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DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 23. -2 -13 BOX 7 ' fG. L '_ �� T L so or 4.''�. FTI ._. , PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 5 McManus Road South Town/Village: Patterson Tax Grid # Map Block I- Lot(s) Well Owner: Name: Address: ill Folchetti - 45 McManus Road South - Patterson, NY 12563 Use of Well: 1- primary XXXXX 2- secondary x Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing x Open hole in bedrock _ Other Casing Details Total length 4�ft. Length below grade 39 ft. Diameter 6 in. Weight per foot 17 lb /ft. Materials: Steel _Plastic Other Joints: _ Welded Threaded — Other Seal: _ Cement grout X Bentonite Other Drive shoe: X 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 —X Compressed Air Hours Yield gpm Depth Data Measure from land surface- static (specify ft) 75 During yield test(ft) 345 Depth of completed well in feet 365 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 2 Fill 2 10 Clay 10 365 Grey & Black Granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type slib _ Capacity7 Depth 340 Model 7GS10412 Voltage 230 HP 1hp. Tank Type d i a p , Volum;� 345 5 Date Well Completed 1.0/:9/02 Putnam County Certification No. 2 Date of Report 1:0/29/02 Well Driller signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be provi o separate sheet/plan. Well D/riller'sName Mill .Drilling, Inc. Address: 75 Putnam AVe Brewster, NY Signa /re: Date: 1/17/03 White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy- Well driller Form WC -97 t I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # Located at * MqIANL6 k Pkp �0 "rH Town tr _P_60 v Owner /Applicant Name WILUPM"r 99AW "El-, I Formerly Tax Map A. Block 2- Lot 1 Subdivision Name P1 rG& t 4 Q-EA 1,TY Subd. Lot # to Mailing Address : iU k k%44_Al40 1)P4"4 Er PATTEp_'6014 i N , Zip 19-606 Date Construction Permit Issued by PCHD oil 11 � m Separate Sewerage System built by WIC I R 4 1=4fNUYET)Address9 -M 0khLA!O DQA'AR Phi W 'r Consisting of 19-60 Other Requirements: Water Supply: Gallon Septic Tank and '5O° I-1= ° I'Mir" V �_ o * . r1w.- Public Supply From Address or: X Private Supply Drilled by MA_ PPWH(A i Ot— Address 15 M"MP45- ATM*Ib m Building Type P-f-_ 95t Del-%a Number of Bedrooms 4 Has erosion control been completed? `Yss Has garbage grinder been installed?� I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations of the Putnam Count DgpartRient of Health. Date: j r - Address P.E. Y, R.A. 661M 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 ^subject to modification or change when, in the judgment of the Public Health Director, such revocati , m 4ificatiqARr change isiecessary. By: Title: Date: L V, 03 White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES WELL COMPLETION REPORT Well Location Street Address: 5 McManus Road South Town/Village: Patterson Tax Grid # Map rL�l+ Block I. Lot(s) ]rO Well Owner: Use of Well: 1- primary XXXXX 2- secondary Name: Address: Bill Folchetti - 45 McManus Road South - Patterson, NY 12563 x Residential Public Supply Air cond/heat pump Irrigation Business Farm Test/monitoring Other(specify) Industrial Institutional Standby Drilling Equipment Rotary Cable percussion X Compressed air percussion Other (specify) Well Type Screened Open end casing x Open hole in bedrock Other Casing Details Total length 4Xft. Length below grade 39 ft. Diameter 6 in. Weight per foot 17 lb/ft. Materials: V Steel Plastic Other Joints: _ Welded Threaded Other Seal: _ Cement grout X Bentonite Other Drive shoe: X Yes -No Liner _ Yes No Screen Details Well Yield Test Diameter (in) Slot Size Length(ft) Depth to Screen (ft) Developed? First Yes—No Hours Hours Yield gpm Second _ Bailed _ Pumped __L Compressed Air Depth Data Measure from land surface - static (specify ft) 75 During yield test(ft) 345 Depth of completed well in feet 365 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 2 Fill 2 10 Cl a 10 365 Grey « Black Granite If yield was tested at different depths during drilling, list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type cat h Capacity7 Depth 340 Model 7GS10412 Voltage 230 HP 1hp Tank Type diap. Volumes`' 345 5 Date Well Completed 10/9/02 Putnam County Certification No. 2 Date of Report 10/2.9/02 Well Driller (signature) NOTE: Exact location of well with distances to at least two permanent landmarks to be prov791,16 separate sheet/plan. Well Driller's Name 11i 11 Drilling, Inc. Address: 75 Putnam AVe. , Brewster, NY SignaLe: Date: 1 / 17 / 03 White copy: HD File; Yellow copy -Building Inspector; Pink copy - Owner; Orange copy -Well driller Form WC -97 -2 747 BRUCE R. FOLEY - LORMA"- MOLINARF R.N., M.S.N. Public Health Director y Q� Armelau Public health Director Dlre-eta q( Patient Service DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Eaviroomealsl Health (911):71.6170 fax (914) 271.7931 Nore:al Services (914) 371.6551 WIC (914) 271.6671 .Pic (914) 271.6015 Eadyla- lerMOB6o'(914)111*. 6014 Prucbool (914) 27W12 fax (914)179'.6641 E911 ADDRESS VERIFICA110 FQRRM_ OWNERS NAME: TAX MAP NUMBER: E911 ADDRESS: TOWN: e� AUTHORIZED TOWN OFFICIAL. (Signature) o. DATE: The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed,' i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. (E91 I VERFRIA) X10 JMS ENVIRONMENTAL SERVICES, INC. 15oo SUMMER STREET STAMFORD, CONNECTICUT o6905 NELAC, CT and NY State Certified Environmental Laboratory Mailing Information: Collector's Information: Name: Mill Drilling Co. Client: Folchetti Name: Russ Address: 75 Putnam Ave Address of site: 45 McManus Rd South City: Brewster City: Patterson State: NY Zip: 10509 State: NY Zip: Telephone: Fax: 845 - 279 -5075 Telephone: Sample's Information: Site: tank Date Collected: 2/25/03 Date Received: 2/26/03 Preservative: HNO3 Time Collected: 14:00 Time Received: 11:45 Temperature: <4C Lab No.: J031019 Method Date Analyzed Test Name Result MCL 2/26/03 15:00 Total Coliform Absent Absent SMWW 9222B 2/26/03 Chlorine Free Residual <0.1 mg /L N/A SMWW 4500CIG 2/28/03 Color ND 15 Units SMWW 2120 B 2/28/03 Odor ND 3 TONs SMWW 2150 B 2/28/03 Iron <0.03 mg /L 0.3 mg /L SMWW 3111B 2/28/03 Manganese 0.013 mg /L 0.3 mg /L SMWW 3111 B 2/28/03 Sodium 12.7 mg /L N/A SMWW 3111 B 2/28/03 Chloride 53.0 mg /L 250 mg /L SMWW 4500 CI C 2/28/03 Hardness 178 mg /L N/A SMWW 2340 C 2/28/03 Nitrate 2.37 mg /L 10 mg /L SMWW 4500 NO3E 2/28/03 10:00 Nitrite <0.1 mg /L 1.0 mg /L SMWW 4500 NO3E 2/26/03 pH 7.11 S.U. 6.5 -8.5 S.U. SMWW 4500 H B 2/28/03 Sulfate 21.8 mg /L 250 mg /L SMWW 4500 SO4F 2/28/03 Turbidity. 1.27 NTU 5 NTUs SMWW 2130 B 2/28/03 Lead . <1.0 ug /L 15.ug /L SMWW 3113 B 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 Signature. '�°'�- State #: PH -0218 . Michael Lapman ELAP M 11715 President Tel 203 961 9911 Toll Free 1 866 567 5097 Fax 203 961 9919 jmsenvironmental.com PUTNAM COUNTY DEPARTMENT OF 11.kALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES . GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM Owner or Purchaser ofBii lding . Tax Map I" Block Lot Building Constructed by Town/Village 4's m mNm per : 5 0 ot'At Location - Street Subdivision Name Building Type Subdivision Lot 1 I represent that I am wholly and completely responsible for the location, Workmanship, material, construction and drainage of the sewage treatment system serving the above-described property, and that is has been constructed as shown on the approved plan or approved amehdment 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 gopd operating condition any part of said system constructed by me which fails to operate for 1, period of two years immediate) following the date of approval of the* "Certificate of Construction Compliance" for the Y g PP 1 P 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 th'e building utilizing the system. The undersigned further agrees to accept as conclusive the defetmin-atiol 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 th! building utilizing"the system. Dated: Month Day �-`� Year Si o gn. afore: a,/k7- Title: C��p General Contractor (Owner) - Signature Corporation Name (if corporation) - Corporation N (if corporation) Address: 2r1-� 1- A'�tlLlaa� 045 � -�Jc� Address:. a? State Zip �ZS6r� State Zip) o Form GS -97 M Harpy W. Nichols Jr., RE Patterson Park, Suite 108 2050 Route 22 Brewster, FAY 10509 October 29, 2003 Robert Morris, P.E. Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: Individual SSTS Compliance — Folchetti 45 McManus Road South Maggio Realty - Lot # 10 Town of Patterson, NY T. M. # 21-2 -13 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing 5 -10, "As Built SSTS ", dated 10/27/03. 2. "Certificate of Construction Compliance for Sewage Treatment System ", dated 10/28/03. 3. Three (3) copies of "Guarantee of Subsurface Sewage Treatment System ", dated 10/28//03. 4. Laboratory Report, dated 02/28/03. 5. "Well Completion Report", dated 10/29/02. 6. Application Fee in the amount of $200.00 payable to Putnam County Health Dept. 7. "E-911 Address Verification Form ", dated 09/11/02. If there are any questions concerning the enclosed, please call. Very truly yours, Harry W. Nic is Jr., P.E. HWN:gav 00- 163.00 30" OAK !2 1p 2> ; 8 so1iD 7 J, 8 p O 2g. °krry V C(.ryp) 5 S ,2q Sq Z3 ' 2! z Z \o �9 Zp � I Sad ip p`C � C rx�STiNG RFS /orNCF Room i j i 'f i i WELL Putnl Division Appro,yl applica P 30° OAK 0 A I—Zzl- O _mot (ON ARSA 4 30" OAK !2 1p 2> ; 8 so1iD 7 J, 8 p O 2g. °krry V C(.ryp) 5 S ,2q Sq Z3 ' 2! z Z \o �9 Zp � I Sad ip p`C � C rx�STiNG RFS /orNCF Room i j i 'f i i WELL Putnl Division Appro,yl applica P DIMENSION CHART (in feet) Number A a G 1 50 26 2 52 45 3 66 96 4 62 120 5 58 116 6 54 112 l 50 108 >3 41 105 9 45 101 10 4Z 98 11 41 g5 12 41 93 13 42 91 14 34 136 15 39 140 16 45 193 17 52 141 is '7Z 1 12 19 71 105 20 91 9 1 21 88 82 22 100 69 23 99 64 24 93 61 25 90 58 26 se 54 27 62- 54 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES ////-1/0 3 FINAL SITE INSPECTION Date: to xX 03 Inspected by: Street Location M eMAV06 ZQ4221 Owner —,o4r_hl�-rn Town P A . . � - - Permit # 7 TM# 2.3 — .1L — 13 Subdivision Lot 1. Sewaze Svstem Area a. STS area located as per approved plans ............................ b. Fill section - date of placement 3:1 barrier Lgth. Width Avg.Dpth_ c. Natural soil not stripped .................................................. d. Stone, brush, etc., greater than 15' from STS area.......... e. 100' from water course/wetlands ........................... 11. Sewaze Svstem fi i ikk 1,000 C6,afO ) .... other ..... a. Septic :t%,..jk$1ze 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. 1'renches 1. Length required 5 e o Length installed -S op 2. Distance to watercourse measured v t 0 0 Ft.......... 3. Installed according to plan ........................................ 4. Slope of trench acceptable 1/16,- 1/32"/foot ............. 5. 10 -ft. from property line - 20 ft. r* foundations.......... 6.. Depth of trench <30 inches from surfice .................. 7. Room allowed for expansion, 100% ......................... 8. Size of gravel 3/4 - 11/7" diameter clean .................... 9. Depth of gravel in trench 12" minimum ....... ........... 10. Pipe ends capped ...................................................... g. Pump or DoseNysterns 1. Size of pump chamber ................ ...................... .......... 2. Overflow tank ........... ............. !**"""**"*"*"***"*"***"*** 3. Alarm, visual/audio ..................................................... 4. Pump easily accessible, manhole to grade ................. 5. First box baffled .......................................................... 6. Cycle witnessed by H.D.estimated flow/cycle ........... Ell. House/Builditig a. House located.per'approved plans..... IV. W611 Well located as per approved plans ................................. b. Distance from STS area measured 4.1 oD ' - ft........... c. Casing- 18" above grade ................................................ d. Surface drainage around well acceptable ............ ........... V. Overall Workmanship a. Boxes properly j- -P. b. pipes C. All pipes flushwith uisde -of .... . d. Backfi.11 material contains stones <4" diameter .............. e. Curtain drain & standpipes installed according to plan.. f. Curtain drain outfall -protected & dinto exist watercourse g. Footing drains discharge away from STS area.......~....... 1.- P-rosion controi proviaea .......... ................................. Rev. 12/02 ES 00 COMAWYn 1�7 zoje -V .N4 0000r ak, 1_0 NAVL4 e.1,0 &Z 0 0 rMis 7 e-14 Y 110 ...... rM ;r 911,6 , 1 SITE INSPECTION FOR FILL PAD All Ah -L ep Rc Ax yav 1.7 die- e, �!6N1 �'��d� Date: Inspected by: 7?E_oz) . Fill pad located per the approved plan Y� Fill Pad Length Required Length_ . Fill Pad Width Required Width Fill Pad Depth Val i' e 15 Required Depth 3, p Run -of -Bank Fill Quality a, Slope from Top to Toe . Impervious Layer Installed Erosion"Control Ins talled yr Sieve Test Results (if applicable) n/`!9 Additional Comments: rol , ff yLU lte� os- fank a..-/- 6-- Q ate dw ote Reserved for Field Sketch if A licable �IBvS,e i \ 14:�l q ei ia , r" 'd a.. r LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, -Brewster, New York 10509 Environmental Health (845)278-6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 June 18, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Patterson. New York 12563 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Folchetti McManus Road, (T) Patterson Lot # 10, TM# 21-2 -13 An inspection of the fill pad at the above referenced project has been completed. Comments are offered as follows. 1. It appears the fill pad was not installed according to the approved design. 2. An intermittent stream exists 24 feet from the toe of the fill pad. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at 845 - 27$-6130, ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR: cj % o LORETTA MOLINARI R.N., M.S.N. Acting Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention /Preschool (845) 278 - 6014 Fax (845) 278 - 6648 August 4, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: ROBERT J. BONDI County Executive Re: Folchetti McManus Road, (T) Patterson Lot # 10, TM# 23-2-13 A re- inspection of the fill pad at the above referenced project has been completed. As discussed with you in the field on August 1, 2003, the following comments are offered as agreed upon. 1. Additional fill is required to entertain the required amount of trench. 2. A revised plan must be submitted to this department for review showing the existing location of the fill pad along with the revised trench layout. Please note that field measurements by this Department in no way suggests the exact size, depth and location of the fill pad. If you have any further questions, please contact me at 845- 278 -6130, ext. 2261. Sincerely, Gene D. Reed Environmental Health Engineering Aide GDR: cj SENDING CONFIRMATION DATE AUG-6 -2003 WED 07:43 NAME PUTNAM COUNTY DEPARTMENT OF HEALTH TEL 845 - 278 -7921 PHONE : 92794567 PAGES : 1�1 START TIME : AUG-06 07:42 ELAPSED TIME : 00'42" MODE : G3 RESULTS : OK FIRST PAGE OF RECENT DOCUMENT TRANSMITTED... a LORSTTA MOIXARI RN., MS.N. ROBERT 1. BONDI Acdna P044 Ned h Dow— IV CapN her f. Dtmcr6r qr Padur 9—ka DEPARTMENT OF HEALTH I Oe=Va Road, Brewster, Now York 10509 B.nvlroa —w Bna9 (845) 279 - 6130 1- (94S) 278 - 7921 pprslaa atrAm (843)278 -6359 WIC (845) 279 - 6678 Fsa(545)278 -6095 Early Int—anded —pool (945) 278.6014 For (845) 270 . M48 August 4, 2003 Harry Nichols, PH Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Re: Folchctti ' McManus Road, (T) Patterson Lot N 10, UAN 23 -2-13 Dear Mr. Nichols: A re- inspection of the fill pad at the above referenced project has been completed. As i discussed with you in the field on August 1, 2003, the following comments are offered as agreed upon. i 1. Additional fill is requited to entertain the requited &mourn of trench 2. A revised plan must be submitted to this department for review showing the mdatiag location of the fill pad along with the revised trench layout. Please note that field measurements by this Department in no way suggests the Exact size, depth and location of the fill pad. If you have any further questions, please contact me at 845 - 278-6130, W. 2261. Sincerely, . 0, «�C rim D. Reed Environmental Health Engineering Aide 13DRcj OCT -21 -2003 09:18 AM HARRY W NICHOLS 914 279 4567 P.01 i �UTNAX COUNTY DEPARTMENT OF HEALTH DIVISION w EN iRoNMENTAL 11 MTH SERVICES RF,OLTFGT�dR1~YY�F�►�o1N�ip:�ll For:, Fill _ Date: Oaf. ZO �d� Trenches • �.�., . ,. PCHD Construction Permit Located: 45 HOIA40S WA)► S (T) M off 622 Owner/Applicant Name: QNC-M& m. $o1.e Za_ Block . .Prot _13— Formerly: Subdivision Name: VIA4410 S'ZswL°6'� Subdivision Lot # W Is'systerd "fill completed ?" Date: - 15 -system complete? 2" Date: ®cs. 80 f e s Is ;;• system constructed as per plans? , Is well drilled? 194 bate: QE,j 103 .Is well located as per plans? , , ,,: „ ,,,, ILI Are erosion control measures in place? �� • -- - I certify that the system(s), as listed, at the above premises has been constructed and I have inspected and verified their completion in accordance with the issued PCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of Health, Daie: _ o Certified by: PE ✓ RA Design Mfossional Address:' 20SQ • 943�6f_ z2 Sits +G� 10 y to5q Lic. # 6t 2 Comments: FOR: 0 ADAM 19 GM 11 (NA E) Form Flit -99 nrT- al -PA03 THE 09:35 TEL:845 -278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 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 October.23, 2003 Harry Nichols, PE Patterson Park, Suite 106 2050 Route 22 Brewster, New York 10509 Dear Mr. Nichols: cv" ROBERT J. BONDI County Executive Re: Field Inspection — Folchetti McManus Road, (T) Patterson TM# 21-2 -13, Lot # 10 The above referenced separate sewage treatment system can be backfilled. The following comments must be corrected in the field: 1. Expose plastic pipe from the septic tank to the cast iron pipe. 2. A bedroom count must be performed by this Department. 3. A re- inspection of the septic line from the septic tank to the system is required by this Department upon completion of backfilling. 4. Erosion control measures must be properly installed below the well and house construction area. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. Very truly yours, A94--4 v Gene D. Reed Environmental Health Engineering Aide GDR: cj 0 .T ®® TNA�e'/1 e es� p� w T z • 4 3 r 1 Geneva, Road , .,: (645) 278-6130 Brewster, NY 10509 9 a a /aagate Received_ of The Sum Of `' Dollars. $ ! J ,. (v nor i- lAlUdC YOUR . , ❑Cash ❑Check.O' ❑ Credit Card By 4 0 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMIT FORS JOATMENT SYSTEM PERMIT # -4 2-- 9 � Date Subdivision Approved ll -'7 -� j Renewal Revision X 1 16�d Owner /Applicant Name �/Ui ! u�,., �t-� �;� �� [t_ Date of Previous Approval ;1---j-0Z. Mailing Address /44 V 1 r, , � `�„so�, y �, Zip / 3 Amount of Fee Enclosed 15 d Building Type z Lot Area 3,ii� -5—No. of Bedrooms ` Design Flow GPD� Located at �� / /Ujp�/�ccNUi o own or village � ������� Subdivision name £ £c . .,, S Subd. Lot # j0 T Tax Map �3 B Block �- Lot � J Other Requirements: To be constructed by 'T`, 6 ; l) Signed: Address WHEN FILL IS COMPLETED Separate Sewerage System to "consist of 1 ?- 5°7J gallon septic tank an Address Water Supply:. Public Supply From or: —iL Private Supply Drilled by '7- 13 J) ereto. d Address " R.A. Date q- 3 -63- License # ��1 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 tem 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 th 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 considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit) App ved for di charge of domestic sanitary sewage ly. By: Title: Date: % 1v White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Oran ge copy - Design 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. September 3, 2003 Robert Morris, P.E. Senior Public Health Engineer Putnam County Health Department One Geneva Road Brewster, New York 10509 Re: . Individual SSTS Revision / Trench Permit - William Folchetti Maggio Realty Subdivision - Lot # 8 45 McManus Road South Patterson, NY T.M. # 23 -2 -13 S.W. 19 -01 Dear Mr. Morris: The fill for the SSTS has been placed and inspected. The layout was modified somewhat, and in that regard we are enclosing the following: 1. Five (5) prints of Drawing SS -10, "ProposedSSTS ", revised 09/02/03 2. "Construction Permit ", revised 08/26/03. 3. Letter of Authorization. 4. "Design Data Sheet ", dated 09/02/03. 5. Money Order in the amount of $150.00. Kindly process the enclosed at your earliest convenience and issue the necessary Trench Permit. Very trul yours, Harry W. Nic s Jr., P.E. HWN:gav 00- 163.00 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH -SERVICES_-" >' LETTER OF AUTHORIZATION RE: Property of c a i z Pdlc e_79� Located at Ac, fa U T/V Tax Map # Z3 Block 2- _Lot g Subdivision of &Cia,4 Subdivision Lot # Filed Map # ; v 1.1 Date Filed. Gentlemen: This letter is to authorized a duly licensed Professional Engine j,,f_ or Registered Architect to ply for the required -Ap :1...4.•r .,.......:,. wastewater treatment and/or water supply permit(s) to serve the above-noted in accordance with the standards, rules or regulations as promulgated by the Public Health Director of:tlie Wam ;. 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. t P.E., R.A., # Mailing Address a-o j State Zip IOSa Telephone: 2-7c 7 o j Very truly yours, Signed: (Owner of Property) Mailing Address: State /y Zip Telephone: 7 S Form LA -97 � V W w Q Q 1. I 1 11 1 •11 \\ � 1\ \ "gam\ i c i 1 I I � ).iyaroau --Jo ,-az NIKUM rte- s.► SOS :P 971sm ON OW ima►LL� W 0 R� 41• V 1�p o- 1. 2 l i rU� � O I ► � Z / �V 4L,) 2 I. z Q Z 2�a ve PUTNAM.-COVNr Ty. .DEPARTMENT OF-HEALTH DIVISIONPF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET SUBSURFACE SEWAGE TREATMENT SYSTEM C c/� Address'd-?�g Owner*: 1b, t 0 l a,,= Located at (Street) -4-5-- - tax Map ..x3_ Block 2 Ldt'--' -,q-- indicate nearest cross street) Municipality. Watershed SOIL PERCOLATION TEST DATA Date of Pre-soaking iq -6:3 Date of Percolation Test NOTES: 1. Te6ts'td W repeated at same dep -5 )2- e, 12- 9 :3 j12- :3 approximately equal peredlation rates are obtained at each percolatio'n test hole. (iwe;:5 I min for 1-30 min/ihch, 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 _A�1 _d_I �0�1 �0�1 �0�1 �0 -1 �0�1 ■1 A NOTES: 1. Te6ts'td W repeated at same dep -5 )2- e, 12- 9 :3 j12- :3 approximately equal peredlation rates are obtained at each percolatio'n test hole. (iwe;:5 I min for 1-30 min/ihch, 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. 1 8.0' 8.5' 9.0' 9.5' 10.0' TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED .IN TEST HOLES. HOLE NO. HOLE NO. HOLE NO. . f Indicate level at which` groundwatef -is encountered — Indicate level at which: mottling is observed Indicate level to which water. level rises after being.encountered Deep hole observations made by: Date. Design Professional Name: ° r Address: / 1js�,.- Design Professional's Seal 08:15 AM HARRY W NICHOLS 914 279 4567 PTAWAX C0VNTYDZ?ART=n 01 MAL= DMON 01 ZNVMQMUMAL SCALTZ UIMCZ$ ArrENTLON OAX O-GENE Fan.. rdl J� All lArMAdW mint 'bs wyampletl4pdartgay bupbc4oas bow =do. PCHD CowwcdoA pgrWt 0 P 0WacjjAppU=tNL Bloa Lot -mummumpa-mm subdivisica Ngmc AA4.q i $vb"gaaLot Yr-e #' W Is sylt= a complolod?, 'Ala- Ifalo.. - a U 3yiem gomoloal "" Dale; h "a% camwoud U Pff Plug AIJA Is w1a dald? , - * A10 , Datoi Is weg tmtw U per plans? ARA Axe 0310.2 00=01 042=0 in Am? yzd I As AaA &t the "Ve primiw hu b6ca con macd &W I im ln*oc%gd end YcrWed their comploUca In accordwe with the issued PCHD COWWWOO PsnUit 04 app; ov . t d pitus and the Stgdudi, Rules and Regulations of the•Putam County NpWmcat of 000, ..A-4'4 A. wsd -by: ya con E- ✓L` FLA Comm#" 1 —14 00 md- Fona M-99 NICK:! P1 ITWOM f WTV Mr:0nm-rmr-kvr nr P.01 Indicate level at which groundwater is encountered - -- :ik-1®„z - - - Indicate level at which. mottling is observed _ _ �l/n.o✓ _ _ .... Indicate level to which water level rises after being encountered Deep hole observations made by: 4 2Z Eon p, G. N . Date_ Design Professional Name: Address: Signature: Design Professional's Seal �r /,yea r'3 to be a vi In�f°el'MitFeHf :`if {eat TEST PIT DATA 2 DESCRIPTION OF SOILS ENCOUNTERED Ili TEST BOLES DEPTH HOLE NO. HOLE NO. Q, HOLE NO. G.L. 0 Y, � /...... :. 0.5' 1.0' ' 1.5' tie S 'IVr - 2.0' 2.5' ; 3.0' 3.5' 4.0' 4.5' 64Zvc-- - - - -- _....._..: . 5.0 51 6.0' 6.5' 7.5' 8.5'.__.- _._... - -- _.... - -------------------------- - - - - -- - -- --- ............. ._............ _..... -- . _.._.... 9.0' 9.5' 10.0' Indicate level at which groundwater is encountered - -- :ik-1®„z - - - Indicate level at which. mottling is observed _ _ �l/n.o✓ _ _ .... Indicate level to which water level rises after being encountered Deep hole observations made by: 4 2Z Eon p, G. N . Date_ Design Professional Name: Address: Signature: Design Professional's Seal �r /,yea r'3 to be a vi In�f°el'MitFeHf :`if {eat PUTNAM COUNTY DEPARTMENT OF HEALTH 'DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner GdNA14r 3�iV G,�OFT' Address P2 mil• f Located at (Street) Ate, /1 ,4AI (/s E0,4D Tax Map 73 Block 3 Lot 2¢ (indicate nearest cross street) Municipality. pgT'TE,��d� Drainage Basin G'OTD /V SOIL PERCOLATION TEST DATA Date of Pre - soaking - z 7- % Date of Percolation_ Test 4- -,�? 7- 8.7 Hole No. Run No. Time Start - Stop Ela se Time �1VIin.) Depth to Water From Ground Surface (Inches) Start Stop Water Level Dropp In Inches Percolation Rate Min/Inch 2-7 3 7 ! .2. 3•' 04 3.`2¢ 2"7 3 7 3 9 :25 -3;4-S 27 3 4 5 -4 2 7 7 Z 2 3 : 33 :23 174 z 7 -3 8 3 24 27 3 4 . 5 1 2 3 4 5, NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtainea 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. Form DD -97 2 t TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE NO. HOLE NO. HOLE NO.. It 0.5' TOPSO iG 1.0' 1.5' 2.0' 25 S/LTY. G014M 3.0' 3.5' 4.0' 4:5 ,eocK 5.0' 5.5' 6.0' 6.5' 7.0' 7.5•._ m 8.0' a, 8.5' 9.0' 9.5' ca c,z c 10.0' C -f GC Indicate level at which groundwater is encountered 4P 0 VF1� Indicate level at which mottling is..observed Indicate level to which water level rises after being encountered Deep hole observations made by: AEI/ /tJUSL)' 4PP�DVED Date Design Professional Name: L,44N, 7 T,!�itIOINe�- / ssoG Address: MILLSg OOKC (IFFiGE GENTLE B96V467-F-)Q N.Y. 1050J Signature: Design Professional's Seal NEW � totiR r- th s'?�`' PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMEN'fAL HEALTH SERVICES INITIAL INDIVIDUAL /COMMERCIAL SITE INSPECTION FORM SECTION A. GENERAL INFORMATION z Name of Project 8,&�vc�eo r (T)(V) ?s1TT0T15 ©.y County Pcl zy A't Site Location N,,- g,¢�1Z � 5 ?Zak Building construction begun _ Ald Extent Is property within NYC Watershed ? ................. Yes No SECTION B. TOPOGRAPHY (Please check all appropria bones) 1. F Hilly Rolling �teep slope Gentle slope F Flat 2. Evidence of wetlands F--J Low area subject to flooding El Bodies of water Drainage ditches a Rock outcrops 3. Property lines or comers evident ....................... ............................... Yes E11NO 4. Do water courses exist on or adjoin the property? ......5 7-9.644 .... Yes F--J No 5. Will these affect the design of the sewage system facilities ?............ Yes F--J No 6. Do watershed regulations apply in this development ? ....................... Yes No 7 Will extensive grading be necessary? ................. ............................... �Y s No 8. Will extensive fill be necessary for SSTS? ......... ..............................: Yes 0 No 9. Do filled areas exist within the SSTS area? ........ ............................... Yes ��`No If yes, what is the condition of the fill? SECTION C. SOIL OBSE . ATION 10. Appearance of soil: Sand Gravel . � Loam ,. Clay 0 Hardpan F Mixture 11. Observed from: 0 Borings F--J Bank cut �Backhoe excavations 12. Soil borings /excavations observed by 4 !2 cE-v �, �, H on / D 13. Depth to groundwater on 14. Depth to mottling Al ®,1 a on / 3 f o 15. Are test holes representative of primary & reserve areas ...... ............................... Ef'yes 0 No 16. Soil percolation tests made by 17. Soil percolation tests witnessed by SECTION D (on back) on on Form ST -1 2 SECTION D. DRAINAGE 18. Will proposed grading materially alter the natural drainage in this or adjacent areas? U ' , s a No 19. Will groundwater or surface drainage require special consideration? ..................... Yes F-I No 20. Will gullies, ditches, etc., be filled and watercourses be relocated ? ......................... a Yes r2jrNo SECTION E. REMARKS 21. • If a common water supply is proposed, has an inspection been made of the existing or proposed source and facilities? ................................ ............................... Yes No Inspection data 22. Do adjacent wells and/or sewage systems exist? ...................... ............................... Yes F--J No 23. Additional comments ago ,r- *-F, G7z6?'W Hole # Lot # 24. Site observer /inspector and title 4&Al 72, 'Rrc,p 4- -P, e-, f% 25. Date(s) of observation(s)inspection(s) 1 /p / - -- - - - TEST PIT PROFILES Hole # Lot # Hole # Lot # Hole # Lot # Depth to water Depth to water Depth to water Depth to mottling Depth to mottling Depth to mottling Depth to rock/imp. Depth to rock/imp. Depth to rock/imp. G.L. G.L. G.L. a 0.5 0.5 0.5 1.0 1.0 1.0 2.0 2.0 2.0 3.0 3.0 3.0 4.0 4.0 4.0 5.0 5.0 5.0 6.0 6.0 6.0 7.0 7.0 7.0 8.0 8.0 8.0 9.0 9.0 9.0 10.0 10.0 10.0 APR -09 -2001 01:24 PM HARRY W NICHOLS BRUCE X FOLBY publk Mega OLraw 914 279 4567 P.02 0;2.' LONMA MOLD" ILK, M.S.N. ,woe(a. Pvblk Nsa*h D&ww AVW or MW &"ka . DEPARTMENT OF HEALTH I 0sova Road Bnwater, New York 10308 ATTENTIOX: o ADAM STIEBELIr ;G ?)44-ENE REED All information below must be &4 completed prior to any scheduling. DATE: -1-cl-Ot ENG C�wi�ILt�ls►. k�tEER OR FIIi1b1; r � PHONE* -709 -400 3 REASON: DEEPS: PERCS: o P[tMP TEST: o ROAD/STREET: TOWN: A, i.� N. .. '' TAX MAP0: SUBDIVISION: —" LOT#.- OWNER: i ___tom= "•�yf�`r"f' .,�..__.__._� ..�.�.� NYCDEP C F- IA FOA JO11Y1'$EMEW AND mnimisr. bF son, TEXEIN YES NO o U Proposed SSTS within the drainage basin of West Branch or B.oyds Corner Reservoirs. . 8 Proposed. SSTS within SM feet of a reservoir, reservoir star or-control lake. G 711 Proposed SSTS within 200 feet of A watercourse or a DEC wetland. o Id Proposed SSTS design flow greater than 1000 galions/day or SPDES Permit required Proposed SSTS for a Commerical Project. It Is the responsibility of the design professional to provide the above Information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Ddegated) based on the response. If you answeredyri to any of the questions, NYCDEP trust witness the soil testing. This Department will coordinate a mutually suitable time for Geld testing with the PCDOH, the Design Professional and NYCDEP: If a project has been determined to be Delegated based on the above response and then subsequent information indicates NYCDEP Is rtquirtd to witness the soil testing, it will be the sole responsibility of the design profeulonal.to schedule re- witnessing of the soil testing with NYCDEP. FOR Couttt'Y lust ony m.1L1tEhLt= - ' Lake 9 or Ivill t \� / I L B Aq Yale Corner Pe e Ter S.C. F ES ESO Lake owe t\ ao roe Town 77- id a Car Dean Pond 12531, M a 48 Ipt mers 84 IV i - - V11 48 NX 44 Le 52 ftD Raymond H111 a C m eman el 60 Palk IL I" Ps C A A HS 41 s County Courthouse County ce Building 57 312 IX I Ludington onument 6 O j 162 AC „,y !00(51 465.45 -' 30 q zMs... AGasm 454.-4612 t X3.40 —�— 61.53 AC. .O2 - - -P/0 _ .,� j1•�•6] _ AC. A2 ICT INFORMATION i TRAL SCHOOL DISTRICT -•- 572002 STATE LINE 0I5PUIFD AAIAS`'- NRAL sDM DISTRICT ••.373001 COUIM LINE —_ CONTINUOUS 22 TOWN LINE - -- VILLAGE LINE ROAD a0.r.:' ti {c SmEAM/M'AI[RR :TION DISTRICT No. 1 -- — —� BLOC( LIMIT -. — — SPECIAL 0 5ISIQ.. PROPEIM LINE so" 011RI10 _ DR)61_NAL LOT LINE PART Of /IJILE 23.10 xt �1 15i►. \ 4 26 88.46 AC. 925 e 17.59 AC. ... ;6 3. I At GAL 456151 , 104.47 K 24 N 1610 At CAL. 29.80 AC. N - - Z1 N I 551.23 23 6.36'. �.. g 21 K. 22 9 s 1.40 H 2.69 At bN 12U AHII 32.68 AC M ii At CAL. ` 2.96 ACS I - $ e ` le k °�. I 29 16 1.54 A n I � 3.02 A' 17 . "`23 AC. - 15 3.160 AC, aa�r+ / •�. O j 162 AC „,y !00(51 465.45 -' 30 q zMs... AGasm 454.-4612 t X3.40 —�— 61.53 AC. .O2 - - -P/0 _ .,� j1•�•6] _ AC. A2 ICT INFORMATION i TRAL SCHOOL DISTRICT -•- 572002 STATE LINE 0I5PUIFD AAIAS`'- NRAL sDM DISTRICT ••.373001 COUIM LINE —_ CONTINUOUS 22 TOWN LINE - -- VILLAGE LINE ROAD a0.r.:' ti {c SmEAM/M'AI[RR :TION DISTRICT No. 1 -- — —� BLOC( LIMIT -. — — SPECIAL 0 5ISIQ.. PROPEIM LINE so" 011RI10 _ DR)61_NAL LOT LINE PART Of /IJILE 23.11 !1 / \ r 36 " z3s. g 32.98 AC. LEGEND 12 13 '$MPAR pq P`6DqP .•......•..••.. Mr AJ1 4 "1"4 "Me kill -- -_ —.�. aft the —F 40 me.." --S WETLANDS LINE AND MIX L.-� DEVELOPEAS LOT MASER J DEED DIMENSION Imw SCALED DIMENSION 100151 CALCULATM AREA E34 At CAL VISUAL colmolo 22 33 34 -- — —� PAIICEL MAA9ER 72 DEC -19 -2000 11:32 AM HARRY W NICHOLS 914 279 4567 P.03 «.v BRUCE IL FOLEY Public Koalth Otreetor DEPARTNMW OF MALTH 1 Geneva Road ' Bmweter, Now York 10S09 LORBI I'A MOLINARI L N,, M.S.N. A,faectare Public Keettk Dkwor �lldst®r �% ��tl�Rl svVi6er ATTENTION: ® ADAM STIEBELIitiG " GENE REED All information below roust be IkU completed prior to any scheduling. DATE: OD ENGIYEER ORFIRid : ���� Vd , k`r ,, �� PHONE 0: REASON: DEEPS: PERCS: Pll O TEST: 0 ROADISTREET: M(- M At H V45 P-09 9 t0o Or 4 SUBDIVISION: LOTO:. 10 OWNER: CoNNti� MGP -o�'T YES NO ® Proposed SSTS within the drainage basin of West Branch or 8.9yds Corner Reservoirs. C) j Proposed SETS within 500 feet of a reservoir, reservoir stem or control take. 0 Proposed SETS within 200 feet of a watercourse or a DEC wetland. _t? Proposed SSTS design flow greater than 1000 galions/day -or SPDES .Permit required. o Proposed SSTS for a Commerical Project. It Is the responsibility of the design professional to provide the above information prior to soil testing. This Department will determine the NYCDEP project status (Joint or Delegated) based on the response. If you answered yA to any of the questions, NYCDEP must witness the soil testing. This Department will coordinate a mutually suitable time for field testing with the PCDOK, the Design Professional and NYCDEP. If a project has been determined to be Delegated based on the above response end then subsequent information indicates NYCDEP Is required to witness the soil testing, it will be the sole responsibility of the design professional.to schedule re- witnessing of the soil testing with NYCDEP. FOR COUNTY USE Ony DATE: /ii �% i -- TDIE: _ e 1111RiTg: (FMLDTEST) Be : e . Terr 311 _ -ES - - - -- -- - - -- - - - -- - - - -- ESO 'Q+ i 84 T_'- I Kentwood - ub -- -- -- - -- - -- -- - -- -- - - - -- -8 - - - -- 1 -I - - -- - -- -- - - — ' - � - - - - - -� - -- - - -- - ti - axau --- --- -- -- - - -- -� _..- ---- -- _— _�r.L- - -p p =g- — -- --- - -= - -- - _ -_ - - - - =f - iru _._ ,«us , o• u .__... .- _._. __ - -. ` �._ ... .- - - - -- -Town - -: - - - - -- -- -- - - -- --- -- - s� J - - � i _ a W1 l i o - Carte - - - 1.—i r ' - a e - p - - —° — — — -- -- - -- — —T . - -- - -- - - - -- - - - - -- _ , �s_ -- —Fe' Dead` - - - - - -- - -- - -- - - -- - - - -- Pond =/ - -— - - - - -- - - - -- - -- - - - -- - - -- L y u a ion g 1� - 1 me _ E4 .0 - - - - - -.. -- -- 51 - - - - - - -- - -- _....- .. Raymond Hill S - -• - - - - -- - - - - ��.. ;; ^ - - - -r cam — - - - -- .. - -- — - - -- - - -- - - -- eman -- r�- -mus -- I- - - - - -- •CARMEL HS r NV � County Courthouse ��Q County ONke Bullding I - - r�" ems'« A r; bil Ludington onumam - v 1: -- - _.._ . __...:. 1- - - - -- - - _ - J -a Glenetda = s 1 rnxx, 5�. Til Im Fo PUG78rn :.r-`r ;kb u����G's :! - pD rr ; ,: r r Tree ■ _. a« a 1 t < Br -Wst q el ' hts' S ` 3 Carm A a up u Hill 7 10.87 AC. CAL. C3 . 5 1 2.78 AC. CAL. 4.18 AC. 1.13 At 463.T5 84 I 2IL16 7= 13ta $ 23 to 4 — -- ----- 1.40 A e2 69 C 59.61 AC cc L-111- '5003 AC 20 - - .4 -M K- k Ole . ...... ..... 6 A I 'I — 1 1- 5 e 5, 29 SIM/ 16 1 . .54 A 9 'll AC. X-1 3. 02' A &as a 88.71 AC OF 15 J!, ✓ 46 3.60 ACS 1 4 o 3 4 All. IS. • AC- w • , • 3WS) Al 10. 00 AC. v Las A 3.73 AC.'sioLd 4W4612 V 4 Af * 0 34-3-415L 1.53 A 3.0 AC — — ---- — — — — — — — Oz REVISIONS SPECIAL DISTRICT INFORMATION. a "...0431A Lor UW cKhmm 3/f/m wa SC OM -Sol- CARVEL, cam SCHOOL DISTRICT -- ofl2002 STATE LINE 013P m AWA MSTER CENTRAL-SCHOOL DISTRICT - -- 373001 COM LINE TOWN LINE ROAD ILOX FIRE -F- FIRE PROTECTION DISTRICT NO. I VILLACE LINE STREAM/Ill At M/I/"VW OM LIMIT SPECIAL DISTRI, MA flopme IM, is w PROPM LINE scNiCcioR10 W-24W*L1V"4ft%L-3,-t/ff NW DRICINX LOT LINE PART OF PARCD 1111, PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Located at (Street) ale KAAhj Qs &QAC2 Tax Map 23 . Block 3 Lot (indicate nearest cross street) Municipality P, =eg,Sp 14 Drainage Basin CgoTo1 A SOIL PERCOLATION TEST DATA Date of Pre - soaking 7 -13 Ae Date of Percolation Test 7- t �9 De th to Water Water 9-&-L- Hole No. Run No. Time Start - Stop Ela se Time Min.) Nth Ground Surface (Inches) Start Stop Level Drop In Indies Percolation Rate 1Vlin/Inch I 1 10:3 2 14 2 240 �J t 2 4 5 3 2 23 2 3 2 2 - t: 23 23 2- 2 3 I: - 12 :v 2 2 23 3 �• 4 Y 5 1 2 �E i' l0 S I G —SS>✓ 3 4 5 NOTES: 1. Tests to be repeated,,q sap (� pt .,ya fi approximately equal percolation rates are obtained at each percolation test hole i' si m h�fo i P- homin/inch, s 2 min for 31 -60 min inch) All data to be submitted for review. :'�i ,':� 2. Depth measurements to ;lid ;iph a,ljr.,Qn it of hole. �.aJFSI_�J.�CJ 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. Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate. level to.which water level rises after being encountered Deep hole observations made by: Date Design Professional Name: Address: Wiz,! 111 LIZQ IN N oAj2 1, c>0 IM 15 Signature: Design Professional's Seal (NF New N►CHp�s LO 1 Yisb 41 \� No. 56124 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES y DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner �1t-1-1'a`M CLAG�4E1 -L� �ot,Uk�'1T) Address RMt' 60141 W, I °L%ro Located at (Street) P-cPIQ Tax Map 1-3 Block 2 Lot (indicate nearest cross street) Municipality FAN fi 41-�H Drainage Basin SOIL PERCOLATION TEST DATA Date of Pre - soaking 110MB Date of Percolation Test Hole No. Run No. Time Start - Stop Ela se Time (�Iin.) De th to `Pater _, )from Ground '= Surface (Inches) Start Stop Water Level Drop In Inches Percolation Rate Min/Inch 100- 101' 2 1 a 3 4 10 ��, -1 4d GO I s ► i °� - i 1 �3 i� �� 26 . 4, 66 i 1 2 ����' - IpLA� tii 2� 26 1 3 I© °- ill 1A 4 5 1 2 3 4 5 _ IYUTEJ: 1. Tests to_be repeated at same deptn until approximately equal percoianon ratcs arc uutauicu at percolatim 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 Design Professlouai's Seat x ua uj ©P ESS11)VI TEST PIT DATA- N TE DESCRYPTYQN Q.F' D Y ; .;:.' HOLE Qn! ENCOVW$.RE NO �- c PTN i0e ;,I' � �. HOLE . HOLE N0. .HOLE LOW rn .. �,', .. ., .,� ��^�•'��1 -lam" 6 01 i ... y 0' 0.0 :nd'cate level at which groundwator Is encountered �4 indicate level at which mottling Is observed M046- !ndicate level (o which. water lovel fleas after being encountered � Deep- hole obsevatlans-made by;• C eN E . lZF0 .... . _" Data Design Profcssional_N.atne,.. (�- a..w :... ; �i �..L� ... _ .Address.: — - of NEW r MICilo Signature Design Professlouai's Seat x ua uj ©P ESS11)VI � m PUTNAM COUNTY DEPARTMENT OF HEAL'T'H DIVISION OF ENVIRONMENTAL HEALTH SERVICES CONSTRUCTION PERMI FOR SEWAGE TREATMENT SYSTEM PERMIT # Located at H5 h'IC-0A 4U6 P-0-6'0 Town or Village pPTrt aDH Subdivision name MA6610 R ALii Subd. Lot # 10 Tax Map 23 Block 2- Lot i3 Date Subdivision Approved i I -1 " 8 Renewal Revision �( NA Gf Owner /Applicant Name \WLWi,M � PCI}P+� RLCREITI Date of Previous Approval ("J o l o l Mailing Address RN -J I "MAD Wyk PATitWH) NY Zip 1U0 00 Amount of Fee Enclosed I o Building Type 4 51 XHQ- Lot Area �'��� No. of Bedrooms 4 Design Flow GPD 800 Fill Section Only 'A Depth 45 Volume 660 Li PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of I'� gallon septic tank and Other Requirements: To be constructed by T B V' Water Supg -ly Public Supply From Address Address or: Private Supply Drilled by T Address . "J. represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment sy,,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 Cons ruction Compliance of the original system or any repairs thereto. /C/ Signed: L I- I P.E. R.A. Date Address �—Q 6 �-� � ��► tis ��- Ali i p � 4 q License # 5 611, APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new pe .' it iroved f discharge of domestic sanitary sewage only. By: Title: Date: �-- 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 # I �� �� Well Location: Street Address: TownNillage Tax Grid # q5 Hq-iA Wu5 R-00 6. FAM5 5014 Map 23 Block E Lots) I Well Owner: Name: V444Wt PLWaI6 Vot.(,HlA Address: ZM � *XtKUO Di -NE PHTT�00 a tie 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 5k gpm # People Served 4 - (o Est. of Daily Usage $oo gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling x New Supply (new dwelling) Deepen Existing Well Detailed Reason for Drilling Well Type SC Drilled Driven Gravel Other Is well site subject to flooding? ................................................. ............................... Yes No Is well located in a realty subdivision? ...................................... ............................... Yes A No Name of subdivision HA 6 & o RE N,11� Lot No. l o Water Well Contractor: i6D Address: - Is Public Water Supply available to site? .................................. ............................... Yes No >( Name of Public Water Supply: '— Town/Village — Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separ a sheet/plan. Date: �-� �'�-� Applicant Signature: Lo-, `w 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 water we l..driller certified by Putnam County. Date of Issue 2,1 , 1 Permit Issuing vial: Date of Expiration I = , Title: Permit is Non-Transferrable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form; WP -97 K �w�yi f DINING ROOM a� 122" X 1311 11 GO FAMILY ROOM 19'4" X 13'1 " GOPNLA LIVING ROOM ....STUDY a FOYER 13'9" X 1311 11 17 3 w X 1 JNAm COUNTY DT2Wfl)*6W OF HE HOB MANS APPRQVED FOR PE OM COUNT ONLY, =.T ONS TO THESE HOUSE iNs Aft} AA ' OH FOR APPROVAL ' - �DATF. . BATH #2 BEDROOM #4 � N .0 �rn 13'40 x 9�9' ft X � 129V X 9'9' O c, .O X 1 , BEDROOM #1 17'3" X 16' 8" .. 1 I OPEN TO FOYER Qo 1 I m 1 1 a BEDROOM #2 13'9" X 132" PUTNAM COUNTY DEPARTMENT OF HEALTH . . DIVISION OF ENVIRONMENTAL HEALTH. SERVICES. LETTER OF AUTHORIZATION RE: Property of _ �i�1M j?Attlr�l Foi.�+l-C -1fil Located at �s MLMI tJ�)' Rc 5nJfN' T/V Tax Map # Block �— Lot Subdivision of M�CIL�O�L` 1 Subdivision Lot # Fil'ed Map # 10h Date Filed 0.Mj_/ Al Gentlemen: -Fri is letter -is to authorize W W, 0 (Lf+0L i + jt— f 15 a duly licensed Professional Engineer N or Registered Architect to apply for the required ,wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance �,Y!Lr, the standards, rules or regulations as promulgated by the Public Health Director of the Putnai;, County Health Department, and to sign all necessary papers on my behalf in connection `� ith thi; maner and to supervise the construction of said wastewater tretment and/or water supply systems is conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Healti, _aw, and the Putnam County Sanitary Code. F NEW D%9 ��.NICII Very truly yours, �' •„ Countersigned: ~* x� p Signed: LU P. E., R. A., # (Owner of Properly) No.56124 Mailing Address o P Mailing Address: 1/0: e /v ✓S O� State Zip State /VV l` Zip 25', 2 Telephone: �� ��" 2� �� ®� Telephone: _ i�L/ S -2-7 Form L-N -9, Harry W. Nichols Jr., P.E. Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 ZZ Telephone (845) 2794003 Fax (845) 279 -4567 February 4, 2002 Robert Morns, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 RE: Proposed SSTS: Name Change William & Rachelle Folchetti (Formerly Connie Bancroft, P- 42 -87) Maggio Subdivision, Lot #10 Town of Patterson, TM #23. -2 -13 Dear Robert: Enclosed are the following: 1. Four (4) prints of Drawing SF -10, "Proposed SSTS," dated 2 -4 -02. 2. Two (2) prints of SS -10, dated 2 -4 -02. 3. "Short EAF," dated 2 -4 -02. 4. "Application for Approval of Plans for a Wastewater Disposal System." 5. "Construction Permit for Sewage Disposal System," dated 2 -4 -02. 6. "Application to Construct a Water Well," dated 2 -4 -02. 7. . "Design Data Sheet." 8. "Letter of Authorization." 9. Two (2) copies of Residence Floor Plans, for Bedroom Count Only." 10. Review Fee in the amount of $150.00. Very truly yours, 0�� Harry W. Achols Jr., P.E. HWN:JM:his 00- 163.00feb PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION, OFs ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM'', ' 1. Name and address of applicant: ��Lr—��`M P-AC k F—IA—1 1�:-o 22� I+Aw ILANQ p�LN 2. Name of project: 1-�O"r `10 5TS 3. Location TN!.,. 4: Design Professional: SAW-► W ` N�CNoLS, gip- Q6 5. Address: _.9_0S0 22 6. Drainage Basin:` �� N 1��u5► M `oSo9 7. Tune,_, 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 I xem Type Status ( check one .... .... Et ......................... " Type II.... `Unlisted X 9. Is a.Draft Environmental Impact Statement (DEIS) required? ......................... 140 10. Has'DEIS been completed and found acceptable by Lead Agency? .........,..... ; ; ``►% 11: Name of Lead Agency N A 12 Is this protect in an area under the control of local planning, zoning, or other officials; ordinances? ....:.:.. :..:.. YES _ ...... ........ 13. If so, have plans been submitted to such authorities? ........ ............................... -IyQ 14. Has preliminary, approval been granted by such authorities? N A Date granted: ti' a "'`: 15. Type of Sewage Treatment System Discharge ................. surface water X groundwater 16.. If surface water dischar e; what is the stream class designation? ...................: N /� g 1� 17. Water's index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? N0: 19. If yes, name „of water supply ' 1,4 N' Distance to water: supply:.:.'`' A 20. Is project site near:a public sewage collection or treatment system? ................. N'p'' 21. Name of sewage systems Distance to sewage system NA 22. Date test holes observed 23. Name of Health Inspector 8.op 24. Project design flow (gallons per day) ................................... ............................... 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?... 4`► p 26. Has SPDES Application been submitted to local DEC office? ......................... N A Form PC -97 2 27. Is any portion of this project located within a designated Town or State wetland? No 28. Wetlands ID Number ........................................................... ............................... NA 29. Is Wetlands Permit required? .............................................. ............................... l�to Has application been made to Town or Local DEC office? . ............................... N A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... ho 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 .. N� 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 N 0. DESCRIBE: . 33. Is there a local master plan on file with the Town or Village? ......................... '�E5 . 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? . ............................... 36. Tax Map ID Number .......................... ............................... Map Z3 . Block . 2 - Lot t� 37. Approved plans are to be returned to ..... Applicant X 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, under penalty of perjury, Ili at 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 aw. SIGNA,A ES & OFFICIAL TITLES: I+A -k W N I o N oth , S@-, P15 Mailing Address: ................................... U 5 ® M titi � Rew,V (1--, W 4 0 5 0 t . APPUCAHTMPON$9R -- Nj1� ►� ''¢- I'stil�tEl� � N' T°rf t. PROJECT NAME--' ...: ` • • Lof 10 — ��� •- J. PROJECT LOCATIONJ; i� t*,- 4 , .; .p,�rrE��aN T „ Coup 4. PRECISE LOCATION "I eddreaa and road Interne 0cm, prominent tandmarka, eta., w provide map) MGMAHUS S. w PROPOSED Aunow' .-. tv� O. Now ....:.. - -._0 5. DESOMBE PROJECT BRIEFLY! 7. AMOUNT OF LAND AFF `'Y' 1 2 M� 25 wiwh -area Ujumpeiy awe a. WILL PROPOSED AMM COMPLY WITH IMTINO ZONING OR-OTHER EXISTING LAND USE RE9MOnOW..: •.:...:...:. • ; ....; ;.:: • .: ~ Ay" 0 No If N% doawu txteillr 9. LAND tU pf VIGNITV OF PROJIIM ':w �PRE8F,�IT tw a lWatrtal ❑ 0wwwlal O Agriculture ❑ PwWFotwt*W apace o Other wscrto« � i jy�t•t -i.% -�'��ni 1..� .. .. .. • ... . . to. DOES ACTION iRVOLV9 A PtiRMR APPROVAL. OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER 00VEW1MPMAL AGENCY MEP-44 STATE OA LOCAL? _ O Yea MX0 a yea, Wt agar am and pemdUapprovala 1!. DOEB ANY A$Pf,OT OF.WW A011901 HAVE A CURAIPMY VALID PMff OR APPROVAL! - . � Yea... ..;�.No�:_ • . U, rN. ua- ag.�ar narrl...�d peraslt/appr0vq . - , u. AS A RE$ULT Of "*nQN WILL EXISTING PEAMfT/A MWAL REOWAE MODIFMTIOW Yes ON. ,.;,, . , 1 CERTIPY THAT THE INI ORMATION PWAD90 A60VE Iii TRUE TO THE 6EST OF MY 10IOyHLEDOE Appkmtlapw" W' Mi h} 6 LAi X PE -5 flame v< Date: S/4 101, Slonaturw If the action is in ft.Coastal Ares, and you are a state agency, complete, the Coastal -Assessment Form before proceeding with this assessment • ^lien e•nT „ r►nnsnuueuTwl wQ0V001a Q►IT rr- ha wn.nnlntari by Onannv% •. A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN d NYCRR, PART 617,87' If yes, 0004681e1Ne review process snd use4h*FULL'EJ1F,° :- oy" No e. WILL ACTION RECEIVE COOROIHATED REVIEW AS PROVIDED FOR VNUSTEO ACTIONS IN 5 NY01% PART 617.07 It No, a npative declaration. may be superseded by another.Involve4 igMOy� , ❑ Yes ONO C. COULD ACTION RESULT.IN ANY ADVERSE EFFECT$ ASSOCIATED WITH THE FOLLOWING: (Answer* may be handwrulen, If legible) C1. Existing. air quallty, .aurlace or groundwater quality of quarnutY, noloo levels, exlatlng tratQq pagprge, .eol!Q waeti production or disposal, potential for erosion, dratnage or Iloodwo problem? Explain brfelly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or nelghbofhood characteR Explain briefly: C3. vegetation or fauna, fish, shellfish of wildlife species, ilgnlfkanl habitats, or threatened or endangered species? Explain bristly: Ca. A community's existing plena or9 011118 U Officially adopted, or a chango In woo or Intsnslty of use of.land ouatber natufal.rescerces? EkDlala btletiy CS. Growth, suosepuent development, or_related aollvltlea likely to by Induced by the proposed sollon7 Explain briefly. C6. Long term, short term, Ounwlative, W guar effects not Idenuflad In 01-057 Explain briefly. - -- - C7. Other Impacts (Including changes In use of either quantity or type of energy)? Explain briefly, 0. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTIERISTICS THAT CAUM THE ESTABLISHMENT OF A CEA? 0 Y0 . ONO E IS THERE, OR IS THERE UKELY TO BE, CONTROVERSY RELATED TO POTENTIAL AOVER$E ENVIRONMENTAL IMPAC717 ❑Tea ❑ NO If Yee, explain brleflY PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect Identified above, determine whether It is substantial, large, Important or otherwise significant. Each effect should be.aaaeased In o6mootlon with Its (a) totting 0.9. urban or ruraig..( b�probabillty .of,•ooagaing;..�)•durs ion; (d) irrevem1blilty; (e) geographic scope; and (t) magnitude..N necessary, add attamments or refonnoe supporting materials. Ensure. that explanations contain sufficient detail to show that all relevant adverse impacts have been Identified and adequately addressed. 11 question D of Part II was checked yes, the determination and slgnlfldartce must evaluate the potential Impact of the proposed action on the environmental charactertstics of the CEA. ❑ Check this box If you have Identified one or more potentially large or significant adverse Impacts which MAY occur, Then proceed directly to the FULL EAF and/or prepare a positive declaration; ❑ check this box..lf.you•hava.determinedr aced on tbo Information and arialysls above and.any supporting documentation, that the proposed action WILL NOT result In any significant adverse, environmental,impacts AND provide on attachments as necessary, the reasons supporting this determinstloni'" aunt of Loa wy Print or Type Narne of a•• in V*&4 A&qncy TIU# W Responsible 011icel . reruture y Wre 0 rmp" aaN Imm responsible o KK as_. �.._. .. n M� 111 I D113 K110 M1 1 W41"It CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM PERMIT # F- A41 e 0i 'S ,(.j —' Q° 0 1 Located at MCHAk4UfP PAD 600-1—+4 Town or Village pATTEg-60H Subdivision name Klp FEAO� Subd. Lot # 1'D Tax Map Block I- Lot 13 Date Subdivision Approved Owner /Applicant Name COW41r * tU Fnk BMG4fl Renewal X Revision Date of Previous Approval 6- jQ °q g Mailing Address BOX C'id' 9307 I ��' 4 hl�' Zip T" Amount of Fee Enclosed Building Type t�i'G� Lot Area S M-5 No. of Bedrooms 4' Design Flow GPD 600 Fill Section Only Depth 02 Volume660 G14 PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage S sK, tem to consist of Other Requirements: lr.�6Q gallon septic tank and To be constructed by b iSD Address Water Supply: Public Supply From or: k Private Supply Drilled by ME Address Address 5 ©A Lf N6 Ifaiuk I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate to Sewage treatmentsystem 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: "`� P.E. R.A. Date �' I � $ I Dp Address 0 05' 0� License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatme system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when c sidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires anew permit A p oved for discharge of domestic sanitary . wage only. By: Title: / Date: G White copy -6 File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CP -97 BRUCE R. FOLEY Public Health Director NAME: ADDRESS. SITE LOCATION: DATE: STAFF PRESENT: 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 (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 PUTNAM COUNTY DEPARTMENT OF HEALTH SPECIFIC WAVIER i SPECIFIC WAVIER REQUEST: 'P ®P (pcJ A ?& 61, frA N A4 057, DOES THE PROPOSED VARIANCE REQUEST POSE A HEALTH HAZARD OR ENVIRONMENTAL CONTAMINATION PROBLEM? YES WILL DISAPPROVAL RESULT IN A SIGNIFICANT HARDSHIP? YES DISCUSSION REQUEST APPROVAL OR DENIED /� ! AP�F�VED REASON FOR DENIAL DIRECTO OF PUBL& HEALTH NO NO DENIED PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL please print or type PCHD Permit # ' 4�— b/ Well Location: Street Address: Town/Village Tax Grid # ry, H C-MAH 0 POP 5 T1 Ik PNTI-GL6 DN Map J!)) Block � Lot(s) 1,! Well Owner: Name: C0H140 N(PPr Address: P° P • 5DA 16� �g4T I I 0'S�""� 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 _+]�j Est. of Daily Usage �� gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling jl�_ 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 No Name of subdivision j)NC-4 0 F-EAU, Lot No. 60 Water Well Contractor: Address: Is Public Water Supply available to site? .................................. ............................... Yes No Name of Public Water Supply: Town/Village Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separa sheet/plan. Date: Applicant Signature: 1 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 water well driller certified by Putnam County. Date of Issue If 31 0/ Permit I g Official: Date of Expiration Title: Permit is Non -Trans errable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 NEW YORK STATE DEPARTMENT OF HEALTH Specific Waiver Bureau of Community Sanitation and Food Protection from Requirements of Part 75 and Appendix 75- A,10NYCRR for Individual Household Sewage Treatment Systems Name of Applicant Address i, `-1 1 or 9 T. 1I / Ilk A P60 1 1. Reason why site does not meet IONYCRR Appendix 75 -A (check appropriate box(es)): Separation distance cannot be achieved. Excessive slope. J High groundwater. Inadequate depth to bedrock or impermeable layer. Soil unsuitable. Other (explain) ... : ...................................................... . ............................. .:............................. �"- 37W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . .. . .. . . . . . . . . . ... . . . .. . . ..... . . .. . . . . . . ... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. The proposed design may have the following limitations (check appropriate box(es)): L] Increased risk of well or spring contamination. Increased risk of surface water contamination. Expected design life of the system will be diminished. Operation of sewage system is subject to mechanical problems. Other(explain) ...................................................................................................................... ............................... ........................................................................ ............................... Additional information attached Construction pursuant to this waiver request should not pose any foreseeable health or environmental problems. In accordance with New York State Department of Health Administrative Rules and Regulations, Part 75.6 (b), a waiver is hereby granted. This waiver may be revoked by tMssuing official for a change in conditions for which this waiver was granted. ........................................................... ............................... 1TIVE O OMMISSIONER OF HEALTH ORIGINAL - Local Health Agency COPY - Applicant/Design Professional I..3 .................. DOH -1326 (7/92) (GEN -152) PART II— ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE (THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF. ❑ Yes 5D No B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another Involved agency. ❑ Yes ® No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WiTH THE FOLLOWING: (Answers may be handwritten, If legible) C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage or flooding problems? Explain briefly. NO C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly: NO C3. Vegetation or fauna, fish, shellfish or wildiife species, significant habitats, or threatened or endangered species? Explain briefly:. NO C4. A community's existing plans or goals as officially adopted, or a change In use or Intensity of use of land or other natural resources? Explain briefly NO C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain briefly. NO C6. Long term, short term, cumulative, or other effects not Identified In C1-05? Explain briefly. NO C7. Other impacts (including changes In use of either quantity or type of energy)? Explain briefly. NO D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? ❑ Yes No If Yes, explain briefly PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it Is substantial, large, important or otherwise significant. Each effect should be assessed In connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse Impacts have been Identified and adequately addressed. 0 Check this box If you have identified one or more potentially large or significant adverse Impacts which MAY occur. Then proceed directly to the FULL EAF and/or prepare a'positive declaration. Check this box If you have determined, based on the Information and analysis above and any supporting documentation, that the proposed action WILL NOT result In any significant adverse environmental Impacts AND provide on'attachments as necessary, the reasons supporting this determination: PUTNAM COUNTY DEPARTMENT OF HEALTH Name of Lead Agency E FOLEY DI TOR Print or Typ ame o Responsible Officer in lead Agency ybl Tit Aofsponsible O icer Signature o R ponsi le Officer in Lead Agency J Signa ure of Preparer (it diffet—e—ni'Tr—om responsible officer) n J `` - _ \\ ` \\ � '.\ \\ ,I �, % li ;1 III �. I!1t� \ \Y \``\ Y ` \\ \1�1� � \,, +,\ `,\ � � I �25• - ' N 81' 13' 55'W _ --_ IDS.' , N DS 14 3 YJ -- � —' \ R'� 1. 55 1 \ - \ i ' � 1 1 IY Y `\ ° \Y \i I i i ` ' \\ ',\ \\ \\ \\ \� \ \\\ \` : \•`�` � �\ `� -• \ \\ `\ �`\�. O • jK D cb O� �' � / / a��p�•,,�g. 1 �1 1 / / / r / i \\ \\ `I , , 1 , 1 \\ \ \ \ \ 1\ \\ \\ ♦ \`\ ♦ \ \\ \\ \ 1 i \\ it • � \\ 11 11 11 \\ ' ' '' i 1 I i 1 \ \\ ♦\ \\ \ \1 1 Y Y` ' i j I PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL IIEALTII INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE TREATMENT SYSTEMS REVIEW SIIEET FOR CONSTRUCTION PERMIT STREET LOCATION A , MAA1 /2s �©%Z�_ NAME OF OWNER (cONlill� GG IGcOIV GK0F7� . REVIEWED BI RNI, � AS, NIB, BH TAX MAP # 1a 3- a.Zi Y fN DOCUMENTS Y PERMIT APPLICATION PC- I WELL PERMIT_ PWS LETTER J LETTER OF AUTHORIZATION J DESIGN DATA SHEET (DDS) J RESOLUTION EAF �� }5 n� desi9w ~I`�R1CrL,JL1.A' z 3 c !" 3 REQUEST SUBDIVISION LEGAL SUBDIVISION SUBDIVISION APPROVAL CHECKED PERC RATE =:- I I - l5 ILL REQUIRED DEPTH URTAIN DRAIN REQUIRED STANDPIPES GENERAL LOCATED IN NYC WATERSHED PLANS SUBMITTED TO DEP DELEGATED TO PCHD DEP APPROVAL, IF REQ'D --� DEEP TEST HOLES OBSERVED 4 7 PERCS TO BE WITNESSED X- APPROVAL SSDS ADJ. LOTS WETLANDS (TOWN /DEC PERMIT REQ'D ?) X%9 NEIGHBOR NOTIFICATION t£fFER BI/ZBA TM-7k. FLOOD ELEVATION 0 '1'1 IER REQ'D PERMITS) REQUIRED DETAILS ON PLANS jZ � G � 0K �i SSDS I IYDRAULIC PROFILL MIGRAVITY PLOW EK9M— aq -CONT E— THOUS PERC & DEEP HOLES LOCATED REPRESENTATIVE OF PRIMARY & EXPANSION LOCATION MAP EXP. AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE IF POMP D, PIT & D BOX SHOWN & DETAILED HOUSE - NO.OF BEDROOMS fropo� ,how del-e--,;l PROPERTY METES & BOUNDS HOUSE SETBACK NECESSARY (TIGHT LOT) VO BENDS: MAX.BENDS 450 W /CLEANOUT FILL SYSTEMS 2LAY BARRIER /-I- . 10- FT HORIZONTAL;SLOPE :I TO GRADE Ii,SPEG FILLNOTES -Fill Pr..d� �jtmp►�sr`vr15 L X W CERTIFICATION NOTE FILL PROFILE & DIMENSIONS VOLUME FILL IN EXPANSION AREA TRENCH / LF TRENCH PROVIDED l 60 FT MAX. PARALLEL TO CONTOURS 100% EXPANSION PROVIDED ON PLAN - FROM SSTS 0� T _'L DRIVEWAY, LARGE TREES, .TOP OF FILL Toe - F �;ll 0 It 20-1'0 FOUNDATION WALLS _15'WELL TO PL T10''I•li, 200' IN DLOD, 150' PITS 100' TO STREAM WATERCOURSE LAKE (inc. expan) 50' TO CATCI I BASIN, 35' STORMDRAIN, PIPED WATER 10' TO WATER LINE (pits -20') 50' INTERMITTENT DRAINAGF, COURSE 200' /500' RESERVOIR, E.I'C. 150' GALLEY SYSTEMS CONSTRUCTION NOTES CDS= >5 %,10'- 4 %,25'- 3 %,30'- 2 %,35' -I %,100' - <I% DESIGN DATA: PERC & DEEP RESULTS to CD discharge/ I 00'with 182 cons day discharge T CONTOURS EXISTING & PROPOSED SEPTIC TANK DRIVEWAY & SLOPES, CUT 10' FROM FOUNDATION; 50' TO WELL FOOTING /GUTTER/CURTAIN DRAINS WELL SOIL TYPE BOUNDARIES DIMENSIONS TO PROPERTY LINE TITLE BLOCK-, OWNERS NAME,ADDRESS c_OCA i t01 I Rwcr- -c NNI�'H©N TM #,PE /RA; NAME,ADDRESS,PHONE# DATE OF DRAWING /REVISION DATUM REFERENCE LOCATION OF WATERCOURSES, PONDS LAKES AND WETLANDS WITHIN 200 FEET PROPOSED FINISH FLOOR AND BASEMENT EL., COMMENTS: Ham b,, `e w -5 Zie-Z y Z 410620 I / �lNa+orJ�a rv,r�Ye 1Yr��vl u �c�' ?u." 9 Tfi Gjr" <t[ ?ol�� l YC' Gtcii ✓S 51- toulcP cue•cz.�1� �o� ^.5ilt-FPa�+ce �jo�r) -r'-I.,e driveu.�«y cu•� ctv'�c� -� 2 P X Harry W. Nichols Jr., P.E. Patterson Paris, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax 184512794167 May 2212001 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road . Brewster, NY .10509 RE: Proposed Construction Permit - Bancroft McManus Road South, Lot #10 Town of Patterson, T.M. #23. -3 -24 Dear Robert: In response to your May 17, 2001 review letter, we note the following: 1. A waiver is hereby requested for construction of an SSTS on a slope of approximately 24 %. This waiver is requested since current sondes only permit an SSTS on slopes of 15% or less. If you have any questions, please call. Very truly yours, Harry W. Nich s Jr., P.E. HWN: his 00- 163.00 0 BRUCE R. FOLEY Public Health Director LORETTA MOLINARI R.N., M.S.N. Associate Public Health Director Director of Patient Services DEPARTMENT OF HEALTH 1 Geneva Road Brewster, New York 10509 Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085 Early Intervention (845) 278 - 6014 Preschool (845) 228 - 6108 Fax (845) 278 - 6648 May 17, 2001 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 .--..Re: -..Proposed Construction Permit: Bancroft- McManus Road South, Lot #10 (T) Patterson, TM# 23 -3 -24 Dear Mr. Nichols: Review of plans dated August 14, 1995 last revision dated April 18, 2001 _and -other materials relative to a construction permit for the above captioned property has been completed by this Department. _Based upon such review, and pursuant to the provision of Article.III of the Putnam County.Sanitary-_ Code, you are hereby advised that the proposed method providing water supply and sewage disposal are considered inadequate as set forth below. Therefore approval of these plans cannot be granted. - - 1. -- The SSTS is proposed on a slope greater than 15 %(approximately 24%).--____-___=____= -- - - - It is your legal right to request a waiver of the denial based on item(s) noted above. The denial request must be submitted in writing after the receipt of this letter. The request must specifically state the waiver being sought. If you have any questions, please call me at (845) 278 -6130 ext. 2166. Very y yours, Robert Morris, P.E. RM :tn Senior Public Health Engineer 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) 278 -6082 . Fax (845) 278 - 6648 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 RE: Brancoft McManus Road South, Lot #10 (T) Patterson, TM# 23.2 -1 -13 Reservoir Basin Dear Mr. Nichols: December 12, 2000 The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on December 5, 2000 is complete. The Department will notify you by December 25, 2000 of its determination. ® The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces; and the project applicant should contact the Department of U Letter to: Harry Nichols, P.E. - December 12, 2000 -2- Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 278 -6130 ext. 2166. Very truly yours, C Robert Morris, PE RM:tn Senior Public Health Engineer 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) 278 -6082 Fax (845) 278 - 6648 Harry Nichols, P.E. Patterson Park Suite 106 2050 Route 22 Brewster NY 10509 Re: Proposed SSTS: Bancroft McManus Road South, Lot #10 (T) Patterson'. TM# 23 -2 -13 Dear Mr. Nichols: December 12, 2000 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) Standard notes 1 -15 have not been provided on plans. 2) Date of Subdivision approval has not been provided on permit application. 3) The results of only one deep test hole has been submitted with the design data sheet. 4) Current codes do not allow the approval of SSTS's on slopes greater than 15 %. Upon receipt of a submission, revised to reflect the above comments, this application will be considered further. Very truly yours, Robert Morris, P.E. RM:tn Senior Public Health Engineer 14.164 (9195) —Text 12 PROJECT I.D. NUMBER 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. APPLICANT /SPONSOR 2. PROJ CT NAME i77T I jG 3. PROJECT LOCATION: PNTTF (, O e Pyri H J� P-6 H Municipality County 4. PRECISE LOCATION (Street address and road Intemectlons; prominent landmarks, etc., or provide map) 5. IS PROPOSED ACTION: E New ❑ Expansion ❑ Modiflcatlonlalteratlon 6. DESCRIBE PROJECT BRIEFLY: — — IHi?iviDJl'si� 7. AMOUNT OF LAND AFFE TED: J � Initially acres Ultimately acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR-OTHER EXISTING LAND USE RESTRICTIONS? VYes ❑ No If No, describe briefly 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? 0 Residential ❑ Industrial ❑ Commercial ❑ Agriculture ❑ Park/ForesUOpen space ❑ Other Describe: 10. DOES ACTION INVOLVE A PERMIT.APPROVAL,,,O(i F.YNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, — STATE OR LOCAL)?� [[ ❑ Yes ILJNo If yes, list agency(,) and permlttapprovals 11. DOES ANY ACT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? ❑ Yes ISNO If yes, list agency name and permitiapproval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION? OF. ❑ Yes I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE TO THEE BEST KNOWLEDGE 7ABOVE ,JO�F -MY 1 iTn t �iC,4U— " , J 1 . ��' M Tq✓F� ApplicanUsponaor name Date: gig Signature: r 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 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION; ,;.OF.;ENVIRONMENTAL HEALTH- SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER, TREATMENT SYSTEM Name and address of applicant: 9. Is a Draft Environmental . Impact Statement (DEIS) required? ......................... 10. Has DEIS been com'" pl6fed and found acceptable by Lead Agency? ............... 1.1. Name QfLead Agency y NA 12.- Is this project ihan area under the control of local planning, zoning, or other officials,'ordinances? .............................................................. .... .. 13. If so,'have.plan's been submitted to such authorities? ....................................... Mo 14. Hasprelim!!�aTaPp�oval . been granted by such authorities?.,. FAO Date granted: Npt 15. Type of Sewage Treatment System Discharge ... :.! ............... surface water x groundwater 16. If surface water discharge, what is'the: stream class designation? ..................... 17. Waters index number (suirifaicidi) ............................................................. NA' A.. 18. Is project located near a public water supply system? ....................................... ho 19. If yes; name of water supply' t4iN Distance to water supply kA 20. Is prod ec - ts : site near: . a, public sewage, collection or treatment system? .... 21. Name of sewage system Distance to sewage system 0A 22. Date test holes, 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................................................. 25., Is State 'Pollutant Discharge Elimination System (SPDES) Permit required ?... HO 26. Has RDES'Aiplk'Alo' n been submitted to local DEC office? ........................... Form PC-97 ij '�. -MVA r T 15 P O Ir 056 1. 2. Name of project: fl'- 3. Location TM P.A J� P- -301H T-T- 4. Design Professional: HiGkL-6, AFIF5. Address: 9-060 P47 ll-� 6. Drainage Basin: F�6r t;roL_ 14 7. Type of Proip- � 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 Revi�ew_ If (SEQR)? - . Type Status (check ,one)..,,, .... ..................................... ;Type I.: Exempt Type 11 Unlisted X 9. Is a Draft Environmental . Impact Statement (DEIS) required? ......................... 10. Has DEIS been com'" pl6fed and found acceptable by Lead Agency? ............... 1.1. Name QfLead Agency y NA 12.- Is this project ihan area under the control of local planning, zoning, or other officials,'ordinances? .............................................................. .... .. 13. If so,'have.plan's been submitted to such authorities? ....................................... Mo 14. Hasprelim!!�aTaPp�oval . been granted by such authorities?.,. FAO Date granted: Npt 15. Type of Sewage Treatment System Discharge ... :.! ............... surface water x groundwater 16. If surface water discharge, what is'the: stream class designation? ..................... 17. Waters index number (suirifaicidi) ............................................................. NA' A.. 18. Is project located near a public water supply system? ....................................... ho 19. If yes; name of water supply' t4iN Distance to water supply kA 20. Is prod ec - ts : site near: . a, public sewage, collection or treatment system? .... 21. Name of sewage system Distance to sewage system 0A 22. Date test holes, 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................................................. 25., Is State 'Pollutant Discharge Elimination System (SPDES) Permit required ?... HO 26. Has RDES'Aiplk'Alo' n been submitted to local DEC office? ........................... Form PC-97 z 27. Is any portion of this project located within a designated Town or State wetland? 1�0 28. Wetlands ID Number ........................................................... ............................... 29. Is Wetlands Permit required? ............................................... .............................. E No Has application been made to Town or Local DEC office? ............................... A 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 0. 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 P 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? ......................... .7..... Yes/No N 0 DESCRIBE: 33. Is there a local master plan on file with the Town or Village? ................... ,:...... `�Ey 34. Are community water and/or sewer facilities planned to be developed 'within . 15 years. in.or adjacent to project site? ................................ ............................... 1-10 35. Are-any sewage treatment areas in excess of 15% slope? . ............................... ` a� 36. Tax Map ID Number ........................... Map Vb Block 2- Lot i/"' 37. Approved plans are to be returned to ..... Applicant X 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 an LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor ,pursuant -to Section 210.45 o the,�enal Lard. SIGNATURES & OFFICIAL TITLES: s�:z wd saeor�oo i�naa -( Mailing Address �� � ` ''�:.:v r j j N :3. •A j,,.. C ? a11Ia, d NJGf40L5' Jezfp 2050 F-oJVI� 21 PUTNAM COUNTY DEPARTMENT OF HEALTH .DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner CL-1 f-I-ON BMC�'f::T Address. P' O' 16� OG(o 1i Located at (Street) HC 4N14j� K 5P &Uff RoLff Tax Map Block Lot . (indicate nearest cross street) Municipality � IT�g-60H Watershed A/oT � 4)-4L* SOIL PERCOLATION TEST DATA t Date of Pre-soaking 41 �1.1 �1 -Date of Percolation Test '011 ...... .... H e: i ""EU—s T' ......... . ........ . Th. D xils rom 49.W ac ea� 'Water -eye P. ercola on.: .. . .. .R ...... .. . .... Y.. .. nc . .. .... . . 2 -Th 3 ILI 4 T7 -711 2 3 �N ^ ��� �- 24 z� gr t 4 5 2 3 5 NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e. ,5 1 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 2 DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES HOLE NO. HOLE NO. HOLE NO. Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: �'R - tol 6 L� w"10 Date Design Professional Name: W I ltlC J� P� Address: IDS 0 f 2� Signature: Design Professional's Seal ra '` t 1 No, 56124 ti06�s� TbPSQiL. _. LARir r 1 s�� R-o UAL r- ko Indicate level at which groundwater is encountered Indicate level at which mottling is observed Indicate level to which water level rises after being encountered Deep hole observations made by: �'R - tol 6 L� w"10 Date Design Professional Name: W I ltlC J� P� Address: IDS 0 f 2� Signature: Design Professional's Seal ra '` t 1 No, 56124 ti06�s� PUTNAM. COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner C,0 t4" l F_ 5/-44U�'OF'r Address p°' W'b GK<j`JajMT Located at (Stree.t).M4AW\4b kffl5d f 0 O-Kt"PL6 n- Tax Map Block h. (indicate nearest cross street) Municipality. �P<Tr --Js 0H_ Watershed SOIL PERCOLATION TEST DATA! Date of Pre - soaking._ -11 Date of Percolatidn- Test Ole' R. MM "Ve t� 0 e ro ®r 6 C 4 - ------- 72% 4-u i 4. CU i v 10AE. JQ----- -- - a, I 2 3 4 5 V1V1r,0. 1. 1 c3t3to be repeated at same depth unto approximately equal percolation . rates. are obtained at each percolation test hole. (i.e. i I min for 1-30 min/inch, :5 2 min for 31-60 mlWinch) All data to be submitted for review. 2. Depth measurements to be made from top of hole. TEST PIT DATA '- DESCRIPTIO_ N OF'SOILS ENCOUNTERED IN TEST HOLES. DEPTH HOLE NO. ) • ' HOLE NO. - HOLE N01 G.L. • 0.5' � _Yoe' � P 4wL. 1.5'. ^2 Co MMES .2-51 3.0' c o ccw �.5 4.0' i - �A ma 5.0' ~ 5.5' 6.0'' 6.5' 7.0' 8.0' 9.0' 10.0 >= c u7•. a e lam. 20-at which groundwater is encountered Ii d =fie 1 1 at which mottling is observed. 1,AF Iridl le l to.which water level rises after being encountered NA Deep hole-observations made by: H-P . \N, N11.t-koLA,) � 1 _ Date 4I 11l*a i L.,cbign rroiessionai Name:.i-rAr, Address: U'5 o' Signature: Design Professional's. Seal NOY -93 -2999 12:26 PH HARRY W HICHOLS 914 279 4567 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES RE: Prop Lock TN Subc LETTER OF AUTHORIZATION P.92 Subdivision Lot # AD ('0 Filed Map # Date Filed i 2� Gentlemen: This letter is to authori2e U CI L a duly licensed Professional Engineer or Registered Architect to apply for the required wastewater treatment and/or water supply permits) 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. Vcry truly yours, Countersigned: Signed' P.E., R.A #�' (Owner or ) Mailing Address T1. J State Zip 0 5 Q Telephone: (00-45) �1 � + a li Received 11 -03 -00 1141em From -814 279 4507 Mailing Address: State Telephone: i r "802- 37 e-- ti t To —CABOT CREAMERY Page 02 Form LA-97 Harry W. Nichols Jr., P.E. _ Patterson Park, Suite 106 2050 Route 22 Brewster, NY 10509 Telephone (845) 2794003 Fax (845) 279 -4567 November 16, 2000 Robert Morris, P.E. Putnam County Health Department 1 Geneva Road Brewster, NY 10509 RE: Proposed SSTS: Renewal ConrueBancroft, P-42-87/ Maggio Subdivision, Lot #10 Town of Patterson, TM #23. -2 -13 Dear Robert: Enclosed are the following: 1. Five (5) prints of Drawing SF -10, "Proposed SSTS," dated 11- 16 -00. 2. One (1) print of SS -10, dated 11- 16 -00. 3. "Short EAF," dated 11- 16 -00. 4. "Application for Approval of Plans for a Wastewater Disposal System." 5. "Construction Permit for Sewage Disposal System," dated 11- 16 -00. 6. "Application to Congtruct a Water Well," dated 11- 16 -00. 7. "Design Data Sheet." 8. "Letter of Authorization." 9. Two (2) copies of Residence Floor Plans, for Bedroom Count Only." 10. Review Fee in the amount of $300.00. H W. '7s Jr., P.E. HWIV:JM 00- 163.00 e PUTNAM COUNTY DEPARTMENT OF HEALTH IVISION OF ENVIRONMENTAL HEALTH SERVICE / TV/ CONSTRUCTION PE44MMAGE TREATMENT SYSTEM PERMIT # -5;5 Located at WWAK05 Town or Village 19A: QO;12_` N Subdivision name l,,l,a,i�/) Subd. Lot # 10 Tax Map 20; Block Lot Date Subdivision Approved Renewal iC Revision Owner /Applicant Name CAN, WI V V' GLj e::V2U EjA tjt�t)ET Date of Previous Approval " 'Mailins Address 12.E ,E35 1P) _ (,,, '[ _ Zip Amount of Fee Enclosed Building Type iz��,�? > "r��41. Lot Areal �7� No. of Bedrooms _�f_ Design Flow GPD o Fill Section Only 4 Depth - �— Volume i9O G 'i o PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of ! Zit) gallon septic tank and✓Do L.F. Other Requirements: To be constructed by , -Tap Address Water Suooly: Public Supply From Address gy Private Supply Drilled by -TE�17 Address I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the senaraT to 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. A - Signed: P.E. 1 R.A. Address Date License # 15 � 12� APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified wh onsidered necessary by the Public Health Director. Any revision or alteration of the approved plan requires a new permit pprove r discharge of domestic sanitary s ge only. By: Title: �� Date: l�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 # Well Location: Street Address: Town/Village Tax Grid # S / ' Map 20 ; Block 0 Lot(s) Well Owner: Name: Address: zjvwe e3, lb Use of Well: F Residential Public Supply Air /Cond/Heat Pump Irrigation 1- primary Business Farm Test/Monitoring Other (specify) - secondary Industrial Institutional Standby Amount of Use Yield Sought _q_ gpm # People Served) -.5 Est. of Daily Usage 62d y gal. Reason for Replace Existing Supply Test/Observation Additional Supply Drilling __�4 New Supply (new dwelling) Deepen Existing Well Detailed Reason S for Drilling Well Type JDrilled Driven Gravel Other Is well site subject to flooding? Yes No Is well located in a realty subdivision? ...................................... ............................... Yes 1,A No Name of subdivision -!s.AA 4 gj�n,Al -(~( 1> . We, Lot No. �D Water Well Contractor: J0V Address: Is Public Water Supply available to site? .................................. ............................... Yes No >C Name of Public Water Supply: 0 /A Town/Village -- T. Distance to property from nearest water main.: Proposed well location & sources of contaminatiog to be provided on separ e s et/plan. Date: ) - - Applicant Signature: �"4 , u 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 water ell driller certified by Putnam County. Date of Issue Permit Issu cial: Date of Expiration 0 Title: 6 C Permit is Non- Transfer able White copy - HD file; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WP -97 LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)278.8108 - (FAX) 278-2658 CONSULTING SITE ENGINEERS "RIO 0 I!. -/i Gentlemen: We enclose copies ot: O B/W Prints O Reproducibles Date: .. O Reports O Tracings Sent Via: O Our Messenger O Your Messenger O Blueprinter `Hand Delivery G- :4 H j 0z inr L6 Copy to: A� r. O First Class Mail 0 O Revision /Date No. O Special Delivery Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: i LAURENT ENGINEERING ASSOCIATES,; P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICH0LS JR., P.E. CONSULTING SITE ENGINEERS March 20, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS - Renewal McManus Road (T) Patterson Dear Mr. Morris: Enclosed are the following: 1. Five (5) prints of SS -117, "Preliminary Design For Fill Placement Only ", revised 2- 20 -98. 2. One (1) print of SS -1, "Proposed SSDS ", revised 2- 20 -98. 3. "Application For Approval oi'Plans Fora Wastewater Disposal System ". 4. "Construction Permit for Sewage Disposal System ", dated 11- 14 -97. 5. "Application to Construct a Water Well ", dated 11- 14 -97. 6. "Design Data Sheet ". 7. "Short EAF ", dated 1.1- 14 -97. 8. "Letter of Authorization ". 9. Renewal 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 ENGINES G SSOCIATES, P.C. c Harry W ichols, Jr., P. . HWN:TR:bd 8753 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York . 10509 Tel. (914) 278-6130 Fax (914) 278-7921 Harry Nichols Laurent Associates N illbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSDS: Bancroftn McManus Road, Lot 910 (T) Patterson, TM# 23 -3 -24 Dear Mr. Nichols: June 18, 1998 BRUCE R. FOLEY Public Health Director Review of plans and other supporting documents submitted at this time relative to the above - captioned 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." 1) If percolation tests were not witnessed by a representative of this Department, the tests must be witnessed by a representative of this Department.. Upon receipt of a submission, revised to reflect the above, this application will be considered further. Ve truly yours, 6w Akk-7 Robert Morris, P. E. Public Health Engineer RM:tn (�JMiMGAACMSMiM AAaM:AArMeM:MSMxMSMfM3A Ai:MeM'�MsMdAI!�d�1ntQIn,MWALAE eaH/�i!1A[ft/.�lAA6A e7M :MiMiM19A:/1.L1:MaMEMSMrAAl- MMAV%Ag"',MZAA C y t / '0 0 r • .� ° 1 l S o i (V1/N[Pllia fYii: llLkVH61Yl/; VY91l 11Y1f►' s1l N.& L° �1(! 1". 1/ V° Y�1�11 11Aby�N�= YNl y11Y1YGiNG7VNd1/ 11�Yryl �l i/ L�l N6�'! i'/ iN1 '/IW711111KHiyyFyNiyY�1/VH11YI' "7 V111N11I y1/ tllillfH11T1 1�"InHV,"F1iY1lN7i/l'Y3Wf) 1 3 DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 April 1, 1998 Harry Nichols Laurent Associates Millbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 RE: Bancroft McManus Road, Lot #10 (T) Patterson, TM# 23 -3 -24 Reservoir Basin East Branch Dear Mr. Nichols: N BRUCE R. FOLEY Public Health Director The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and received by this Department on March 23, 1998 is complete. The Department will notify you by April 19, 1998 of its determination. If the Department fails to notify you within the above referenced time frame, you may notify the Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 days of the receipt of the notice, your application will be deemed complete, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Dept. of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Dept. of Environmental Protection regarding such activities to see if Dept. of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (914) 278 -6130 ext. 166. Ve ly yours Robert Morris, PE RM:tn Public Health Engineer DEPARTMENT OF HEALTH Division of Environmental Health Services 4 Geneva Road Brewster, New York 10509 Tel. (914) 278-6130 Fax (914) 278-7921 April 1, 1998 Harry Nichols Laurent Associates 1Vlillbrook Office Centre Route 22 & Milltown Road Brewster NY 10509 Re: Proposed SSTS: Bancroft McManus Road, Lot #10 (T) Patterson TM# 23. -3 -24 Dear Mr. Nichols: BRUCE R. FOLEY Public Health Director Review of plans and other supporting documents submitted at this time relative to the above captioned 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." 1) Reservoir Basin has not been noted. a 2) Filed map number and date filed has not been noted on Letter o/O Authorization. 3) Three feet of fill is not provided for the entire system. The minimum depthC from the bottom of a trench to ledge rock is 5 feet. 4) All details not pertinent to the fill plan are to be removed or crossed out, e.g., 621 junction. box, trench and baffle box. 5) A four bedroom house is proposed, house has been labeled as three bedroom on plan. 6) Fill pad dimensions have not been noted. 7) Depth gauges have not been shown. 8) All existing and proposed systems within 200 feet of this proposal are to be shown. 9) Erosion control measures for the house, well and SSTS are to be shown and the detail provided. 10) Location of the service connection from the well to the house is to be shown. Letter to: Harry Nichols - April 1, 1995 -2- 11) All slopes greater than 20% are unacceptable. All slopes greater than 15% and less than or equal to 20% must be reduced to 15% the addition of fill or the SSTS designed 10 feet on center. 12) Proposed SSTS is in direct - line -of drainage to the proposed well. Upon receipt of a submission, revised to reflect the above, this application will be considered further RM:tn Ve ruly yours, Robert Morris, PE Public Health Engineer T LAURENT ENGINEERING ASSOCIATES, P.C. / \ \ MILLBROOKE OFFICE CENTRE Route 22 8 Milltown Road Brewster, New York 10509 (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS May 19, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Individual SSDS - Renewal McManus Road, Lot #10 (T) Patterson TM# 23. -3 -24 Dear Mr. Morris: In response to your review letter dated April 1, 1998, we offer the following: 1. Reservoir Basin has been noted on the Design Data Notes and added to Form PL -97. 2. Filed map number and dated filed have been added to the Letter of Authorization. 3.1 Three (3) feet of fill has been provided.. 4. All details not relevant to the Fill Plan have been crossed out. 5. The house has been labeled as four (4) bedroom on the Plan. 6. Fill pad dimensions have been provided. 7. Depth gauges have been shown. 8. All systems within 200 feet of this proposal have been added to the Plan. 9. Erosion control measures have been shown and the detail is provided. 10. The well service connection has been shown on the Plan. 11. SSTS has been redesigned to eliminate encroachment of system on slopes greater than 20 %. 12. Well is located greater than 100 feet uphill of proposed SSTS. Enclosed are the following: a. Five (5) prints of SS -1, "Proposed SSDS ", revised 5- 18 -98. b. One (1) copy of "Letter of Authorization ". c. One (1) copy of "Application for Approval of Plans for a Wastewater Disposal System ". D May 19, 1998 Page 2 Y 8753 We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Very truly yours, LAUREN'T ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:bd 8753 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of .. Located at W,, hAAN o s gQAo T/V Tax Map # 23. Block 3 Lot 24 Subdivision -of Subdivision Lot # p Filed Map # 2011 Date Filed 12 5 Gentlemen: This letter is to authorize 4Agg�j J-g . // a duly licensed Professional Engineer T or Registered Architect to apply for the required wastewater treatment and/or water supply.permit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater treatment and/or water supply systems in conformity with the pWQf Article 145 and/or 147 of the Education Law, the Public Health Law, and Countersigno P.E , R-. A., # Mailing Address M ! L L f5 00 S State Zip 10 L�;Dfl Telephone: Very truly yours, Signed: Mailing Address: State \/T Zip 056,43 Telephone: Form LA -97 PUTNAM COUNTY DEPARTMENT Or' HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: C,!9UW I GI,I 1'x.41,1C,9QE' T CAt2TTy T 0 S�F� 2. Name of project: _fI ag2Gep 1�� 3.. Location TN: 4. Design Professional: �, N tlti �-s� p,� 5'. Address: M►I_I P>i?tX�i� G��icr--C[ iffW 6. Drainage Basin: GPLoToN 7. Type of Project: u Private/Residential Food Service Apartments Institutional Office Building Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality Review (SEQR)? Type Status (check one) ....................... ............................... Type I Type II 9. Is a Draft Environmental Impact Statement (DEIS) required? ........... i.............. 10. Has DEIS been completed and found acceptable by Lead Agency? ............... Exempt. Unlisted X 110 11. Name of Lead Agency S 1A 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 approval been granted by such authorities ?R Date granted: 1�1% 15. Type of Sewage Treatment System Discharge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .................... N 1A 17. Waters index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... p 19. If yes, name of water supply Distance to water supply 20. Is project site near a public sewage collection or treatment system? ................ N 0 21. Name of sewage system N A Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector 24. Project design flow (gallons per day) ................................. ............................... o u 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... 26. Has SPDES Application been submitted to local DEC office? ......................... Fnrm hf' -�•'� M 2 27. Is any portion of this project located within a designated Town or State wetland? 28. Wetlands ID Number ... : ......................................................................................... N f4 29. Is Wetlands Permit required? ......................................:....... ... ..................... .I....... n Has application been made to Town or Local DEC office? ............................... glA 30. Does project require a DEC Stream Disturbance Permit? .. ............................... , 31. Is or was project site used for agricultural activity involving application of pesticides to orchards or other crops, solid or hazardous waste disposal, landfilling, sludge application or industrial activity? ............................ Yes/No 32. Is project located within 1,000 feet of existing or abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potentially known source'of contamination? ............................... Yes/No 1A DESCRIBE: Z 33. Is there a local master plan on file with the Town or Village? ......................... 34. Are community water and/or sewer facilities planned to be.developed within z; ran. CDM 15 years in or adjacent to project site? ................................ ............................... 35. Are any sewage treatment areas in excess -of 15% slope? 36. Tax Map ID Number .......................... ............................... Map �3, Block Lot 37. Approved plans are to be returned to ..... Applicant _� Design Professional- NOTE: All applications for review and approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need not be sent in duplicate to the DEP, although the project may require DEP approval of the SSTS prior to final approval by the Department. Projects within the watershed may,also require DEP review and approval of other aspects of a project, such as stormwater,plans or the creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forms to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item l .,the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I hereby affirm, under penalty of perjury, that information provided on this form is trite to the best of my knowledge and belief .False statements made herein are punishable cis a Class A misdemeanor pursuant to SIGNATURES & OFFICIAL TITLES: Mailing Address: ................................... RE: Proposed SSDS - Bancroft ' McManus Road, Lot #10 (T) Patterson, TM #23 -3 -24 Dear Mr. Morris: In response to your review letter dated June 2, 1998, we offer the following: 1. This office will contact your Department with regards to setting up a date for percolation testing. 2. Street. address has been provided in the title block. 3.1. Plans have been revised to reflect guidelines for fill sections greater than 2 feet. Enclosed for your review are five (5) prints of SS -1, "Proposed SSDS ", revised 6/5/98. We trust the above adequately addresses your concerns. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:bd 8753 j j LAURENT ENGINEERING ASSOCIATES, P.C. j \ MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road / \ Brewster, New York 10509 \ \ (914)278 -6108 - (FAX) 278 -2658 HARRY W. NICHOLS JR., P.E. CONSULTING SITE ENGINEERS June 5, 1998 Robert Morris, P.E. Putnam County Health Department 4 Geneva Road Brewster, NY 10509 RE: Proposed SSDS - Bancroft ' McManus Road, Lot #10 (T) Patterson, TM #23 -3 -24 Dear Mr. Morris: In response to your review letter dated June 2, 1998, we offer the following: 1. This office will contact your Department with regards to setting up a date for percolation testing. 2. Street. address has been provided in the title block. 3.1. Plans have been revised to reflect guidelines for fill sections greater than 2 feet. Enclosed for your review are five (5) prints of SS -1, "Proposed SSDS ", revised 6/5/98. We trust the above adequately addresses your concerns. Very truly yours, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W. Nichols, Jr., P.E. HWN:JM:bd 8753 To: t�.q�� mONI� Job No.: �D Project: BAHO-OFT C' eme"4 N M IhQmArUS k Attention: Ja Gntlemen: We enclose 6 ) copies of: W Prints ❑ Reproducibles ❑ Reports ❑ Tracings ❑ Specifications ❑ Memorandum ❑ Copy of Letter ❑ Description: Revision/ Dote. No.. (I ) 01" MRMD 69M M 196 s t via: . Our Messenger ❑ Your Messenger Copy to: ❑ Blueprinter ❑ Hand Delivery ❑ First Class Mail 0 ❑ Special Delivery Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: �04 P • w- �j LAURENT ENGINEERING ASSOCIATES, P.C. MILLBROOKE OFFICE CENTRE Route 22 & Milltown Road Brewster. New York 10509 HARRY W. NICHOLS JR., P.E. \ (914)278 =6108. (FAX) 278 -2658 CONSULTING SITE ENGINEERS Date: rp -G)- q$ To: t�.q�� mONI� Job No.: �D Project: BAHO-OFT C' eme"4 N M IhQmArUS k Attention: Ja Gntlemen: We enclose 6 ) copies of: W Prints ❑ Reproducibles ❑ Reports ❑ Tracings ❑ Specifications ❑ Memorandum ❑ Copy of Letter ❑ Description: Revision/ Dote. No.. (I ) 01" MRMD 69M M 196 s t via: . Our Messenger ❑ Your Messenger Copy to: ❑ Blueprinter ❑ Hand Delivery ❑ First Class Mail 0 ❑ Special Delivery Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: �04 P • w- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION Property 6i. /M ice. C94 5i Located at Mc hj W o s goA TN ,y��-�-j' � Tax Map # 23 . Block 3 Lot Subdivision of M A&&1 /2 Subdivision Lot # 10 Filed Map # Date Filed Gentlemen: This letter is to authorized -( W , N jG4DLS �2 . 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 treatment and /or water supply systems in conformity with the p%w-��Qf Article 145 and/or 147 of the Education Law, the Public Health Law, and the ©, /G A ��, it k'r No. oz4 E ,A., # Mailing Address M) L Lj?) ooK Code. State Zip ► p L�iDl Telephone: cl a 1- , 2 -7P -(o I D 8 . Very truly yours, Signed: (Owner of Pc Mailing Address: State \/I Zip 05(oAl Telephone: Form LA -97 si7:2o - Appendix. C State. Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For. UNLISTED: ACTIONS' Only Part 1 - PROJECT INFORMATION (To be completed -;by Applicant or Project' sponsor) 1. APPLICA T /SPONSOR: 2. PROJECT NAME. ps SS 3. PROJECT LOCATION: Municipality So County 4. PRECISE LOCATION: (Street address and road intersections, prominent landmarks, etc., or provide map) N141461015 5. PROPOSED ACTION IS: 2New DExpansion ❑Modification /alteration 6. DESCRIBE PROJECT BRIEFLY: 7. AMOUNT OF LAND'AFFECTED: Initially 3. tecres Ultimately , t acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS? RYes ONo If No, describe briefly. 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? IgResidential (:]Industrial ❑Commercial ❑Agricultural OPark /Forest /Open space ❑Other Describe: 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL, STATE OR LOCAL)? DYes 9No If yes, list agency(s) name and permit /approvals - 11. DOES ANY ASPECT OF THE ACTION. HAVE A CURRENTLY VALID PERMIT OR APPROVAL? DYes 16No If yes, list agency(s) name and permit /approval 12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT /APPROVAL REQUIRE MODIFICATION? DYes RNo I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF PAY KNOWLEDGE C.t�niirarit 1C•1r1r c r name• --L .✓ FY V) X . I i NJ' iTe�G -t' r._ _ , h 1 /1. 6I _ Sicnature: •01 r I I n'A Y 2 (A'/ If the action is n a CoVstal Area, and you are a state agency, complete a Coastal Assessment Form before proceeding with this assessmet:t PART II- ENVIRONMENTAL ASSESSMENT (To be completed by Agency) A. DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6. NYCRR; PART 617.47 If yes, coordinate the review process and use the FULL EAF. OYes ONo ' B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.6? If No, a negative declaration may be superseded by another involved agency. OYes ONo C. COULD. ACTION RESULT, IN ANY ADVERSE- EFFECTS 'ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible.) C1. Existing eir.qual ty, surface or groundwater quality-or quantity, noise levels, existing traffic patterns, solid waste production or disposal, potential for erosion, drainage, or flooding problems? Explain briefly: C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? ,Explain briefly: C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly: C4. A community's existing plans or goals as.officially adopted, or a change in use or intensity of use of land or other natural resources ?`" Explain "briefly: C5. Growth, subsequent development,, or related activities likely to be induced by the proposed action? Explain briefly: C6. Long term, short term, cumulative, or other effects not identified in C1 -057 Explain briefly: C7. Other impacts (including changes in use of either quantity or type of energy)? Explain briefly: D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT. OF A CRITICAL ENVIRONMENTAL AREA (CEA)? OYes ONo If Yes, explain briefly: E. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? OYes ONo If Yes, explain briefly: i Part III - DETERMINATION OF SIGNIFICANCE (To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or other.vise significant. Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d) irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add att?chments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question D of Part II was checked yes, the determination'of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. • Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur. Then proceed directly to the FULL EAF and /or prepare a positive declaration. • Check this box if you have determined, based on the information and analysis above and any supporting documentation, that the proposed action WILL NOT result in any "significant adverse environmental impacts AND provide on attachments as necessary, the reasons supporting this determination: " Name of Lead Agency Print or Type Name of Responsible Officer in Lead Agency Daze Title of R s.PQn�sib}� x414 �9► add uu Signature of Responsible Officer in Lead Agency Signature of c` 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: - CIIPET/ ?)A,14 .C90. EZ 2. Name of project: T90 _roGev 55T5 3. Location TN: 4. Design 5 Address: : �i cE �t�ff W 6. Drainage Basin: 7. Type of Pro-ject: Private/Residential Apartments Office Building Food Service Institutional Realty Subdivision Commercial Mobile Home Park Other (specify) 8. Is this project subject to State Environmental Quality kevie'w'* (SEQR)? Type Status (check one) .................. Typ, ..................................... e I Type 11 0 T ' 7"% ft Environmental E)_� empt Unlisted J( s La impaCL otatement (E)EIS) require-a-1 ... .......................... 10. Has DEIS been completed and found acceptable by Lead Agency? ............... M /A 11. Name of Lead Agency MIA 12. Is this project in an area under the control of local planning, zoning, or other Officials, ordinances? .......... .................................................. I ........ ..................... 13. If so, have plans been submitted to such authorities? ........................................ 14. Has preliminary approval been granted by such a*uthoritie- s?fi� Date gr6ted: WA 15. Type of Sewage Treatment System Dischar . ge ................. surface water groundwater 16. If surface water discharge, what is the stream class designation? .......... _ .......... � 1A 17. Waters index number'(s 4T�ace) .......................................................... ............... 18. Is project located near a public water supply system? ........................................ R 19. 11 if yes, name of water supply -"IA _Distance to water supply 20. Is project site near a public sewage collection Or treatment . sy'stem? .......... I ....... Nto 21. Name of sewage system N l Distance to sewage system 22. Date test holes observed 23. Name of Health Inspector-- 24. Project design flow (gallons per day) ................................................................. F2 25. Is State Pollutant Discharge Elimination System (SPDES) Permit required ?... Ki 0 26. Has SPDES Application been submitted to local DEC office? .........................I L4 Form !T-97 I 2 27. Is any portion of this project located within a designated Town or State wetland? ,9/) J 28. Wetlands ID Number ........................ ............ ........................................................ >� _ 29. Is Wetlands Permit required? .............. .:.... ..........:........:...... Q Has application been made to Town or Local DEC office? .................. 30. Does project require a DEC Stream Disturbance Permit? .. ............................... 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 I'A/9 32. I's 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? ........................:_. 34. Are community water and/or sewer facilities planned to.be.developed within 15 years in or adjacent to project site? ................................ ............................... /15 35. Are any sewage treatment areas in excess of 15% slope? ............ 36. Tax Map ID Number ... Map �25, 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 stormwatertiplans orIthe creation of impervious surfaces, and the project applicant should obtain the appropriate forms for such activities from DEP and submit those forrins to DEP for review and approval. If the application is signed by a person other than the applicant shown in Item 1.,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 SIGNATURES & OFFICIAL .TITLES. Mailing Address: .l..;lv .................... F�flllA� [CODIfITDWARbIWOFMrtLY'® r 4 DI+OtI� a* D�+tarhl.� 8aerkaa. Cils�sai, NsY 1lSl? b Fravlia Faebtlt B OF jCO�IJACRC� 1 SKWA63 DEFOSAL STSTM v "Awl 1 rwesent that 1 arm wholly,Mtl eofnpletely roe above desire d will be aonst►irctae as shown onA County Department of NMRq, and thait on ea be momated to the DaOartment. and a urine, placa'M gaud :eparatbN .Condition a ent ty p of W49 M the aypmal of the Certificate Of Cot w* b lotatad M sltoww en the approved Olen ahe County Dapartwom of INilth.' APPROVED FOR CONSTRUCT /ON This appro"l -up" revoolble for or inay be amMide Or w4dMiad when 'c moluka a snit.. A for dirpOaal, of defhad REV.. 10/88_Data �Y- be furnished the owner, his successors, heirs or asaians by the budder, that said bulkier, will spool system during -the period of two.121 years Immediately following thedato Of.tha kau- liance of the orljinal system or any r"WirsIherato ;'2) that the drilled well Aria rload n6aro IIIMHnMl(ad In aceArWnq with U@ Ragdros. rubs and reguias of the Putnern pied' P.E: RA. c �IQ� a'sofl 1�5(a3 License No -719/ e aitn the data Istuad unb s Construction at the buiklifp has Oven ufkwmken and is rY by the missionr of Haalth: Any sYtange or alteration of construction to star w�pJp/� o+ ly. Title n DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL IvG� l 02 3' PCHD PERMIT WELL LOCATION Street Address Town Tax Grid Number L> C ) — Z- WELL OWNER Name eon P% t � alt Mailing Address �? �� ©, ivate D c; ry"4 O Public USE OF WELL ®- primary 2 - secondary RESIDENTIAL ® BUSINESS ® INDUSTRIAL O PUBLIC.SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify, CIINSTITUTIONAL O STAND -BY AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED 3'-S /EST. OF DAILY USAGEFrO6 gal O REPLACE EXISTING SUPPLY O TEST/ OBSERVATION 11 ADDITIONAL SUPPLY 14NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING 0 7,0- S �PKe WELL TYPE IMDRILLED ODRIVEN []DUG GRAVEL. OOTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:. a Lot No. ! O WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >C NO NAME OF PUBLIC WATER SUPPLY: /{J/ TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: /V//Q LOCATION SKETCH & SOURCES OF CONTAMINATION PR 7 ON SEPARATE SHEET (d e) (signature) 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 thirt;! (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is cleat. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form 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 dr' g operations be contained on this property and in such _a manner as not to degrade or h ise conta . to surface or groundwater. Date of Issue: �9 19 Date of Expiration v 19� ermit Issuing Official Permit is Non - Transfer able White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller _ L-fW4 COCUN DEPARTHEV OF HFml i DIVISION OF ENVgtO L HEALTH-- SMMCES - - - - -- DESIGN UATA SHM- SUBSUFACE SMGE DISPOSAL SYSTEM FILE M. Omer Ac1dress ZZ .QF/> 'e6 g/?�i ✓S /I Located at (Street) Alc 4(Aal'u-S . ILAP ,Sec. 79 Block 3.- 'Lot c// (indicate nearest cross street) Municipality - 194 Watershed SOIL PERCOLATION TFST DATA RD01= 110 BE SUm'Pl'ID WITH APPLICATIONS }. Date of Pre - Soaking Y Z 7- t3 7 Date of Percolation Test Z7 HOLE Mom CL= TIME PERCOLAT•.LON PERCOLATION Run Elapse Depth to Water Fran Water Level . No. Time Ground Surface In inches Soil state Start-Stop Min. Start Stop Drop In Min/In Trop Inches Inches Inches ' 2 3 .3 zs. =3;x%8 �z3 Z- L/ LS .. 4 5 2 :�.� 3 : 3 z3 24/ Z? 3. o 4 5 1 1. . Tests to be repeated' at sacra depth until approximately equal soil rates are obtained at each percolation test hole. All data to' be sutmf.ttiba for review. 2. Depth measuremnts to be made fran top of hole. 12' . 13' 14, INDICATE. LEVEL AT WHICH: GROUNDWATER Is ENOOQN' ED INDICATE LEVEL TO WHICH WATER IEM RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: �SGY ��PaV'�� DATE: DESIGN Soil Rate Used %/ /S� Min /1" Drop: S.D. Usable Area Provided No. of Bedrooms Septic Tank Capacity Z a gals. Type Absorption Area Provided By S L.F. x 24" width trench %pF NEw� Other Name G/Jl�%/f�i > �iyG /r ✓f�y7 //�1� 2.SS.x.. PC. Signature Address Sm N 12 /VV %ZSG3 �OA9�FESSIDNP�� THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date , PUIWMCD : DEeARTMORf OF OOAWa -. am . Dlahipd Dtiiita�rlrl Ba�ilr S�ole�s. Wit. P Y l�l? �`� on le�rli t�sat CH�[CAiB OF COSOUAlft OA Fislt # , LaesNi at CL i-t rp os air iel/ia Nhtti� Let # l.� Hloelt Y3 e it �- 157c, 11) ReJ14 Oaa.dw,.a rL.. C.' o +�. >� Y JJ `) j� r / Daa al Frsvw. Ap�O►r S 2.2 8 yid AA M= ' 4 C. - % . !"' t� Tower Y 1 l S AY �F �_ © ^ d vis n; Fee Enclosed 0. . DtiS 1YN.' ' '$? Lot Ana FFSI See1Gf10 Depttivolsaee DSO C Plaihar 4 Iledeavoka Dedgu Flow G P D 0.G PCHD is Oegihed When FW is oa plated a Swa m" swomw Sp� „ ph T Y eaarees,ead,b� � �'; �� ,Addreae *Mar sg14; Prick S** Ftw Aditieas ae+ bat SIW* DiBed I repassm that I am •iholly arw tompNtNy ►asponswoefoutne design anA location' of the prole :Yatem(al .1) •that -the oaparste .tow di !=l do Mom ddCribad will a eonstrueted a•'shown onxnrapproved amendment there to and in aeeo►danop with th4 starwards, rules a ►eau ns o M. County liepMtmelt ,of__"Rhr, and that on conlplapanahereat a •.'cartifkste of construetlon Compliancwl satisfactory tO the Commissioner 'of "aafhwill M submitted to the OeMrtnrMtl, and',* written tlwnntp:will be .fureik+nsd the owner, hii auecaaors, heirs of asstpnt by the AufWer , thin siW' builAe► will NKe in Hood; oparatirrg, .condition any part .et_ieid low Aisposal, system during the period - -of two (2) yens bnntiegtey following thedati et aIN ;iatY ante of the .approval .ofthe Certifieat .oi Construetlon Compliance of `tM,oiginal system o►:any repairs thereto; 2) that -tln drilled well 0.84 above ., W* be "HwAted as slydarei on the'approved, plan and that saW well will ter, Instil , fn a- -rdanp 'witA atanWrO ruMt a ` rMu�aifons of :.tlna . Putpunr County Do"" Mat of Fl(a�dtl6 P ERA, AtlpMa = e �-. z 1. v ti i- d„ l loon» No �... APPROVED FON I:ONSTiijOloN MrdcaOM Ior.ceusa or'npaY ba amore ree kft a new .pWrnit -. ADM”' s'z -- onstr ksn 'ot tpna building has bean und"ken and ps rr- FIMnh. Any change or of construct . - pply onpy. .. Y I DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT 7 WELL LOCATION Street Addr GGS Town _ Tax Grid Number _ 3 _ Z WELL OWNER /� Name l(�Nhl; G�i Mailing Address Ccz j, �� ivate c ,9 / irk" OPublic USE OF WELL 5- primary 2- secondary RESIDENTIAL O BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION 0 OTHER (specify b INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT 5 gpm /# PEOPLE SERVED 3 —S /EST. OF DAILY USAGF800 gal O REPLACE EXISTING SUPPLY ❑ TEST/ OBSERVATION 0 ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING O DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING 0 %4 - S -P%A-e WELL TYPE ®DRILLED ®DRIVEN ®DUG ®GRAVEL ®OTHER IS WELL SITE SUBJECT TO FLOODING? YES x NO IF WELL IS LOCATED IN-1 REALTY SUBDIVISION, NAME OF SUBDIVISION: M-Q a A�f D�_��t Y 00, J�4 a Lot No. / O WATER WELL CONTRACTOR: Name T 8 D, Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >C NO NAME OF PUBLIC WATER SUPPLY: /U�/4 TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PR ON SEPARATE SHEET (mad te) (signature) 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 thirt;! (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 requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form 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: Date of Expiration 19 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 DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL f, 214 r PrUn PVPMTT � Y % WELL LOCATION Street Addr J Town Git3r_ Tax Grid Number !> c7 - 3 — Z WELL OWNER Name Mailing Address (2 2b 0� iivate ,g / rvn OPublic USE OF WELL 1 - primary 2- secondary RESIDENTIAL O BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY O AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION 0 OTHER (specify O INSTITUTIONAL O STAND -BY Q AMOUNT OF USE YIELD SOUGHT_ r gpm /# PEOPLE SERVED 3 'S /EST. OF DAILY USAGE gal REASON FOR DRILLING O REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION 13. ADDITIONAL SUPPLY NEW SUPPLY NEW DWELLING 17 DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING �,t,►- S L ZI -eve WELL TYPE ®DRILLED DRIVEN DDUG GRAVEL 11 OTHER IS WELL SITE SUBJECT TO FLOODING? YES X NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: 0. ETA/ d �4 1 r'1Y 0c.. Lot No. / O WATER WELL CONTRACTOR: Name T,8 ,D , Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES >C NO NAME OF PUBLIC WATER SUPPLY: /ULig TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PR 7 ON SEPARATE SHEET fy) (d e) (signature) 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 third! (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 requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form 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 Expiration Permit is Non - Transferrable 3/89 19 Permit Issuing Official White copy: HD File Pink copy: Owner Yellow copy: Bldg. Insp. Orange copy: Well Driller PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property of Located at e_ QA^ u S ZCZ 14 % MR U44,C j2 eL Section 2 Block Lot Subdivision of Subdv. Lot # Filed Map # Gentlemen: Date This letter is to authorize vokc('2 6(® A a duly licensed professional engineer or registered architect (Indicate to apply fora 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. , IFUNIt. , # 7C -1 73 E2Z Ze/'2 On J it' Address G � �A)Y (wi f) 2,7e- -AlOr Telephone Very truly yours,. Signed �- Ow t r of Prop ty Address Town pro- b3 ° X02 ✓ Te ephone Re: Pro Loc (T) PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Subdivision of Subdv. Lot # Filed Map # Gentlemen: Date This letter is to authorize J y`d y 6t! 4 w , L�,(�_ 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. Counte signed: P. E. , . , # elf?eI 73 zel x&, 14 On Address R ��, A) Y X9'/5/) 7, 7k- -A !vrp Telephone Very truly yours, Signed - 0 er of Prop y D Address Town Xbc; 5 (63 - E 0- 2 Te ephone PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Re: Property o Located at MR I I a n Section 23 Block Lot (9,j�� Subdivision of 0 P1-0 -GLNC1 a J1IG Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize' L 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 yours, ryry r S i gn e Countersigned: 0 er of Prop ty ( P. E. , . , # 7� ^7�� RC) Address 70 - �ld)r o(:!- 6 o—(O Address Town OA V/' ;�' Y O-)'C 5 (.3 2, %E - !� ` /OP Te ephone Telephone Date: May 22, 1989 To: Job No.: 'Putnam County Depart. of*Health 8753 110 Old *Rte: 6 Center Project: Bancroft .Residence Carmel, NY 10512. McManus Road Attention: John Karell, P.E. Patterson, NY Director Gentlemen: We enclose (1 ) copies of: O 81W Prints 0 Reproducibles 0 Reports 0 Tracings 0 Specifications 0 Memorandum 0 Copy of Letter ® Permit Description: Revision /Date No. "Construction Permit for Sewage Disposal System" (Fill Application) dated 5- 22 -89. Requesting a renewal. Sent Via: • Our Messenger 0 8lueprinter 0 First Gass Mail 0 Special Delivery • Your Messenger 91 Hand Delivery O Copy to: Very truly yours. Ms. C. Bancroft LAURENT ENGINEERING ASSOCIATES, P.C. HWN : mt Per: Harry W. Nichols Pr., P.E. LAURENT ENGINEERING ASSOCIATES, PC. 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 914.278.6108 CONSULTING SITE ENGINEERS Date: May 22, 1989 To: Job No.: 'Putnam County Depart. of*Health 8753 110 Old *Rte: 6 Center Project: Bancroft .Residence Carmel, NY 10512. McManus Road Attention: John Karell, P.E. Patterson, NY Director Gentlemen: We enclose (1 ) copies of: O 81W Prints 0 Reproducibles 0 Reports 0 Tracings 0 Specifications 0 Memorandum 0 Copy of Letter ® Permit Description: Revision /Date No. "Construction Permit for Sewage Disposal System" (Fill Application) dated 5- 22 -89. Requesting a renewal. Sent Via: • Our Messenger 0 8lueprinter 0 First Gass Mail 0 Special Delivery • Your Messenger 91 Hand Delivery O Copy to: Very truly yours. Ms. C. Bancroft LAURENT ENGINEERING ASSOCIATES, P.C. HWN : mt Per: Harry W. Nichols Pr., P.E. DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 APPLICATION TO CONSTRUCT A WATER WELL %L� �� PCHD PERMIT # WELL LOCATION Street Address Town Village City Tax Grid Numbe A/c ,44 vs '�?D ; - "?_Oz WELL OWNER Name Mailing Address. grPrivate X1E Z A,6:1'2 lv . J�/2 'v ✓lid /? i(/' O Public USE OF WELL � primary 2 - secondary RESIDENTIAL 0 BUSINESS ® INDUSTRIAL ❑ PUBLIC SUPPLY O AIR /COND /HEAT PUMP D ABANDONED O FARM O TEST /OBSERVATION ❑ OTHER (specify O INSTITUTIONAL O STAND =BY AMOUNT OF USE YIELD SOUGHT ,5_ gpm /# PFOPLE SERVED 3,S /EST. OF DAILY USAGE 003 gal REASON FOR DRILLING qNEW SUPPLY O PROVIDE ADDITIONAL SUPPLY O TEST OBSERVATION OREPLACE EXISTING SUPPLY ®DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING i{!, ,�fir�.�i✓G WELL TYPE WDRILLED DRIVEN ®DUG ® GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES -NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: %/VG. Lot No. Jp WATER WELL CONTRACTOR: Name J Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _X _NO NAME OF PUBLIC WATER SUPPLY: A4 TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: ,v /4 If LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED ®ON REAR OF THIS APPLICATION .ON SEP TES ET = A/ (date) I s gnature) 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 thirty (30) days of the completion of water well construction, the applicant s.hall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the re O r ments f the Put am County Health Department attached to this pe mit 3. Submit a Well Pcompletion Report on a form pr vi d by ia ou Health De nt. Date of Issue: Z --19 Date of Expiration: 19 it Issuing Off cial Permit is Non- Transferrable Mi copy: copy: 2/87 Pink Copy: Orange copy: H. D. File Building Inspector Owner Well Driller RANDOLPH W. LAURENT / ASSOCIATES, 3 FAIIRF ELD 7 DRIVE / PATTERSON, NEW YORK 12563 914.278.6108 CONSULTING SITE ENGINEERS Date: A/ 07 To: �J .dird� Job No.: — Project: 6C. /' /4�yyr� 6 C4/17TO? Attention: Gentlemen: We enclose (41) copies of: CAB /W Prints ❑ Reproducibles ❑ Reports ❑ Tracings ❑ Specifications ❑ Memorandum ❑ Copy of Letter ❑ Description: Revision /Date No. � >� f f� / /�'T G �f'i��d�lii ✓C� SS °- / ;' i�/T�� /� ��ir//dfI Y /�.�.Sic..�/ r'�yTI f=ib �C�� i=✓ i D i� /G Y T�'1 s = 6-- c,r,7 %?C''i/= VIA r 1�� jC�v /SGC� %e �i?GjiGG t %✓1%��'/L�j Sent Via: • Our Messenger ❑ Blueprinter First Class Mail ❑ Special Delivery • Your Messenger ❑ Hand Delivery ❑ Copy to: Very truly yours. RANDOLPH W. LAURENT ASSOCIATES,PC. ��i�i0 Per. ►• !• • �1• • y�T�� • :1 • • P • ' Iii :1 : �I• Mn;. t.19 VA I big F.1 M74MAP ' _ i'_' WN-111553*411 , .M 571..C'1 t :l.. You (Name of Owner) CGMMENTS LF trench provided required. k 60 ft: Par el to ntou v new i SHEET - CONSTRUCTION PERMIT (S YES DATE REVI BY: Permit Application Corporate Resolutio Plans - Three sets s/s Engineers Authorization Design Data Sheet (DDS) Deep Hole Log Consistent Perc Results (3) Perc Hole Depth SUBDIVISION Perc / /- / .S Fill 3 cd House PJ„�ns - Two sets Well '/ permit; PWS letter Variance Request GENERAL Legal Subdivision Subdivision Approval Checked Ex- approval SSDS Adj. Lots Checked Wetland (Town/DEC Permit R & D) Data On DDS Plans & Permit Same REQUIRED DETAILS ON PLANS Sewage System Plan - (north arrow) Sewage System Hydraulic Profile — Gravity Flow Fill Profile & Dimensions - Volume D or J Box;Trench /Gallery; Pump pit details Septic Tank - Size, Detail Well Detail, Service Line if over Construction Notes (grinder notes) Design Data: perc and deep results Two-Foot Contours Existing & Proposed Driveway & Slopes Cut Footing /Gutter,Curtain Drains (discharge OK) Perc & Deep Holes Located Representative of primary and expansion Expansion Area;shown;gravity flow,suff. size If Pumped Pit & D Box Shown & Detailed House - No. of Bedroans Wells & SSDS's w /in 200 ft. of Proposed Systems Property Metes & Bounds . House Setback Necessary (Tight lot) House Sewer - 1 /4 " /ft. 4 "0; Type pipe No Bends; Max. Bends 450 w /cleanout SEPARATION DISTANCES SPECIFIED ON PLAN Fields 10' to P.L., Driveway, Large Trees,Top of fill 20' to Foundation Walls 100' to Well; 200' in D.L.O.D, 150' pits 100' to Stream, Watercourse, Lake (inc. expan) 15' to Drains - Curtain, Leader, Footing 351to catch basin,stormdrain,piped watercourse_ 10' to Water Line (pits -201) 50' intermittent drainage course Se ptic Tanks 10' fran Foundation; 50' to well 15' Well to PL N N / TERRACE DINING RM. 134x 12° , LIVING RM. 13 x 210 840° TERRACE �. i' i�' h' �af �_ �.•. s- 's��i:r.3EY:6�S� *.7'.�:''�r3� ■® • • K FAMILY RM. oil DN.. .. �ivi,►�5t ' s ' � sir y- ' 1.' J .p. ' • ®— 13AIH UP �r ENTRANCE • '�;. • �� j: HALL Sc 0 3N 3 � :o U J< UP TO STUDIO - STORAGE AREA OVER GARAGE ?� 4i GARAGE 224 x 234 w PUTNAM COUNTY DEPARTI -ENT Oi' 11EATp. iUSE FLANS PPPEOVED FOR :M OM COUNT ONLY; ,r a;= 91;wa & 1.1 Q9 _.. Dato E House Beautiful's Spey SECOND FLOOR- 993 SO. FT. specially developed for the read Build 'Inq Manual /Ho - �.. __ _ •v - _ _ - - -T__- iI All - -••� Located at (Street) Sec. = Block ; 3.: 'Lot Z� (indicate nearest cross street.) Municipality - ,�Ai »Sa %/ Watershed- SOIL PEROOLA'L'ION TEST DATA PSOUIRM TO BE SUBMrr= WITH APPLICATIONS Date of Pre- Soaking y Z 7- Date of Percolation Test 27 0 ? HOLE NLJ�MFR CIACR TIME PERCOLATION TEROOLATION Run Elapse Depth to Water Fraa Water Level No. Tim Ground Surface In Inches Soil mate Star Stop Min. Start s t Stop Drop In Min /In -lDrop Inches inches Inches . -/9 2y z7 3 .2 3 3;.Vg.. '. Z3 4 5 1 2;�g - 3'v� ; zi 2y 27 3 2 . F 2 Y :/Z1 - 3; 33 Z3 ZV Z? ?J .J1 0 - 5 ' __ `- lJ r'i 2 b 3. n 5 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 submittt!d for review. 2. Depth measurements to be made from top of hole. r= 10' ... Ill. 12' 13' 14' INDICATE.: LEVEL AT WHICH GROUNI MTER. IS ENOOUNTERED A/fle-V/00SL.Y . /,)P/ 9a V INDICATE.LEVEL TO WHICH WATER LEVEL RISES AFTER BEING ENCOUNTERED DEEP HOLE OBSERVATIONS MADE BY: /oc�SGY �iPc� ll' DATE: DESIGN Soil Rate Used �/ /.S� Min/1". Drop: S.D. Usable Area Provided No. of Bedrooms 3 Septic Tank Capacity gals. Type CZ Vc Absorption Area Provided By 3.75 L.F. x 24". width trench Name L/��i%1 'tiT_ i�/�G��i/F�i? /�!/� . 6-KS4c D6.. Signature z cc Address, 73 �/� //IC /�� ,��. SEAL No. 66124 /!/.1� /ZSG3 �OA9nFESS10. THIS SPACE FOR USE BY HEALTH DEPARTMENT ONLY: Soil Rate Approved sq.ft /gal. Checked by Date Gentlemen: This letter is to authorize ///1RW 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 t, 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. Countersign( P.E., R.A., 7 3�'�Ir.�.�i��,� 19119, Address (9/0 Telephone Very truly yours, Signed &,A C�kd±_ Owner of Propert A 12 Address Ax" -A sT�jr �y Town 2Z) 9o. Telephone RANDOLPH W. LAURENT, P.E. HARRY W. NICHOLS JR:. P.E. May 07, 1987 Putnam County Department of Health 110 Old Route 6 Center Carmel, N.Y. 10512 �,• v � Att: John Karell, Jr., P.E. Re: Bancroft Residence McManus Road Patterson, New York Dear Mr. Karell: V7 Enclosed are the following: 1. Three (3) prints of Drawing SS -1F "Preliminary Design For Fill Placement Only, dated 5 -6 -87; 2. One (1) print of Drawing SS -1 "Preliminary Design For Fill Placement Only, dated 5 -6 -87; 3. "Construction Permit for Sewage Disposal System" (Fill Application), dated 5 -6 -87; 4. "Design Data Sheet" 5. "Letter of Authorization ", dated 5 -6 -87; 6. Two (2) copies of Residence Floor Plan (s), for //"Be room Count O�yn�ly" 7 ( 4et L," ' "? �.� Tic. q -velvJ c��1 16 p 4%Pit.Gir. We would appreciate your review, approval and issuance of the Construction Permit at your earliest convenience. Sincerely, LAURENT ENGINEERING ASSOCIATES, P.C. Harry W.(Aichols, Jr., P.E. HWN:map enclosures CC: Mrs. Connie Bancroft w/ one copy each PQ1riAM CODNTY DEPARTM`OF 29FWALTH,". DbUm e[ fttv6wpe W ROM 111 '4 a. CsteieL N Y.1051? BnQisees oo Paoelde Pastttlt i a CEBIIPICATB OF COtID'IIANCE COMMUCM14 PMW FOR SEWAGE MWOSAL.SYSTEM LeeaMd ti •�'" /C,.` /,�t` /Zi't/!U C �l� � V®nge, , sww lvbk+n Nome "l �ci ! n �IrIV —Subd. Let i Tax Pap � Block tot 2� /AppYs.�t ri alie i7sra: �G/ �'�or� ,[�At�Gt�J 7 Benewd_X Bevlebe ° jj ``'' Date of Ptevtobs Appmel V. A... U �SdX ��:5� i�iiGb r &S61-17 Town TJp Date Subdivision &2proved Fee Enclosed ❑ Amniinf Type R sl"G/eh 7 i�i� Lot Area ,3.7 c [F7U[SWdWo*'N/1 Deptb LZ-�Lvob ms A5zele . Nslubw of Bedtooau Dad gu Flow G P D P,CjjHD Notlfkatlou 4 Bego4ed W6eu FM is completed Sop mb Sewmp Syden to omldst of GaDm septic Took and .21904-1-- h -65- 1 r&3 0P C To be. onshoeted by �.L3 Addles: Water sopply3 -Pd& Sappy Ptim Address an ,_PAvate Sappy Drilled by �b�b Add,... Olber a 1 reprewnt'.that l am wholly and completely responsible for the design and location of the proposed system(:); 1) that the separate save disposal s stem above described will be constructed as showgon the approved amendment there to and in accordance with the standards, rules a regu erns o nom County Department of MWlth, and that on completion thereof a "Certifkate of Construction Compliallea" satisfactory to the Commissioner of Nealthwill tee submitted to the Aepa►tmant, and. a written guarantee will be furnished the owner, his successors, heirs or assigns by the bulkier. that sold builder will place in good operating condition any part of said sewage disposal system during. the period of two (2) yeas Immediately following the date of the Igu- ana of the approval of the Cartificats of Construction I Compliance of .t original system or any repairs t eto; ) that the drilled wsII'described above will be located as shown oe'the approved plan and that laid well will be Inst in accordant wit sta ds, r l and rpuTaiM f the Putnam County Department of."ealth. oats G lJ+�" Signed y P.E._ R.A. Address '/ �r•"" 'r+P� y license No SK/1 APPROVED FOR CONSTRUCTION: This approval expires two years from the data revocable for cause or may be amended or modified when considered nsicefsary by i requires a. w. permit. ApprpveD for disposal of dom k-sanitary sewag�i Rev. C /mac. 10/88 Date er unless Construction of the building .has been undertaken and is missions►. of Health. Any Change or alteration of Construction i;;�4& only. Title e C®<7NTS Dom? OF B�l1AlaII � . • tb alsOYld peassllt d ima T0 er; F ooMunrlcE: ap N !SW FOR SSWAGR DEPOSAL SYSIM 7 / -crS6� NMO a r of o Trra Hi4 �Z , MAI 3 RIM VVIA Dab off Ap@sov®l Date Subdivision Approved Fee Enciosed ❑ Am tint- i2�.0 r e _. i,>,t A� 3 .-7 Z.S. FE c male Dv& 3 vt�mo • 6s� ' Nmber of Badseents 6F Dodo Plow G P D R'00 n PCHD No1Wastlon la Begdmd When Pie h caiiil d Sepwab SeweeeCe Syapean i "now d J2-Sr) Gall. Sf .Teek Pisa To be oaolabaseted by Addreeo gYaber.Stapp �1dbBe SW* Pt{om . Addrese on pre.Ue S p* MEW by -•TR Q. eta . of 1 rep"rettnt that 1 arti wholly and completely �esponfibie tor'tho design and location of the proposed system(s); 1) that the separate few di' ' fel Item *bovp imwibed will be:construeted as shown on the approv". amendment thereto and in accordance with the standards, rules a . requ ions nam County ' I I ' 'pant .of 1faaRly and that ;On eornplotion thweof o , Certificate, of Constryction Compl{aneo ` Ytiafattory to the Coanmisfbew of Health milli to be . ubnlitted to the'Oepartgiant and w►Ittori,'gua►ant®e' will bi_ furnish" in* owner, his succesaeas, helve or aasigne by the builder, that said builder will pierce . iA good opaatMp COnditleh any 'part of fold fawage disposal, system,ouring the period of two (Y) years iminedialely 4ollowireg thidato`of the iYU- Once' of the appr0ay.of the ,Certificate of.-. Construction Compliance of the originat.system or: any repeNs thereto; 2) that the drilled well defcribod above be belted es sltdw� on the approved pion and that tail arch will 0,'instol n accordance' i4h then roe rules end rig ns 'of ' the Putnam V '•.� County Deportment Of .Malth , , . n P E/1 L- -,RpA. _ lldtl► Q t Lleerne No '. `7 J / q ) APPROVEO,FOR CONSTRUCTION This:app►ovat aupNet two yoen ,Isom the -date issued un construction of the building has been undertaken and is A revocable fo►.ceust,or' may be amended or'modif" when considered necessary by, the Commissioner of Health. .Any change or alteration of construction `!C requNef e w par Approval ior.iliapossl bU ornostic sanitpry'`eawagt, a alwor private wator supply , pply only. F ® 10/ Date Title n I represent that =l am' wholly and completely responsible for the design I above described will be constiucteil as shown on the °approved amentlme . County Department of Health; - and that on c6rnpt@ticn thereof a "Ce be "submitted`fo the Department, and "a -guarantee wJl'be fi place in good:operating condition zany,. part of, :Said'sewage disposal once of the, - approval of the Certificate of Construction Compliance will be located as shown on the approved plan and that said well'will.be_ County Dep'artme�ntt Health �!Signed APPROVED FOR CONSTRUCTION: This, approval; expires two ears 1 revocable for; use or a amendetl or modified when cons a ed n requires roved for disposal of 'doi- lc far, /t 81. Date BY L... nd location,ot' the proposed system(s);'1) that the separate sewage.P4 sal system It her teto and. in aCCOrdance W. iih the standards, rules an requ a Ions.0 0 Putnam tificate of Construction Compliance^ .satisfactory to the Commissioner of Healthwill rn'isfied - the - owner; his successors,, heirs or, assigns by the buiklei,'that said builder Will system during the period of.:two (2) ears Immediately foilowing'thodate of the issu- of the original system or, any repair ther to; 2 that the drilled well described above �s led in accord nce `, w' the st dor rul and regulations of the Putnam ✓�! / P.E. '' IL R.A. - /�/sjJ�� license No L e 0 tB i suetl unlefsconstruction Of the building has been undertaken and if ht Com 'f o .Health. Any change o d/ ' t Title r> U'T'NAN� CO'CJNT'�SZ" XDEPAR.'TMENT O&' 1 EA.L.'x')&X APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAG.SYSTEM 1 . Name and Address of Applicant:����� 1/7 2S� 7 2. Name of Project: 3.,_; Location&V /C: 4. Project Engineer: 5. Address: Millbrooke Office CentrE Brewster, NY 10509 License Number: 56/Z y Phone: (914).278 -6108 6. Type of Project: Private /Residential Food-Service ....Commercial , Apartments Institutional Mobile Home Park Office Building Realty Subdivision Other. (specify). 7. Is this project subject to State Environmental-Quality Review (SEQR) ?. Type Status (Check One) Type I.. Exempt Type II. Unlisted. x_ 8..I8 a Draft Environmental Impact Statement (DEIS) required? ........... :.. 9. Has DEIS been completed and found acceptable by Lead Agency? 10. Name of Lead Agency 11. Is this project in an area under. the control of -local planning, zoning, or other officials, ordinances? _7ie_5- 12. If so, have plans been .submitted to such ; authorities ?.. ................... ye_S 13,. Has preliminary approval been'granted by such authorities? YES Date Granted: 7 -i3 -9 Type of Sewage Disposal: System 'Discharge...... Surface Water __.Z _Ground Waters 15. If surface water discharge, what is the stream class designation? ...... .. �� :6i Waters index number (sur,face) /�q :7. Is project located near a public water supply system ?. ................ ... 8. If yes, name of water supply — Distance to water supply. 9. Is project site near a public sewage collection or disposal system ?..... ,0. Name of sewage system if /, C% Distance, to sewage system 1• Date observed: 23. Name of Health Inspector: �- Project design flow (gallons per day) ..................................... IFOK7 25. Is State Pollutant Discharge El imi.nation� System (SPDES) Permit required ?.. �yb .26. Has SPDES Application been submitted to local DEC Office? ............... A11V 27. .Is any portion of this project located within a designated Town or State �/U wetland ?. ................. ............. ............................... 28. Wetland ID Number .....................:... ............................... All 29. -Is Wetland Permit• required?• .............. ............................... Has application been made to Town or Local DEC Office ?. ................`... NC 30. Does project require a DEC Stream Disturbance Permit? ................... A) 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchardsior other crops, solid or hazardous waste disposal, landfilling,*sludge application or industrial activity? ........ YES'or NO 32. Is project located-within 1;000,feet oi= -existence of abandoned landfill, hazardous waste site, salt stockpile., landfill, sludge.disposal site or any otherppotential known source of contamination? .....'............YES or NO NO DESCRIBE: 33 Is there a local master plan or file with the Town or Village? ...:........ A/in 34. Are cornmunity water, sewer facilities planned to be developed. within 15 years? 35. Are any'sewage disposal areas in excess of 15% slope? i 36. Tax:Map ID Number ......................... ............................... 2,?-,31- 2tf 37. Approved Plans are' to 'be returned to: ............... Applicant __ Engineer i.= the application is signed by a person other fihan the applicant shown in Item.1, the. pplication must be-accompanied by y-a Letter of Authorization: Failure to comply with this provision may be grounds for the rejection of ary submission. I hereby affirm, under penalty of perjury;- that information provided on this form is true to the best of my knowledge and bet ief. Fa Ise state,re'nts made herein are punishab7e as a Class A.Hisdazeanor p suent to Section .210.45 of the . Pena 1 Law. 31G,NATURES & OFFICIAL TITLES: 'AILING ADDRESS: v J Miiibr ke Office Centr, Brewster, NY 10509 I'Jli- 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 # P 0-0 WELL LOCATION Street Address Village City Tax Grid Number WELL OWNER Name Mailing dress pPrivate C1.601 oS6 `f O Public USE OF WELL 4V- primary 2- secondary PRESIDENTIAL D BUSINESS D INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O ABANDONED O FARM O TEST /OBSERVATION O OTHER (specify b INSTITUTIONAL O STAND -BY O AMOUNT OF USE YIELD SOUGHT gpm /# PEOPLE SERVED /EST. OF DAILY USAGE__ _gal REASON FOR DRILLING ❑ REPLACE EXISTING SUPPLY ❑ TEST /OBSERVATION E2. ADDITIONAL SUPPLY j9NEW SUPPLY NEW DWELLING D DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING WELL TYPE DRILLED DRIVEN DDUG GRAVEL. 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES ')< NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. !� WATER WELL CONTRACTOR: Name Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION .PROVIDED ON SEPARATE SHEET -K-3 -2S - (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 thirt- (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 requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form 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 s ch a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: 19 �--z_ Date of Expiration 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 PUTNA�M COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIROINDIENTAL HEALTH SERVICES Date Re: Property of i✓oHe�ie a.�GL /�o�, 1nc���� Located at ltlla4us5 (T) Section 23 Block 3 Lot Zy Subdivision of Subdv. Lot Filed �Iap 1 Date Gentlemen: This �16tt.er is to authorize _a duly license¢ professional engineer X or registered architect (Indaicate) to- apply for a Construction Permit for a separate -sewage system, to serve the above noted property in acc.ord'ance with the standards-., rules. or regulations..as promulagated by the Commissioner of the Putnam County Department of Heaith', 'and to sign, al-1 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 Lazy, the -Public Health Law, and the Putnam County Sani- tary Code. L. i Countersigne : P.E. , R.A. , ;11 Millbroo4 Office Centre Address $rewster,,NY 10509 914 - 278 -6108 Telephone: ; i Very truly yours, , , Signed Oi,mer of Property - I i /sue Address To i.-n Telephone PUTNAM COUNTY DEPARTMENT OF HEALTH C Dlvialm df Hrvbeosental Red& Services. Carmel. N.Y.1IS12 b4blew to Provide PeesU g am CERMCATE OF COMPLIANCE CONSTRUCTION PERMIT FOR SEWAGE DISPOSAL SYSTEM P eN Lec"W at or vIDllae Stibd)vlafsn Name %��%1G .: n /� / Subd. Lot, //> Tax Map— Block Renewal_X Revidon ❑ /App�t Name C:'3hif,1 .r G% �i�?n .dSnt,G,��;�1 _ Date of Previous Approval Adieus y CS d X / _ Cp:C,i? f. V / Q S 6 yy Town Zip Date Subdivision Ao /moved � Fee Enclosed ❑ Amnnnt- T3" Re si ,rzeo 7 /a% Lot Are. ,, % Z ,r M Section Only Depth �_volome Nslsber d Belizean—y Deatp Flow G P D !JC% PCHD Nod5cedon Is R•pbei Wben FIR Is compbted Sepeeab Sewera" Sydem to coedd of /25o Galloa Septic Teak and .`�J[� L, t. /�, %rP:x.�y c- To be anetrucfed by 71U�p Address Water Supply: Padb& Supply From Address an 71s Pdvsfe Supply De1Bed by 7'.J�� _ Address Otbw Readrements 1 represent that 1 am wholly and completely responsible for the design and location of the proposed system(s); 1) that the separate sewage dispO"I system above described will be constructed as shown on the approved amendment there to, and in accordance with the standards, rules an regu sons O M. Putnam County Department Of Health, and that on completion thereof a -Certificate of Construction Compliance" satisfactory to the Commisslonw of Healthwill be submitted to the Department. and a written guarantee will be furnished the owner. his successors, heirs or assigns by the bulkier. that said builder will Place in good operating condition any part of said sewage disposal system during the period of two (2) yens immediately following the date of the issue once of the approval of the Certificate of Construction Compliance of t`0 original system or any repaks t.%d7.•to; ) that the drilled well described above will be located as shown on the approved plan and that saki well will be Insyl in accordan m witp-M• ita�las, r1f14"and reign kin-' of the Putnam County Dapartnent of Health. �� // 1. / �/ 14" and q -3 -ys APPROVED FOR CONSTRUCTION: This approval expires two years from the date revocable for Cause or may be amended or modified when considered necessary by t Rev.I•euires a w permit. ADpr for disposal of do m is sanitary sewag Date / 10/88 T _ P. E. _,V_ R.A. unless construction of the building has been undertaken and is missioner of Health. Any change or alteration of construction t%.0 --s"Paly only. Title f P TKAM COUNTT D91PARTMENr OF HBALTH sonlema.CaMMLN.Y.MS12 B toPrevhiePtisndt ma CZRTWWATE OF COMPLIANCE AfirOCbON*PZMM1r FOR SEWAGE DEPOSAL sYSr>Qi1 �Q Pee>mlt 4 _ r Nl o K 1, S' J�0 4 ✓/l own et V1ftV Na®a Q ' T rltmd. Lt Y (J Tu Mop 71-30 Hloek 3 Lot ( 1�- C 1 i Ta'1 /� c� h L► 0 �`� Resewot_'.J � s O ApPifaid No®s O V1 N f ,r p a BoY 1p� TT Cube .v..;y�tt zip natg Subdivision Awvroved Fee Enclosed ❑ Amn„nt 0 Typie /2;�((�f: �, c e _ Lot Aim 3 . -7 Z.S F® Seedw fib, D"& -1!-9.htere C oSU �• , N1111011ker of Bedleome Deoipt Fla w G P D • fJ' 00 PC1ID NdtMCndm is @ellubed When Fm Im ceoph>eeJ S�� S�10+la S>e� to oemew Ge ) ' .GtaBm Steppe TrAh To he eontuetod,hy ri? .D Addceee Woter sttppbc 1011M sepor P110212 Ad&vw an !/ Drt.nba So* DM d by TR !� ___Addrm Ober R"uhsaente 1 represent that I am wholly and completely responsible for the design and location of the proposed systerm(s); 1) that the separate sewage disposel system .bow described will be constructed as shown on the approved amendment there to and in accordance with the standards, rules and regulations ream County ,Department of Meekly and that on completion thereof a -Certificate. of Construction Compliance". satisfactory to the Commissioner of Heakhwill be submitted to the Department, and a written guarantee will be furnishod the owner, his successors, heirs or assigns by the bulkier. that sold builder will place 'in good operating condition any part of said sewage disposal system'durkq the period of two (2) yeas immediately following thedate of the In- ane of the approval of the Certificate of Construction Compliance of. the original system or any repairs thereto; 2) that the drilled well desfaibed above will be located as shown on the approved plan and that said well will be InstFT, n accordance lth tho'st rds, rules and rpu a -TT%ns of the Putnam County /Department of )H"Ith. Date _ , cr ` ��i - G/ •3 -1 �n p. .. __9Z R.A. Address Q License No- APPROVED FOR CONSTRUCTION: This approval expires two years fr4p4the date issued unless construction of the building has been undertaken and is revocable for cause or trey be amended or modified when considered noceseary by the Commissioner of Health. Any change or alteration of construction resuNef a Dar ADlxovaf for disposal oT omesik YnI[ary,_sew0ge, private orator supply Only, .zp 0/88 °sea ftle �'� 77 7�7 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 # P_42 -87 WELL LOCATION Street Address,//� own Village City Tax Grid Number WELL OWNER Name %rah, Mailing d Address / Q '6'0'y_163 a ,,• Private O Public �SE OF WELL ] - primary 2- secondary RESIDENTIAL b BUSINESS 0 INDUSTRIAL O PUBLIC SUPPLY ❑ AIR /COND /HEAT PUMP O FARM O TEST /OBSERVATION 0 INSTITUTIONAL O STAND -BY O ABANDONED O OTHER (specify O AMOUNT OF USE YIELD SOUGHT gpm /# 0 REPLACE EXISTING SUPPLY 20NEW SUPPLY NEW DWELLING PEOPLE SERVED-3 -�_ /EST. OF DAILY USAGE UG gal O TEST/ OBSERVATION 12-ADDITIONAL SUPPLY 13 DEEPEN EXISTING WELL REASON FOR DRILLING DETAILED REASON FOR DRILLING WELL TYPE V[DRILLED DRIVEN ODUG 13GRAVEL 0 OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCAT IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Ato� Q 10 77--d- (C Lot No. / 1 WATER WELL CONTRACTOR: Name 7-132) Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES �_NO NAME OF PUBLIC WATER SUPPLY: ,ci /A TOWN /VIL /CITY DISTANCE TO PROPERTY FROM NEAREST WATER MAIN: VIA LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED QON SEPARATE SHEET P "�q (date) (sitnatutMY 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 thirti, (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 requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form 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: 19i� '_i� ---- Date of Expi ation 19 Permit Issuing Officia Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller PiJTNAM COUNTY DEPARTMENT O>E' HEALTH APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL' SYSTEM 1 . Name and Address of Applicant: Co (..� c 9L C c `l"l�-� wo 2. Name of Project: .L� ��� U����� SS�� 3.._, Location /C: �4z7 -cY�o� 4. Project Engineer: /�InI��G / �v 5. Address: 73 7�a►r- �I( d CM License Number: I-tL`7 2 L Phone: Type of Project: r :' +;.. �.... �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. 8. Is a Draft Environmental Impact Statement (DEIS) required? ............. G 9. Has DEIS been completed and found acceptable by Lead Agency? ........... 10. Name of Lead Agency A(� - 11. Is this project in an area under the control of -local planning, zoning, or other officials, ordinances? ......... ............................... X0 12. If so, have plans been..submitted to such:. author .s ties? ..................... 13. Has preliminary approval been 'granted .by such authorities ?/07,4- Date Granted : -g 14. Type of Sewage Disposal_ System, Discharge....... Surface Water L-"__GrouAd Waters? 15. If surface water discharge, what is the stream class designation ?........ t :6. Waters index number (surface) ........... ............................... r- E7. Is project located near a public water supply system? .................. %n cn 8. If yes, name of water supply /V /A— Distance to water supply :9. Is project site near a public sewage collection or disposal system ?..... VID6 :0. Name of sewage system !V //4- Distance to sewage system A. Date observed: 23. Name of Health Inspector: 4. Project design flow (gallons per day) ...... ............................... '960 1. 2 •. 25. Is State Pollutant Discharge Elimination System ( SPDES) Permit required ?.. a 26. Has SPDES Application, been submitted to local DEC Office? 27. Is any portion of this project located within a designated Town or State c�J wetland ?. ............... /" CJ 28. Wetland ID Number ........................................................ 29.-Is Wetland Permit - requi red? ................................................... Has application been made to Town or Local'DEC Office? .................. 30. Does project require a DEC Stream Disturbance Permit? 0 31. Is or was project site used for agricultural activity involving application of pesticide$ to orchards or other crops, solid or hazardous waste disposal;`'`` landfilling,*sludge application or industrial activity? YES or NO 32. Is project located within 1.000•feet of existence.of abandoned landfill, hazardous waste site, salt stockpile, landfill, sludge disposal site or any other potential known source of contamination? ..............YES or NO a. DESCRIBE: 33. Is there a local master plan or file with the Town.or Village? ........... _ \ S 34. Are community water, sewer facilities planned to be developed within 15 years? 35. Are any sewage disposal areas in excess of 15% slope? ........................ A 36. Tax Map ID Number ......... ............................... .. .......... . ;'-3 37. Approved Plans are to"be< returned to: Applicant �ngineer If the application is signed by a person other than the applicant. shown in Item.1, the. application must be-accompanied by y-a Letter of Authorization .': 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 know7edge and belief. False statements made herein are punishable as a Class A Xisdemeanor pursuant to Section 210.45 of the Pena.? Law. SIGNATURES & OFFICIAL TITLES: TAILING ADDRESS: PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES Date. 5 lS— cZ Re: Property of Located at ' V\ N\ CAM u - er r'S (T) Section Z3, Block ___3 Lot . Subdivision of G r a,?, qt 0 P-� Wc., (� ,-E-" Subdv. Lot # 10 Filed Map # Gentlemen: This letter is to authori: Date a duly licensed professional engineer or registered architect (Indicate) to apply for a Construction Permit for a separate sewage system, to serve the�:abo.ve'noted property in accordance with the standards, rules or.regulat.ions 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 ofArticle 145 or 147, Educ 'the Public Health Law, and the Putnam County Sani- a 5 Flq, tary Cod. ��WILLigy� O Very truly yours, J` 0 781 Signed 4- A Countdrsi P. E. , _ , # 7S7k'1 73 (Je Address � .Ny z7� -A /orP Telephone Oh er of Prop ty,. Address "J-- V7 Cn - o Town Te�ephone To: Putnam County Health Dept. 4 Geneva Road. Brewster, NY 10509 Attention: Mr. William Hedges Job No.: 8753 Project: SSDS - Bancroft McManus Road Patterson, N.Y. Gentlemen: We enclose( 1) copies of: ❑ B/W Prints O Reproducibles ❑ Reports ❑ Tracings O Specifications ❑ Memorandum O Copy of Letter O Description: Revision /Date No. "Construction Permit" "Letter of Authorization" "Well Application" "Application for Approval of Plans for a Wastewater Disposal System" Kindly process the enclosed renewal. . 6 -30 -93 5 -15 -93 LAURENT ENGINEERING Fn 6 -30 -93 ASSOCIATES, P.C. j r 7YD 73 FAIRFIELD DRIVE PATTERSON, NEW YORK 12563 914.278.6108 CONSULTING SITE ENGINEERS Date: 7 -6 -93 To: Putnam County Health Dept. 4 Geneva Road. Brewster, NY 10509 Attention: Mr. William Hedges Job No.: 8753 Project: SSDS - Bancroft McManus Road Patterson, N.Y. Gentlemen: We enclose( 1) copies of: ❑ B/W Prints O Reproducibles ❑ Reports ❑ Tracings O Specifications ❑ Memorandum O Copy of Letter O Description: Revision /Date No. "Construction Permit" "Letter of Authorization" "Well Application" "Application for Approval of Plans for a Wastewater Disposal System" Kindly process the enclosed renewal. . 6 -30 -93 5 -15 -93 Fn 6 -30 -93 r 7YD .. ` J... Sent Via: 00 Our Messenger O Blueprinter O First Class Mail ❑ Special Delivery O Your Messenger G Hand Delivery 0 Copy to: Ms. C. Bancroft Very truly yours. LAURENT ENGINEERING ASSOCIATES, P.C. Per: nlIA'AnAl LID, 110apacL, C -b-') Randolph W. Laurent, P.E.