Owner: Nam Address: //e: U1►►. l0 GJU � G�2 e•�7 Well Type: Drilled Driven Dug Gravel Other Depth Data: Well Depth Jh0 ft Static Water Level 50 ft Date Measured Use of Well: Residential Public Supply Air /Cond/Heat Pump Abandoned 1- primary Business Farm Test/Observation Other (specify) 2- secondary Industrial Institutional Standby Water Well Name: Address: t =/�sTl`J' �` LL _ _�t�--t✓!✓lz°S Contractor: Reason For `i a o G•l05 v X t 5' �%'Vn Q j a ,- �- Abandonment: ea-� S Description of Work To Be Performed: wG aa 11 II \— V'UaA '"T Date: 0 Z Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code, Subpart 5 -2 of Part 5 of the New York State Sanitary Code and /or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Department a certified statement that the information delineated on the application for this permit has been completed. D e of rdue Permit Issuing Official Title White copy: HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WA -97 EXPER1AN ' 1- 800 -345 -7334 , ocw u utx xvAx ucx - i tumor $fv - -_- uT P 2.7 . vI I \ N D 4 H' 11/ 0 '000�''.:'� ' oo ru\ \ ter- � qa Gyp -• /� �e � i! /•i0 r (/d 7� i A 'O Ci % /. c %v I 1 1: T qn �- � — _ . Ile 1 l 1 • /7�5 1 _ S -pv P sl 1 1 Row 'a.T I CCHO Ir+1f � 3)1 61 _ �, a �, V ri% / .11 11 11 11 11 ,1 ; 1 / ; b i -77 �� G �G. ,C.� 13 8 1 NaN All 1 1 , IYplau ,rt\v ,lw Irnv p.lnavr i 7 -Z Svl(o 5 q c. o� coi✓ R� r� FOR ASSESSMENT PURPOSES ONLY REY NOT TO OE USED FOR CONVEYANCES -- MIIKI q JAMES W. SEWALL COMPANY 147 CENTER STREET, OLD TOWN. MA IN� �T�S IlelQ� I'a � 3t'z 3 °fig: uK KlW, �IK i- 3 ♦ c- ash mn -q 7,;c y 360 i APLS) \ _ HCMER DRIVE,{ j M 'l,V 4 . o-7 (APHALT SURFACE) �� 0 �J O V U'I:1TY POLE S Fq TYPICAL) WALL CORNER w _AT CORNER /c9���Ty x STONE WALL - STONE WALL S25'14'40 "E II S25'14'40 "E _ GUY MEk 6Q,QQ' P,EBAR ! 6Q.QQ REBAR w. X TYPICAL I I SET 1, I I SET i X r LL' O O o I I 0 �PIPE 0 v MONUMENT 0 o TAX LOT DESIGNATION TAX 0 DESIGNA ON w 0 m O SECTION 2$.40, BLOCK 12, LOT 14 SECTION 2$. , 0, BLOCK 12, LOT 13 v L IRON PIPE FOUND .0 AREA = 6000± S.F. OR I 0.14± AC. AREA = 60p0 S.F. OR 0.14f AC.- Z Flt sOUTHERLY�z L.h419, C.P. 103 L.j3 9, c. p. 2{�2 > .. .__.�.��� O FRAN.E `` .Q. .... --- _ O I I O I STEPS 1 1 Z Z O o w w In 0 N 1 r m m - rn I i 1 0 p I I C N. Z Z kPA . IRON PIPE FOUND. I ON LINE , I I A l co ° 0 0 U) i I 0 N Z i 1 0 22.2i s rO PE FOUND O r+— " N d' E �3S 11 =- 1 351.3 I ��' 3'51.4 .515 1 3556 I 3511 Clio): Sib •� N EBAR �v (0 SET 1 I RSETR SET s0.Q0'y�� Z / 60.00' 1 �— X125'14 40" 4 I 125'14 40 "%� 1554 756- 3�ei I TAX I LOT DESIGNATION, I SECTION 125.40, o B�OCKi54s 2 ,1 LOT 6 31 TAX LOT DESIGNATION SECTION 25.40, BLOCK 2, LOT 4 3512- LENOTES LOT CN FILED MAP No. 149E. PREMISES HEREON BEING LOT Nos. 3512 -3517 AS SHOYIN ON A CERTAIN MAP ENTITLED SIXTH "MAP OF PUTNAM LAKE, etc... ", AND FILED IN THE PUTNAM Con —1 rlrau'- nrrirc — AI54rw on inz+ — �tllf \IG•v %� ww�w.�we.• � _ ___ 'Y JUN­�25 -01 TUE 12:54 PM PUNAM CTY ENV HEALTH FAX N0, 19142787921 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES P, 7 APPLICATION TO CONSTRUCT A WATER WELL picue print or type PCHD Permit # _ 0 Well Location: Street Address:. own/Village Tax Grid # X90♦ Ma 2Z.8y 2, Block - Lot ( s ) game. A ess: Well Owner: 1 t0� 1 d e Rom-1 Use of Well: 0. Residential Public Supply Air /Cond/Heat Pwnp Irrigation I- primary _ Business Farm . Test/Monitoring Other (specify) 2- secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily Usage gal. Reason fbr Replace Existing Supply Test/Observation Additional Supply Drilling New Supply (new dwelling) Deepen Existing Well Detailed Reason -Q� T for Drilling Well Type J.2L Drilled Driven Gravel Other Is well site subject to flooding? ............. ............................... .............I'll.............. Yes- -- No ,X Is well located in a realty subdivision? ........................... .............. ...................... Yes No ^ Name of subdivision Lot No. Water Well Contractor: 9dr4Xn StgAM UktI D6 1Tkoldress: • l�l is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan, Date. glan OApplicant Signature: d�( ngv 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 S of the New York State S €unitary 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. My revision or alteration of the approved plan requires a new permit. Well to be constructed by a water well driller certified by Putnam County. Date of Issue Permit Issuing Official. Date of Expiration Title: Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner-, Orange copy - Well driller Form WP -97 Y,e t" W. "' ^y w 4 k -'S T -'� '-K " �3 d' r t` y„. f by f, r ,/Y° "C ..a- �r S� -t - .�.,. �. }.v t "� s r - s r �L`: r r � _ "4` i ,..t• § a x `-' �- �i �.„ s�__ _ . , FY �' ' �, , � s k _. ,ter§' � of '�, F :Y E. -' a " `' - �" ,, ,a,� S f _ - -11 •ti s -' x s. ' a°' �} 3 - E,°&- ° xi. a 5� $ d.;, F[� s,.(�' F x- a a _ � 11 } sr �r«5 tT _ ,r , , C: # .z r f� Yr.... " ,�'�,. ° "�4���Et Ol a - "* ' UTNAM COUNTY,DEPARTMENT;OF fIEAL'I'FI ;_ K � ,- n DIVISION OFrENVIRONMENTAL I, EATLH �SERYICES u � y � r ��'f{r. y04 FIELD ACTIVITY REPORT 3 . 11 ;r _ -: z _ _.:, 'F _. �. ­1 1 '` exe% '" r �.`z -t arr F'� tg s r` G a'�t y� ".s f - t .`r z 5 .'� f w i' " F L. "3 3 § .. �. " 11 Q�F 3 xP .$ Tet l: 3 _ . Y yy P 3 r+' 3 +C k 4 X y S• E - b ./ -11 z Streets , E Town ' K x State Zip t s r & ; `� 4 4 9 - -' E '3 fir - ; •#'r^ t 5 x ( ,� f 3t Y d < S t PERSON IN CHARGE � 3 o�� > ¢ W +s° l < Name andrtle _, t TYPE OF FACILITY r -� �� . =�`� c?. Gtr: r. - > �, �� f 3 a' e — $ S � 4 . _k FINDINGS. �, �_v �a -� a s § r d 9 °'.,, t. I 11 4 3..-. .: _ t.. _ ' .x "t .._, a.3 7 yi 4= ` 3 r 11 'i � I f r i S ' . , I... �%-' � .� , ;�'�`_ " �11. ', '�­ � ­� , _'�" ' X � , 4 -, 1 r -­;�' - __ ''. __ . 1� " j � "�� � _' - � �,c , I - I. d 1 �"%� L n 1 f, " t'tc F 4" ,t1 d " s r 1'rs t �� F -sue z '- f_ fa a 4 b "AL F « d . , 1. " �'�'�� �' _ , - - � , -41] . '. �'��­ �' l t '. 4 " - i,- �s. ,� ,6 } P �' ,.tj,4 bk �� . , , , t `� ` 1- - - -'t� -' "'A" ., s I .� > s - -.r - e .� s as d i- L .`` -a ,.e ?: r a4 �4rz; ' y_='- ¢ . Y,,,, ,_- � . ., :.yw?3 'a". -3 "'ws— - .`YS - ._ "fir. 1. rt' 6 - Y i f c y L z 4 - A y A rP s- ; �a ,n, �;-'" a �"'as "' ,�- r'x.i ,; nay Y. �+ b.t Y l ry �v C is 3 iL „7,t€� �' s r ?` c . r �, r" f, ^o- 5 .,� y 2 5 y .R fS 11 . 0f b .� ; t 9 .g h r .1 I Y b 9 S - :-P x. .* R - Y -" r^„ - �S t xe y a r�� .- .r" n r4 , ks _ sue+- ,.h _ t e - '`J'ss TNcp�TClgo - TFT �� E 5 Y Signatu ,eland Trtl'e � h , t t a 3 a R FPl1R T R --r. - FT) RY " f Q I aeknowledgezreceigt of this report r SIGNAT'URE;; - a - F .ke e e 3 3 - _ # 1. .~ - } t - ` 1. Ju. y 20, 2001 Mr. Biff& Putn,avw Cau*niy Bovwdl of Nea ltbv Carved, NY Dear Mr. Ate' I am enclos4ig, the- repeat leads teWtvig, well water report cw,, requ,ebte& by th& PCBff : Our property ik locatecL at 3 99 Sau& M&a+gtaiw Pa k l+v GarrWivNY. I wa- aAv4eZto-sencLth, akrepot to- yowand. re&rto-our frlei# 1Z- 155 -00. I hope, that the i n form ax'urw +k sat4facctory. I aav(4eZ our en# veer, M%ke,Svobodw, that the, reu4tk wovI& be, famard &D&yaw. s6v7eLy your�� Regina. raolan. 0 CURTISS, LEI-BELL Er SHILLIW, P.C. Aitarvi eykAt Law 20 Church Street Carmel, New York 10512 Timothy J. Curtiss William A. Shilling, .Jr. Craig T. Bumgarner ,Jennifer M. Herodes Giusepp i na R. Lita Augusf 30, 2001 William Hedges Putnam County Health Department 1 Geneva Road Brewster, New York 10509 Vincent L. Leibell, l/l Of Counsel (845) 225 -5500 tel. (845) 225 -5946 fac. Re: Gilbert Rios Appkcationfor Permit for Well and Septic System 46 Concorde Road, Town.of_Pattterson TM#22..842 -20 Dear Bill: Enclosed please find the above- refdrermed- appficatfsmfib.r w ll and .septic_syste.m permit, as well as the permit fee-of .$1.00.00. The notice to the neighbors-have-been -sent ( copy - enclosed)- and-certified receipt -of same will be forwarded to your office.--u pon my receipt. Should you have any questions, please do not hesitate to contact me. Ve truly ours, 4 Jo p Giuseppina R. Lita encs. 14.16 -4 (11/95) —Text 12 I PROJECT I.O. NUMBER I 617.20 SEQR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLII T /SPONSOR G `I, P �!-l0GI 2. PROJECT NA E 3. PROJECT LOCATION: Municipality f /-� 1� �fl Count 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map 5.. IS PROPOSED ACTION: ❑New ❑ Expansion Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: \ c) � AA1VJ -- CVts � 7. AMOUNT OF LAND AFFECTED: �� Z'� '�"� Initially acres acres _Ultimatelyd 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ❑ No if No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial 13 Commercial ❑ Agriculture ❑ Park/Forest/Open space ❑ Other Des ibe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERN14ENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑Yes 4No If yes, list agency(s) and permit /approvals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑Yes fr&J& If yes, list agency name and permitlapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes No i CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLIEDGE Applicant /sponsor name: dS Date: ZD �? Signature: If the action is in the Coastal Area, and you are a state agency, compl,:te the Coastal Assessment Form before proceeding with this assessment OVER 1 14 -16.4 (11/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEOR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLI T /SPONSOR 2. PROJECT NA 6E&, t3lio � Zp 3. PROJECT LOCATION: Municipality 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map 5. IS PROPOSED ACTION: ❑ New ❑ Expansion Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: �o �uls�s tea, -�r,r -�w-�s l2 t� o�� d °P f beau {t c lasR— r 1c 11, w► lase - AVt � 1 V'KV 7. AMOUNT OF LAND 'AFFECTED: ,I Initially C2'Z'" w1: acres Ultimately"�+' acres 6. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential 1:1 Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest /Open space ❑ Other DesT;ribe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL., STATE OR LOCAL)? ❑Yes XNo If yes, list agency(s) and permit /approvals 11. DOES ANY INSPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Y.es �f N9 If yes, list agency name and permiUapprovai 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? [3 Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE S 20 AppllcanUsponsor name: � d 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 14 -16.4 (11/95) —Text 12 PROJECT I.D. NUMBER 617.20 SEOR Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor) 1. APPLI T /SPONSOR �J XLL P '� C✓� OS 2. PROJECT NA E ��/D Lo�� IZD 3. PROJECT LOCATION: Municipality �Ir�fl County 4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map 5. IS PROPOSED ACTION: New El Expansion M—Modiflcation /alteration 6. DESCRIBE PROJECT/1 BRIEFLY: k � 1�✓ �po�Q A o --4. :gV,6C _ C At& CAOSA— py'px L 1,10 �� \ � J0 t L AV i t/tf:)-% �6�1�� • 7. AMOUNT OF LAND AFFECTED: Initially �z'�' acres Ultimately acres 6. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/Forest /Open space ❑ Other Des ibe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? ❑Yes XNo If yes, list agency(s) and permitiapprovals 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes 6tb6 If yes, list agency name and permit / approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? ❑ Yes No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE C o S ApplfcanUsponsor name: Date: Z D 07— Signature: If the action is in the Coastal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessmei OVER 1 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner lA�ILAjS" Fto,5, Address 41 WQW_W_601(- Wt:L. toQl. Located at (Street) Tax.Map Block. 7, Lot 4 -q- Zo (indic;te'nea"' ' stzross.street) re Municipality Watershed �StA4 SOIL PERCOLATION TEST DATA Date of Pre-soaking Q Date of Percolation Test N v I Ea. i. i ests to be repeated at same depin unTa approximlateiy equal percoianon rates are obtained at each percolation test hole. (i.e. 15 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 .... .. ....... ...... . - .......... D6ptht -6 Water , ......... . ................... Wafer ...... .... ...... .... .. . ... . .. . ........... F rom ...... "p, ..... ... .... ..... .... Hai . .......... ....... .. . . . . .. .. ... . . ... Rua Notnrt .. .......... .......... tme . a.. p... s Time me ...... . .... . ... ............. fa� I.fi! sto Stop . ... . ... Aropp In Rate ...... to'."Z 11i'T I AS zi z4 2 41; 3 Ao ZI :z 4 4 1' 2-4 5 2 3 4. 2- 3 4 5 N v I Ea. i. i ests to be repeated at same depin unTa approximlateiy equal percoianon rates are obtained at each percolation test hole. (i.e. 15 1 min for-1-30 . min/inch, s 2 min for 31-60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 DEPTH G.L. 0:5" 1.0' 1.5' 2.0' 2.5' 3.0' 3.5! 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. ��4 2 Indicate level at which groundwater is encountered �V-,�uza Indicate level at which mottling is observed Indicate level to which water level rises after being encountered o Deep hole observations made by: Date %' �9 op Design Professional Name: G�.���. �.���, l�U• Address:��°/ A W/66a �rl� lV Signature: /�,2/a Design Professional's Sea! Lr J n ` V n} , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner L, vifs" t 0 e7 Address 3 j Located at (Street) _Z0 Block �-CJZ, r,7. Tax Map BI c 7, Lot (indicate neariest•crOss:street) Municipality kj*z tershed Wa �StAi k-(0j&V- SOIL PERCOLATION TEST DATA Date of Pre-soaking aK. JA 1% Cc i Date of Percolation Test �1. 717411 solp Hole I�Fo Run Notarf Stop ............ .. S t Ir.t . ...... . . Stogy Inc es .. h. 4- 1 10:1,4 116.14. AS 21 24 .2 -z1 Z4 3 —11. 1z: 33 A-5 ILI 7-4 4 5. 2 3 4 5 24 - 3 4 5 INVILb: I . I ests to be repeated at same depth until approximately equal percolation rates are Obtained at each percolation test hole. (i.e. i5 I min for-1 -30 min/inch, :5 2 min for 31 -60 min/inch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 DEPTH G.L. 0'.5'' 1.0' 1.5' 2.0' 2.5' 3.0' 3.5' 4.0' 4.5' 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. ��hh CarasS . L V 2 Indicate level at which groundwater is encountered T},l o p �1Ci6�Z E►.u�) Indicate level at which mottling is observed �kt.Z Indicate level to which water level rises after being encountered o Deep hole observations made by: \�1%►.1i 6, aft,-►Eu? . L:6M 1�� Date to 30 oi Design Professional Name: LL,-5 Address: �; ►�L��y �,.� i LLB �17 �►��liLl�r�_� �� I,d51d Signature: O Design Professional's Seal PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Address Owner WE: L Lqre L I Located at (Street) Tax Ma Z.$ Block 7, Lot 4J- 7,0 (indicate 'nea"'r'est•crOss.:street): Municipality Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking Date of Percolation Test tieIr. Inv. ?,em I Ifil NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min ford -30 min/inc'h, 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 10:1,Z 11., zt 7-4 3 IS 2 It. 4-L, -zi 7-4 3 12. -45 74 Z4 4 1, S 2 2-4 :> 5 --7 2 3 4 5 2° - 3 4 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. s I min ford -30 min/inc'h, s 2 min for 31-60 min/inch). All data to be submitted for review. 2. Depth measurements to be made from top of hole. Form DD-97 DEPTH G.L. 1.0' 1.5' 2.0' 2.5' 3.0' TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST MOLES HOLE NO. 1 �ircti',h 1 4 9 3.5' 4.0' 4.5' Ma r�l mow► 5.0' 5.5' 6.0' 6.5' 7.0' 7.5' 8.0' 8.5' 9.0' 9.5' 10.0' HOLE NO. HOLE NO. Scsiv�,vl I.G�N^^ 2 Indicate level at which groundwater is encountered t.l o azo--& 6A q-" �-- Indicate level at which mottling is observed i k,,,,Z Indicate level to which water level rises after being encountered 14o Deep hole observations made by: 64*9. H. 4„ ul j G Date td 30 01 , Design Professional Name: 0. �ELl.S_ 1 �Z- Address: Signature: 0 Design Professional's Seal �ti;� Ayr- ..[,,....,\ �. ••��..,�.` rn r: ; �r'r X A Consu.lting_Engi:neers, Surveyors & Photogramrnetrists April 22, 2002 Mr. Bill Hedges Putnam County Health Department Division of Environmental Quality 1 Geneva Rd. Brewster, NY 10509 Re: Sewage Disposal System for Existing Cottage 50 Concord Rd. Patterson, NY Dear Mr. Hedges: On behalf of our client, Gilbert Rios, we submit herewith, for your review and approval, the following: A. Five (5) sets of construction drawings for a subsurface treatment system and drilled well; -B. Letter of authorization; C. Three (3) copies of the Proposal for Sewage Disposal System Repair; D. One copy of the Design Data Sheet; E. One (1) copy of the short environmental assessment form; F. Incomplete well completion report. PRINCIPALS STEVEN W. SMITH, P.E. SUSAN K. FASNACHT, P.E. MOSE D. BUONOCORE, P.E. THOMAS NOVELLINO, C.P. SENIOR ASSOCIATES PHILIPPE BOUSADER, P.E. SCOTT W. DUNCAN, C.P. NAOMI ISAACS DAVID A. WEBBER, P.L.S. Please note that the existing dwelling consists of two bedrooms. Utilities are Drilled well and outhouse. Our client proposed to relocate the well to maintain 100' setback from neighboring septic fields and to construct a sewage disposal system that is more in compliance with current Health Department Standards. © rn Gc= We trust that the enclosed material meets your requirement for approval. However, should yob. have an questions concerning this submission, or require additional info lease call Y q g q � r^ at 747 - 1120.' rn Y s ;rs� Y N Cn :.. cn to /wab 555 Pleasantville Road o South Building . Briarcliff Manor, NY 10510 o Tel: 914.747.1120 o Fax: 914.747.1956 o www.chashsells.com AN EQUAL OPPORTUNITY EMPLOYER, M/F PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: V49 U p Town/: � � Gad Tax Grid # Map 72.J5 lock 2,, Lot(s)l+Z0 Well Owner: Name: L111. Pf -I ___j Address: l Oy Use of Well: 1- primary 2- secondary Residential Business Industrial Public Supply Air cond/heat pump rrigation Farm Test/monitoring Other(specify) Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type Screened Open end casing Open hole in bedrock Other Casing Details Total length ft. Length below grade ft. Diameter in. Weight per foot lb /ft. Materials: Steel Plastic Other Joints _ Welded Threaded _ Other Seal: _V— Cement grout _ Bentonite Other Drive shoe: Yes No Liner: Yes No Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Test _ Bailed _ Pumped Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) During yield test(ft) Depth of completed well in feet Well Log If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter(in) Formation Description ft. ft. Land Surface If yield was tested at different depths during drilling, list: Date Well Completed Feet Gallons Per Minute Pump/Storage Tank Information Pump Type Capacity Depth Model Voltage HP Tank Type Volume Putnam County Certification No. Date of Report Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sheet/plan. Well Driller's Namelk2 fm4 Signature: Address: Date: White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of_ GAO Located at LETTER OF AUTHORIZATION ('> SOtj Map # ZZ 8 Block ?/ Lot Iq - 7.0 Subdivision of Fjf-rI i t'AA'p l- Subdivision Lot # �ZZ3-6Z'24 6' z5Filed Map # 17xo vv-1 Date Filed 2 - Z- 1 a 3 I Gentlemen: This letter is to authorize - -1k - �J, a duly licensed Professional Engineer _� or Registered Architer. L.._ -= to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the;Public Health Law, and the Putnam County Sanitary Code. Countersigned: P.E., R.A., # Very truly yours, (Owner of Property) Mailing Address Mailing Address: 0-,4W cz>0 State Pi�c1 v--• Zip 10G;10 Telephone: Cg14� �ixr�t�c L State{, &� Zip 1 o512 Telephone: S L g4�1 ZZS -ZO23 Form LA -97 PUTNAM COUNTY DEPARTMENT OF HEALTH . DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of e (,1 R j 1� as Located at Tax Map # 22.8 Block 7i Lot Iq - 20 Subdivision of FjKVk t-Mk -e C7e Subdivision Lot # Map # « VP Date Filed Gentlemen: This letter is to authorize - V� - I/-. a duly licensed Professional Engineer � or Registered Architect_ to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health 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 County Sanitary Code. Countersigned: P.E., R.A., # Very truly yours, Signed: C---u N_�� . (Owner of Property) Mailing Address r :' Mailing Address: State itk! Zip low ► o Telephone: (�L14) 14-1 - 11 Z O State �0 Zip 1 0512. Telephone: L S � ZZS - Zfl Z 3 Form LA -97 08/09/01 THU 17:01I FAX !914 225 5946 CURTISS LEIBELL SHILLING 9 002 FROM:: Harry Diane Mahan FAX NO. : 8455264831 Aug. 10 2001 04 :42AM P1 ?\o i �of \and, C�►`go \`[1 c.1u �Qd ^�-wza o`�'�r.,ex 5�Q£�S �i�o-� CQri L�Q q� � ex %n ow ace )Pcau) and 'cue a� V VA V; 1, ot�.x iC he g 1 'McrAed OS Coi `(tilt( tl e� t;, C3�s RbC1c� GS �1�h2. 0 GG of If - o -amrAl TWI I 17-Mr- TPI ! P4c,- a7P -74 ?1 NAME: PI ITNAM rni INTY nFPARTMFNT nF P. 2 BRUCE R. FOLEY Public Health Director April 23, 2002 DEPARTMENT OF HEALTH 1 Geneva Road. Brewster, New York 10509 LORETTA MOLINARI R.N., M.S.N. Associat? 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 Mr. Winston Byfield, PE Charles H. Sells Inc. 555 Pleasantville Road, South Building Briarcliff Manor, New York 10501 Re: Proposed SSTS - Rios, 50 Concord Road Town of Patterson Dear Mr. Byfield: 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 proposal for sewage disposal system repair permit is incomplete (enclosed). 2. A well permit application must be submitted (enclosed). 3. A well abandonment permit must be submitted (enclosed). 4. A copy of the floor plan for the existing residence should be submitted,. 5. A fee for the new well of $100.00, certified check or money order must be submitted. Upon receipt of a submission revised to reflect the above comments, this application will be considered further. ------------ ---- — - - -- Sincerely, William Hedges Sr. Public Health Sanitarian WH:cj PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Property of_ GAO Located at LETTER OF AUTHORIZATION l tV Tax Map # 22.84 Block ?/ Lot 1q, 7.0 Subdivision of Subdivision Lot # Map # i VV Date Filed 7- Gentlemen: This letter is to authorize G- a duly licensed Professional Engineer �or Registered Xrchitec to apply for the required wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity with the provisions of Article 145 and/or 147 of the Education Law, the.Public Health Law, and the Putnam County Sanitary Code. Countersigned: P.E., - ; # 67-110 Very truly yours, Signed: C—U (Owner of Property) Mailing Address r�X:-,,5 ?[tk�,N �j. -/ (gyp Mailing Address: i�,4 �k�cz> o State i ci v Zip Ics 10 Telephone: L'qw 1 4'( - 112 State Zip 1 oSt Z. Telephone: Form LA -97 Wonk tr`£ .. �' ,�„ f' � f H, i? r � i.. -� j •� f' .+ . 1� 4 .. r s, 19 t h N r q �s "- nIP wig 5 j sc ,S✓ - A M Z S f I- � _ _ S iF 04% � S u� st l" t - yam. y, _ . - - A '° -- .a . ar x f.. s s r _ t a. �, -• Vol pool �k� k 1Q S Y aov £ ;q� i ? ,� :� •"' Fr t if ,y 4., e✓' .Sr_ ... l e> �� �_k; not - zat p[; � � it r• k ScM 1- 5 k � i i fin' . i [A� Y• • +1' J k ".r n 71 4� _ r �7�, s .J'�a oslgnature and TltleAy fi Th Vs RE r AR receipt of thts report SIGI�fiATURE, F z ' �' � Y i � ✓ i �� L t4 _ 42%96 �' �5 r_ Title 3' I i X 9 L Y •g r x x � t � -. e �" x {,, r`• '� .� ��.' •r -. s � � � '� b ��� 4 �'; a- a > t -,t , n. ,, a ' r ? QI � PUTNAIVI COUNTY DEPARTMENT OF HEALTH �k � n ` r r lye �. , ! 4 ilia, Ifii YO FIELD ACTIVITY REPORT i y " " NINE 1 nr n n 1II1I1[k x - QTlT1RFCC, x- x F TDYTn b TIE to Street. -c4 F "Ann- # „ PERSON IN CHARGE s KNOW; nu mTT�u NWr.. " f Marne and Title r Y = i i " =TYPE OF FACILITY p f f {{tK Q S S Sao f F 4 y vh 4 y, " Q4„ � � Y � FINDINGS: -� :C ^mpg c - o�kb ~ + WK, Fi.. i —�% - i r 9 9 L + + '!i, _ _+ POW Ojnso r 5 _ r t• 'FF -�q,w -_f. Nr -. 1 -. 5 1 t _3„y k 6y f a; Y 4 ae q,p 4 ' Zvi Sep �s ^aP 3 �� y +fri'. ' y. - 4 On onto i ti F F x � +•5 x clock oil, f ¢ ter. P.4 . �2. ..}cyT '� si'• L t, F 3 - 9 � °r �' C i 1 k got 08/09/01 THU 17:01 FAX 914 225 5946 CURTISS LEIBELL SHILLING la003 FROM.: Harry Diane Mahon FAX NO. : 8455264B31 Aug. 10 2001 134:42RM P2 14 r� P dft " i's A pop 1p -1 11 1 4 -7. MC -rm -0Ar--97Q--7QP1 NAME: P1 ITNAM COUNTY DEPARTMENT OF P. 3 08/09/01 THU 17:02 FAX 914 225 5948 FROM : Harry Diane Maken �Y • �d lla waN� rl ca 3ya eslatllAlo� oats w �,2,.• „�,..o ssaa �o•.�. ►....,�lou+lfl�da P mar `� ;�31�ras s •��a ddW � or"'il�i4MZ� n n ” of R 1� CURTISS LEIBELL SHILLING FAX N0. : 8455264831 oA MIN •A1Npo Yv'VNAJ XONINI -13W 9 004 • 10 2001 04:43AM P3 AUG-9-2001 THU 17:06 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 4 08!09/01 THU 17:02IIFAX.914 225 5946 cLRTISS LEIBELL SHILLING Ca 005 FRT .: Harry Diane Mahon FAX NO. 84M264831 Rug. 10 2001 04 :43AM P4 --�- -� r► 4 �.•, _.. LOT H Q 5.5. G S. a ds4d Qq 2" C- FwsNr-b �.On1E Bra�E kill. bE �GZ, AZE1 A Min a- K-UN OF 5A V-- I�' TOPS061L a � 11: TOP501L c-cj, t P'.aGTE- Q 5Li e,5ASr— ► SAUDY L:Am Q Ito Dr- 1VF- WAY DE. p,iL 1E,rop -D!L. X3.3 °f, la Wr 5 �.. IZ' TOpwl L •Y) 4 sn�,uY wa,M 5 % MAX. 20 )'-A/ CA L. A74 L SoEC 7710�/ .SSE o T If DETAIL -84ff -WDW a- ale aopwra •�ER✓�auS a e, +Pr��s 70 'S. o �• +6RvrGcA� ,�erEi7uoL m'4 i I r�toERrraus :. •'t>�'+SOrL �S�'EC�o� I , °ti MATtc•R/A� ' QRryr^IRt. y 1►1 GRa17 • ROCK W%CTER ' /- i'- "ice /C',�{�L -. OR . I-E VEL GPOLIND - 77-11 7- RE Q U/ ' -c/L L r «;..ad ZaC 7R6iyCN oN IO. oi'• A llo, -1 �,� � ro Ol G p4 val- n . •• o r�.pa c.s •'r GwG N s r _ _� Tr, . nitC_77C1 -7QP I NAME: PUTNAM COUNTY DEPARTMENT OF P. 5 -. BRUCE R FOLEY Public Health Director LORETTA MOLINAtI RN., M.S.N. Associate Public Health 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 PROCEDURE FOR NEW "ELL PERMIT APPLICATIONS -1. Well permit application is to be submitted along "'vith fee. $100.00 certified check or money order, for all permits other than redrills. Redrills require only permit applications. 2. Locations of all sources of possible contamination tivithin 200 feet of the proposed well location are to be shown on a plan or tax map. 3. Neighbor notification is required for all property owners within 200 feet of the proposed well location.. 4. Feasibility of well location is to be confirmed by a representative of this Department. 5. If the proposed well is within 15 feet of the property line the approved well location is to be staked by a Licensed Surveyor. If the proposed well location is within 100 feet of any source of contamination, the well location is to be staked by a Licensed Engineer, Registered Architect or Land Surveyor prior to drilling. 6. As -built and well log to be submitted no later than 30 days after completion; by permittee. BRF/RWtn August, 1999 pnwpa 08,09/01 THU 17:02 FAX 914 225 5946 � CIRTISS LEIBELL SHILLING Rom.: Harig Diane Mahon FAX W. 8455264831 [a 006 Aug._ 10 2001 04:44AM P5 r S90 ,vtoU 'rrc..rg�.,ENG7i� C7F TILE F1 trL t DEPT{ CUCTAIM VOL- 02A]w *3:s�or�- QOD_ 8R. FT C•Y- DEPT LG7H. E�LFW DE P-rHTO: . 300 L F t C)() L. 1' x x 30Co N. a N A roaL F. I co 7 L F 3r/, (o4 f) N. A' t 'Z9 t r 143 t.F N.k IA3 if . r.. l xE m/y�� BO4LDeK5 AND � *"► -G- �'/ ` _ '•' TOM At t-i1"d, t �! MA X S. opf- MgrT�C SEBL r'c. ji GAP ,ct��IAVOV -+E 'Q'; '�•K : GPVPLI3 T. tawC• 3Cfi9 Sa. Po AwAr aVlO� F171oy r ' /$ 1 RSA �`k"�p A T��6 •F� '..•THE �NSJGE PT. ; rv4F4�L C•tS+N6 25 16N4 rM } vv�£O 'CLA✓ • vQ c1��+6•v r' ' � I v *4tX/r 6,9,0 u7" RM CT PV OF p -7,7"rr ,4d VV r ram ",r..w TD .l�ET' PVMO tiM ,...., rv�iAEO PIPE Se")oe c%ET PUMP A p�7 TY� COA/Cs7ETE �IiGK a ND MANN04 E PCiM p/•/DUS5 ,VSTQLL•ED �" H RE ORA1AI A 1� 7- 19 ' 5RA V1 7Y / 5 Ab55 OVAT�R .pE7 ,9M r 7Z5 . 1 rA /L. OF r/4 E jC'ieG DS c l r r. r� roM PK•t Q5 Hul)som tp IaF�E2S�N It KOPOL- ov tz � AI -IG -9 -2001 THU 17:07 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 6 SITE LOCATION OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAI)F; OFITCIAL USE ONLY fi d q TM# Q. PHONE PERSON INTERVIEWED PCHD Complaint # ame & Relationship i.e., owner, tenant, etc. DATE PROPOSED INSTALLER ADDRESS TYPE FACILITY_ PHONE REGISTRATION# Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or reported agent of owner aAee to the conditions stated on this form U I d 011(-� Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name DAT!FE kv b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house congers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title COPES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE n DEPARTIVfENT OF HEALTH I Geneva Road ,y� 4 Brewster, New York 10509 W �� Emironmeocal Health (845)218.6130 Fax(845)278 -7921 5.f W? faesi de try nsmit�al To: From: ° � Da'e: Re: 49 Q Pages: CC: ❑ For Review ❑ Please Ccmment " 0 Please Reply Please Recycle Nq NMI WAY m 0' Fal l In the event of transmittal difficulties, please contact this office. rvA 1 4 dr. M r 1 tl t /> fo�zzas�z�T io'r4 A F `riw n`,pY 10 , r.l m am i H Z 1� r , t N -tl t1 N 1 t a N 1 ROM 19 M9 1 I't T 1 .1 11 l � ar �`- 1 11 8 1 1 ., Y 1 '`r1�1 /evllmrY� - Imf 4H 1 ai,anllNir PJ1 i c.�l as ltrr 1 �M C . FVISIDIS'.` SPECIAL DISTRICT t�piMATIDN H4[ttK' "� FDR��SSESSYIENT PURPDSES DfST 1 agYlauR NDT TD RE USED f0R'CDNTEYdNfES ,. uN . taw in[ mu¢ ur . ' aatraKO ar. JAMES W COMPANY SEWALL: �aatuna;' nmrm ua• 10 CE MER STREEY,DLD. iDNN, MARX ..,� t ,t CCnn �. I r o' , , w • / R I I AC •: ! ,N x: 22 2 k y , A I LLJ kh �"Z 4 ✓fir �2= 4 ifV aY ti 3 •� ... STATE ROUTE . 311 - L T r 3940 AC CAE' 28 ',,K , i2 1• i3 ° PEEL i M I NARY s ��£ I 2t400 ,m,rv., ` q v-. W» w,amgcdw, ran 23 5 '` TOWN Of PATTER$ON - --c- -� .`,.- . txawie rx w ¢ uA - «a.• , ! • :.' -�=� IPS YA@ A.. 33 �' 34 - a ' PUTNAM COUNTY. NEW YORK .tr tt�II'R>t aOO,stp aIIrm urW.. �. •. w , , 353 , 1 1 , , f i 1 t Inv { r}1, � -° - i- �����) __`- - -. -- •- --_- ran I . - _ , � � 115 ~ ^� I� l�'l ✓�,f'�Y - _ Yf ��� - _ .� - , 1 f f�l c - ITT- -. x ✓ a w t1 SCALE M 1/10 OF All Q1C11 6 22.76;2'1 / sur � mo slfe uJs ��pOpS`p fry °s 13_ 1-- r L LJ I ECN� l tes 1 13 S 1 k ( r- z w 22.16 STATE ROUTE 311 S,A 9J, F i lb z I ' �2 76 39.40 AC. CAL. a P/0 33_2 23_ s9tscecxnl 23 9Z� 623.03 -0 =9�s t • Iti 33.96 AC. CAL. I 22 I I 10.98 AC✓ zo 215.89 / fb 1 1 7.82 AC. CAL. zsZ 22 / 5/54 AC. ej6eo CAL L� AL / 25 j` 29 / CAI. •- y 11 3APLS). HOMER DRIVE���((( ] o,� (APHALT SURFACE) ° — ` UTILITY POLE S` FqO (TYPICAL) WALL CORNER T�,o� Lj� w AT CORNER cq��ij} STONE WALL 0 STONE WALL S25'14'40 "E S251 4'40 "E 0 GUY WIER �� J 60.00 RE AR w D D TYPICAL 60' 00' REBAR a SE� i x X I I SET r I I z o ° 2"IRON PIPE FOUND o O TAX ILOT DESIGNATION TAX- LO DESIGNATION w o MONUMENT o SECTION 215.40, BLOCK 12, LOT 14 SECTION 2$. 0, BLOCK 12, LOT 13 u N IRON PIPE FOUND O AREA = 6000± S.F. OR 0.14± AC. AREA = 60p0 S.F. OR 0.14± ACai D O.tS' So- UTHOU z L.h419, C.P. 1(53 _ L.j3 9, c.p. 2 2 �! FRAME _._ . STEPS I , .... -- - - - - - -- . O o I w N z I O N m to n m I O I I CONC. Z Z I I APAD IRON PIPE FOUND N ON LINE O I ' 1 3 O y 3 0 CE N N z I. 1 V �O 22.2 01 IR PIPE FOUND 0-10- FA ON LINE j7 ^ty -. >.- I ..�. 13P 3`.ii ;. 575 1 35tu I 3577 �35t5 - � a. N rn I I REBAR REB� z SET SET 60.00"1 z 60.00' -- I I � 2514 40'4 125'14'40 "1� 7564 I 556:5 I 756: TAX i LOT DESIGNATION, i SECTION 125.40, BOCK 2 ,i LOT 3I TAX LOT DESIGNATION SECTION 25.40, BLOCK 2, LOT 4 s/ (7 �d ..... "l.- DENOTES LOT ON FILED MAP No. 149E. PREMISES HEREON BEING LOT Nos. 3512 -3517 AS SHOWN ON A CERTAIN MAP ENTITLED SIXTH "MAP OF OII —., . - . 11 ..in — Cn IKI TWr 01 ITNI AAA r WELL PERMIT' LOCATION MAP EXAMPLE SHOWING ALL. SOURCES OF CONTAMINATION WITHIN 200 FEET OF PROPOSED WELL Copies of the tax map pagge for your property can be obtained at your Town Building Department and the Putnam County Dept. of Health 30 V ss•d�s ocatio,, S 1.13 AC. IF a s name tax ma 0 1.40 K r� o Hers n me s / t x map m proposed we o existing we 1 -(if apps.' o1e) =, m ' ,5 45 a g i.to tt.. ssds t o a n& 1.00 AC. B ss s oca io {i171 d ers• .name E o = tax .map d - r owners' name .' tax map ® ssds l cat 1.00 AC. Id ssds location J/' u,,�• �p o. c 0 p 1.0. 51 43 ;2 " RC. 1.00 AC. 1.40 AC. .1.30 a s '91 � '% �� ...i \� ,p �9n �� � .., sac.. + • -- •- .. ccue ON tno OF u nru EXPERIAN 1- 800 -345 -7334 ,rIW, 10 S� as+ �ap0 I+ aX - F- „( -¢ ;; P, n cJ % f-Oi7COic/ 2 \ rm '6 ' x'17 B ¢A 9 _ �� J /•� � f � I 1 , 1 r " r rN/ J`o � .1 /-i O. r• (la /rt O L 1 a; F y n nri� i,Jr e\ �v,o J pill 2 A/ Al / // 1 % 7 c iiG !1 tl ` 8 1 1 1 1 1 ¢u 1 Ivrl Iml /� N l /G 5 /L 1, fir` PU` P/I` R•/ v/r 1¢ir 1 O r iyr J t /' vn 1 v/r1 1 I N I r i 4d I e� �I -' - FOR ASSESSMENT PURPOSES ONLY NOT TD BE USED FOR CONVEYANCES JAMES W. SEWALL COMPANY . I47 CENTER STREE7, OLO TOWN, MAINE �- p✓ /�.lrw5se�3z 308 cenr uR ,mI rllA ,µ14r LI% 0.0a UMI, 3' -2 -j /17 3z3v� - 360 10 - F- „( -¢ ;; P, n cJ % f-Oi7COic/ 2 \ rm '6 ' x'17 B ¢A �� J /•� � f � I 1 , 1 r " r � � i vll "s J`o � .1 /-i O. r• (la /rt O L 1 a; F y n �v,o -7 (1-y6 T trey j ✓I /E �F✓ <I'v �A /735 colo 1 2 A/ Al / // 1 % 7 c iiG !1 tl ` 8 1 1 1 1 1 ¢u 1 Ivrl Iml /� N l /G 5 /L 1, fir` PU` P/I` R•/ v/r 1¢ir 1 O r iyr J t /' vn 1 v/r1 1 I N I r i 4d I e� �I -' - FOR ASSESSMENT PURPOSES ONLY NOT TD BE USED FOR CONVEYANCES JAMES W. SEWALL COMPANY . I47 CENTER STREE7, OLO TOWN, MAINE �- p✓ /�.lrw5se�3z 308 cenr uR ,mI rllA ,µ14r LI% 0.0a UMI, 3' -2 -j /17 3z3v� - 360 N8 °08'10'E 112.10' 10' ;MIN. iDR -35 PVC 1/4" FT. F 8' MIN. 24' h i0 GAL. ST. IF w O 10' MIN. H V` 00 EXIST. 2 -BRM. COTTAGE �- PROP. WELL O �s +E- XIST. WELL h O BE ABANDONED T N8 °08'10 "W 98.0' N ORZ) /)?Z) w O ♦ O 0 v W I� O ,O n ati ilg f 1; 1 \\\\\\\X\ STA. YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown Heights, N.Y. 10598 (914) 245-2800 Albert H. Padovani, Director LAB #: 32.105143 CLIENT #: 13571 NON STAT [:'-ROC PAGE TOOLAN, REGINA DATE/TIME TAKEN: 07119/01 01:15P 135 MAPLE AVE. DATE/TIME REC'D: 07/19/01 01:45P NEW CITY, NY 10956 REPORT DATE: 07/20/01 PHONE: (845)-634-5819 SAMPLING SITE: 399 SOUTH NOUNTAIN PASS SAMPLE TYPE..: POTABLE : GARRISON, NY PRESERVATIVES: NONE COL'D BY: REGINA TOOLAN TEMPERATURE..: NOTES...: KIT TAP COLIFORM METH: N/A DATE FLAG PROCEDURE RESULT NORMAL - RANGE METHOD 07/19/01 LEAD <1 ppb 0-15ppb 9101 COMMENTS: Pb/Cu LEAD limits for p EPA Lead & Copper than 10% of their than 15 ppb and a treatment must be potential. SUBMITTED BY: ublic schools are set at 15 ppb. Rule for Public Systems requires that no more distribution points have a LEAD value of moWe ~` COPPER value of 1.3 mg/L, else water undertaken to reduce the waters corrosive ELAP# 10323 , PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAY', SITE LOCATION TM# OWNER'S NAME MAILING ADDRESS OFFICIAL USE ONLY -0- t b E5 — 0-2--- of O �, ! — ,--7 — 15P-2,0 PHONE 6M; S) 7-2S - PERSON INTERVIEWED PCHD Complaint #. Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER Cu t L :7 t �Z 11 S PHONE -+1, O - (01>44 FaVOTIT'llygm enc:;'AA Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or reported agent of owner agree to the conditions stated on this form. SIGNATURE ke TITLE ���G- R� DATE 5/`% /.�� Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title �TE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99M L EASTERN STATES WELL DRILLERS, INC. 6073 Route; 22 l-1illcrton, NY 12546 (5 18)789 -467() fax- '789-6246 April 21, 2003 PUTNAM COUNTY HEALTH DEPARTMENT 1 GENEVA R.D. BREWSTER, NY 10509 Dear Sir, On April 4, 2003 this well had been grouted closed with cement and capped off permanently. GJ Y, tt ! Sincerely, Joseph Flood, pres. ` PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well D.ocation Street Address /: CQN e0 Town/Village: Tax Grid V iManL-thlock Z Lot(s)/ f,0 Well Owner: Name: Address: Air ielOS j 7 A/DD 5 4 o Use of Well: 1-primary 2- secondary Residential Public Supply Air cond /heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion _)� Compressed air percussion Other (specify) Well 'Type Screened Open end casing )�, Open hole in bedrock _ Other Casing Details Total length ft. Length below grade ft. Diameter (-p in. Weight per foot jTlb /ft. Materials: Steel _ Plastic _ Other Joints: _ Welded Threaded _ Other Seal: _ Cement grout )4 Bentonite Other Drive shoe: ) Yes No Liner _ Yes No . { Screen Details Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes No Hours Second Well Yield Vest _ Bailed _ Pumped )(_ Compressed Air Hours Yield gpm DDepth DData Measure from land surface - static (specify ft) During yield test(ft) Depth of completed well in feet Well Hog If more detailed information descriptions or sieve analyses are available, please attach. Depth From Surface I Water Bearing Well Diameter(in) Formation Description fft. ft. Land Surface CD 9 —3 p ` a If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Su Capacity Depth s Q Model S' ( J 06 `%/c), Voltage A_-j° HP )/-L_ Tank Typel iLffPr- Volume 30 Date Well Completed Putnam County Certification No. Date of Report Well Driller ,signatur NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a, separate sheet7plan. Well Driller's Name Address: �e a `7 Signature: Date: m �0' 0,lu VtJy 4/ White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 T, Y� PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT N. Well Location Street Address: C 0A1 co�o '0 b Town/Village: Tax Grid # YBIock 'L-'Lot(s)'/f Zb Well Owner: Name: Addres;* Af - L� Use of Well: 1-primary 24ecbndary Residential Public Supply Air cond/heat pump :Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion Compressed air percussion Other (specify) Well Type ..Screened Open end casing )<, Open hole in bedrock Other Casing ,be ais' Total length' ft. Length below grAde, 114`ft. Diameter -in. Weight per foot 7 lb/ft. Materials: ie Steel Plastic Other Joints- elded t4qedded. :Other. Seal: Cement grout 30 Bentonite Other Drive shoe: X Yes No Y No Liner: es Screen Details Diamefer (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Second Well Yield Test Bailed Pumped Compressed Air Hours Yield 9 gpm Depth Data Measure from land surface-static (specify ft) During yiel,d test(ft) Depth of completed well in feet Well ,Log If more detailed information descriptions or sieve analyses are available, please attach. -Depth From Surface Water Bearing Well' Diameteron) Formation Description ft. ft. Land Surface p CD 9 SQ -f-0 N e-S A) 0 C? V 0-, qrv\ 6 n C, K 19/ n 0 V-0 'r, %Ij '0_A C&�a owl Qjyi'l, W C e V If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump/Storage Tank Information Pump Type Su L Capacity K Depth 4 S� 10 Model 9 C- S 0�� 414=% Voltage p HP YA Tank TYPO�LPiter Volume, 10. L Date Well, Completed Putnam County Certification No.. Date of Report 03 Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provided on a separate sneevpian. Well Driller's Name- 0 0"r) Address: Signature: Date: Pink copy - 0 Weli driller Whitecopy:' HD`File-,'Ye 16W copy - uild'ing Inspector, wner; Orange copy Form WC-97 C PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVIC E.S.. APPLICATION TO ABANDON A WATER WELL pleekprint or type PCHDPERMIT Well Location: Street Address: TownNillage Tax Grid # s) Map Block. Lots) Well-Owner: Name: Address: 11 Type: Drilled Driven Dug Gravel Other Depth Data.,, Well Depth TSta ic.W atertevel ft Date Measured Use of Well �,.­Residential -'Public- Supply Aik6ndffleat Pump 'Abandoned 1- primary` Business Farm Test/Observation Other (specify) 2-secondary Industrial "likitutional Standby Water Well Name: Address: Contractor: Reason For Abandonment: Descriptioi of Work To Be Performed: Date: Applicant Signature: PERMIT This permit, to abandon one water well as set forth above, is granted under provisions of Article 10 of the'Putnarn County Sanitary Code,, Subpart 5-2 of Part 5 of the New York State Sanitary Code and/or Part 75 of 10 NYCRR and provided that: Within 30 days of the completion of the abandonment of the water well, the applicant shall submit to the Eiepartment a certified statement that the information delineated on the application for this permit has been completed. Date of Issue. Permit Issuing Official Title White copy: HD file;,_Ye11Q.iKcopy -7 Building.Ins ect . r; Pink copy- Owner; ,.OraigecQpy7,W911..driller Form WA-97 I _r f; d ,►� ✓- 4" DU►. SDR -35 PVC MIN. SL 1/4" FT. 74 l Z r. �1 I EXIST. 2 -BRM. COTTAGE N8 08'10'E 112 10' b.;= off-In IA PROP. WE9 dw ,— EXIST. WELL TO BE ABANDONED N8 08'10 "W 98^ O' VCORD KU. VENT." PROP. 750 GAL ST. Health Putnam Count�,� 'a' ;Gyn Sarvice Division of i cewrittl p��J Q O Approved as natrc`. ; >' ' `� r -.7 Of the �'_ iii, •� ides =^ applicable'R " "':: :: : i. :::...: PutnaEn county, L Dac.� Siure gnat 50 Lila Z r. �1 I EXIST. 2 -BRM. COTTAGE N8 08'10'E 112 10' b.;= off-In IA PROP. WE9 dw ,— EXIST. WELL TO BE ABANDONED N8 08'10 "W 98^ O' VCORD KU. VENT." p��J OR SANiTARY .� 0 Ica